ROYAL ACADEMY OF MEDICINE IN IRELAND IRISH JOURNAL OF MEDICAL SCIENCE
23rd Sylvester O’Halloran Perioperative Scientific Symposium Friday 6th March–Saturday 7th March 2015
Graduate Entry Medical School, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
Irish Journal of Medical Science Volume 184 Supplement 5 DOI 10.1007/s11845-015-1259-8
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
Disclosure Statement The operational costs of the Sylvester O’Halloran Perioperative Scientific Symposium 2015 are funded with the support of a number of commercial bodies through educational grants. These are listed overleaf.
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
Sponsors 2015 The 23rd Sylvester O’Halloran Surgical Scientific Symposium greatly acknowledges the support given to the meeting by the following companies:
Bronze Sponsors MSD
Acelity Covidien Ireland
Silver Sponsors MED Surgical LEO Pharma
Tekno Surgical Sisk Group
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
SANOFI Ireland Ltd
Johnson & Johnson Ireland Ltd Olympus Medical Cook Medical Baxter Healthcare
3 M Ireland Ltd
RCSI Grunenthal Pharma Ltd
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
23rd Sylvester O’Halloran Perioperative Scientific Symposium The Graduate Entry Medical School, Faculty of Education & Health Sciences, University of Limerick Friday 6th March 2015 GEMS0-016 GEMS0-028 9.00-11.00am 9.00-11.00am Session 1: Clinical Session I Session 2: Clinical Session II Chairs: Mr Sean Martin & Ms Anne Merrigan Chairs: Mr David Waldron & Mr Ashish Lal Papers 1-12 Papers 13-24 Coffee 11.00-11.30am & Poster Viewing (Poster Prize sponsored by Applied Medical) GEMS0-016 GEMS0-028 11.20-1.20pm 11.30-12.30pm Session 3: Clinical Session III Session 4: ASGBI Prize Paper Chairs: Prof Kevin Barry & Mr Peter Murchan Chairs: Prof Michael Larvin & Mr John Moorehead Papers 25-36 Lunch (Sponsored by Barringtons Hospital Limerick) 1-1.50pm GEMS0-016 1.50-2.00pm Teaching Sonoanatomy to UL Undergraduate Students in 2015: > Building on International Experience GEMS0-028 GEMS0-016 2.00-4.00pm 2.00-4.00pm Session 6: Scientific Session Session 5: Plenary Session Chairs: Prof Colum Dunne & Dr Pat Kiely (sponsored by Covidien) Papers 49-60 Chairs: Prof Ronan Cahill & Prof Michael Kerin Papers 37-48 GEMS0-028 GEMS0-016 4.00-6.30pm 4.00-5.30pm Session 7: Head & Neck Session Festschrift to Professor Pierce Grace Chairs: Prof John Fenton & Prof Aongus Curran Chair: Mr Paul Burke Papers 61-76 Speakers: Prof O James Garden, Prof Paul Finucane & Mr John Moorehead 5.30-6.30 pm Sylvester O’Halloran Lecture Sponsored by Covidien GEMS0-016 Chair: Prof J Calvin Coffey Mr Edward Kiely, Consultant Paediatric Surgeon at Great Ormond Street Hospital, London "Paediatric Surgery - the Art and the Possible"? Saturday 7th March 2015 GEMS0-016 GEMS0-028 GEMS0-029 9.00-11.00am 9.00-11.00am 9.00-10.45am Session 9: Anaesthesia Session Session 8: Clinical Session IV Session 10: Orthopaedic Chairs: Mr Brian Mehigan & Ms Chair: Prof Dominic Harmon Session I Chairs: Mr Dermot O’Farrell & Papers 89-96 Shona Tormey Mr Lester D’Souza Papers 77-88 Papers 97-108 11.00 – 11.30am Coffee & Poster Judging GEMS0-016 GEMS0-028 GEMS0-029 11.20-1.00pm 11.20-1.00pm 11.05-12.45pm Session 11: Clinical Session V Anaesthesia & Critical Care Session 12: Orthopaedic Chairs: Prof Simon Cross & Mr Medicine Session Session II Myles Joyce South of Ireland Joint Session Chairs: Mr T. E. Burke & Mr Papers 109-118 Colm O’Boyle Brian Lenehan Obstetric and Obstetric Papers 119- 130 Anaesthetic Emergencies Simulator Munster Critical Care Audit 1.00-2.00pm Sir Thomas Myles Lecture Sponsored by Applied Medical GEMS0-016 Chair: Prof Michael Larvin Mr Brendan Moran, Lead Surgeon, Colorectal Unit at Basingstoke Hospital, UK "Improving Outcomes in Colorectal Cancer : Aggregation of Marginal Gains" Awards of Sylvester O Halloran Prize, ASGBI Paper, ENT and Orthopaedic Sessions The Sylvester O’Halloran Surgical Scientific Symposium qualifies for 10.5 CPD Credits
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
Friday, 6th March 2015 SESSION 1:
CLINICAL SESSION I
9.00–11.00am (7 mins Presentation & 3 mins Discussion)
Mr Sean Martin & Ms Anne Merrigan
1. One-Stage Vs Two-Stage Brachio-Basilic Arteriovenous Fistula for Dialysis Access: A Systematic Review and a Meta-Analysis K. Bashar, D. Healy, S. Elsheikh, Leonard D. Browne, Michael T. Walsh, M. Clarke - Moloney, PE Burke, EG Kavanagh, SR Walsh Dept of Vascular Surgery, University Hospital Limerick, Dept of Acute Medicine, James Connolly Memorial Hospital, Dublin, University of Limerick & National University of Ireland, Galway
2. Complete Pathologic Response to Neoadjuvant Therapy for Oesophageal Cancers A. Zaborowski, H.M. Heneghan, A. Granahan, S. King, N. Ravi, J.V. Reynolds Dept of Surgery, St James’s Hospital & Trinity College Dublin
3. Evidence for Varicose Vein Surgery in Venous Leg Ulceration Elrasheid A. H. Kheirelseid, Thomas Aherne, Khalid Bashar, Thamir Babiker, Peter Naughton, Daragh Moneley, Stewart R Walsh & Austin L. Leahy Dept of Vascular Surgery, Beaumont Hospital, Dublin
4. Is There a Role for Routine Duodenal Biopsy in all Adult Patients Undergoing Upper GI Endoscopy? K.C. Ng, Y. Mihes, E. Myers, D.P. O’Leary, B. Waldron Dept of General Surgery, Kerry General Hospital, Tralee
5. Genitourinary and Gastrointestinal Toxicity after Radical Radiotherapy for Prostate Cancer Redmond EJ, Dolbec KS, Fawaz AS, Flood HD, Giri SK Dept of Urology, University Hospital
6. Accuracy of Breast Examination in a Tertiary Referral Centre with a Focus on Clinically Occult Tumours C.J. Barter, P.W. Owens, E.J. Fahey, J Ashraf, R. McLaughlin Dept of Surgery, University Hospital Galway
7. Development of a Process by Which a Three-Dimensional Reference Standard of the Human Mesentery can be Generated L.G. Walsh, D.J. Walsh, J.C. Coffey Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School & Dept of Surgery, University Hospital Limerick
8. Medical Specialty Choice: Does Personality Matter? M.F. Duignan, S. Lydon, P. O’Connor, T.P. McVeigh, G. Offiah, D. Byrne School of Medicine, NUI Galway, Dept of Psychology, Trinity College & Beaumont Hospital
9. Comparative Effectiveness of Adrenal Sparing Radical Nephrectomy and Non-Adrenal Sparing Radical Nephrectomy in Clear Cell Renal Cell Carcinoma: Observational Study of Survival Outcomes L. G. Walsh, G. J. Nason, C. E. Redmond, N. P. Kelly, B. B. McGuire, V. Sharma, M. E. Kelly, D. J. Galvin, D. W. Mulvin, D. M. Quinlan, H. D. Flood, S. K. Giri Dept of Urology, University Hospital Limerick, St Vincent’s University Hospital, Dublin & North Western University, Feinberg School of Medicine, Chicago, Illinois, USA
10. The Efficacy of Percutaneous Tibial Nerve Stimulation (PTNS) for the Treatment of Urge Faecal Incontinence S.M. Abd Elwahab, M. Majeed, M. Hannon, P.S.Waters, M. McCourt, E.J. Andrews Dept of Surgery, Cork University Hospital
11. The Use of Inflammation-Related Markers to Predict Outcome in Rectal Cancer C Reid, CA Fleming, HM Mohan, K Schmidt F Cooke, South Eastern Rectal Cancer Network, Dept of General Surgery, Wexford General Hospital, South Eastern Rectal Cancer Network, University Hospital Waterford
12. Validation and Assessment of a Technology Familiarity Score in Patients Attending a Symptomatic Breast Clinic C. O’Brien, J. Kelly, B. Cotter, E. Lehane, M. A. Corrigan Cork Breast Research Centre & Catherine McCauley School of Nursing and Midwifery, Cork University Hospital
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 SESSION 2:
CLINICAL SESSION II
9.00–11.00am (7 min Presentation & 3 min Discussion)
Mr David Waldron, Mr Ashish Lal
13. The Use of Needle Catheter Tippped Feeding Jejunostomy Tubes in Cancer Patients and the Varying Degrees of Complications That Can Occur Post Operatively S. Tarrant, I. Tiedt, C. O’Neill, N. McCawley, M. Arumugasamy, Prof P. Broe Beaumont Hospital
14. An Audit of Culturally Sensitive Service Provision S. Akasha, D. Nally, R. McLaughlin, M.J. Kerin, C. Malone, K. Sweeney Dept of Surgery Galway University Hospitals
15. Contrast Enhanced Digital Mammography as an Adjuvant in Predicting Breast Cancer Size A. McGuire, D.P. O’Leary, M. Ryan, Z. Khan, M. Corrigan, H. P. Redmond, N. Relihan Dept of Academic Surgery & Breast Radiology, Cork University Hospital
16. What’s Dominating Surgical Research? A Review Of The Design Of All Trials Published In The Top Four Surgical Journals By Impact Factor In One Calendar Year A. Lawlor, S.P. Murphy, C. Rice, L. Kieswetter, C. O’Rourke, J.E. Fenton, J.C. Coffey Graduate Entry Medical School, University of Limerick & University Hospital Limerick
17. The Reporting of Ethical Approval and Informed Consent in the Top Five Surgical and Colorectal Journals by Impact Factor S.P. Murphy, C. Rice, A Lawlor, L. Kieswetter, C. O’Rourke, J.E. Fenton, J.C. Coffey Graduate Entry Medical School, University of Limerick & University Hospital Limerick
18. Randomised Controlled Trials in Surgery. A Review of the Categories, Surgical Sub-Specialty and Patient Numbers of all RCT’s Published in the Top Four Surgical and Colorectal Journals by Impact Factor in One Calendar Year A. Lawlor, S.P. Murphy, C. Rice, L. Kieswetter, C. O’Rourke, J.E. Fenton, J.C. Coffey Graduate Entry Medical School, University of Limerick & University Hospital Limerick
19. Does Tumour Biology Impact Upon Surgery Type and Complete Pathological Response After Neoadjuvant Chemotherapy in Breast Cancer Patients with Axillary Nodal Metastases? M.R. Boland, A.J. Lowery, D. Evoy, J.Rothwell, J. Geraghty, C. Quinn, G. Gullo, J. Walshe, J. Crown, A. O’ Doherty, E.W. McDermott, R.S. Prichard Dept of Breast Surgery, Pathology, Oncology & Radiology, St Vincent’s University Hospital
20. 20 year experience of liver transplantation in a single centre N.J. O’Farrell, N. Saeed, M. Sheehan, A. Cooney, J. Geoghan, D. Maguire, E. Hoti Liver Transplant Unit, St Vincent’s University Hospital, Dublin
21. Long-term Outcomes after Multimodal Therapy for Oesophageal Cancer H.M. Heneghan, A. Zaborowski, A. Granahan, S. King, N. Ravi, J.V. Reynolds Dept of Surgery, Trinity Healthcare Sciences Building, St. James’s Hospital
22. Initial Experience With Use of a Synthetic Mesh in Patients Undergoing Tissue Expander Breast Reconstruction A.T. Manning, S. Sharma, P.A. Cronin, M. Barry, M.R. Kell Dept of Surgery, Mater Misericordiae University Hospital, Dublin
23. The Accuracy of Urgent Pre-Operative Imaging in Correctly Pinpointing the Pathology in Patients Undergoing Emergency Abdominal Surgery at a Busy Acute Surgical Unit M. O’Sullivan, O.S. Mansour, D.J. Waldron, J.C. Coffey Dept of Surgery, University Hospital Limerick
24. Evaluation of Nurse Led Discharge (NLD) protocol on a Surgical Dayward R. Sheeran, E. O’ Malley, B. Moloney, F. Orefuwa, C.G. Collins Portiuncula Hospital, Ballinasloe
Coffee & Poster Viewing
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
CLINICAL SESSION III
11.20–1.20 pm (7 mins Presentation & 3 mins Discussion)
Prof Kevin Barry & Mr Peter Murchan
25. Can ‘Hotspotting’ Prove to be a Useful Tool to Reduce ED Attendance in The General Hospital Setting? E.J. McGovern, J. Bolger, P. Coyle, R.M. Waldron, D. Courtney, A. Jackson, K. Barry Dept of Surgery, Mayo General Hospital
26. Differences in Metastatic Patterns between Luminal B and HER2 over Expressing Breast Cancers and Changes since the Introduction Of Trastuzumab A. McGuire, A. Lowery, J.A.L. Brown, M. J. Kerin Discipline of Surgery, School of Medicine, University Hospital Galway
27. The Effect of Obesity on the Clinicopathological Characteristics of Colorectal Cancer: A Systematic Review and MetaAnalysis J.G. Solon, J.P. Burke, G. Handelman, D.C. Winter Centre for Colorectal Disease, St Vincent’s University Hospital, Dublin
28. Vascular Endothelial Growth Factor (VEGF) Expression in a Wistar Rat Model Following Induced Acute Limb Ischemia O.P. Godkin, A. Potempa, O. Budzak, A. Kosican, S. Toth, P. Stasko Dept of Vascular Surgery, VUSCH, Cardiovascular Institute, Ondavska Kosice, Slovak Republic, Wexford General Hospital & Dept of Histology and Embryology Srobarova, Kosice, Slovak Republic
29. The Biopsychosocial Impact of Vesicovaginal Fistula Repair; A Cross-Sectional Analysis L.M. Houlihan, M. Lynch Dept of Surgery and Obstetrics, Kitovu Hospital, Masaka, Uganda
30. Weight Loss in Oesophageal and Gastric Cancer Patients; Can We Mitigate The Risk? S. Tarrant, C. O’Neill, N. McCawley, M. Arumugasamy, P. Broe Dept of Upper GI Surgery & Dietetics, Beaumont Hospital
31. Impact of a Clinical-Decision Making Module on the Attitudes of Surgical Trainees in Ireland N.R. Bhatt, E. Doherty, E. Mansour, O. Traynor, P.F. Ridgway Dept of Surgery, Adelaide and Meath Hospital, Dublin & RCSI
32. Surgeon and Pathologist Assessment of Acute Appendicitis: How Accurate are we? P.N. Stassen, D. Mullan, H. Mohan, C. Fleming, J. Foley, A. Heeney, K. Schmidt, K. Mealy Dept of General Surgery, Wexford General Hospital
33. Should all Trauma Patients Undergo Routine Whole Body Computed Tomography on Admission: A Systematic Review and Meta-Analysis K.C. Chong, S. MacCormick, K. Bennet, D. Mockler, D.B. O’Connor, K.C. Conlon Professorial Surgical Unit &, Pharmaco-Epidemiology Dept, Trinity College Dublin & Tallaght Hospital Dublin
34. Carotid Artery Stenting – Cervical Approach Vs. Femoral Approach — 11 Years Experience N. Elsafty, W. Tawfick, S. Sultan Western Vascular Institute UCHG, School of Medicine, NUIG, Galway Clinic, RCSI
35. Examining the Role of the ‘‘Letter to the Editor’’ J. Fay, C. O’Rourke, JC. Coffey, JE. Fenton GEMs, University of Limerick, Dept of General Surgery & ENT, Limerick
36. Supervised exercise therapy (SET) for intermittent claudication: factors that determine compliance and outcomes S. Carr, E.A.H. Kheirelseid, T. Aherne, D. Moneley, A. Leahy, P. Naughton Dept of Vascular Surgery, Beaumont Hospital, Dublin
ASGBI PRIZE PAPER sponsored by Applied Medical
Prof Michael Larvin & Mr John Moorehead
1.00–1.50 pm sponsored by Barringtons Hospital Limerick
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
Teaching Sonoanatomy to UL Undergraduate Students in 2015: Building on International Experience Time:
PLENARY SESSION sponsored by Covidien
2.00–4.00 pm (7 min Presentation & 3 min Discussion)
Prof Ronan Cahill & Prof Michael Kerin
37. The Approach to Involved Anterior Margins after Breast Conserving Surgery; Whether Or Not to Re-Excise L.O. Connell, S. Walsh, C.X. Cheung, Z. Al Hilli, J. Rothwell, D. Evoy, J. Geraghty, C. Quinn, A.O. Doherty, E.W. McDermott, R. Prichard Dept of Breast-Endocrine-General Surgery, St Vincent’s University Hospital, Dublin
38. Can Inflammatory Markers be Used to Predict Complete Pathological Response in Rectal Cancer C.A. Fleming, C. Reid, H.M. Mohan, K. Schmidt, F. Cooke South Eastern Rectal Cancer Network, Wexford General Hospital
39. Informing Consent: Health Literacy and Perception of Risk in a High-Risk Cancer Clinic E. Rutherford, J. Kelly, E.A. Lehane, B. Cotter, M.A. Corrigan School of Medicine, University College Cork, Breast Cancer Research Centre, CUH, Wilton, Cork & Catherine McAuley School of Nursing & Midwifery, Brookfield, University College Cork supported by Aid Cancer Treatment Cork
40. Analysis of Adipose Tissue Distribution and Patient Outcomes in Colon Cancer Patients E.P. O’Connell, M. Twomey, D.P. O’Leary, M. Maher, H.P. Redmond Dept of Surgery & Radiology, Cork University Hospital
41. Preoperative Short Course Radiotherapy With Long Interval Surgery In A Series Of High Risk Patients With Locally Advanced Rectal Cancer M. Flanagan, V. Brennan, I. Reynolds, B. O’Neill*, D.A. McNamara Dept of Colorectal Surgery & St. Luke’s Radiation Oncology Centre, Beaumont Hospital
42. Laparoscopic Heller Myotomy: Effect of Age on Perioperative Outcomes B.C. Murphy, T.J. Murphy Dept of Oesophago-Gastric Surgery, Mercy University Hospital, Cork
43. Untangling the Role of Protein Kinase C in Breast Cancer Downstream of Growth Factor and Adhesion Signalling Mary McCumiskey, Catriona Dowling, Susan Dwane, Shona Tormey, Tara Dalton, Patrick A. Kiely Dept of Life Sciences, University of Limerick, University Hospital Limerick & Graduate Entry Medical School
44. Identification of TTBK1 as a Novel RACK1 Binding Partner in Breast Cancer S. Hayes, M. Kiely, M. McCumiskey, S. Tormey, T. Dalton, P.A. Kiely Dept of Life Sciences, and Materials and Surface Science Institute, Stokes Research Institute, Graduate Entry Medical School, University of Limerick & Dept of Surgery, University Hospital Limerick.
45. PI3 K Pathway as a Novel Target in Androgen-Driven Aromatase Inhibitor Resistant Breast Cancer A. Ali, L. Creevey, F. Bane, W.A. Marzuki, A.D.K. Hill, L.S. Young, M. McIlroy Endocrine Oncology Research Group, RCSI & Dept of Surgery, Beaumont Hospital, Dublin
46. Investigation of Exosome-Encapsulated Micrornas as Potential Circulating Biomarkers of Breast Cancer D.P. Joyce, M. Higgins, C.L. Glynn, J. Brown, E. Holian, P. Dockery, M.J. Kerin, R.M. Dwyer Discipline of Surgery, School of Medicine, National University of Ireland Galway
47. Co-Delivery of Pro-Angiogenic Agents as a Treatment Strategy for Peripheral Vascular Disease C.C. Herron, C. Hastings, C.O. McDonnell, F.J. O’Brien, G.P. Duffy Tissue Engineering Research Group, Dept of Anatomy, RCSI & Dept of Vascular Surgery, Mater Misericordiae University Hospital, Dublin
48. Investigation of the Role of STAT3 Signalling in Obesity-Associated Adenocarcinoma of the Oesophagus K.E. O’Sullivan, M.C. Cathcart, E. O’ Regan, J. Michaelson, N. Gilmartin, A. Cannon, G. Moore, J. Lysaght, J.N. O’ Sullivan, J.V. Reynolds Institute of Molecular Medicine, St James’s Hospital, Dublin
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
2.00–4.00 pm (7 min Presentation & 3 min Discussion)
Prof Colum Dunne & Dr Pat Kiely
49. Management of Infected Pancreatic Necrosis: A 5 Year Experience O. Ahmed, G. McEntee Dept of Hepatobiliary & Pancreatic Surgery, Mater Misericordiae University Hospital
50. Lipopolysaccharide (LPS) -Induced Tolerisation of Colorectal Cancer Cells Increases Their Metastatic Potential in Vitro and in Vivo D. Hechtl, J.H. Wang, H.P. Redmond Academic Surgical Research Department, University College Cork & Cork University Hospital
51. Morphine Potentiates the Action of 5-Flourouracil, Possibly Through Inhibition of Autophagy D. Brinkman, T. O’Donovan, S. Mckenna, J.H. Wang, H.P. Redmond Dept of Surgery, Cork University Hospital, Cork Cancer Research Centre
52. Molecular Cues to Angiogenesis in the Chick Extra-Embryonic Membrane Following Cadmium Exposure A. Kaskova-Gheorghescu, J. Duess, J. Thompson, School of Medicine & Medical Science, University College Dublin, St Vincent’s Dublin, National Children’s Research Centre, Our Lady’s Children Hospital Crumlin
53. Evolution of a Research Field – A Microrna Example M.C. Casey, J.A.L. Brown, M.J. Kerin, K.J. Sweeney Discipline of Surgery, Galway University Hospital
54. ‘Recruitment of AIB1 as a Result of HER-2 Over-Expression Confers Resistance to Aromatase Inhibitor Therapy’ E. Burke, D. Vareslija Endocrine Oncology Research Group RCSI
55. Protein Biomarkers; HOXC11 and S100b, for the Prediction of Recurrence and Response to Endocrine Treatment in Breast Cancer S.E. Kelly, C. Byrne Endocrine Oncology Research Group, Dept of Surgery, RCSI, Dublin
56. Do Genes Involved in DNA Repair Harbour Breast Cancer Susceptibility Loci? R.J. Mulligan, T.P. McVeigh, K.J. Sweeney, J.B. Weidhaas, N. Miller, M.J. Kerin Discipline of Surgery NUI Galway 7 Breast Check Western Unit & Yale University
57. A 5-Year Review of the Correlation between Primary Tumour and Lymph Node Response Following Neoadjuvant Therapy in Breast Cancer C.A. Fleming, K.M. McCarthy, T.J. Browne, M.J. O’Sullivan, H.P. Redmond, M.A. Corrigan Breast Research Centre, Cork University Hospital. Supported by Aid Cancer Research Cork
58. Tamoxifen Drives AIB1 Recruitment to Oestrogen Receptor Response Genes in HER2 Positive Breast Cancer Cells M.D. Ryan, F.T. Bane, A.D.K. Hill, L.S. Young School of Medicine, Dept of Surgery & Endocrine Oncology Research Group, RCSI & Dept of Surgery, Beaumont Hospital, Dublin
59. Investigating the Role of Microrna-Associated Single Nucleotide Polymorphisms in Breast Cancer R.J. Mulligan, T.P. McVeigh, K.J. Sweeney, J.B. Weidhaas, N. Miller, M.J Kerin Discipline of Surgery NUI Galway, Breast Check Western Unit, Yale University
60. A Case Control Study Examining the Association of Smad7 and TLR Single Nucleotide Polymorphisms on Colorectal Cancer Risk in Ulcerative Colitis F. Reilly, J.P. Burke, G. Lennon, D.A. McNamara, E.W. Kay, G. Cullen, G.A. Doherty, H. Mulcahy, J.M. Hyland, S. Martin, D.C. Winter, K. Sheahan, P.R. O’Connell School of Medicine & Medical Science, UCD; Centre for Colorectal Disease, St. Vincent’s University Hospital; Dept of Colorectal Surgery & Pathology, Beaumont
Festschrift to Professor Pierce Grace Time:
Mr Paul Burke
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
Speakers Prof O James Garden, Regius Professor of Clinical Surgery, Clinical Surgery, University of Edinburgh, Prof Paul Finucane, Foundation Head, Graduate Entry Medical School, University of Limerick Mr John Moorehead, President of ASGBI SESSION 7:
ENT/HEAD & NECK SESSION
Viewing: 4.00–4.30 pm
Prof John Fenton & Prof Aongus Curran
5 Minutes Presentation/2 Minute Discussion
61. Anaplastic Thyroid Carcinoma in Ireland P.Lennon, S. Deady, M.L. Healy, J. Kinsella, C.I. Timon, A. J Hill, J.P. O’ Neill St James Hospital Dublin, National Cancer Registry Ireland & RCSI
62. ‘‘Throat Awareness’’ is a Variation of Normal: A Retrospective Chart Review of So-Called ‘‘Globus’’ Patients C. Byrne, K. Gullane, J. Doody, C. O’Rourke, J.E. Fenton Dept of Otolaryngology & Head and Neck Surgery, University Hospital Limerick
63. Racial Variations in Thyroid Cancer Presentations and Outcomes E. Keane, E. O’Cathain, T.K. Subramaniam, H. Rowley, RCSI
64. Preliminary Comparative Observational Study of the Effects of Gelorevoice Throat Lozenges on the Symptoms Of Globus Pharyngeus R. Woods, T. Subramaniam, Ci Timon Dept of Otolaryngology, Royal Victoria Eye and Ear Hospital, Dublin
65. Post Radiotherapy Hypothyroidism; Hypo-surveillance? E. O’Reilly, S. Brennan, C.Timon, J. Kinsella Dept of Otolaryngology, Head & Neck Surgery, St James Hospital, Dublin
66. Rapid Access Clinics in ENT: University Hospital Waterford Experience F. Alsabah, W. Hasan, E. Lang, L. Skinner, D. Smyth, M. Donnelley Otolaryngology, Head & Neck Surgery Dept, University Hospital Waterford
67. A Comparative Audit of FNA Thyroid Indications, Results and Needles Used O’Rourke, T. Kelly, C. Hogan, J. Fenton, JE University Hospital Limerick
68. Difficult Access to the Cochlea in Cochlear Implantation C. Wijaya, P. Walshe, F. Glynn, L. Viani Cochlear Implant Department, Beaumont Hospital
69. Sublingual Immunotherapy for Grass Pollen induced Rhinoconjunctivitis. An Initial Experience T. Subramaniam, P. Lennon, R. Kaulsay, Clontarf Allergy Clinic, Dublin
70. Is Day Case Septoplasty safe or just efficient? GUH Retrospective Review S. Jaber, O. Young, Galway University Hospital
71. The Role of Adjuvant Radiotherapy in the Management of Recurrent Pleomorphic Adenomas of the Parotid: A Systematic Review and Meta-Analysis of the Literature P. Lennon, A. White-Gibson, S. Brennan, J. Kinsella, C.I. Timon, J.P. O’ Neill St James Hospital Dublin, St. Luke’s Hospital Rathgar & RCSI
72. 14 Year Retrospective Multicentre Review of Lip Malignancies A Single Surgeon Experience: Management And Outcome F. O’Duffy, E. O’Reilly, C.I. Timon St James Hospital, Dept of Head and Neck Surgery, Dublin
73. Is Four The Magic Number? A Retrospective Analysis of Radiological Findings and Final Histology in Four Years Of Thyroid Surgery in a Tertiary Institute S. Casey, S.M. Walsh, A. Heeney, D. Evoy, E. McDermott, R.S. Prichard Dept of Breast and Endocrine Surgery, St Vincent’s University Hospital, Dublin
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
74. Sphenopalatine and Anterior Ethmoidal Artery Ligation for Epistaxis: The Clinical Experience of a Tertiary Referral Centre A.M. McDermott, E. O’Cathain, J. Doody, D. Coakley, G. O’Leary, P. O’Sullivan, P. Sheahan Dept of ENT, South Infirmary Victoria University Hospital, Cork
75. Presentation and Management of Laryngomalacia in Children Above Age 1 at a Tertiary Referral Centre: A Retrospective Review T.S. Ahmed and C.G. Jephson Dept of Paediatric Otolaryngology, Great Ormond Street Hospital, London
76. Differentiated Thyroid Cancer: Assessment of Clinical Practice in a Tertiary Referral Centre P.W. Owens, E.J. Fahey, A.J. Lowery, D.S. Quill, M.J. Kerin Dept of Surgery, University Hospital Galway
Head & Neck Oral Poster Session Time:
1 Minute Summary at Poster Stand & 1 Minute Questions
Sylvester O’Halloran Lecture Sponsored by Covidien Chair:
Prof J Calvin Coffey
Mr Edward Kiely, Consultant Paediatric Surgeon at Great Ormond Street Hospital, London
‘‘Paediatric Surgery - the Art and the Possible’’?
Saturday, 7th March 2015 SESSION 8
CLINICAL SESSION IV
9.00–11.00am (7 Min Presentation & 3 Min Discussion)
Mr Brian Mehigan & Ms Shona Tormey
77. Unplanned Second Operations in Breast Surgery: A Single Centre Experience D. O Connor, D. Nally, R. McLaughlin, M. Kerin, C. Malone, K. Sweeney Dept of Surgery, Galway University Hospitals
78. The Impact off Biliary Pancreatitis: Real-World Experience Versus the Guidelines M. Kelly, D.B. O’Connor, A. Gillis, K. Utley, M. Egan, G. Fitzpatrick, P.F. Ridgway, K.C. Conlon Professorial Surgical Unit, Trinity College Dublin & Dept of Anaesthesia & Critical Care, Tallaght Hospital
79. Determining the Prevalence of Sarcopenia in Chronic Pancreatitis Using CT: A Pilot Study in an Irish Cohort D.B. O’Connor, C. Purcell, M. Egan, R. Ryan, O. Griffin, S. Duggan, K.C. Conlon Professorial Surgical Unit, Trinity College Dublin, Tallaght Hospital & St. Vincent’s University Hospital, Dublin
80. Do Urgent Cardiac Cases Utilise More Resources Than Elective? A Single Unit Audit M. Tarazi, M.N. Anjum, B. Philip, K. Doddakula Dept of Cardiothoracic Surgery, Cork University Hospital
81. Epidemiological study of Soft Tissue Sarcomas in Ireland Nikita Bhatt, Sandra Deady, Amy Gillis, Alexia Bertuzzi, Aurelie Fabre, Eric Heffernan, Charles Gillham, Gary O’Toole, Paul F. Ridgway. Dept of Surgery, Adelaide & Meath Hospital, Tallaght, Dublin
82. The impact of Social Work Intervention in Alcohol-Induced Pancreatitis in Ireland: A Single Centre Experience C. Beagon, N.R. Bhatt, S.M. Donnelly, M. Egan, A.P. McKay, B. Mehigan, K.C. Conlon, P.F. Ridgway Social Work Department, at the Adelaide & Meath Hospital, Tallaght & Trinity College
83. Risk of Colon Cancer after Acute Uncomplicated Diverticulitis: Is Colonoscopy Really Necessary? An Irish Perspective A. Moorthy, E. O’Connor, H. Al-Chalabi, N. Ravi, J.V. Reynolds Dept of Surgery, Trinity Centre, St James’s Hospital, Dublin
84. The Role of the General Hospital In The Era Of Run Through Surgical Training Donald Courtney, Jarlath Bolger, Ronan Waldron, Peter Coyle, Emma Jane Mcgovern Claire Connellan, Waquer Khan, Kevin Barry Dept of Surgery, Mayo General Hospital
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
85. Competency in Scrotal Examinations – A Survey of Newly Qualified Doctors N.P. Kelly, J.C. Forde, S.K. Giri, H.D. Flood Dept of Urology, University Hospital Limerick
86. 10 Year Experience of Thoracic Endovascular Aortic Repair Z. Ahmed, S.M. McHugh, A. Elmallah, N. Hamada, M.P. Colgan, A. O’Callaghan, S.M. O’Neill, P. Madhavan, Z. Martin St James’s Vascular Institute, St James’s Hospital
87. Changing Trends of Acute Pancreatitis – St. Luke’s Hospital in Comparison To the Irish Population Umair Muhammad, Awan Faisal, Elfaedy Osama, Pretorius Fredrick, Balfe Paul Dept of Surgery, St. Luke’s Hospital, Kilkenny
88. Feeding Jejunostomy Tubes in Cancer Patients; Not Without Risk? S. Tarrant, I. Tiedt, C. O’Neill, N. McCawley, M. Arumugasamy, P. Broe Dept of Upper GI Surgery Dietetics, Beaumont Hospital, Dublin
ANAESTHESIA & CRITICAL CARE MEDICINE SESSION
9.00–11.00am (7 Min Presentation & 3 Min Discussion)
Prof Dominic Harmon
89. Narrative and Pain Medicine M. Elhadi, D. Doltani, H. Misran, D. Harmon Dept of Pain Medicine, University Hospital Limerick
90. Perceived Injustice in Chronic Post Surgical Pain Patients A. Imran, D. Doltani, D. Harmon Dept of Pain Medicine, University Hospital Limerick
91. Cervicogenic Headache: A Prospective Study of Patient Characteristics and Medical Care M. Alhomary, H. Misran, D. Harmon Dept of Anaesthesia, Pain & Intensive Care Medicine, University Hospital Limerick
92. Case Series of Perceived Injustice in Chronic Pain H. Misran and D. Harmon Dept of Pain Medicine, Univeristy Hospital Limerick
93. Patent Blue V Anaphylaxis - A Typical Presentation K. Doody, E. McGloughlin. S. Mahdy Dept of Anaesthesia, University Hospital Limerick
94. Who Accompanies Patients to the Chronic Pain Clinic? D. Doltani, A Imran, D. Harmon Dept of Pain Medicine, University Hospital Limerick
95. Surviving Maternal Sepsis: Are We There Yet? R. Irwin, J. Shannon Dept of Anaesthesia, Limerick University Hospital
96. A Systematic Review of Undergraduate Ultrasound Education in Medical Schools M. Creaney, H. Misran, S. Keane, B. Rosenbloom, C.M. Nix Dept of Anaesthesia, Intensive Care & Pain Medicine, University Hospital Limerick
Brooke Shaughnessy Medal Medical Student Anaesthesia Essay Prize
South of Ireland Joint Session - Colm O’Boyle Obstetric and Obstetric Anaesthetic Emergencies Simulator
Munster Critical Care Audit
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
ORTHOPAEDIC SESSION 1
9.00–10.45 am (5 min Presentation & 3 min Discussion)
Mr Dermot O’Farrell & Mr Lester D’Souza
97. Assessing the Accuracy of Measuring Leg Length and Knee Genu Varum/Valgum Angle Using a New Markerless Motion Analysis System in Orthopaedics R. Hurley, A. Devitt Orthopaedic Surgery Dept, Galway University Hospital
98. Pain and Functional Outcomes with Tourniquet Use in Total Knee Arthroplasty A. Abdulkarim, K.E. Krause, E. Sheehan Midland Regional Hospital Tullamore & University of Limerick
99. Placing a Screw across the Ankle Syndesmosis: What are the Ideal Anatomical Landmarks? A Computed Tomography Evaluation Carmody Olan1, Kennedy Muiris2, Leong Sum2, Kennedy Cian2, Dolan Mark2 1 Trauma and Orthopaedic Surgery, Cappagh National Orthopaedic Hospital
100. Tranexamic Acid: An Audit of Use in a Single Institution E.F. Pomeroy, G.F. McCoy Lourdes Orthopaedic Hospital, Kilcreen, Kilkenny
101. Diagnostic Accuracy of Thessaly test for Detection of Meniscal Tears A. Hashmi, P. O’Loughlin, Hussain, S. O’Flanagan, P. Keogh, P. Kenny Connolly Hospital, Dublin
102. Radiographic and functional Outcomes Following Knee Arthrodesis using the Wichita Fusion Nail P.M. McQuail, J.F. Baker, P. Keogh, P. Kenny Dept of Trauma & Orthopaedics, James Connolly Memorial Hospital
103. Novel Biomimetic Osteochondral Defect Repair Scaffold Demonstrates Directed Stem Cell Differentiation in Each Distinct Layer C.J. Moran, T.J. Levingstone, F.J. O’Brien Tissue Engineering Research Group (TERG), Dept. of Anatomy, RCSI
104. Olecranon Fractures in the Elderly Population. Is Tension Band Wiring the Appropriate Treatment? M.M. Hennessy, S. Umar, P. Fleming, J.A. Harty Dept of Trauma & Orthopaedic Surgery, Cork University Hospital
105. A Radiological Assessment Using Magnetic Resonance Imaging of the Anterolateral Ligament of The Knee R. Hurley, C. Barry, D. Bergin, F. Shannon Dept of Orthopaedics & Radiology, Galway University Hospital
106. Cost-Utility Analysis In Fracture Care, What Pays? A Systematic Review S. Coyle, J.M. Queally, B. Lenehan Dept of Orthopaedic Surgery, University Hospital Limerick
107. Agricultural and Equestrian Injuries in the Irish Midland Ali Abdulkarim, Peter Coffey, Eoin Sheehan Specialist Registrar in Orthopaedics, Midland Regional Hospital Tullamore
108. A Comparison of Pin Site Infection Rates Between Percutaneous Buried and Exposed K-Wires in Treating Distal Radius Fractures P.M. McQuail, N. Awan Dept of Trauma & Orthopaedics, Our Lady of Lourdes Hospital
CLINICAL SESSION V
11.20–1.00 pm (7 Min Presentation & 3 Min Discussion)
Prof Simon Cross & Mr Myles Joyce
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
109. Improving Rectal Cancer Outcomes Through the Development of a Regional Cancer Unit E. O’Keane, E.M. Quinn, C. O’Neill, S. Zeeshan, F. Cooke Dept of Surgery, University Hospital Waterford, Ardkeen, Co. Waterford
110. Use and Abuse of the PSA Test By Non-Urologists in The Hospital Setting A.S. Fawaz, E.J. Redmond, K.S. Dolbec, H.D. Flood Dept of Urology, University Hospital Limerick & Graduate Entry Medical School, Limerick
111. The Role of MRI in Screen-Detected Invasive Lobular Carcinoma of the Breast C. Nı´ Leidhin, A. Heeney, C. Quinn, A. O’Doherty, R. Prichard Depts of General, Breast & Endocrine Surgery, Histopathology & Radiology, St. Vincent’s University Hospital
112. Early experience from Endotherapy for Dysplasia in Barrett’s Oesophagus in a Tertiary Centre in the Republic of Ireland J. Witherspoon, D. O’Toole, N. Ravi, J.V. Reynolds National Oesophageal & Gastric Cancer Centre, St. James’s Hospital, Dublin
113. An Outline of Barrett’s Oesophagus in Ireland: Preliminary Data from a Collaborative Multicentre Registry in Ireland J. Witherspoon, N. Ravi, J.V. Reynolds National Oesophageal & Gastric Cancer Centre, St. James’s Hospital, Dublin
114. National 10-Year Experience with Management of Total Anomalous Pulmonary Venous Drainage in Ireland Tetyana Kelly, Fabrizio De Rita, Yoginee Sritharen, Jonathan McGuinness, Mark Redmond, Lars Nolke Dept of Cardiothoracic Surgery, Our Lady’s Children’s Hospital Crumlin, Dublin
115. FYI Breast Cancer: Making Healthcare Information Accessible E. Rutherford, E.A. Lehane, P. Waters, A. Ashraf, J. Finn, M.A. Corrigan Breast Cancer Research Centre, Cork University Hospital, Catherine McAuley School of Nursing & Midwifery, Brookfield, University College Cork. Supported by CUH charity Cork
116. Predictors and Patterns of disease recurrence following a negative Sentinel Lymph Node Biopsy in Malignant Melanoma E.P. O’Connell, D.P. O’Leary, K. Fogarty, Z. Khan, H.P. Redmond Dept of Surgery, Cork University Hospital
117. Clinicopathological study of Atherosclerotic and Inflammatory Abdominal Aortic Aneurysms A. Elhelali, E. Kavanagh, V. Lundon, L.Morris, N. Hynes, W. Tawfick, S. Sultan Western Vascular Institute, University College Hospital Galway, Galway Clinic & Galway Mayo Institute of Technology
118. Does Antibiotic Prophylaxis Prevent Surgical Site Infection in Laparoscopic Cholecystectomy: A Prospective Observational Comparative Study K. Clarke, H. Mohan, E. Nugent, A. Heeney, M. Selmia, K. Mealy, K. Schmidt Dept. General Surgery, Wexford General Hospital
Coffee & Poster Judging 11.00-11.30 SESSION 12
ORTHOPAEDIC SESSION II
11.05–12.45 pm (5 min Presentation & 3 min Discussion)
Mr Dermot O’Farrell, Mr TE Burke & Mr Brian Lenehan
119. Do Medical Students Believe the Myths Regarding Low Back Pain? Improving Understanding with Targeted Education E. McCabe (1), D. Abdallah (1), S. Munigangaiah (2), N. Basavaraju (3), J.P. McCabe JP (2), School of Medicine, NUI Galway
120. The Use of Validated Clinical Outcome Measures in Spinal Surgery: An Analysis of Recent Annual Meeting Abstracts I.R. Perlus, J. Kennedy, J. Street, B. Lenehan Department of Orthopaedic Surgery, University Hospital Limerick
121. The Benefits of an MSK Clinical Specialist Physiotherapy (CSP) led Triage Service in Reducing an Orthopaedic / Rheumatology Waiting List in University Hospitals of Limerick (UHL) L. Ryan, P Julian, F. Steed, A. Fraser, B. Lenehan University Hospital Limerick
122. Inter-Observer and Intra-Observer Variability in the Assessment of Urgency of Low Back Pain Referrals from Primary to Secondary Care J.E. Gilmore, B. Lenehan Department of Trauma Orthopaedics, University Hospital Limerick
123. Evolving Techniques in the Innominate Osteotomy for Developmental Dysplasia of the Hip O. Carmody, D.T. Cawley, M.K. Dodds, D. McCormack Temple Street Children’s University Hospital
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
124. Lateral Trochanteric Pain Following Total Hip Arthroplasty: Radiographic Assessment of Altered Biomechanics as a Potential Aetiology Ali Abdulkarim, Raazi Bajwa, Eoin Sheehan, RCSI
125. Heterotopic Ossification Following Operative Treatment of Acetabular Fractures: The Ten Year Experience of the Tertiary National Referral Centre R.P. Piggott, Y. Elhassan, A. Abdelhaq, M. Leonard National Centre for the Treatment of Pelvic and Acetabular Fractures, Department of Trauma and Orthopaedics, The Adelaide and Meath Hospital
126. Metal on Metal Total Hip Replacement: Assessing the Quality of Patient Information on the Internet G .Crozier Shaw, D. Gibbons, J.M. Queally, J.Quinlan Dept of Orthopaedic Surgery, Adelaide, Meath & Children’s Hospital, Tallaght
127. Outcome of Hip and Knee Arthroplasty in HIV-Infected Patients- A Systematic Review and Meta-Analysis S.C. O’Neill, J.M Queally, A Hickey, KJ Mulhall Dept of Orthopaedic Surgery, Cappagh Hospital, Dublin & RCSI
128. Audit of Orthopaedic Operation Notes C. Ni Fhoghlu, F. Coughlan, P. Ellanti, N. Hogan Dept of Orthopaedic Surgery, St. James’s Hospital, Dublin
129. The Quality of Online Orthopaedic Information and its Impact on Contemporary Clinical Practice J.T. Cassidy, J.F. Baker Dept of Orthopaedics, The Adelaide & Meath Hospital & Galway University Hospital
130. Total Joint Arthroplasty: Do Referring Doctors Overestimate the Risks? Carmody Olan, Nugent Mary, Rowan F, Kelly M, Kenny P Trauma and Orthopaedic Surgery, Cappagh, Dublin
Sir Thomas Myles Lecture Sponsored by Applied Medical 1.00–2.00 pm GEMS0-016 Chair: Prof Michael Larvin Mr Brendan Moran, Lead Surgeon, Colorectal Unit at Basingstoke Hospital, UK ‘‘Improving Outcomes in Colorectal Cancer: Aggregation of Marginal Gains’’
GENERAL POSTER SESSION 1.
Bleeding submucosal oesophageal lesion in a pregnant female: a case report B. Murphy, A. Coveney, T. Murphy Department of Oesophago-Gastric Surgery, Mercy University Hospital, Cork
Admitting and discharging diagnosis—how good are we? P.N. Stassen, M. Butler, I. Callanan Department of Clinical Audit, Medicine and Surgery, SVUH, Dublin
Is catheter directed thrombolysis without thoracic outlet decompression sufficient to manage upper limb effort deep vein thrombosis? A single centre vascular surgery unit experience A. Kiernan, I. Robertson, D. Brophy, C. Cantwell, J. McCann, D. Mehigan, S. Sheehan, J. Dowdall, M.C. Barry Department of Vascular Surgery and Interventional Radiology, St. Vincent’s University Hospital
Peptic ulcer disease in the era of proton pump inhibitors—a population analysis S. Chalasani, A.C. Rogers, D.C. Winter. Department of Surgery, St Vincent’s University Hospital
Attitudes of clinical staff to the national early warning score system M.F. Duignan, P. O’Connor, G. Offiah, S. Lydon, D. Byrne West Northwest Intern Network, Galway University Hopsitals, Beaumont Hospital and Trinity College, Dublin
A prospective analysis of thyroidectomy outcomes in a resource limited setting N.O. Donohoe, J. Bolger, R. Kintu-Luwaga, J. Odubu Fualal Mulago hospital, Kampala, Uganda
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
A five year systematic review of published surgical research from nine east African countries N.O. Donohoe, J. Reilly, P. Sweeney, A. Khan, S. Tierney. The RCSI-COSECSA Collaboration Programme
The accuracy of urgent pre-operative imaging in correctly pinpointing the right pathology in patients undergoing emergency abdominal surgery at a busy acute surgical unit O.S. Mansour, M. O’Sullivan, A. Rutledge, E Condon Department of Colorectal Surgery, University Hospital Limerick
A comprehensive analysis of colorectal cancer staging and their demographic distribution at a specialist colorectal unit O.S. Mansour, E. McNamara, M. O’Sullivan, D. Kearney, C. Coffey Department of Colorectal Surgery, University Hospital Limerick
Effect of concurrent thyroid pathology on surgical intervention for primary hyperparathyroidism M.C. Casey, T.P. McVeigh, J.A.L. Brown, A.J. Lowery, D.S. Quill, M.J. Kerin Discipline of Surgery, Galway University Hospital
Evolution of trends in breast reconstruction in a single institution N. O’Halloran, A.J. Lowery, M.J. Kerin Department of Surgery, Galway University Hospital
Assessing the surgical outpatient—‘‘the patient’s perspective’’ C. Broderick, A. Courtney, M.E. Kelly, I.Z. Khan Department of Surgery Mayo General Hospital
Venous thromboembolism in patients with gastrooesophageal cancer treated with curative intent: a tertiary referral centre fourteen year experience E.M. O’Connor, S. Croghan, J.V. Reynolds Department of Surgery, Trinity Centre and St James’s Hospital, Dublin
Profile of acute surgical admissions over a three month period at St. Luke’s Hospital, Kilkenny Khalid Haroon, Umair Muhammad, Awan Faisal, Pretorius Fredrick, Elfaedy Osama, Balfe Paul Department of Surgery, St. Luke’s Hospital, Kilkenny
Clinical and histopathological appraisal of negative appendectomies: one year retrospective single centre study with two year follow up Charandeep Singh, Rishabh Sehgal, Faisal Awan, Osama El-Faedy, Frederik Pretorius, Leonardo Silvio-Estaba, Paul Balfe Department of Surgery, St. Luke’s Hospital, Kilkenny
Older women with triple negative breast cancer are less likely to get neoadjuvant chemotherapy N.M. Foley, C. Murphy, M. Jinih, Z. Khan, A. Khan, N. Relihan, H.P. Redmond Department of Surgery, Cork University Hospital
Availability of accessible and high-quality information on the internet for patients undergoing laparoscopic cholecystectomy T.P. Burke, C. Fenelon, D. Dalton, H. Mohan, K. Schmidt Department of Surgery, Wexford General Hospital and Department of Trauma and Orthopaedics, St Vincent’s Hospital, Dublin
Is patients understanding of sedation for gastroscopy adequate? A. Khan, M.E. Kelly, W. Khan, K. Barry, R. Waldron, I.Z. Khan Department of Surgery Mayo General Hospital Castlebar
Segmental duodenal resection: indications, surgical techniques and postoperative outcomes B. Alhamdan, D. Dorcaratto, H.M. Heneghan, B. Fiore, F. Awan, D. Maguire, J. Geoghegan, K. Conlon, E. Hoti St.Vincent’s University Hospital Dublin (Hepatobilliary Service)
Does body surface area predict post operative outcomes more accurately then body mass index in cardiac surgery? J. McLoughlin, R. Kelly, B. Hendrick, P. Keartland, D.G. Healy National Centre for Cardiothoracic Surgery, Mater Misericordiae University Hospital, Dublin
Sedation and bowel preparation for colonoscopy in elderly: a nationwide survey in Ireland J. Rehman, M.E. Kelly, W. Khan, K. Barry, R. Waldron, B. Egan, I.Z. Khan Department of Surgery Mayo General Hospital Castlebar
Antibiotic prophylaxis and extracorporeal shock wave lithotripsy (ESWL) G. Hann, F. Abogunrin, M. Young Department of Urology, Craigavon Area Hospital, Northern Ireland
A study of histopathological findings in appendectomy specimens in Kerry General Hospital P.G. Nicholas, L. Selvarajah, K.C. Ng, K. Feely, T. McCormack Department of Surgery, Kerry General Hospital
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
The role of the surgical oncologist in managing soft tissue sarcoma—a 10 year review of consecutive cases in a tertiary referral centre Z. Khan, C.A. Fleming, H.P. Redmond Department of General Surgery, Cork University Hospital
Trends in service delivery and clinical practice in laparoscopic cholecystectomy H. Mohan, G. Kelliher, F. Keane, K. Mealy National Clinical Program in Surgery, RCSI
Feasibility and safety of laparoscopy in the surgical management of small bowel obstruction—a single surgeon experience S.M. Abd Elwahab, M. Majeed, P.S. Waters, E.J. Andrews Department of Surgery, Cork University Hospital
Implementing a care bundle to reduce the incidence of surgical site infections in breast surgery A. O’Mahony, M.P. Murphy, M.J. Kerin, K.J. Sweeney, R. McLaughlin, C. Malone Department of Surgery, University Hospital Galway
Emergency admissions for acute diverticulitis; burden of disease in a tertiary referral centre G. Crozier Shaw, C. Cheung, D. Collins, P. Neary, D. Kavanagh Department of Colorectal Surgery, AMNCH (Tallaght) Hospital, Tallaght
Aspirin significantly impacts on prediction of blood usage post operatively in cardiac surgery N. Mayooran, M. Tarazi, P. Mohanarajah, O. Olakunle, B. Philip, M.N. Anjum, M. Anwer, K. Doddakula Cardiothoracic Surgery, Cork University Hospital
VATS versus thoracotomy in management of stage iii empyema—a retrospective audit P. Mohanarajah, N. Mayooran, M. Tarazi, B. Philip, M.N. Anjum, M. Anwer, K. Doddakula Cardiothoracic Surgery, Cork University Hospital
Surgical repair of congenital aorto-atrial fistula: a rare case with an unusual presentation N. Mayooran, M. Tarazi, P. Mohanarajah, B. Philip, M. Anwer, M.N. Anjum, K. Doddakula Cardiothoracic Surgery, Cork University Hospital
Patients age ‘‘a major factor in the pain threshold post VATS procedures’’ M. Tarazi, N. Mayooran, P. Mohanarajah, O. Olakunle, B. Philip, M.N. Anjum, M. Anwer, K. Doddakula Cardiothoracic Surgery, Cork University Hospital
Transition to day case laparoscopic cholecystectomy in an Irish hospital: review of outcomes E. O’Malley, B. Moloney, C. Collins Portiuncula Hospital Ballinasloe, Co Galway
Laparoscopic cholecystectomy as a day case procedure: a review of outcomes E. O’Malley, B. Moloney, C. Collins Portiuncula Hospital Ballinasloe, Co Galway
Patient satisfaction assessment following day case nasal surgery E. O’Reilly, T. Subramaniam, B. Conlon, J. Kinsella Department of Otolaryngology, Head and Neck Surgery, St James Hospital, Dublin
Open cholecystectomy: declining experience, a cause for concern? T.P. Burke, P.S. Waters, R.M. Waldron, K. Joyce, I. Khan, W. Khan, K. Barry Department of Surgery, Mayo General Hospital
The skin sparing mastectomy: optimising reconstructive outcomes by applying the three-step principle of breast analysis K. Ringrose, R.T. Dolan, P.N. Blondeel, C.M. Morrison Department of Plastic and Reconstructive Surgery, St Vincent’s University Hospital, Dublin and University Hospital Gent, Belgium
Simulation-based deliberate practice improves performance in laparoscopic skills in novice surgeons G. Browne, D. O’Connor, T.P. McVeigh, P. O’Connor, M.J. Kerin, D. Byrne School of Medicine, National University of Ireland Galway
The long road? Restructuring a national trauma service H.M. Mohan, D. Mullan, F. McDermott, R.J. Whelan, C. O’Donnell, D.C. Winter Department of Surgery, St Vincent’s University Hospital
Ultrasound abdomen and pelvis for right iliac fossa pain; misuse of resources? A. Galbraith, A.C. Rogers, L. Loughlin, K.S. Cross, C. O’Riordan, M. Farrell, F.P, Pretorius, M.P. McMonagle Department of Surgery, University Hospital Waterford
Post-prandial hypoglycaemia complicating oesophagectomy: the role of preoperative obesity and pancreatic beta cell hypertrophy P.N. Stassen, J.A. Elliott, J. Gibney, C.W. Le Roux, J.V. Reynolds Department of Surgery, Trinity Centre for Health Sciences, Trinity College & St. James’s Hospital, Dublin
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
Systematic review of video-assisted parathyroidectomy for primary hyperparathyroidism compared to open parathyroidectomy techniques S.M. Abd Elwahab, A.J. Lowery, K. O’Brien, P.H. Redmond Cork University Hospital, Univeristy College Hospital Galway and RCSI
Variations in breast screening in BRCA/high risk mutation carriers in a dedicated breast centre L.M. Houlihan, N.M. Foley, M. Jinih, Z. Khan, A. Khan, N. Relihan, H.P.R. Redmond Department of Surgery, Cork University Hospital
Acute appendicitis—efficacy of clinical diagnosis and financial implications of ‘over-investigation’ Inder Shakeel, Umair Muhammad, Khalid Haroon, Awan Faisal, Elfaedy Osama, Balfe Paul, Pretorius Fredrick Department of Surgery, St Luke’s Hospital, Kilkenny
Explant of aortic stent grafts following endovascular aneurysm repair M. Lynch, D. McGuire, S.M. McHugh, Z. Ahmed, A. El-Mallah, A. Amin, N. Hamada, M.P. Colgan, S. O’Neill, A. O’Callaghan, Z. Martin, P. Madhavan Department of Vascular Surgery, St James Hospital, Dublin
Evolving changes in the operative management of cholangiocarcinoma in a national centre M. Sheehan, N.J. O’Farrell, N. Saeed, A. Cooney, N. Swan, O. Traynor, J. Geoghegan, D. Maguire, E. Hoti Liver Transplant Unit, St Vincent’s University Hospital
Prophylactic minimally invasive gastrectomy in hereditary diffuse gastric cancer: a case series report B.C. Murphy, T.J. Murphy Department of Oesophago-Gastric Surgery, Mercy University Hospital, Cork
Enhanced experiential learning and improved surgical patient safety through the application of NFC technology E.O. Connell, J. Pegler, E. Lehane, N. McCarthy, L. Sahm, S. Tabirca, A.O. Driscoll, M. Corrigan. Cork Breast Research Centre, Department of Surgery, Cork University Hospital
The conservative management of acute appendicitis: a national perspective M.E. Kelly, A. Khan, W. Khan, K. Barry, R. Waldron, I.Z. Khan Department of Surgery Mayo General Hospital Castlebar
Introduction of a weekend surgical handover for surgical patients: the complete audit cycle J.P. Gibbons, E. Nugent, S. Tierney, D. Kavanagh Department of Surgery, Tallaght Hospital
Laparoscopic cholecystectomy, a safe treatment for acute cholecystitis in secondary care hospital Y. Bashir, N. Cliodhnna, Q. UlAin, A. Rayis, S.M. Johnston, D. Hehir Surgical Department Midlands Regional Hospital Tullamore
Loupe magnification for skin lesion excision: a prospective comparative analysis D. Duggan, K.M. Joyce, J.J. Dorairaj, J.L. Kelly Department of Plastic and Reconstructive Surgery, Galway University Hospital
Implementation of a care bundle for surgical site infection—a single centre experience D.O. Connor, A.O. Mahony, S. Abd El Wahab, K.J. Sweeney Department of Surgery, University College Hospital, Galway
Comparison between laparoscopic partial and radical nephrectomy for renal tumors: health-related quality of life L.C. McLoughlin, C. O’Sullivan, N. Kelly, H. Flood, S. Giri Department of Urology, University Hospital Limerick
Effect of supervised and non-supervised recovery modalities on physiological parameters and mood state following high intensity combat/karate training Brendan Moran National University of Ireland, Galway
A bibliometric analysis of the literature on the use of medical apps D. O’Connor, S.M. Abd Elwahab, K.J. Sweeney. Department of General and Breast Surgery, University College Hospital Galway
Homemade portable laparoscopic trainer: a trainee’s cost-effective model to counteract curtailed training time in the era of European working time directive A. Aslam, G.J. Nason, S.K. Giri Department of Urology, University Hospital Limerick
Prime location for pressure sensor reading in the abdominal aortic aneurysm sac B. Lynch, T.M. McGloughlin, E.G. Kavanagh, J. Nelson Centre for Applied Biomedical Engineering Research (CABER)
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
Ego depletion in surgical trainees M. McCumiskey, D. Dorris, F. Doyle, D. Walsh, E. Doherty, J.C. Coffey University Hospital Limerick, Limerick, RCSI, University College Cork and Graduate Entry Medical School, University of Limerick
Serum C-reactive protein as a predictor of anastomotic leak in the first week after anterior resection for rectal cancer I. Reynolds, F. Reilly, A. Deasy, M.H. Majeed, J.P. Burke, J. Deasy, D.A. McNamara Department of Colorectal Surgery, Beaumont Hospital
ENT Head and Neck Oral Poster Session 1.
Detecting Internet search trends for mouth cancer since the introduction of mouth cancer awareness day in the Republic of Ireland G. Murray, C. O’Rourke, J. Hogan, J. Fenton Graduate Entry Medical School, University of Limerick, Department of Otolaryngology, University Hospital Limerick
The publication of biomedical meeting abstracts in high-impact otolaryngology journals L. Kieswetter, C. O’Rourke, J. Fenton Department of Otorhinolaryngology, University Hospital Limerick
Reporting of institutional review board approval and informed consent in American otolaryngology journals F. Murray, C. O’Rourke, J. Fenton Graduate Entry Medical School, University of Limerick. Department of Otolaryngology/Head and Neck Surgery, University Hospital Limerick
To examine what percentage of patients referred to centre for tongue tie release were referred for breastfeeding difficulties and how many of them stopped breastfeeding as a result C. Nolan, P. Corry, C. O’Rourke, J.E. Fenton University of Limerick
Audit of GP referrals for tonsillectomy to the ENT clinic using present HIQA guidelines I. O’Riordan, W. Hasan, E. Keane, J. Kinsella, D. McShane Otolaryngology, Head and Neck Surgery Department, Tallaght Hospital, Dublin
Ultrasonographic characteristics of thyroid nodules and prediction of malignancy. a review of 800 US guided FNAS C. Brophy, J. Stewart, J. McCarthy, S. Blake, M.S. Murphy, P. Sheahan Department of Otolaryngology, Head and Neck Surgery, South Infirmary Victoria University Hospital, Cork
Thyroid cancer in Ireland: a ten-year review of the National Cancer Registry P. Lennon, S. Deady, M.L. Healy, J. Kinsella, C.I. Timon, J.P. O’ Neill St James Hospital Dublin, National Cancer Registry Ireland and RCSI
Medullary thyroid cancer: outcomes and prognostic indicators within the Irish population P. Lennon, S. Deady, M.L. Healy, J. Kinsella, C.I. Timon, J.P. O’ Neill St James Hospital Dublin, National Cancer Registry Ireland and RCSI
Infectious mononucleosis: frequently asked questions P. Lennon, M. Crotty, J.E. Fenton University Hospital Limerick and General Practice, Edmonton, Albert
A preliminary study of the intracranial multilayer flow modulator and its ability to occlude cerebral aneurysms S. Sultan, E.P. Kavanagh, A. Alves, I Wanke, D. Ruefenacht, N. Hynes Western Vascular Institute, Department of Vascular and Endovascular Surgery, University College Hospital Galway, NAMSA, Chassesur-Rhoˆne, France, University Hospital Essen, Germany and Clinic Hirslanden, Zurich, Switzerland
Anaesthesia Poster Session 11.
Does the aging process have an effect on patients’ concerns and expectations in relation to chronic pain? M. Mc Loughlin, A. Imran, D. Harmon Department of Pain Medicine, University Hospital Limerick
Preoperative anaemia in the elective orthopaedic surgical patient in University Hospital Limerick J.O. Connor, D, Harmon Department of Anaesthesia, Limerick University Hospital
Perioperative management of patients with opioid tolerance H. Misran, C. Trebuain, W. O’Brien, D. Harmon Department of Anaesthesia, University Hospital Limerick
Continuous central venous oxygen saturation assisted intraoperative hemodynamic management during major abdominal surgery may improve outcome A. Mikor, D. Tra´sy, M.F. Ne´meth, S.Z. Kocsi, A. Osztroluczki, I. Kova´cs, G. Demeter, Z.S. Molna´r Department of Anaesthesiology and Intensive Therapy, University of Szeged, Hungary
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 15.
A survey of chronic pain patients’ experiences in the emergency department G. Fitzpatrick, S.O. Chonghaile, D. Harmon Beaumont Emergency Department and Department of Anaesthesia, University Hospital Limerick
Epidural block assessment in an obstetric setting D. Burns, J. Shannon. Department of Anaesthesia, University Hospital Limerick
Orthopaedic Poster Session 17.
Internal immobilisation versus external immobilisation for primary anterior shoulder dislocations—a systematic review and meta analysis I. Feeley, G. Rattan, J. Lunn, E. Sheehan Midland Regional Hospital, Tullamore and University of Limerick
Knee flexion as a means to reduce blood loss post total knee arthroplasty S. Sasikumar, I. Feeley, D. Niall University of Limerick and Midland Regional Hospital, Tullamore
A systematic review assessing surgical versus conservative management of the true jones fracture J.A. Yates, G. Rattan, S. Sasikumar, I. Feeley Department of Surgery, Midlands Regional Hospital Tullamore
Factors contributing to patients’ non-attendance at orthopaedic and bone health clinics post hip fractures P.N. Stassen, F. Coughlan, J. Mahon, N. Maher, M. Casey, J.B. Walsh, R. Lannon, K. McCarroll, Department of Surgery, Trinity Centre for Health Sciences and St. James’s Hospital Health Sciences
Systematic review of complications in spinal surgery: a comparison of retrospective and prospective study design C.L. Power, S. Henari, J. Street, B. Lenehana University of Limerick Graduate Entry Medical School and University Hospital Limerick, Department of Surgery, CNOSP Vancouver General Hospital, University of British Columbia
Christmas tree related lower limb trauma—a festive case series of serious lower limb fractures P.M. McQuail, J.F. Baker, S. O’Flanagan, P. Keogh, P. Kenny Department of Trauma and Orthopaedics, James Connolly Memorial Hospital
Diathermy awareness among surgeons—adequate or inadequate? P.M. McQuail, J.F. Baker, P. Kenny Department of Trauma and Orthopaedics, Connolly Hospital Blanchardstown
Is there an association between patella spurs and quadriceps tendon ruptures? N. Svirkov-Vainberg, P. Ellanti, A.R. Moriarity, Ni Fhoghlu, T. McCarthy Department of Trauma and Orthopaedics, St. James’s Hospital
Upper limb surgeons—so you think you’re funny! A study of nominative determinism in orthopaedics P.M. McQuail, J.C. Kelly, K. O’Shea Department of Trauma and Orthopaedics, St. Vincent’s University Hospital
A case report of a bosworth fracture-dislocation ankle injury G.A. Kelly, D.I. Morrissey, M.E. O’Sullivan, S.R. Kearns Department of Orthopaedic Surgery, University College Hospital Galway
A case study of three abscesses of iliopsoas: variety in etiology, presentation and organisms G. Crozier Shaw, P. Magill Department of Orthopaedic Surgery, AMNCH (Tallaght) Hospital
The impact of ‘scoliosis awareness month’ on Internet activity-hit or miss? P.M. McQuail, A. Canas-Martinez, J.C. Kelly, D. Moore, P. Kiely Department of Trauma and Orthopaedics, Our Lady’s Children’s Hospital, Crumlin
What Dr. Youtube teaches patients about osteoporosis. does it help or hinder? J.T. Cassidy, J.F. Baker, Department of Orthopaedics, The Adelaide and Meath Hospital and Galway University Hospital
Assessment of the quality and content of information on lumbar disc herniation on the Internet G.A. Kelly, J.F. Baker Department of Orthopaedic Surgery, University College Hospital Galway
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 DOI 10.1007/s11845-015-1259-8
1. Bleeding submucosal oesophageal lesion in a pregnant female: a case report B. Murphy, A. Coveney, T. Murphy Department of Oesophago-Gastric Surgery, Mercy University Hospital, Cork The vast majority of primary oesophageal lesions are malignant, with benign pathology accounting for 2 % of all oesophageal tumours. Of these benign lesions, oesophageal leiomyomas account for greater than 80 %. Schwannomas are rare, benign nerve sheath tumours composed of schwann cells, comprising less than 0.2 % of primary oesophageal tumours. We present the case of a 37-year-old lady of Chinese origin with a background of idiopathic thrombocytopenia purpura who attended hospital at 29 weeks gestation with an unstable GI bleed and large volume haematemesis. She required an intravenous immunoglobulin G infusion to elevate her platelet count and massive blood transfusion of 15 units. The patient subsequently underwent an emergency Caesarean Section. CT Thorax Abdomen Pelvis showed a large right para-oesophageal mass compressing the upper and middle oesophagus. Oesophagogastroscopy was performed, demonstrating a bleeding 9 9 5 9 3 polypoid, submucosal lesion, differentials for which included a gastrointestinal stromal tumour, leiomyoma and schwannoma. Due to persistent haemorrhage, the patient underwent an emergency minimally invasive oesophagectomy with primary anastomosis and feeding jejunostomy placement. Histology results revealed spindle-shaped cells arranged in a fascicular manner with nuclear palisading. Immunohistochemistry studies tested positive for S100 protein, consistent with a diagnosis of an oesophageal schwannoma. Her post-operative stay was uncomplicated with the exception of some persistent basal atelectasis. She was discharged home well day 16 post-op.
2. Admitting and discharging diagnosis—how good are we? P.N. Stassen, M. Butler, I. Callanan Department of Clinical Audit, Medicine and Surgery, SVUH, Dublin Background: This audit was carried out to study the concordance of diagnosis on admittance to diagnosis on discharge from SVUH Dublin. Methods: This is a baseline audit, with no pre-existing standards published. It uses as its foundation, a paper by Elizabeth McGlynn (The Quality of Care delivered to Adults in the United States, NEJM 2003) that highlighted that 54 % of admissions get the recommended acute care across different disease / conditions. Results: Sample number n = 70. No. of cases with concordance of diagnosis on admittance to diagnosis on discharge = 49 No. of cases with disconcordance of diagnosis on admittance to diagnosis on discharge = 2 No. of cases with a degree of concordance of diagnosis on admittance to diagnosis on discharge = 15 No. of cases with concordance of diagnosis on admittance to diagnosis on discharge on the second booking of the patient, but disconcordance on the initial booking = 3 No. of cases with no diagnosis on admittance documented in charts = 1
Conclusion: 70 % of SVUH admissions receive the recommended acute care based on an accurate working differential diagnosis being made when the patient is booked into the system. This is higher than the 54 % result from Elizabeth McGlynn paper. There was only one case where a working differential was not documented. There were 6 cases included in the concordance (70 %) statistic above that may not be allowable as the working differential diagnosis was given by a pre-admittance ECG investigation. The 720-77 Discharge note and Discharge letter were not present in 100 % of cases. Our recommendations include: senior doctor should ensure a working differential diagnosis has been made when reviewing initial booking of patient. If it is absent, that doctor should make one and document it. A checklist in the charts should make a record that both a 720-77 Discharge note and Discharge letter are present.
3. Is catheter directed thrombolysis without thoracic outlet decompression sufficient to manage upper limb effort deep vein thrombosis? A single centre vascular surgery unit experience A. Kiernan, I. Robertson, D. Brophy, C. Cantwell, J. McCann, D. Mehigan, S. Sheehan, J. Dowdall, M.C. Barry Department of Vascular Surgery and Interventional Radiology, St. Vincent’s University Hospital Upper limb effort deep venous thrombosis (DVT) is rare. There is little consensus on the most appropriate management, specifically regarding the need for thoracic outlet decompression following initial thrombolysis and anti-coagulation. Our aim is to evaluate the management of upper limb effort DVT and compare our experience to international practice. We retrospectively reviewed patients presenting from 2006–2014. Patient demographics, likely precipitants and procedures were included. Outcomes were assessed using follow up outpatient notes. Eleven patients underwent intervention. Median age was 26; female to male ratio was 6:5. Mean duration of symptoms prior to intervention was 10.2 days. Likely precipitants included repetitive upper limb movement caused by weight training (n = 2), sporting activity (n = 3), occupation (n = 5), other (n = 1). Diagnosis and decision to thrombolyse was made using duplex ultrasound (n = 8), CT venogram (n = 8). Procedures included thrombolysis with tissue plasminogen activator (tPA) (n = 11), venoplasty (n = 7). Results included complete dissolution of thrombus (n = 10) and incomplete (n = 1) secondary to an organised clot. There were no complications noted. All patients were anti-coagulated with warfarin for minimum of 6 months. No patient underwent thoracic outlet decompression. One patient re-presented within 6 months with recurrent DVT but was found to have had sub-therapeutic INR. The remaining 10 patients have remained asymptomatic to date with a mean follow up of 59 months. Patients presenting with upper limb effort DVT can be safely and effectively managed with initial thrombolysis followed by anticoagulation for 6 months. Our experience suggests that surgical thoracic outlet decompression may not be necessary in the management of these patients.
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
4. Peptic ulcer disease in the era of proton pump inhibitors—a population analysis
S149 Conclusion: The NEWS system appears to positively impact patient care. There is a need to reinforce the use of the system to ensure it is being properly used by all members of the clinical care team.
S. Chalasani, A.C. Rogers, D.C. Winter Department of Surgery, St Vincent’s University Hospital Peptic ulcer disease (PUD) is a cause for significant mortality and morbidity. There is a substantial reduction in surgical interventions for uncomplicated PUD since the discovery of proton pump inhibitors (PPIs) and triple therapy for Helicobacter pylori eradication. Despite this the management of PUD and its complications continues to be a challenge. We evaluated national outpatient PPI prescribing data and population-based trends for patients with perforated PUD admitted to hospitals in Ireland from 1995 to 2010. This population-based retrospective cohort study was conducted using the Hospital In-Patient Enquiry (HIPE) database and the Primary Care Reimbursement Service (PCRS) database. A total of 4,332 patients were admitted in Ireland with perforated PUD over the time period, of which 83 % were localised to the duodenum. The age-adjusted incidence of perforated duodenal ulcers significantly decreased from 103.9 to 62.6 per 1,000,000 population, while the incidence of perforated gastric ulcers remained the same over the time period. This coincides with a massive increase in outpatient PPI prescribing, with just €8.6 million spent in 1995 and over €100 million spent in 2010. Over 80 % of patients were treated operatively and the death rates in this cohort did not change over the time period, despite increased use of preoperative CT and laparoscopic surgery. With the widespread introduction of PPI prescribing, the incidence of perforated duodenal ulcer has decreased, however operative mortality rates have not improved despite the widespread availability of computed tomography and laparoscopy.
5. Attitudes of clinical staff to the national early warning score system M.F. Duignan, P. O’Connor, G. Offiah, S. Lydon, D. Byrne West Northwest Intern Network, Galway University Hopsitals, Beaumont Hospital & Trinity College, Dublin Introduction: Track-and-trigger warning systems (TTs) are used to aid the early identification of patients at risk of deterioration. TTs use periodic observation of selected basic vital signs (‘‘tracking’’) with predetermined criteria (‘‘trigger’’) for requesting clinical review. In Ireland a TTs called the National Early Warning Score System (NEWS) was introduced in 2012. TTs can positively impact patient outcomes, but are often improperly implemented. Aim: The aim of this study was to examine the attitudes of clinical staff to the NEWS system and identify potential barriers to its use. Methods: Thirty semi-structured interviews were performed with 18 interns, 2 non-consultant hospital doctors, and 10 nurses using the theory of planned behaviour as a framework. Based upon the interviews, a 30-item questionnaire was designed and distributed to clinical staff in two large Irish teaching hospitals. Results: Responses were obtained from 122 doctors and 90 nurses. The majority of respondents believed that NEWS was easy to use, and that it positively impacted on communication, patient safety, and quality of care. Negative comments included: restrictive ‘‘normal’’ range of parameters, and failure of the medical team to reset the parameters during working hours. It was suggested that the NEWS system can negatively impact clinical judgement and flexibility, and can be a source of friction between nurses and interns.
6. A prospective analysis of thyroidectomy outcomes in a resource limited setting N.O. Donohoe, J. Bolger, R. Kintu-Luwaga, J. Odubu Fualal Mulago hospital, Kampala, Uganda Background: This study aimed to document thyroidectomy outcomes in the surgical endocrine unit, Mulago Hospital, Kampala, Uganda. The burden of global surgical disease is currently receiving much attention, especially in countries experiencing epidemiological transition. There is a paucity of publications on surgical outcomes from Sub-Saharan Africa. International thyroid guidelines from high income countries do not factor in the logistical challenges or the advanced pathology faced by the surgeon in resource limited settings. Methods: This was a prospective cohort study in 2013. Eight peri-operative variables of poor outcome were analysed statistically against six outcomes variables. Data was collected from 0–6 months post operatively. Results: 42 thyroidectomies were performed over a 3 month period (female = 38). Intraoperative events recorded included rebleeding = 10 %, infection = 0 %, transient voice symptoms = 30 %, transient hypocalcaemia = 12.5 %, recurrent laryngeal nerve (RLN) paralysis = 7.5 %, permanent hypocalcaemia = 15 %. There was a weak powered association between RLN paralysis and total thyroidectomy and smaller thyroid size. There were associations between large thyroid size and both permanent hypocalcaemia and rebleeding. Younger patients showed statistically more transient voice changes compared to older patients. Older patients were statistically more likely to develop rebleeding. Shorter operative duration was associated with transient voice change, permanent hypocalcaemia and rebleeding. Airway difficulties and transient hypocalcaemia were statistically significant in prolonged procedures. Conclusions: Whilst the thyroidectomy outcomes are not equal to international standards, an acceptable standard is achievable in this resource limited setting. Poor outcomes are multifactorial but extremes of thyroid size, extremes of operation duration and total thyroidectomies all have statistically poorer outcomes in this setting.
7. A 5 year systematic review of published surgical research from nine east African countries N.O. Donohoe, J. Reilly, P. Sweeney, A. Khan, S. Tierney The RCSI-COSECSA Collaboration programme Aim: The study aim was the quantitative and qualitative analysis of published surgical research from the nine countries that form the College of Surgeons South, East, Central and Southern Africa (COSECSA). Health research plays a pivotal role in addressing health inequities. Currently 90 % of the global disease burden, produces only 10 % of the global research.1 Method: A PubMed search was undertaken from September 2008– September 2014 using the relevant country name and the word ‘Surgery’. Search results were then individually audited by country, surgical specialty, study title, journal name, journal impact factor,
The 10/90 report on Health Research, The Global Research Forum 2000 Annual Report.
S150 senior author’s country of origin, associated African institution and type of study design. Results: There were 552 research papers published in 189 Journals. 49 % had non-African senior authors. 45 % came from 7 institutions. 50 % were published in journals with no impact factors. The study also looked at the current World Bank data on Total Health Expenditure (THE) per capita2 for each country. These figures were divided into the research papers per country to give a ratio (Table 1). This ratio allowed comparison against Ireland, whilst reducing economic disparity as confounder. Conclusion: Despite good efforts, particularly in Ethiopia, Kenya, Malawi, Tanzania and Uganda, East African research remains undeveloped, under resourced and too reliant on non-African researchers.
8. The accuracy of urgent pre-operative imaging in correctly pinpointing the right pathology in patients undergoing emergency abdominal surgery at a busy acute surgical unit O.S. Mansour, M. O’Sullivan, A. Rutledge, E. Condon Department of Colorectal Surgery, University Hospital Limerick Aim: To establish the accuracy of emergency imaging in diagnosing acute abdominal emergencies requiring surgery. To establish a relationship between radiological findings and the rate of positive/negative operative findings and the final diagnoses in patients undergoing emergency surgery. Methods: A retrospective analysis was performed on a consecutive series of acute abdominal emergencies requiring surgery in University Hospital Limerick over the period of 1 year from October 1st 2013 to October 1st 2014. Data was collected regarding: age; pre operative blood test: CRP, WCC, ESR; time of day of the procedure; type of surgery: laparoscopy versus laparotomy; radiological findings and histopathology reports. Results: This study is currently ongoing but primitive results suggest that radiological findings do not correspond with operative findings in the majority of cases. Conclusions: Our study will highlight the correlation between radiological and operative findings.
9. A comprehensive analysis of colorectal cancer staging and their demographic distribution at a specialist colorectal unit O.S. Mansour, E. McNamara, M. O’Sullivan, D. Kearney, C. Coffey Department of Colorectal Surgery, University Hospital Limerick Aim: To stratify the distribution of colorectal cancers, identify the percentage of different stages, quantify average number of LN’s obtained, and study tumours from screening programme. Methods: A retrospective analysis was performed on colorectal cancers at the Department of Surgery in UHL over 12 month period. Results: N = 174 cases of colorectal cancer diagnosed in last 12 months: 118 males (67.8 %), 56 females (32.2 %). Mean age 68.4 years. N = 12 cancers through screening. Locations: 115 left sided (66 %): 48 rectal (27.6 %), 35 sigmoid (20.2 %), 32 descending (18.4 %); 10 transverse (5.7 %), 45 right (25.9 %) (9 hepatic flexure and 7 caecal), 2 appendiceal (1.1 %), 2 gynaecological (1.1 %). N = 154 had surgery, 11 emergency (6.31 %): (7 stomas, 4 Hartmann’s); 5 unfit for surgery (2.87 %), 15 are awaiting surgery (8.6 %). Histopathology: 46 2
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 poor-Diff (29.9 %), 63 mod-Diff (40.9 %), 32 mod/Poor-Diff (20.8 %), 7 well differentiated (4.45 %), 1 LG mucinous (0.60 %) 1 GIST (60 %). Screening: (n = 12, 6.9 %): 9 Mod-Diff (75 %), 3 poorly differentiated (25 %). Mean number LN’s: 14.8. Mean positive: 1.5 LN. CRM positive in 2 cases. Pathology staging: 4 stage 0 (2.5 %), 25 stage 1 (16.2 %), 40 Stage 2 (26 %), 57 stage 3 (37 %), 11 stage 4 (6.1 %). Screening programme (n = 12): 2 had no cancers in specimen (16.7 %), 2 stage 3 (16.7 %), and 7 stage 1 (58 %). Conclusion: Distribution of colorectal cancer correlates with national and international data. Patients referred through screening had earlier stages (58 vs 16.2 % sage 1, respectively) despite worse differentiation (25 vs 21 % poorly differentiated, respectively).
10. Effect of concurrent thyroid pathology on surgical intervention for primary hyperparathyroidism M.C. Casey, T.P. McVeigh, J.A.L. Brown, A.J. Lowery, D.S. Quill, M.J. Kerin Discipline of Surgery, Galway University Hospital Minimally invasive parathyroidectomy (MIP) is the gold standard treatment of hyperparathyroidism in cases of single-gland disease with adequate pre-operative localization. The presence of concomitant thyroid pathology can negatively impact the accuracy of preoperative imaging, thus limiting feasibility of MIP in these patients. The aim of this study was to evaluate the effect of concomitant thyroid pathology on the pre-operative workup for primary hyperparathyroidism and the impact on surgical approach. A retrospective cohort analysis of patients undergoing surgical intervention for parathyroid disease in our centre from 1999 to June 2014 was conducted. Of 429 parathyroidectomies performed on 424 patients during this period, coexisting thyroid pathology was identified in 61 patients, comprising multinodular goitre (35), thyroiditis (15), solitary nodules (8), papillary carcinoma (2) and cysts (1). In these patients, the sensitivity of pre-operative imaging for localization of parathyroid pathology was considerably lower than in patients without concurrent thyroid disease; ultrasonography 56 vs 63 %, sestamibi scintigraphy 49 vs 60 % and CT 29 vs 49 %. While singlegland parathyroid adenoma was present in 85 % of patients, parathyroidectomy was conducted in conjunction with thyroidectomy in 29 patients, via MIP in 20 patients with open/four-gland exploration in 12 patients. Of these 12 open procedures, 10 patients had singlegland parathyroid adenoma. Intra-operative PTH monitoring was employed in 31 procedures, radioguidance in 8 and video-assistance once. During follow-up of median 84 months, no patient experienced recurrent hypercalcaemia, or required re-intervention. Concurrent thyroid pathology reduces sensitivity of pre-operative localization in hyperparathyroidism resulting in higher rates of open parathyroidectomy in single-gland disease. Despite this, operative success can be achieved with intra-operative adjuncts and the appropriate surgical approach.
11. Evolution of trends in breast reconstruction in a single institution N. O’ Halloran, A.J. Lowery, M.J. Kerin Department of Surgery, Galway University Hospital Breast reconstruction is an important component of multidisciplinary breast care, affording clearly defined psychosocial and aesthetic
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 benefits to women undergoing mastectomy. Evolving practice has resulted in an increasing range of reconstructive options available to breast cancer patients. The aim of this study was to examine the practice of breast reconstruction over the last decade at a specialist tertiary referral Breast Cancer Centre. A prospectively maintained breast cancer database reviewed to collate data on all patients who underwent breast reconstruction between 2004 and 2014. Data on patient demographics mastectomies, reconstructive timing and method were analysed. 546 (56.28 %) of 970 patients who underwent mastectomy had a breast reconstruction. 90.5 % of breast reconstructions were immediate. There was a marked increase in breast reconstruction rates from 13 (17.57 %) in 2004 to 68 (46 %) in 2013. 19.57 % of reconstructions were performed by plastic surgeons and 80.43 % by oncoplastic surgeons. Reconstructive techniques included: Implant (28 %), LD (62 %) DIEP (7 %), TRAM (3 %). There has been an increase in the % of implant based reconstructions in recent years, compared to LD flaps, which comprised 88 % of reconstructions performed in the first 5 years of the series compared to only 41 % in the latter 5 years. The age of patients undergoing reconstruction ranged from 21 to 86 years, however the mean age of patients undergoing mastectomy and reconstruction (46.64 years) was significantly lower than mastectomy alone (62.99 years). In conclusion breast reconstruction rates are increasing with a transition of recent trends toward immediate implant-based reconstruction.
12. Assessing the surgical outpatient—‘‘the patient’s perspective’’ C. Broderick, A. Courtney, M.E. Kelly, I.Z. Khan Department of Surgery Mayo General Hospital Little data is available assessing patient’s level of comprehension prior to attending surgical outpatient clinics (OPD). Additionally, the impact of patient research including usage of alternative information sources (internet) is poorly appreciated. A prospective analysis via questionnaire of patients attending the surgical OPD was performed over a 6-week period. The primary objective was to evaluate the extent of information desired, where it was sourced and whether a dedicated hospital information site would be desirable. In addition the option of online Skype consultation was appraised. 110 new patients presenting to the surgical OPD participated in this survey. 60 % were female (n = 66), and 48.1 % (n = 53) were 50 years or older. Interestingly, though 50 % of patients use the Internet on a daily basis, only 16 % investigated their illness online prior to attendance. Despite this, over half (55 %) expressed a substantial interest in the availability of a dedicated hospital website that provide information relating to common surgical conditions and their treatment. Moreover, the overwhelmingly majority stated that they explicating avoided online searches due to concerns that information may mislead them and cause undue distress. One quarter of patients also expressed an interest in the possibility of a Skype consultation to save time and reduce inconvenience. However, the majority of these patients were younger, more technology savvy with minor surgical complaints. Empowerment of patients with good quality data improves understanding and compliance. A considerable amount of current online material is misleading. Physicians therefore should take the lead in providing good quality medical information via a multimodal approach.
13. Venous thromboembolism in patients with gastrooesophageal cancer treated with curative intent: a tertiary referral centre 14 year experience E.M. O’Connor, S. Croghan, J.V. Reynolds Department of Surgery, Trinity Centre and St James’s Hospital, Dublin Introduction: Although the association between venous thromboembolism (VTE) and gastrooesophageal malignancy is well recognized, few studies are available regarding the prevalence, clinical characteristics and prognostic impact in gastrooesophageal cancer patients. This study audits a 14 year experience of VTE in relation to patients with gastrooesophageal cancer treated with curative intent, analysing changing patterns of care and clinical outcomes. Methods: All cases of VTE in patients with gastric, oesophageal and oesophagogastric junction cancer that were treated with curative intent in the 2000–2014 study period were collected retrospectively from a prospectively maintained database. Results: A total of 1,398 patients were identified as having been treated with radical curative intent for gastrooesophageal cancer during our study period 2000–2014. Of these, 32 patients (2.3 %, male:female ratio 1:1) were diagnosed with VTE, either 1 month prior to their cancer diagnosis (n = 1), during neoadjuvant treatment (n = 16), within 4 weeks of their cancer surgery (n = 13), or [1 month from surgery (n = 3). Patients were diagnosed with pulmonary embolism (PE, n = 19, 59 %), deep venous thrombosis (DVT, n = 11, 35 %) or both PE and DVT (n = 2, 6 %). 87.5 % (n = 28) of patients were symptomatic, with shortness of breath and chest pain being the predominant symptoms in those diagnosed with PE. All patients presenting with DVT had limb swelling documented. The majority of patients (n = 30, 94 %) were initially treated with low molecular weight heparin (LMWH) with subsequent treatment including warfarin and inferior vena cava filter insertion. Conclusion: VTE in gastrointestinal cancers remains a prevalent issue that can have significant implications for long term morbidity and mortality. Much information is yet to be elucidated with regard to optimum VTE prophylaxis and treatment, particularly in the growing era of novel chemotherapeutic and anticoagulant drugs.
14. Profile of acute surgical admissions over a three month period at St. Luke’s Hospital, Kilkenny Khalid Haroon, Umair Muhammad, Awan Faisal, Pretorius Fredrick, Elfaedy Osama, Balfe Paul Department of Surgery, St. Luke’s Hospital, Kilkenny Objectives: To profile and analyse acute surgical admissions over a 3 month period at St. Luke’s Hospital, Kilkenny. Method: Retrospective data over the period January 2014 to March 2014, were evaluated. Patients were stratified according to age, gender, final diagnosis, public/private status, length of stay, ICU admission, length of ICU stay and the final outcome. Descriptive analysis was performed and frequency distributions plotted. Results: There were 391 acute surgical admissions over the 3 month period, including 4 readmissions. 51.7 % were male. In terms of age profile, the largest patient group were between 40–49 years (14.3 %). 74.7 % of patients had a length of stay of 3 days or less. Head Injuries accounted for 12.8 % of acute admissions with Acute Appendicitis at 10.7 % and Acute Cholecystitis accounting for 7.4 %. 5.6 % were directly admitted to ICU.
S152 Conclusions: This study analyses the profile of surgical admissions at St. Luke’s Hospital, Kilkenny over a 3 month period and helps in the planning and optomisation of scarce hospital resources.
15. Clinical and histopathological appraisal of negative appendectomies: one year retrospective single centre study with 2 year follow up Charandeep Singh, Rishabh Sehgal, Faisal Awan, Osama El-Faedy, Frederik Pretorius, Leonardo Silvio-Estaba, Paul Balfe Department of Surgery, St. Luke’s Hospital, Kilkenny Introduction: Despite laboratory, radiological and various scoring systems, the diagnosis of appendicitis can be elusive. The aim of this study was to determine the rate of histopathological negative appendicitis and to interrogate factors affecting diagnosis and outcome. Methods: All appendectomies performed on patients [7 years were retrospectively studied between January-December 2012 in St. Luke’s Hospital, Kilkenny. Paper and electronic charts were interrogated to gather demographic and histopathological data including age, gender, presenting complaints, laboratory, radiologic, and histological reports. The rate of histological negative appendectomy rate was determined and followed up by a telephone questionnaire. Results: 158 appendectomies were performed during the study period. The histopathological negative appendectomy rate was 8 % (N = 13). The majority of these patients were female (N = 11) and were operated during the index admission by a consultant surgeon. In patients who underwent pre-op ultrasound, the majority were reported normal (N = 4) or revealed free fluid in the pelvis (N = 3). Four patients were excluded from the telephone questionnaire. 92.3 % of patients reported resolution of their symptoms post operatively. External influencing patient factors included having had a close relative who had an appendicectomy in the past, having a relative working in healthcare, and being told of the diagnosis by an external medical practitioner prior to attending the emergency department. Conclusions: The diagnosis of appendicitis remains clinical in the majority of cases. Although there was complete resolution of symptoms in the majority of histological negative appendicectomy cohort, our data sheds light into several important subjective factors influencing the diagnosis and management of patients presenting with right iliac fossa pain.
16. Older women with triple negative breast cancer are less likely to get neoadjuvant chemotherapy N.M. Foley, C. Murphy, M. Jinih, Z. Khan, A. Khan, N. Relihan, H.P. Redmond Department of Surgery, Cork University Hospital Introduction: Triple negative breast cancer (TNBC) conveys a significant negative prognosis. These breast cancers affect women of all ages and tend to be aggressive, yet younger women are more likely to receive neoadjuvant chemotherapy. It is now recommended that all patients with TNBCs over 5 mm receive neoadjuvant chemotherapy. Methods: A prospective database of all breast cancers diagnosed in the Southern breast cancer centre has been maintained since 2010. We interrogated this database and isolated the triple negative tumours diagnosed between 2010 and 2014. The database was consolidated with the TNM stage of the tumour, the use of neoadjuvant therapies and survival status of the patients.
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 Results: 119 triple negative breast cancers have been diagnosed between 2010 and 2014 with an average age of 58 years (range 27–91). 55 % of our cohort are aged over 55, and 8 % of our cohort are aged over 80 years. 29 % (n = 35) of TNBCs have had or are receiving neoadjuvant chemotherapy [average age = 49 (range 27–77)]. 71.5 % of patients receiving neoadjuvant chemotherapy are aged under 55 years. Two of our patients are currently receiving metronomic chemotherapy. Conclusion: TNBC is a poor prognosticator in breast cancer. We are seeing a significantly increased incidence in older women. These patients present a therapeutic dilemma as comorbid conditions and ageism can limit the use of neoadjuvant chemotherapy. With the use of metronomic chemotherapy we may see increased utilisation of neoadjuvant chemotherapy in older patients.
17. Availability of accessible and high-quality information on the internet for patients undergoing laparoscopic cholecystectomy T.P. Burke, C. Fenelon, D. Dalton, H. Mohan, K. Schmidt Department of Surgery, Wexford General Hospital and Department of Trauma and Orthopaedics, St Vincent’s Hospital, Dublin Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstone disease and is one of the most commonly performed surgical procedures today. The internet provides a vast information source that patients can access. It is imperative that the information relating to the procedure, possible complications and likely postoperative course be accurate, relevant and understandable. We identified 125 websites from searching ‘‘laparoscopic cholecystectomy’’ in the 5 most popular internet search engines. The websites were examined for readability by measuring the Flesch Reading Ease Score, the Flesch-Kincaid Grade Level, and the Gunning Fog Index. The quality of the websites was measured by the DISCERN instrument , the Journal of the American Medical Association benchmark criteria , and Health on the Net Foundation certification. There were 50 individual URLs analyzed. Overall, the quality was poor, with the average DISCERN score being only 32.72 (0–80). Furthermore, the mean reading grade level was 9 (recommended level, 6). Health on the Net Foundation certification did correspond to significantly worse readability scores. Those that satisfied more of the Journal of the American Medical Association benchmark criteria had significantly better DISCERN scores (P \ 0.001). Information relating to the laparoscopic cholecystectomy procedure is of a low standard and is in many cases written at too high a level for the general population. There are instruments available to evaluate these online resources. We, as surgeons have a responsibility to recommend accurate patient centred online websites and thus ensure patients receive reliable information regarding their condition and treatment options.
18. Is patients understanding of sedation for gastroscopy adequate? A. Khan, M.E. Kelly, W. Khan, K. Barry, R. Waldron, I.Z. Khan Department of Surgery Mayo General Hospital Castlebar Sedation uptake rates for Oesophagogastroduodenoscopy (OGD) vary. Issues concerning adequate understanding prior to consenting have been raised. The aim of this study was to assess patient satisfaction and understanding relating to this decision process.
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 A prospective audit of patients undergoing OGD over an eightweek period was performed. All participating patients were contacted within 48-h post-procedure via phone-call to complete a survey. The survey included questions relating to patient demographics (age, gender), whether sedation was given, and their post-procedure satisfaction ratings. 111 patients were recruited, of which 61.2 % were female. 56.7 % of the participants chose sedation. Sedation was more popular among women, and the extremes of age. The majority (82.8 %) was satisfied with their decision. Interestingly, the largest discrepancy in understanding was relating to the level of consciousness with sedation. Only two-thirds were aware that receiving sedation does not put you to sleep, but has an amnesic quality. 81 % of patients knew that anesthetic spray was a viable alternative to sedation, while 25 % were cognizant that patients can now tolerate OGD without sedation. Only 63 % understood that when only anesthetic throat spray was used, that they could go home unaccompanied and 71 % knew that a delay of approximately 1 h is necessary before eating after local anesthetic spray administration. Patient understanding of sedation practices in endoscopy is suboptimal. Although those who opt to have sedation have a high postprocedure satisfaction rate, they lack basic understandings. This highlights the need for improved patient education prior to OGD to improve patient knowledge.
S153 National Centre for Cardiothoracic Surgery, Mater Misericordiae University Hospital, Dublin Body surface area (BSA) is used for cardiopulmonary bypass support (CPB) calculations in cardiac surgery and is considered a more accurate tool then body mass index (BMI) for predicting cardiac parameters. BMI is known to correlated with a number of postoperative complications. We evaluate whether BSA rather then BMI should be used as a predictor of post-operative morbidity and mortality. This is a retrospective study involving 4,962 patients undergoing cardiac surgery procedures involving cardiopulmonary bypass over 10 years in a single hospital. The data was extracted from a prospectively recorded electronic database and clinical follow-up from electronic patient hospital records. There was a U-shaped curve association with mortality using BMI. Low BMI was associated with the highest mortality. Surgical site infection and length of hospital stay were also associated with BMI. However assessment by BSA offered no improvement in predictive accuracy over BMI. Mortality and EuroSCORE was also tested to determine if addition of body size parameters would improve accuracy. However adding BMI or BSA to the EuroSCORE calculation did not improve the prediction of mortality. BMI is associated with a number of significant post operative outcomes. However, although BSA is considered superior for CPB operational calculations, BSA offers no predictive advantage over BMI for post-operative performance.
19. Segmental duodenal resection: indications, surgical techniques and postoperative outcomes B. Alhamdan, D. Dorcaratto MD PhD, H.M. Heneghan MD Phd, B. Fiore MD, F. Awan MD, D. Maguire MD, J. Geoghegan, K. Conlon MD PhD, E. Hoti MD St. Vincent’s University Hospital Dublin (Hepatobiliary Service) Introduction: Segmental duodenal resections (DR) have been increasingly performed for the treatment of primary duodenal tumors. The aim of the study is to review the indications for, clinical and operative details, and outcomes of patients undergoing elective DR. Materials and methods: We retrospectively reviewed all patients who underwent elective segmental DR for the treatment of primary duodenal tumors, at a single institution between January 2007 and December 2013. Demographic data, clinical presentation, preoperative investigations, operative details, postoperative complications/ mortality and histopathological results were recorded. Results: In the study period 11 duodenal resections were performed (7 male, median age 61 years). 36 % of the patients presented with anemia. Surgical resection included two or more segments in 7 patients. The most frequently resected part of the duodenum was segment 3 (n = 7). Median operative time was 191 min and blood loss was 675 ml. End-to-end and end-to-side anastomoses were performed in equal numbers. The pathology of resected specimens included adenocarcinoma (n = 4), GIST (n = 1), adenoma (n = 5) and lymphoma (n = 1). Median hospital stay was 14 days. Overall 30-day morbidity rate was 82 % (78 % Clavien 2 or less). Conclusions: Segmental duodenal resection is a safe and effective surgical technique for the resection of primary duodenal tumors.
20. Does body surface area predict post operative outcomes more accurately then body mass index in cardiac surgery? J. McLoughlin, R. Kelly, B. Hendrick, P. Keartland, D.G. Healy
21. Sedation and bowel preparation for colonoscopy in elderly: a nationwide survey in Ireland J. Rehman, M.E. Kelly, W. Khan, K. Barry, R. Waldron, B. Egan, I.Z. Khan Department of Surgery Mayo General Hospital Castlebar The practice of colonoscopy in elderly is not standardized in Europe. Recent European Society of Gastrointestinal Endoscopy (ESGE) guidelines are concerned primarily with safety aspects of the procedure in this age group. In view of this, a national survey of sedation and bowel preparation for colonoscopy in elderly was performed. A questionnaire was mailed to all consultant general surgeons and adult gastroenterologists. The practice of monitoring of elderly patients, sedation, and bowel preparation methods for colonoscopy were assessed. The endoscopists’ perceived barriers to optimal bowel preparation were also evaluated. The response rate was 48.5 % (99 endoscopists). The majority of colonoscopies in elderly patients (95 %) were carried out under sedation. The most frequently used pharmacological agent was midazolam (90 %), while propofol and diazepam were less common (6 and 4 % respectively). Respondents routinely monitored vital signs and pulse oximetry (100 %), and/or electrocardiography (35 %). Supplemental oxygen was routinely administered in 90 % of the cases. Endoscopists’ satisfaction with sedation was greater among those using propofol than in the groups using conventional sedation (score on a 10-point visual analogue scale, 9.5 ± 0.8 vs. 8.3 ± 0.9, p = 0.003). Sixty-two percent of the respondents used polyethylene glycol for bowel preparation in the elderly, and 88 % respondents believed that patients-related factors were the main barriers to optimal bowel preparation. Use of sedation and physiologic monitoring is currently the standard practice during colonoscopy in elderly Irish patients. Benzodiazepines remain the most commonly used sedative agents. Patients-related barriers are the prime contributors to poor bowel preparation in the geriatric population.
22. Antibiotic prophylaxis and extracorporeal shock wave lithotripsy (ESWL) G. Hann, F. Abogunrin, M. Young Department of Urology, Craigavon Area Hospital, Northern Ireland Antibiotic prophylaxis before ESWL is controversial, with differing recommendations in American and European guidelines [1, 2]. We audited our current practice of universal prophylaxis and compared to prophylaxis in targeted cases only. A prospective, single centre audit was performed from October 2013 to March 2014. All patients attending for ESWL received either universal antibiotic prophylaxis or targeted antibiotics, alternating every 6 weeks. Targeted prophylaxis was given in cases with positive urine dipstick, symptoms suggestive of urinary tract infection (UTI), staghorn calculi or indwelling stents or nephrostomy tubes. Urine dipstick and culture were performed prior to each ESWL treatment and urine culture sent 1 week post treatment. Endpoints were asymptomatic bacteriuria, urinary tract infections requiring treatment and hospital admission for urinary sepsis. Patients were excluded if they had recent or concurrent antibiotic therapy. 76 patients were included. 29 patients had no antibiotics pre-ESWL. None of these patients had positive post-treatment urine cultures or symptoms of UTI. 47 patients received prophylactic antibiotics. Eight had a positive pre-treatment urine culture. Six of these had asymptomatic bacteriuria. Three of these patients had asymptomatic bacteriuria post-treatment. Five others developed asymptomatic bacteriuria post-ESWL. No patients developed a symptomatic UTI. Using targeted antibiotics pre-ESWL is safe. Patients with negative urine dipsticks pre-ESWL do not require routine prophylaxis. In cases with positive dipstick who receive prophylaxis, the rates of symptomatic UTI after ESWL are low.
23. A study of histopathological findings in appendectomy specimens in Kerry General Hospital P.G. Nicholas, L. Selvarajah, K.C. Ng, K. Feely, T. McCormack Department of Surgery, Kerry General Hospital Background: Appendicitis is by far the most common emergency surgery performed in Kerry general hospital. Previous studies showed negative appendicitis rates ranging from twenty-five to forty percent [1, 2]. Histopathological examination of the appendix is routinely performed following appendectomy. The aim of this study was to determine the proportion of those undergoing appendectomies that had acute appendicitis histologically versus those with a normal appendix and correlate with inflammatory markers, radiological studies, and patient demographics. Methods: This was a retrospective analysis of six hundred and eighty nine appendectomies performed from January 1st 2012 to October 1st 2014. Pathological reports were analysed for the aforementioned parameters. Incidence of perforation, neoplastic lesions and other pathological diagnosis were also investigated. Chi square tests were performed for correlation analysis. Results: Acute appendicitis was evident in four hundred and thirty four specimens (63 %). In 2012, fifty-nine percent of specimens showed inflammation, this rose to sixty percent in 2013 and seventy one percent in 2014. Conclusions: This study found a similar proportion of normal appendix specimens as previous comparable appendectomy studies . Appendicitis is still largely a clinical diagnosis. Before proceeding to surgery, the clinical exam should be supported with
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 inflammatory markers and imaging in those with an uncertain clinical picture to increase specificity. The patient’s gender and age should also be considered before deciding on early surgical intervention or prolonged observation and conservative management. The continued reduction in negative appendectomy rates over time, also evident in other studies , suggests these recommendations are being implemented in Kerry general hospital.
24. The role of the surgical oncologist in managing soft tissue sarcoma—a 10 year review of consecutive cases in a tertiary referral centre Z. Khan, C.A. Fleming, H.P. Redmond Department of General Surgery, Cork University Hospital Introduction: Sarcomas are a rare, heterogeneous group of malignant tumours that comprise 1 % of all adult malignancies. Almost 80 % of sarcomas originate from soft tissue, the other majority from bone. It is known that optimum outcomes from sarcoma are best achieved through multidisciplinary management at tertiary referral centres. We aimed to describe the demographic, histological subtypes and survival outcomes of consecutive soft tissue sarcomas presenting to a tertiary referral centre over a 10 year period. Methods: We performed analysis of a prospectively maintained database of patients with soft tissue sarcoma presenting to a surgical oncology department from 2004 to 2013 inclusive. Patient demographics were identified including age at presentation and gender. Patient presentation and tumour location were recorded with size of tumour at presentation. The WHO histological subtype classification for soft tissue sarcoma was used to categorise tumours for the purpose of tabulating survival statistics. Statistical analysis was performed using SPSS, version 22. Results: During the study period, 98 patients with soft tissue sarcoma were treated at our centre. A relatively even gender reason was seen with 42 % (n = 41) female and 58 % (n = 57) male. The mean age at presentation was 53 years (range 12–87). 80 % (n = 78) of patients presented with a mass. Masses were seen mostly on the thigh/buttock/ groin (28.6 %), the upper limb (21.4 %) and the torso (17.3 %). At presentation 15 % of patient’s hade metastases, most commonly of lungs and liver in keeping with haematogenous spread. The most common histological subtype were undifferentiated sarcomas (34.7 %), followed by liposarcoma (22.4 %) and leiomyosarcoma (15 %). A number of rare sarcomas were also seen including angiosarcoma (n = 3), rhabdomyosarcoma (n = 2) and giant cell sarcoma (n = 1). Mean survival from diagnosis was 19 months with liposarcoma and undifferentiated sarcomas having the poorest outcome. Conclusion: Sarcoma is a rare but important malignancy affecting predominantly younger patients. For optimum outcomes patients should be managed in a designated soft tissue tertiary referral centre with multidisciplinary input.
25. Trends in service delivery and clinical practice in laparoscopic cholecystectomy H. Mohan, G. Kelliher, F. Keane, K. Mealy National Clinical Program in Surgery, RCSI Background: The National Clinical Program in Surgery was established to improve the quality of care, access to services and efficiency. Data collection and audit is key to informing strategic planning. UK
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 guidelines currently advocate an overall daycase rate for laparoscopic cholecystectomy of 60 %. This study looked at national trends in laparoscopic cholecystectomy in Ireland and resource utilisation. Methods: Data collected by the National Clinical Program in surgery based on HIPE coding were analysed over a 3-year period from 2010 to 2012 for laparoscopic and open cholecystectomy. Average length of stay (AvLOS), day of surgery admissions (DOSA) and day case rates were calculated. Results: In 2012, there were 3,723 discharges following elective laparoscopic cholecystectomy, with an overall conversion rate of 3.4 %. 79.1 % of patients were day of surgery admissions. The AvLOS in 2012 was 1.99 days. Nationally, the number of laparoscopic cholecystectomies performed as daycases has increased over the past 3 years from 16.9 % in 2010 to 23 % in 2011 and 27.7 % in 2012, but this remains less than half the UK target of 60 %. There is wide variation in daycase surgery rates between hospitals, ranging from 0 to 70 % of laparoscopic cholecystectomies. Five hospitals currently exceed the UK target. The overall average readmission rate was 5.14 %. Conclusion: There is considerable variation nationally in daycase rates. A combined approach of increasing day case rates, DOSA and reducing the AvLOS is needed nationally to improve efficiency.
26. Feasibility and safety of laparoscopy in the surgical management of small bowel obstruction—a single surgeon experience
S155 Department of Surgery, University Hospital Galway Surgical site infections (SSIs) remains a consistent problem in surgery today, causing significant morbidity among breast surgery patients. Our study aimed to reduce incidence of SSIs among breast surgery patients in the practice of three breast surgeons at UCHG. We endeavored to achieve by the execution of a care bundle, interventions specially designed to reduce infection incidence. Our baseline SSI rate by telephoning patients on their 30th postoperative day with a standard set of questions to determine if they fit our infection criteria. We then conducted an audit of surgical practices already in place within the theatre, observing which parts of our care bundle were already in place and which aspects may prove difficult to accomplish. We then carried out multiple tests of change during theatre days. Implementation of the entire care bundle then took place. Shortly after, an audit determining compliance was carried out. A total of 21 patients were interviewed with one confirmed infection, showing the incidence of SSI of the surgeons collectively was 4.76 %. As the rate of infection was already low, we decided to not to do a follow up telephone questionnaire. However our baseline audit showed several key aspects of our care bundle were not adhered to in day-to-day practice. We continued our implementation, in order to optimise best surgical practice. Despite a low SSI incidence rate, it always sensible to improve our breast surgery practices so patients have the best chance of recovery post-operatively.
S.M. Abd Elwahab, M. Majeed, P.S. Waters, E.J. Andrews Department of Surgery, Cork University Hospital Small bowel obstruction (SBO) is a common surgical emergency accounting for approximately 15 % of surgical admissions annually. The majority of patients settle with non operative management, however 25–30 % of patients require surgical intervention. Laparoscopy is emerging as a new modality of treatment in SBO but debate surrounding its efficacy exists in the literature. The aim was to examine the efficacy and safety of laparoscopy in radiologically diagnosed complete SBO. An analysis of a prospectively updated database of all patients requiring surgical intervention for SBO performed by a single surgeon during 2010–2014 was conducted. Data was collated from hospital databases, theatre registers and patient charts. Statistical analysis was performed using STAT 12 software with p \ 0.05 considered significant. Sixty-six patients (34 M, 32F) underwent laparoscopic intervention for SBO. Mean age was 57.39 ± 20.6 years (range 2–89 years). The most common cause of obstruction encountered was adhesions. 53 % of patients underwent a complete laparoscopic procedure with 31.4 % of patients undergoing a laparoscopic assisted procedure for resection and primary anastomosis. 18.6 % of patients were converted to an open procedure. No patients required a re-intervention. There were two (3 %) post-operative complications, wound infection and lower respiratory tract infection. The total laparoscopic group had a significant reduction in hospital stay (p \ 0.05). In conclusion, laparoscopy is a feasible and safe operative option for the management of SBO. It offers a safe and less traumatic option for the elderly and moribund patients who would benefit from minimal intervention.
27. Implementing a care bundle to reduce the incidence of surgical site infections in breast surgery A. O’Mahony, M.P. Murphy, M.J. Kerin, K.J. Sweeney, R. McLaughlin, C. Malone
28. Emergency admissions for acute diverticulitis; burden of disease in a tertiary referral centre G. Crozier Shaw, C. Cheung, D. Collins, P. Neary, D. Kavanagh Department of Colorectal Surgery, AMNCH (Tallaght) Hospital The management of acute diverticulitis is continuing to evolve and recent evidence suggests the disease spectrum is less virulent than previously thought. This study aims to analyse acute diverticulitis emergency admissions at Tallaght hospital. A retrospective analysis of all patients presenting with acute diverticulitis over a 24-month period was undertaken. Data collected: demographics, clinical features, CT reports, inflammatory markers, length of stay, anti-microbial regimens and radiological drainage or surgery. Of 173 presentations, 160 patients had CT evidence of diverticulitis. There were 81 males, 79 females with a mean age of 57.3 years. There were 122 (76 %) cases of uncomplicated diverticular disease (diverticulosis and stranding) and 38 (24 %) cases of complicated disease (abscess, pneumoperitoneum, free fluid). The mean CRP on admission was 51 in uncomplicated disease and 88 in complicated cases. 94 % (115) of uncomplicated cases were treated conservatively (broad spectrum anti-microbial therapy and clinical surveillance). Seven cases (6 %) were treated with supportive measures alone. In complicated disease, 42 % (16/28) were managed conservatively, 7/38 (18 %) underwent radiological drainage and 17/38 (45 %) underwent operative management. Operative interventions included: Laparoscopic lavage 35 % (6), Hartmann’s procedures 29 % (5), resection with primary anastomosis 23 % (4) and diverting stoma formation (2) 12 %. Acute diverticulitis is a common emergency surgical presentation. The majority with uncomplicated disease settle with conservative therapy. Only 24 (15 %) of patients required radiological or surgical intervention. Inflammatory markers may play a role in determining disease severity with a significantly higher mean CRP in cases of complicated diverticulitis.
S156 The management of acute diverticulitis is continuing to evolve and recent evidence suggests the disease spectrum is less virulent than previously thought. This study aims to analyse acute diverticulitis emergency admissions at Tallaght hospital. A retrospective analysis of all patients presenting with acute diverticulitis over a 24-month period was undertaken. Data collected: demographics, clinical features, CT reports, inflammatory markers, length of stay, anti-microbial regimens and radiological drainage or surgery. Of 173 presentations, 160 patients had CT evidence of diverticulitis. There were 81 males, 79 females with a mean age of 57.3 years. There were 122 (76 %) cases of uncomplicated diverticular disease (diverticulosis and stranding) and 38 (24 %) cases of complicated disease (abscess, pneumoperitoneum, free fluid). The mean CRP on admission was 51 in uncomplicated disease and 88 in complicated cases. 94 % (115) of uncomplicated cases were treated conservatively (broad spectrum anti-microbial therapy and clinical surveillance). Seven cases (6 %) were treated with supportive measures alone. In complicated disease, 42 % (16/28) were managed conservatively, 7/38 (18 %) underwent radiological drainage and 17/38 (45 %) underwent operative management. Operative interventions included: Laparoscopic lavage 35 % (6), Hartmann’s procedures 29 % (5), resection with primary anastomosis 23 % (4) and diverting stoma formation (2) 12 %. Acute diverticulitis is a common emergency surgical presentation. The majority with uncomplicated disease settle with conservative therapy. Only 24 (15 %) of patients required radiological or surgical intervention. Inflammatory markers may play a role in determining disease severity with a significantly higher mean CRP in cases of complicated diverticulitis.
29. Aspirin significantly impacts on prediction of blood usage post operatively in cardiac surgery N. Mayooran, M. Tarazi, P. Mohanarajah, O. Olakunle, B. Philip, M.N. Anjum, M. Anwer, K. Doddakula Cardiothoracic Surgery, Cork University Hospital Aim of the study was to predict blood usage in elective coronary artery bypass graft patients who underwent surgery in our institution. We also wanted to analyse if Aspirin consumption influenced the prediction. 232 patients who underwent elective CABG were included in the study. Independent predictions were performed by a surgeon, anaesthetist and a perfusionist pre operatively. 124 pts were on Aspirin preoperatively while 108 patients had no Aspirin 1 week prior to surgery. Chi square test was used for statistical analysis and the results showed that patients on Aspirin were under predicted and patients not on Aspirin were over predicted. This was found to be statistically significant.
30. VATS versus thoracotomy in management of stage iii empyema—a retrospective audit P. Mohanarajah, N. Mayooran, M. Tarazi, B. Philip, M.N. Anjum, M. Anwer, K. Doddakula Cardiothoracic Surgery, Cork University Hospital
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 The standard of care for stage 3 empyema is performing posterolateral thoracotomy with ribs spreading with or without rib excision. Thoracotomy is associated with significant morbidity and increased length of stay having economic implications. In our centre, we retrospectively analysed 16 cases of stage 3 empyema managed by modified VATS along with 3 cm utility incision with or without excision .No ribs spreading was performed. These patients were compared with 15 cases managed by conventional posterolateral thoracotomy. Average length of stay of patients underwent modified VATS was significantly shorter than conventional posterolateral thoracotomy with very good pain control. There were no significant differences in clinical and radiological outcome. Hence we propose that this technique is superior to traditional thoracotomy which is the gold standard for stage 3 empyema.
31. Surgical repair of congenital aorto-atrial fistula: a rare case with an unusual presentation N. Mayooran, M. Tarazi, P. Mohanarajah, B. Philip, M. Anwer, M.N. Anjum, K. Doddakula Cardiothoracic Surgery, Cork University Hospital 50 year old lady presented with palpitations and was diagnosed with new onset atrial fibrillation with no coronary or valvular heart disease. She was extensively investigated and identified to have an aorto-atrial fistula. Intra-operatively, it was identified that the patient’s right atrial, right ventricle and pulmonary artery pressures were normal contrary to the pre-operative diagnosis. We identified 2 chambers with high pressure between the SVC and the roof of the left atrium. These chambers were directly communicating with the fistula which was established when the chambers collapsed after ligation and excision of the fistula near the aortic end. The probable reason for the existence of these chambers is a stricture of the fistula near the right atrium causing pre-stenotic dilatation of the fistula presenting as chambers and impinging on the left atrium leading to supra-ventricular arrhythmias. No similar cases have been reported in the literature.
32. Patients age ‘‘a major factor in the pain threshold post vats procedures’’ M. Tarazi, N. Mayooran, P. Mohanarajah, O. Olakunle, B. Philip, M.N. Anjum, M. Anwer, K. Doddakula Cardiothoracic Surgery, Cork University Hospital Pain following video assisted thoracic surgery is a major concern and has huge economical implication. We aimed to evaluate if age of patient plays a role in their pain tolerance. We retrospectively studied 93 consecutive VATS patients performed between April 2012 to March 2014. Patients were subdivided into groups as follows: 20–29, 30–39, 40–49, 50–59, 60–69, [70. Numeric pain rating was used for pain assessment. A telephone interview was performed for pain scoring .Pain severity was assessed during immediate postoperative period, post discharge, at outpatient department visit at 6 weeks, and 3 months post operatively. Our results showed that older patients had a better tolerance of pain during the initial post op phase and during chronic phase.
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33. Transition to day case laparoscopic cholecystectomy in an Irish hospital: review of outcomes E. O’Malley, B. Moloney, C. Collins Portiuncula Hospital Ballinasloe, Co Galway Background: Laparoscopic cholecystectomy (LC) is one of the most common minimally invasive elective procedures performed in Ireland. Evidence has shown that day surgery (DS) LC is a safe and costeffective treatment for symptomatic gallstones. To date, however, few national centres in Ireland regularly preform LC as a day-case procedure. Aim: To assess the outcomes of all LC performed in Portiuncula Hospital, Ballinasloe between January 2008 and November 2014, and to assess the impact of the introduction of DS LC in November 2011 to patient outcomes. Method: In this cohort of patients who underwent LC, we identified two groups, patients who had LC prior to November 2011 (Group A), and those who had LC subsequent to this date (Group B). Rate of conversion to open, readmission rate, operation times and ASA classification were analysed. A comparison was generated between these groups. Results: 655 LC were performed overall. There was 318 patients in Group A (82.4 % female), and 337 patients in group B (76.3 % female). Median ASA in both group is 1 (1–3). Readmissions resulted in 4.55 % overall (n = 30), 6.45 % (n = 20) in Group A and 2.86 % (n = 10) in Group B. There was no statistical difference in complications between the two groups. There was no mortality. Conclusions: DS LC has been proven to be safe and feasible. Following introduction of DCLC, our results remain comparable with international standards. Transition to DS LC is occurring with reluctance in Ireland, but our results suggest that with careful patient selection, this transition can occur seamlessly without compromising standards of care or patient safety.
34. Laparoscopic cholecystectomy as a day case procedure: a review of outcomes E. O’Malley, B. Moloney, C. Collins Portiuncula Hospital Ballinasloe, Co Galway Background: Economy and efficiency has seen a sour in Day Case procedures. Wide-spread introduction of day-case (DC) Laparoscopic Cholecystectomy (LC) is a major target of healthcare providers. Acceptability amongst surgeons, however, remains a subject of debate. Aim: Following introduction of DCLC to our institution in November 2011, we assessed objective outcomes of all patients who lad LC performed as a DC procedure. Method: A review of all procedures was performed to determine DCLC performance. Intraoperative times, readmissions and complications were recorded. Successfully discharged DCLC patients were followed up with a telephone call at 48 h. Results: Since November 2011, 60.8 % of 337 (n = 208) LC performed in this institution were deemed suitable for DC surgery. 71.1 % of the suitable candidates (n = 148) were successfully discharged as a day case. Of DCLC, median age was 40.9 (14.9–74.0). 78.4 % were female. Median weight was 76 kg (46–138). While median ASA was 1 (1–2). Inpatient duration was determined and median stay was 9 h (5–12). Median operation time was 66 min (27–160). Of patients discharged as DCLC, 2.9 % were readmitted.
S157 Conclusion: With careful patients’ selection and hospital organisation, DCLC is a safe and effective intervention with low rate of complications and readmissions. Implementation has resulted in a significant economic benefit for this hospital. Our results are comparable with international standards.
35. Patient satisfaction assessment following day case nasal surgery E. O’Reilly, T. Subramaniam, B. Conlon, J. Kinsella Department of Otolaryngology, Head and Neck Surgery, St James Hospital, Dublin Introduction: Septoplasty and Functional Endoscopic Sinus Surgery (FESS) are common surgeries usually performed in an inpatient setting worldwide. In recent years St James’ Hospital has began to implement it as a day case surgery due to the chronic shortage of inpatient beds. These procedures are also safe, have low complication rates and do not restrict mobility, rendering them ideal to be performed in a day service setting. Objective: The aim of this retrospective study is to observe the rate of unplanned admission post op day case FESS or septoplasty in addition to obtaining feedback in relation to patient satisfaction. Methods: Ethical approval submitted. Records obtained from day ward theatre logs for patients undergoing septoplasty, FESS or combined procedure between December 2012 and October 2014. Patients were contacted via telephone and consent was obtained prior to answering a brief telephone questionnaire. It assessed unplanned admission rates, readmission rates, complications and patient satisfaction scores. Results: We have a cohort of 50 patients, 17 female and 33 male. The average age is 45 years with a range from 22 to 70. Of the 50 patients only one was admitted giving a 2 percent unplanned admission rate. Overall patients were very satisfied with the care they received. Conclusion: Performing septoplasty and FESS as a day case procedure is an ideal means of overcoming chronic shortage of elective hospital beds. A day case procedure is well tolerated by patients. Furthermore in this modest subset of patients almost 50,000 euro would have been saved.
36. Open cholecystectomy: declining experience, a cause for concern? T.P. Burke, P.S. Waters, R.M. Waldron, K. Joyce, I. Khan, W. Khan, K. Barry Department of Surgery, Mayo General Hospital Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstone disease. Despite increasing experience with this procedure, it is still necessary to convert or perform a primary open cholecystectomy in selected instances for patient safety. We have previously reported a 1.7 % conversion rate in a series of 1937 cholecystectomies performed over an 11-year period (2003–2013) at Mayo General Hospital. We analyse risk factors for conversion and outcomes in the combined open cohort. We also explore the implications of reduction in the numbers of open cholecystectomies performed for surgical training. During the study period, 94 open cholecystectomies were performed, 62 as planned open and 32 as converted laparoscopic procedures. No open cholecystectomies were performed during the last 2 years of the study. The most common indications for performing a primary open cholecystectomy were a previously failed
S158 ERCP (30.6 %) and empyema of the gallbladder (25.8 %). Four deaths were recorded in the primary open cholecystectomy group. The most common indications recorded for conversion from a laparoscopic procedure were presence of dense adhesions (34.4 %), active inflammation (28.1 %) and inability to define the critical anatomy (21.9 %). No deaths were recorded in the laparoscopic conversion group. With increasing experience with both laparoscopic surgery and ERCP, the need to perform an open cholecystectomy has declined. However a primary or converted open cholecystectomy may still be necessitated in selected patients. The reduction in number of open cholecystectomies performed may lead to reduced training opportunities and expertise among surgeons currently in training and is therefore a cause for concern.
37. The skin sparing mastectomy: optimising reconstructive outcomes by applying the three-step principle of breast analysis K. Ringrose, R.T. Dolan, P.N. Blondeel, C.M. Morrison Department of Plastic and Reconstructive Surgery, St Vincent’s University Hospital, Dublin and University Hospital Gent, Belgium Background: The skin-sparing mastectomy (SSM) with immediate breast reconstruction is an effective treatment for patients with earlystage breast cancer. Preservation of the native breast skin and inframammary fold in a skin-sparing mastectomy (SSM) greatly enhances the aesthetic results of an immediate breast reconstruction. Recent reviews have shown an increase in the use of SSM amongst breast surgeons from 21 % in 1997 to 73 % in 2001 but many surgeons continue to avoid a SSM due to uncertainty regarding its indications (46 %), benefits (63 %) and oncological safety (37 %) (1). However, despite the recent surge in its popularity, there is a paucity of studies to describe the basic surgical principles of the SSM. We aimed to translate the established 3-step principle of breast analysis to the SSM technique, to encourage the wider practice of these basic plastic surgery principles by surgical oncologists (2–4). Methods: The 3 step-principle of breast analysis divides the breast into a footprint, conus and envelope (5). The breast ‘footprint’ is the outline or footprint that the breast makes on the chest wall. It’s boundaries are well defined by the sternal attachments of the skin medially, the infra-mammary fold inferiorly and the anterior axillary fold laterally. The breast conus refers to the three-dimensional shape, projection, and volume of the tissue on top and anterior to the footprint of the breast. Anatomically the female breast projects from the 2nd to 6th ribs and from the anterior axillary line to the lateral border of the sternum. A skin envelope of appropriate quantity and quality functions to hold the parenchymal volume, or conus, in an appropriate position. Results: We demonstrate how application of the 3 step-principle of breast analysis to the SSM technique can optimize oncologic safety whilst achieving an aesthetically-pleasing breast. Conclusion: The 3-step principle of breast analysis applied to the SSM, allows use of a systematic, reproducible technique for both novice and experienced surgical oncologists, with minimal complications and optimal aesthetic outcomes for patients undergoing reconstructive breast surgery (5).
38. Simulation-based deliberate practice improves performance in laparoscopic skills in novice surgeons G. Browne, D. O’Connor, T.P. McVeigh, P. O’Connor, M.J. Kerin, D. Byrne
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 School of Medicine, National University of Ireland Galway Introduction: Simulation-based training can improve real-life technical skills in a low-risk environment3. PicSOr is a validated predictor of laparoscopic skill based on perceptual ability4. Aim: To investigate the efficacy of deliberate practice using a boxtrainer in acquisition of laparoscopic skills compared to repetitive practice of perceptual skill. Methods: A randomised control trial was performed. Novice surgeons were randomised into three groups: 1. 10 h deliberate practice using box-trainer. 2. 10 h repetitive practice using PicSOr. 3. No intervention. Students were objectively assessed pre- and post-intervention using three validated laparoscopic exercises5. Results: Groups were matched in pre-intervention skills performance and dexterity. Following the intervention, all individuals using deliberate practice had significantly improved scores (p \ 0.001). No significant improvement was appreciated in the other two groups. Conclusion: Deliberate practice leads to increased speed and accuracy in laparoscopic tasks in novices compared to perceptual skillsbased practice.
39. The long road? Restructuring a national trauma service H.M. Mohan, D. Mullan, F. McDermott, R.J. Whelan, C. O’Donnell, D.C. Winter Department of Surgery, St Vincent’s University Hospital Background: Internationally, a major trauma center surrounded by a trauma network is the gold standard in trauma care. Ireland does not have a co-ordinated trauma network with designated major trauma centers (MTC). This study aimed to examine international trauma systems, and determine how to ‘‘best fit’’ trauma care in a small country (Ireland) to international models. Methods: An estimate of Irish trauma burden and distribution was made using data from the Road Safety Authority (RSA) on serious or fatal RTAs. Models of a restructured trauma service were constructed and compared with international best practice. Results: Currently, 26 acute hospitals provide trauma care, with a mean distance to hospital from RTAs of 20.6 km ± 15.6. Based on our population, Ireland needs two Level 1 MTCs (in the two areas of major population density in the East and South), with robust surrounding trauma networks including level 2 or 3 trauma centers. With this model, the estimated mean number of cases per Level 1 MTC per year would be 628, with a mean distance to MTC of 80.5 km ± 59.2 km (maximum distance 263.5 km).
Ericsson KA, Krampe RT, Tesch-Romer C (1993) The role of deliberate practice in the acquisition of expert performance. Psychol Rev 100(3). 4 Gallagher AG, Cowie R, Crothers I, Jordan-Black J-A, Satava RM (2003) PicSOr: an objective test of perceptual skill that predicts laparoscopic technical skill in three initial studies of laparoscopic performance. Surg Endosc Other Interv Tech 17(9):1468–1471. 5 Schreuder HWR, van den Berg CB, Hazebroek EJ, Verheijen RHM, Schijven MP (2011) Laparoscopic skills training using inexpensive box trainers: which exercises to choose when constructing a validated training course. BJOG 118(13):1576–1584.
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 Conclusion: Investment in prehospital infrastructure and clearly designated and adequately resourced MTCs with trauma networks are needed to bring Ireland in line with international trauma models.
40. Ultrasound abdomen and pelvis for right iliac fossa pain; misuse of resources? A. Galbraith, A.C. Rogers, L. Loughlin, K.S. Cross, C. O’Riordan, M. Farrell, F.P. Pretorius, M.P. McMonagle Department of Surgery, University Hospital Waterford Appendicitis remains the commonest surgical complaint presenting to the emergency department with right iliac fossa pain. Currently ultrasonography is the imaging modality of choice in females of reproductive age. Presently there is no overall consensus on whether a targeted ultrasound pelvis or a full abdomino-pelvic Ultrasound scan should be performed within this particular group of patients. Of late there has been a vogue for CT imaging in those above 45 years of age and international suggestion that a Focused Appendiceal Computerised Tomography may yield adequate results whilst decreasing radiation exposure for the patient. Our study aims to analyse the relevance of ultrasound abdomen and pelvis in females between the ages of twelve to fifty. A retrospective analysis of the radiology database was carried out identifying patients for whom ultrasonography was performed with the indication of right iliac fossa pain in two institutions. Findings of these images were analysed. The results of 400 patients were reviewed, 25 % of which revealed findings of clinical significance, 8 % which required clinician follow-up and, 8 % where extra-pelvic findings, of which less than 1 % required clinician follow-up. In conclusion routine US abdomen and pelvis as first line radiological investigation for this large sub-group of patients is of limited clinical utility. Focussed US pelvis may yield equally sensitive and specific results whilst relieving pressure and unnecessary workload on the radiology department.
41. Post-prandial hypoglycaemia complicating oesophagectomy: the role of preoperative obesity and pancreatic beta cell hypertrophy P.N. Stassen, J.A. Elliott, J. Gibney, C.W. Le Roux, J.V. Reynolds Department of Surgery, Trinity Centre for Health Sciences, Trinity College and St. James’s Hospital, Dublin Reactive post-prandial hypoglycaemia is a cause of significant postoperative morbidity in a proportion of post-oesophagectomy patients, but risk factors for this condition are poorly understood. We describe a case of reactive post-prandial hypoglycaemia in a patient with preoperative morbid obesity and type 2 diabetes mellitus (T2DM). A 67-year-old gentleman was diagnosed with cT1N0 Type I oesophagogastric junction adenocarcinoma on a background of Barrett’s oesophagus. The patient achieved intentional preoperative weight loss of 12.8 % and underwent an Ivor Lewis oesophagectomy with pyloroplasty and insertion of jejunostomy feeding tube. The patient’s post-operative course was complicated by ischaemic anastomotic dehiscence and extended supplemental jejunal feeding was undertaken. At 1 year post-operatively the patient had a total initial body weight loss of 40 kg (32.0 %) and anti-diabetic medications were discontinued with initial satisfactory glycaemic control. However, by 18 months post-operatively the patient began to experience recurrent episodes of post-prandial hypoglycaemia following high
S159 glycaemic load meals, reporting characteristic early blood glucose peaks with subsequent hypoglycaemic episodes. Post-prandial plasma glucagon-like peptide-1 (GLP-1) was elevated, consistent with reactive hypoglycaemia. Management strategies including low glycaemic index diet, acarbose and octreotide are under consideration. Symptomatic post-prandial hypoglycaemia is an uncommon complication of oesophagectomy associated with significant morbidity and altered quality-of-life. In patients with preoperative obesity, exaggerated post-prandial GLP-1 secretion may be compounded by weight loss-related improved peripheral insulin sensitivity. Pancreatic nesidioblastosis (islet cell enlargement, b-cells budding from ductal epithelium) and preoperative T2DM-related beta cell hypertrophy may play a role in the pathogenesis of this condition.
42. Systematic review of video-assisted parathyroidectomy for primary hyperparathyroidism compared to open parathyroidectomy techniques S.M. Abd Elwahab, A.J. Lowery, K. O’Brien, P.H. Redmond Cork University Hospital, University College Hospital Galway and RCSI Traditionally, the gold standard surgical approach to primary hyperparathyroidism has been bilateral neck exploration and resection of pathologic gland(s). However, coupled with advances in diagnostic and localisation techniques, more targeted surgical approaches have developed for adequately localised adenomas. Video-assisted parathyroidectomy (VAP) is one strategy employed to facilitate less invasive surgery, however there is a lack of evidence comparing this approach to open parathyroidectomy (OP) and the benefits remain debatable. A meta-analysis was conducted according to the PRISMA guidelines, including only randomised controlled trials (RCT) that compared VAP to OP for primary hyperparathyroidism. Endpoints included operative time, failure rates, conversion rates, post-operative pain and cosmesis. Three RCTs were eligible for inclusion, comprising 241 patients. VAP operative time (57 ± 15 min) was found to be comparable to OP (70 ± 18 min (I2 = 87.9 %). VAP patients had less early postoperative (VAS score 0.19 vs. 0.29 in OP) pain and higher cosmetic satisfaction, but the difference was not statistically significant. The failure rate of VAP was found to be 4 % compared to no failure with OP approach. 25 % of VAP required conversion to OP. VAP was found to be less expensive than OP and had six times lower risk of post-operative hypocalcaemia (RR 6.4). VAP is a feasible approach to parathyroidectomy but is limited by a higher failure rate and a high risk of conversion to OP. Careful patient selection is critical to the success of this procedure and it should only be considered for patients who fit the selection criteria and have un-equivocally positive pre-operative localisation.
43. Variations in breast screening in BRCA/high risk mutation carriers in a dedicated breast centre L.M. Houlihan, N.M. Foley, M. Jinih, Z. Khan, A. Khan, N. Relihan, H.P.R. Redmond Department of Surgery, Cork University Hospital Background: The recommended screening of BRCA and other genetic carriers at high risk of breast cancer has been subject to debate and change recently. A UK guideline has set out recommendations for
S160 both the intensity and type of imaging recommended in different risk categories. Our aim was to characterise the screening of a high risk population in a dedicated breast centre and to compare the interval and type of screening with international guidelines. Methods: A database has been prospectively maintained since 2003 and includes confirmed mutation carriers (BRCA1, BRCA2, p53, CDH1) and untested patients with a greater than 30 % carrier probability. This database was consolidated with additional information including patient demographics, frequency and type of surveillance imaging, whether patients availed of risk reduction surgery and breast cancer status. Results: Women who underwent risk reduction surgery or those who had a diagnosis of breast cancer were excluded from further analysis. 26 women were included for analysis. The average age was 44 years (range 21–63). The intention for patients between the ages of 30 and 50 is annual mammography and MRI, while in those over 50 years it is annual mammography. In our cohort, 12/19 patients under 50 years of age have had at least one MRI, with 14/19 having annual mammography. All patients in the over 50 group have had annual mammography. Conclusion: Identification of BRCA/genetic mutation carriers at higher risk of breast cancer is increasing. Factors such as, the limited availability of public MRI, coupled with competition for slots with women embarking on neoadjuvant treatment, pregnancies, symptomatic episodes and appointment defaulters are hindering our ability to adhere strictly to screening intervals.
44. Acute Appendicitis- efficacy of clinical diagnosis and financial implications of ‘over-investigation’ Inder Shakeel, Umair Muhammad, Khalid Haroon, Awan Faisal, Elfaedy Osama, Balfe Paul, Pretorius Fredrick Department of Surgery, St Luke’s Hospital, Kilkenny Background: Acute appendicitis represents the most common abdominal surgical emergency. The aim of this study was ascertain how acute appendicitis was diagnosed at our institution, the financial burden of diagnosing acute appendicitis and whether the investigations performed helped towards diagnosis. Methods: Data was collected retrospectively on 105 patients that underwent open/laparoscopic appendicectomy over a 14 month period. Laboratory and radiological results were obtained from the patient information systems. Patient charts were analysed for demographics, admission and operative notes. Financial details were obtained from the finance, laboratory and radiology departments. Results: The average age at diagnosis was 16.8 years. RIF pain associated with nausea was found in more than 80 % of patients together with raised WBC (88 %), raised CRP (61 %) and anorexia (73.3 %). 97 % of patients were diagnosed with acute appendicitis clinically. Nevertheless, 50 patients underwent an ultrasound scan with only 36 % diagnostic of acute appendicitis. At surgery, acute appendicitis was macroscopically diagnosed in 95.3 % of patients and histopathological confirmation of acute appendicitis was found in 85.8 % of patients. The average length of stay was 2.58 days. The negative appendicectomy rate at our institution was only 10.4 %. We found that costly unnecessary investigations were commonly done: PFAs-98.1 %, CXR-56.2 %, LFTs-91.4 %, Urea and Electrolytes-100 % and Coagulation profile-37.1 % of patients. Conclusion: Acute appendicitis was effectively diagnosed at our institution but unfortunately the associated unnecessary investigations account for an extra 115 Euros per patient (total of 12,000 Euros).
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 Recommendations: With the implementation of an Acute Surgical Assessment Unit at the St Luke’s Hospital, Kilkenny, it will be of interest to see if there is a decrease in unnecessary investigations thus a decrease in additional cost. Re-auditing will be required to confirm the latter.
45. Explant of aortic stent grafts following endovascular aneurysm repair M. Lynch, D. McGuire, S.M. McHugh, Z. Ahmed, A. El-Mallah, A. Amin, N. Hamada, M.P. Colgan, S. O’Neill, A. O’Callaghan, Z. Martin, P. Madhavan Department of Vascular Surgery, St James Hospital, Dublin Introduction: Failure of endovascular aneurysm repair (EVAR) may require explant of the stent graft in a subset of patients. Methods: Patients undergoing explant of EVAR were identified from a prospectively maintained online database, with additional information obtained through retrospective analysis of medical records. Results: Over an 18 year period 1996–2014, there were 496 EVAR procedures performed in our institution for abdominal aortic aneurysm. There were 11 explants, three of these were referrals from other vascular centres. The average age was 72 years (range 65–77). The median length of time from implantation to explant was 33 months (range 0.3–106). Overall 6/10 cases were elective procedures. Indications for elective explant were Type 1 endoleak (n = 3), type 2 endoleak with increasing sac size (n = 1), type 4 endoleak (n = 1) and increasing sac size without evident endoleak (n = 1). The remaining 5 cases were emergency procedures, with three patients presenting with rupture post EVAR, and two patients presenting with acute stent thrombosis. There were no mortalities in the elective group and two mortalities (40 %) in the emergency group. Conclusion: Endoleak remains the most common indication for EVAR explant. Explant of aortic stent grafts in an elective setting is a safe and effective treatment option.
46. Evolving changes in the operative management of cholangiocarcinoma in a national centre M. Sheehan, N.J. O’Farrell, N. Saeed, A. Cooney, N. Swan, O. Traynor, J. Geoghegan, D. Maguire, E. Hoti Liver Transplant Unit, St Vincent’s University Hospital Introduction: Initial studies demonstrated poor outcomes and survival with liver transplantation for unresectable cholangiocarcinomas. However, the Mayo Clinic subsequently published 5-year survival rates [60 % in cases which undergo neoadjuvant chemoradiotherapy following liver transplantation. This approach has not been adopted internationally. Here, we examine our centre’s success with this treatment strategy. Methods: Data were collected from a prospectively maintained liver transplantation database and retrospectively retrieved from the hospital’s pathology database, between 2005 and 2014. Patients treated either with neoadjuvant chemoradiation and liver transplantation (n = 24) or liver resection (n = 27) were compared. Survival analysis was performed using Kaplan–Meier curves. Results: Patients were significantly younger in the transplant group (median 51 years [24–67]) compared with the resection group (median 61 years [24–67]) (p = 0.05). Eighteen (75 %) transplants had an underlying diagnosis of primary sclerosing cholangitis compared with 11 % of resections (p \ 0.0001). There was a trend
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 towards increased in-hospital mortality in the transplant cohort (16.7 %, n = 4) compared with resections (3.7 %, n = 1) (p = 0.12); these patients were excluded from long-term survival analysis. Overall, estimated median survival for treated cholangiocarcinoma was 8.29 years (3.9–12.7 years) and comparable between the two groups (p = 0.788). However, 85 % (n = 23) of resection-cholangiocarcinomas were Tis, T1 and T2 tumours. Conclusions: We have replicated results of the initial Mayo study, which has demonstrated neoadjuvant chemoradiation and liver transplantation is a feasible treatment option for advanced, previously unresectable, cholangiocarcinomas.
47. Prophylactic minimally invasive gastrectomy in hereditary diffuse gastric cancer: a case series report B.C. Murphy, T.J. Murphy Department of Oesophago-Gastric Surgery, Mercy University Hospital, Cork Mutation of CDH-1 gene coding for Epithelial Cadherin protein carries an 80 % lifetime risk of developing diffuse gastric cancer, for which the only potentially life-saving procedure is a total gastrectomy. Open gastrectomy is, traditionally, a morbid operation associated with a long hospital stay and significantly impacts on quality of life. We present a case series of 3 patients with a CDH-1 mutation who underwent a prophylactic gastrectomy via a minimally invasive approach. Three sisters aged within the range of 40–55 presented following the death of a sibling from diffuse gastric cancer were subsequently found to have a CDH-1 mutation. Following extensive genetic counselling and multidisciplinary input, each underwent a prophylactic laparoscopic total gastrectomy with a D1 lymphadenectomy. The 50 cm Roux-en-Y reconstruction was constructed with a stapled jejeuno-jejeunal anastamosis and a 25 mm ‘‘orvil’’ device used to fashion a gastrojejeunal anastamosis. The specimen was delivered through a 2.5 cm transverse mini-laparotomy incision. Histopathological examination yielded a mean of 28 nodes (range 15–56). 2 patients had foci of T1a adenocarcinoma. There were no immediate post-operative complications with a 0 % 30-day readmission rate. Mean length of stay was 7 days. In conclusion, prophylactic minimally invasive gastrectomy is a feasible, safe treatment in the management of hereditary diffuse gastric cancer with favourable short-term oncological outcomes and is associated with a short hospital stay.
48. Enhanced experiential learning and improved surgical patient safety through the application of NFC technology E.O. Connell, J. Pegler, E. Lehane, N. McCarthy, L. Sahm, S. Tabirca, A.O. Driscoll, M. Corrigan Cork Breast Research Centre, Department of Surgery, Cork University Hospital Introduction: Excellent surgical care requires the optimal management of medications. It is estimated that hospitalized patients are subject to at least one medication error per day. Electronic prescribing reduces medication errors but few systems have been developed to
S161 allow effective electronic prescription at the bedside. Near Field Communications (NFC) is an emerging technology that allows data transfer between remote mobile devices. Methods: An NFC-based system was designed facilitating prescribing and drug administration using a smart phone or tablet. The system allows information pertaining to medications, allergies and medical conditions to be stored within a patient’s identification bracelet. Such information is retrieved by simply scanning the bracelet with a smart phone. Advice regarding interactions and allergies is provided by the system as prescriptions are completed. Final year medical school students were recruited to test the electronic system as an educational initiative on a simulated ward. Prescribing errors were compared against errors recorded using a paper system. Results: A significant difference was seen between the median errors per person committed using each system with median errors per person of 0.18 for tablet prescribers versus mean errors per person of 4.09 for paper prescribers (p \ 0.05). A mean satisfaction score of 2.45 was reported for the group (rated on 7 point scale with 1 denoting total satisfaction with system use). Conclusions: This emerging technology can be incorporated into training to produce an innovative educational tool. Further testing is in progress to evaluate its role in a clinical surgical environment to enhance surgical management.
49. The conservative management of acute appendicitis: a national perspective M.E. Kelly, A. Khan, W. Khan, K. Barry, R. Waldron, I.Z. Khan Department of Surgery Mayo General Hospital Castlebar Acute appendicitis is the most common acute surgical operation. In recent years, this management strategy has been challenged. Several randomized controlled trials have demonstrated that antibiotics (conservative management) can be as efficacious as surgery. A national cross-sectional study of all consultant general surgeons evaluating their current management practices via an online questionnaire (Monkey Survey) was sent. Those that regularly managed patients conservatively were asked why they have changed their practice, which antibiotics regimens they used and what follow-up investigations/if any they utilized. Additionally, the role of interval appendectomy and conservative management in the paediatric population was also assessed. There was a 73.7 % (n = 73/99) response rate. Of those, only 23.3 % (n = 17) routinely treated acute appendicitis conservatively. However, another 15 % (n = 11) stated they would consider this approach in selected cases. Main reasons for changed practices included; presence of inflammatory phlegmon (75 %), delayed presentation (63 %), and recent changes in evidence-based medicine (49 %). The most popular antibiotic used was co-amoxiclav/clavulanic acid (69 %). Alternatively, combination of antibiotics was also popular. Only 31.9 % of participants felt interval appendectomy was warranted and only 13.1 % supported a conservative management approach in a paediatric population. The overwhelming majority supported follow-up colonoscopy +/- computed tomography in any patient aged [40 years. Preliminary evidence suggests that a conservative management of acute appendicitis is safe, reducing post-operative complications and overall healthcare costs. However, there remains lack of consensus regarding its indication and role. In addition, there are considerable concerns regarding the over-use of antibiotics, especially in an era of increased resistance.
50. Introduction of a weekend surgical handover for surgical patients: the complete audit cycle
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 Conclusions: With adequate experience, early laparoscopic cholecystectomy can be performed safely in a peripheral hospital with shortened hospital.
J.P. Gibbons, E. Nugent, S. Tierney, D. Kavanagh Department of Surgery, Tallaght Hospital The implementation of the European work-time directive has created increased transitions of care during weekends as doctors adhere to a shift-work structure. This has raised concerns over continuity of care and patient safety1. To overcome this, clinicians must develop a timeefficient yet safe system of handover of patients to the weekend team on-call. Data on inpatients over weekends was collected at three timepoints over a 6 month period encompassing development, implementation, re-evaluation and modification of the handover process. During the cycles the introduction of formal verbal registrar-to-registrar handover of inpatients to the on-call team was then modified to a written handover tool. The outcomes measured were: number of weekend discharges, length of stay (LOS) for the 4 weekends within the month, and total emergency response team (ERT) calls for each month. Mean number of included patients each month was 294 (r = 14). Following the introduction of weekend handover there was a 40 % increase in weekend discharges which was consistent for subsequent time-points (p \ 0.05, Student’s t-test). Following the second intervention there was a statistically significant reduction in mean LOS from 13 to 5.4 days (p \ 0.05) and the total number of ERT calls for the month reduced from 12 to 4 (p \ 0.05). The standardisation of weekend handover using a combination of an electronic tool supplemented with verbal handover is feasible. It resulted in an improvement in surrogate markers of patient care quality as demonstrated by the results above.
51. Laparoscopic cholecystectomy, a safe treatment for acute cholecystitis in secondary care hospital Y. Bashir, N. Cliodhnna, Q. UlAin, A. Rayis, S.M. Johnston, D. Hehir Surgical Department Midlands Regional Hospital Tullamore Background: Symptomatic cholelithiasis is a common cause of surgical admissions. There is not a clear consensus in relation to the management of acute cholecystitis. We reviewed management of all the patients undergoing cholecystectomy between January 2012 to December 2013. Multiple meta analysis are done on this topic, which that there is comparable safety and efficacy (1), similar complications and conversion rates (2) and significantly reduced hospital stay for patients undergoing early laparoscopic cholecystectomy as compared with delayed (3). But all these researches were done in tertiary care units with all the specialised facilities. We wanted to determine its functionality in secondary care unit with limited facilities. Methods: There were 350 patients aged 15–81 (mean 45.2) had cholecystectomy. 99 patients 63 were females aged 17–81 (mean 43.5) and 36 males aged 25–78 (mean 51.5). 47 had early laparoscopic surgery (ELS), 52 has delayed surgery (DS). Results: 99 patients met the inclusion criteria. 47 patients underwent early cholecystectomy whereas 52 patients had interval cholecystectomy. 63.6 % were females and 36.4 % were males. Mean age was 46.23 years in early group and 44.43 years in delayed group. Morbidities, length of hospital stay and readmission until July 2014 were noted. There was no significant difference between the morbidities, complications and readmissions of the two modalities whereas hospital stay was significantly reduced in the early group.
52. Loupe magnification for skin lesion excision: a prospective comparative analysis D. Duggan, K.M. Joyce, J.J. Dorairaj, J.L. Kelly Department of Plastic and Reconstructive Surgery, Galway University Hospital Loupe magnification is used by surgeons to improve visualisation of skin lesion margins. The aim of this study was to compare the use of loupe magnification and normal vision for the excision of basal cell carcinomas (bccs) at our institution. A prospective analysis was carried out for consecutive bccs excised by a single surgeon under local anaesthetic over a three-year period from November 2011 to November 2014. Patients were not randomised to excision groups with or without loupe magnification. Patient demographics, anatomical location, recurrence rate and method of closure were recorded. Statistical analysis was carried out using SPSSv18. A total of 610 bccs were excised with 494 excisions without loupe magnification and 116 performed under loupe magnification. The overall rate of recurrence was 2.3 % (14/610). The rate of recurrence of facial bccs was higher when compared to non-facial bccs (2.3 vs 2.1 %). Loupe magnification was used less frequently on facial bccs (170 vs 292). However, it was more commonly applied when requiring a local flap or skin graft on the face (47.6 vs 19.5 %). Loupe magnification was found to have a lower incomplete excision rate when used for facial bccs compared to without its use (2.4 vs 2.7 %). Our results demonstrate the low recurrence rate of bccs; however, those most likely to recur are located on the face or bccs requiring closure with local flaps or skin grafts. This study supports the use of loupe magnification in these circumstances and particularly in cosmetically sensitive areas.
53. Implementation of a care bundle for surgical site infection—a single centre experience D.O. Connor, A.O. Mahony, S. Abd El Wahab, K.J. Sweeney Department of Surgery, University College Hospital, Galway Surgical site infections (SSIs) are a common and serious cause of morbidity in the post operative period. They constitute a significant economic burden, due to the inflated cost of caring for those affected and to the wider economy owing to a loss of man hours in the working community . The use of care bundles (CB) in the perioperative period has been shown to combat this important healthcare issue . Our aim was to implement an evidence based care bundle in the breast surgery unit at University College Hospital, Galway. Five key, evidence based interventions made up the CB (see Table 1). All components included in the CB were supported by the highest levels of evidence. Observation of current practice and tests of change identified barriers to be overcome for individual components of the CB. Keeping the sterile dressing intact was well accepted by all. Staff members do not routinely perform hair removal preoperatively however patients were not being advised to refrain from this practice. There were practical difficulties monitoring intra operative temperature continuously. Specific instances were identified when antimicrobial use extended beyond best practice guidance and at times skin antisepsis was not most effectively carried out. Through
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 communication with and education of all stake holders these barriers have been overcome. In conclusion, the implementation of a care bundle for a breast surgery service is an achievable goal. However, it effectively requires a paradigm shift in current thinking and practice. Successful implementation warrants the investment of all concerned parties, to facilitate these simple changes in practice.
54. Comparison between laparoscopic partial and radical nephrectomy for renal tumors: healthrelated quality of life L.C. McLoughlin, C. O’Sullivan, N. Kelly, H. Flood, S. Giri Department of Urology, University Hospital Limerick The effect of nephron sparing surgery (NNS) and radical nephrectomy (RN) on patient’s quality of life (QoL) post operatively remains a primary concern to the health care provider, as the long term survival rates are high in patients with small tumours. The impact of the surgical approach on QoL is controversial with contradictory reports published in the literature. We hypothesised that QoL scores post operatively are positively correlated with nephron mass, with less impact on QoL in patients undergoing NNS. Our aim was to compare baseline and post-operative QoL scores in patients undergoing RN and NNS. This is the first study to directly compare baseline and post op QoL scores in patients undergoing laparoscopic RN and NNS. We performed a retrospective longitudinal analysis of 75 patients who underwent laparoscopic NNS or RN at our institution by a single surgeon from 2012–2014. Health-related QoL scores were recorded on the SF-12: Short Form questionnaire. 19 patients underwent laparoscopic NNS, 10 male and 9 female, with a mean age of 57.7 years (34–74 years) and mean pre-operative haemoglobin of 13.5 g/dL (11.2–15.5 g/dL). 56 patients underwent laparoscopic RN, 28 male and 28 female patients, with a mean age of 64.1 years (24–82 years) and mean pre-operative haemoglobin of 10.7 g/dL (8.3–15.4 g/dL). We found no significant difference in baseline QoL scores between the groups. Post-operatively, RN patients had lower QoL scores than NNS patients. RN patients had a greater reduction in baseline QoL scores at post operative follow up. In conclusion, preserved renal mass has a positive correlation with post operative QoL, as demonstrated by increased post operative QoL scores in our NNS group compared to RN patients.
55. Effect of supervised and non-supervised recovery modalities on physiological parameters and mood state following high intensity combat/karate training Brendan Moran National University of Ireland, Galway Background: Stand-up, full contact karate is a combat sport. Intensive training can push athletes to the limits of physical and emotional capacity, and effective recovery strategies are required to enhance performance and prevent injuries and symptoms of overreaching that result from the high intensity of training and competition. The aim of this study was to determine the effect of supervised and non-supervised recovery strategies on physiological parameters and mood state in karate athletes preparing for competition.
S163 Methods: 8 karate athletes performed an identical training schedule each week for 10 weeks while preparing for competition. Recovery consisted of one of three techniques: supervised meditation, supervised massage/stretching and self-directed recovery. Heart rate(HR), BP, and temperature were taken before, during and after training and the recovery period. Additionally, athletes mood was analysed using a Profile of Mood States questionnaire (POMS) before and after training and recovery. Results: HR (expressed in % of Max HR) increased from a mean of 39.9 % pre training to 68.9 % immediately after the work-out. All three methods of recovery were equally effective in restoring athletes HR and BP to pre-workout levels; there was no difference in % max HR at the end of the cool-down between the 3 techniques (supervised massage 56 % vs supervised meditation 57 % vs self-directed recovery 55 %, p = 0.778). Similarly, while median POMS scores increased from 4.6 pre-training to 6.8 after the work-out, there was no significant difference in mood score following recovery between the 3 modalities p = 0.665. Conclusions: These results suggest that self-directed recovery methods are equal to supervised methods for karate athletes undergoing intensive combat training.
56. A bibliometric analysis of the literature on the use of medical apps D. O’Connor, S.M. Abd Elwahab, K.J. Sweeney Department of General and Breast Surgery, University College Hospital Galway The mobile application (or App) was first introduced in 2008 and since then health-related apps remain one of the largest areas of business in the industry. Despite limited regulation, these apps are being increasingly used in the Healthcare sector. The evidence base for such practice rests with peer review publications. The aim of this study, conducted as per PRISMA guidelines, is it to objectively assess the quantity and quality of research into health-related apps using bibliometrics, the science of quantitative analysis of research publications and citations . The databases searched were the Web of Science, Pubmed, Embase, Cochrane library and CINAHL. The MESH terms were: apps, OR applications, AND medical, smartphone, and health. Articles addressing medical applications were included, and those addressing use of non-medical apps for medical purposes were excluded. Analysis was performed using Web of Science tool. The first publication relating to medical apps was in 2009. Since then 725 articles have been published, 271 (37.4 %) articles were eligible for the study. Analysis showed that this research field is in ascendance, with a significant increase in the number of published articles in each consecutive year since 2009. To date, the highest number of publications was in 2013, and for citations was 2014 (see Table 1). Bibliometric analysis of medical apps research show that research in this area is small but appears to be increasing. Given the ubiquity of mobile technology it is critical that research output matches the expansion in health related apps in medicine.
57. Homemade portable laparoscopic trainer: a trainee’s cost-effective model to counteract curtailed training time in the era of european working time directive A. Aslam, G.J. Nason, S.K. Giri
S164 Department of Urology, University Hospital Limerick Introduction: Laparoscopic urologic surgery is becoming the standard of care in increasing number of urological operations. Because of European Working Time Directive (EWTD), the trainees are faced with shortened exposure to theatre time and this has profound effect on acquiring skills for urologic laparoscopic surgery. Cost and access to a laparoscopic trainer are the main hindrance for use of laparoscopic trainer model. We report our experience on a novel homemade laparoscopic trainer model and its effectiveness among trainees to acquire essential basic skills required for laparoscopy. Methods: Online survey using SurveyMonkeyÒ was conducted between 1st of April and 1st of July 2014 to ascertain the challenges faced by Irish urology trainees’ in acquiring laparoscopic surgical skills. A laparoscopic box trainer was constructed using 18 litre translucent plastic storage box, high definition web camera, screws and glue. Disposable laparoscopic instruments were used for various practical tasks. Total cost was calculated. Efficacy was evaluated by feedback questionnaire from trainees and compared with a commercially available expensive laparoscopic trainer model. Results: Online survey results showed a high general interest towards laparoscopy but limited availability of or access to laparoscopic trainers in their institutions. Total cost for each of our model was 70 euro. Feedback was obtained from 20 trainees with the use of this model and commercially available expensive lap trainer model. Trainees’ overall satisfaction was similar but all agreed that it was easy to make and the cost was negligible compared with commercially available one. Conclusions: This homemade laparoscopic trainer is an excellent cost-effective model. It can be used to acquire and enhance basic laparoscopic skills necessary for urologic laparoscopic surgery in the era of EWTD.
58. Prime location for pressure sensor reading in the abdominal aortic aneurysm sac B. Lynch, T.M. McGloughlin, E.G Kavanagh, J. Nelson Centre for Applied Biomedical Engineering Research (CABER) The idea of a non-invasive, remote aneurysm sac pressure measurement was previously explored through the Remon Impressure AAA Sac Pressure Transducer and the CardioMems EndoSure Wireless AAA Pressure Sensor. With respect to the location of the pressure sensors, the clinical trials carried out to date involve two different locations. The Endosure sensor was placed into the aneurysm sac and the Impressure sensor was hand-sewn to the outside of stent graft. However, there is a lack of explanation regarding the choice of location and to the author’s knowledge; a comparative study has not been completed regarding the location and its influence on the acquired pressure measurements. A recent study has shown the potential of sensor ‘‘sandwiching’’ between the endografts and aortic wall resulting in an expression of systemic pressures in the absence of an endoleak (1). The primary focus of this study will be to identify a prime location of a pressure sensor for the measurement of intrasac pressure with a view of early identification of the presence of endoleaks. A number of locations will be examined in an idealised model with a selection of stent grafts. These results will be corroborated using patient specific models. The demand remains to enhance more efficient follow up assessments tools post EVAR so the location of the sensor may be fundamental in maximizing its functionality and performance. Acknowledgements: The authors would like to thank our Funding Source; HEA PRTL I-5 under the Biomedical Engineering and Regenerative Medicine (BMERM) programme.
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59. Ego depletion in surgical trainees M. McCumiskey, D. Dorris, F. Doyle, D. Walsh, E. Doherty, J.C. Coffey University Hospital Limerick, Limerick, RCSI, University College Cork and Graduate Entry Medical School, University of Limerick Ego depletion is a phenomenon which suggests that exerting self control on an initial task, temporarily reduces one’s performance on a subsequent task that also requires self control (1). It has been proposed in the strength model that self control is a limited resource and once it has been depleted, a person has less capacity to exert control over their behaviour and therefore they should perform worse in any subsequent task that involves self control (2). Using a repeated measures design, 20 Surgical Trainees alternatively completed a high and a low depletion task on separate occasions prior to completing the, ‘‘object positioning task’’ on the ProMIS (Haptica, Boston, Massachusetts) laparoscopic simulator. The high depletion task comprised of the participant having to count backwards from 1,000 in multiples of 7 whilst standing on one leg, whilst the low depletion task involved the participant counting from 0 to 1,000 in multiples of 5. In addition to the score’s generated by the ProMIS simulator the time taken to complete the simulation was recorded as well as the number of times the object was dropped. Upon completion of the laparoscopic task they subsequently completed questionnaire. Using the Wilcoxon signed-rank test the overall completion time was shorter following the low depletion task when compared with to the high depletion task P = 0.0304, Z = 2.165. The number of times the participant dropped the object was higher following the high depletion task P = 0.0168, Z = 2.391. This is the first study to show that performance on an object positioning task in surgical trainees may be affected by ego depletion.
60. Serum C-reactive protein as a predictor of anastomotic leak in the first week after anterior resection for rectal cancer I. Reynolds, F. Reilly, A. Deasy, M.H. Majeed, J.P. Burke, J. Deasy, D.A. McNamara Department of Colorectal Surgery, Beaumont Hospital Anastomotic leakage following anterior resection is a major complication, with early diagnosis paramount in reducing its clinical consequences. The current study examined the ability of C-reactive protein (CRP) to predict anastomotic leakage in the first week after anterior resection for rectal cancer. Patients who underwent anterior resection for colorectal cancer and had post-operative CRP assessed in a tertiary referral centre were identified from a prospective database. The primary outcome measure was the area under the curve at receiver operating characteristic (ROC) curve analysis of CRP in relation to anastomotic leak. A cohort of 211 patients was identified. Clinical anastomotic leakage occurred in 15 (7.1 %). The mean age at surgery was 64.2±11.4 years, 70.6 % were male, 47.4 % received neoadjuvant radiotherapy and 67.3 % had a defunctioning ileostomy. The optimal diagnostic accuracy of CRP for clinical anastomotic leak was on post-operative day 4 with an area under the ROC curve of 0.534, a cut-off value of 75 mg/l, sensitivity of 81.8 % and specificity of 37.0 % corresponding to a negative predictive value of 96.8 % but a low positive predictive value (8.1 %). Post-operative CRP has poor diagnostic accuracy in the prediction of anastomotic leakage after anterior resection, but may be of use as a negative predictive test.
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ENT/HEAD AND NECK POSTER ORAL SESSION 1. Detecting internet search trends for mouth cancer since the introduction of mouth cancer awareness day in the republic of Ireland G. Murray, C. O’Rourke, J. Hogan, J. Fenton Graduate Entry Medical School, Limerick, Department of Otolaryngology, University Hospital Limerick Mouth cancer awareness day was launched in the Republic of Ireland (ROI) in September 2010. We aimed to assess internet search trends for mouth cancer subsequent to the annual public mouth cancer awareness campaigns launched in ROI to evaluate whether the introduction of these campaigns correlates with increased Internet search activity for mouth cancer and online awareness. Google Trends was utilized to examine Internet search trends for the terms ‘mouth cancer’ and ‘oral cancer’ across all Google domains between January 2005 and December 2013. Search trends for these terms were limited to users from the ROI. The search volume data collected may be inferred as the probability that a user searched for that specific search term at a particular location and time. Statistical analysis of the data was performed using one-way ANOVA and student t-tests to assess for significant differences in activity. The annual search activity for the term mouth cancer from 2009 to 2013 was recorded, showing a significant increase in search activity in 2010 (p \ 0.001), since the introduction of mouth cancer awareness day. There was a further increase in search activity in 2011, but following this there is a decline in search activity in 2012 and 2013. The mean monthly search activity for mouth cancer was recorded and the trends show that there is a significant increase in average search activity within the month of September (p \ 0.001). Illustrating that September is the most active month for searching mouth cancer. The advent of recent media campaigns and the introduction of mouth cancer awareness day is associated with a significant increase in online activity for mouth cancer in the Republic of Ireland. Novel online technologies appear to provide a useful tool for educating the general public on the symptoms and treatment options available for mouth cancer.
S165 them had an impact factor greater than or equal to 1.350 and were listed in the upper half of the top 40 ENT impact papers of 2013. In total, only 2 journals were noted to have continued to publish meeting abstracts annually since 2002, with 3 additional journals missing only 1–2 years. Overall 6 journals that have previously published meeting abstracts were noted to have now stopped. However 3 of these journals only published meeting abstracts on one occasion since 2002. Of the 39 high-impact otolaryngology journals identified in this study, it was concluded that less than half have published meeting abstracts at least one time between 2002–2013, and only approximately one-quarter continue to do so currently.
3. Reporting of institutional review board approval and informed consent in american otolaryngology journals F. Murray, C. O’Rourke, J. Fenton Graduate Entry Medical School, University of Limerick and Department of Otolaryngology/Head and Neck Surgery, University Hospital Limerick Objectives: Recently published research indicates a poor compliance with the reporting of ethical approval and informed consent in European Otolaryngology journals. This study aimed to assess the incidence of reporting of informed consent and institutional review board (IRB) approval in all original research articles published in 4 major American Otolaryngology journals in 2013. Design: All clinical research articles published in 2013 in the relevant journals were reviewed. Participants: Annals of Otology, Rhinology and Laryngology, Head and Neck, Otolaryngology—Head and Neck Surgery and the Laryngoscope.. Results: 981 articles were reviewed, of which 814 met the inclusion criteria of this study (articles reporting on human subjects including identifiable human material or data, which require ethical approval.) 36.0 % of the papers reviewed provided no statement of IRB approval while 66.5 % failed to report acquisition of informed consent. There were significant differences in the reporting of both IRB and informed consent between the various journals. Conclusion: Acknowledgment of IRB approval and informed consent are frequently omitted in published research articles in major otolaryngology journals.
2. The Publication of biomedical meeting abstracts in high-impact otolaryngology journals L. Kieswetter, C. O’Rourke, J. Fenton Department of Otorhinolaryngology, University Hospital Limerick, Limerick The aims of our study were to assess the current number of otolaryngology journals publishing meeting abstracts. In addition, from 2002–2013 we hoped to identify the number of ENT journals that previously published meeting abstracts and have since stopped doing so, as well as gain insight into why they stopped. Our study was conducted using the journal of citation reports for 2013 in which we identified and selected the top 40 Otolaryngology journals based on impact factor. We retrospectively reviewed each volume and encompassing issues from 2002–2013 for evidence of published meeting abstracts. We were able to analyse 39/40 journals. Of 39 journals investigated, 41 % (n = 16) were noted to have published abstracts of posters and papers presented at associated biomedical meetings between 2002–2013. Of these 16 papers, 12 (75 %) of
4. To examine what percentage of patients referred to centre for tongue tie release were referred for breastfeeding difficulties and how many of them stopped breastfeeding as a result C. Nolan, P. Corry, C. O’Rourke, J.E. Fenton University of Limerick Aim: To examine what % of patients referred to centre for Tongue Tie release were referred for breastfeeding difficulties and how many of them stopped breastfeeding as a result. Methods: Observational analysis with planned data collection. Examining all paediatric patients referred to a tertiary referral centre over a 1-year period. Results: 96 patients were included, with a male:female ratio of 2:1. 87 % were specifically referred due to breastfeeding difficulties, with the median age at referral being 15 days. 28 % of women had stopped
S166 breastfeeding as a result of complications potentially related to the tongue-tie including: difficulty latching on (35 %), sore nipples (24 %) and baby failing to gain weight (6 %). Referral to the centre was made either by the GP (42 %) or lactation nurse (36 %). The average length of time awaiting appointment with ENT was 46 days. On examination of the patients, the median grade of tongue-tie found was 3. 30 % of patients required a general anaesthetic, with these patients having a higher average age. The incidence of complications as a result of the surgery was reported as 3 % with prolonged or excessive bleeding being the only complication identified. Conclusion: This study identifies a high incidence of breast feeding difficulties in mothers of children who are referred for tongue tie procedures.
5. Audit of GP referrals for tonsillectomy to the ENT clinic using present HIQA guidelines
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 nodules should undergo fine needle aspiration. Various sonographic characteristics of a thyroid nodule have been associated with a higher likelihood of malignancy. Purpose: To investigate which sonographic features are predictive of malignancy (thy 4/5) in thyroid nodules. Also to investigate which sonographic features are predictive of malignant final histology in nodules of all thy classifications. Methods: Retrospective review of 811 US-FNAs. Thy-1 cases were excluded. Results: 110 Thy-1 s were excluded. There was 499 thy 2 cases, 175 thy 3 cases and 27 thy 4/5. We found that size, any calcifications and presence of a solitary nodule were not predictive of malignancy. The presence of microcalcificaitons and solid consistency were predictive of thy-4/5 cytology. Microcalcifications were significantly more common in thy-4/5 than thy 2 (p = 0.02), not significant vs. thy 3 (p = 0.10). Solid significantly more common in thy4/5 than thy 2 (p = 0.005), and also vs. thy 3 (p = 0.03). Size thy-4/5 vs. Thy 2 not significant p = 0.15. Conclusion: Solid nodules and nodules with microcalcifications are predictive of malignancy and should be prioritized for FNA.
I. O’Riordan, W. Hasan, E. Keane, J. Kinsella, D. McShane Otolaryngology, Head and Neck Surgery Department, Tallaght Hospital Introduction: Recurrent sore throat for possible tonsillectomy is the commonest clinical entity referred to the ENT out patient department. The numbers involved represent a large clinical burden on the service. Not all of these patients require surgical interventions. The aim of this study was to analyse the percentage of referred patients with sore throats requiring tonsillectomy versus those not needing surgery, using the present HIQA guidelines for this operation. Methods: A prospective study of one hundred consecutive patients of all ages referred to our ENT clinic in Tallaght hospital with recurrent sore throat for possible tonsillectomy was undertaken. A proforma abased on the exact HIQA guidelines for tonsillectomy in patients with sore throat was completed during each consultation. Patients were booked for tonsillectomy, discharged back to their GP or reviewed after 6 months in the clinic. Results: Provisional results indicate that a significant number of referrals for possible tonsillectomy did not meet the HIQA criteria for this operation. Conclusion: Improved awareness by GPs of the HIQA guidelines for tonsillectomy would significantly reduce the number of referrals to the ENT outpatient service. An educational programme in this regard for GPs would likely have a significant effect in reducing waiting times for ENT outpatient appointments. Also consideration should be given to a specialist nurse led assessment service whereby unnecessary referrals can be screened out and returned to the referring doctor.
6. Ultrasonographic characteristics of thyroid nodules and prediction of malignancy. A review of 800 US guided FNAS C. Brophy, J. Stewart, J. McCarthy, S. Blake, M.S. Murphy, P. Sheahan Department of Otolaryngology, Head and Neck Surgery, South Infirmary Victoria University Hospital, Cork Introduction: Thyroid nodules are common in the general population, being present by palpation in up to 5 % of individuals, and by ultrasonography in up to 50 %. Ultrasound guided fine needle aspiration (FNA) cytology represents a first line diagnostic tool for thyroid nodules. Certain sonographic features may predict which
7. Thyroid cancer in Ireland: a ten-year review of the national cancer registry P. Lennon, S. Deady, M.L. Healy, J. Kinsella, C.I. Timon, J.P. O’Neill St James Hospital Dublin, National Cancer Registry Ireland and RCSI The increased incidence of thyroid cancer is driven mainly by a large increase in Papillary thyroid cancer (PTC). The number of patients that succumb to the disease has remained stable. The aim of our study is to analyze the incidence and mortality of thyroid cancer in Ireland. A retrospective analysis of the National Cancer Registry was undertaken, between 1st of January 1998 and the 31st December 2007. The Kaplan– Meier method was used to determine overall survival using Stata 13 software. A total of 949 patients were diagnosed, 781 (82.2 %) were welldifferentiated thyroid cancers (Papillary 565, Follicular 177, Hurtle Cell 39) whilst there were 44 medullary thyroid cancers and 61 anaplastic thyroid cancers. The female to male ratio was 3:1, with a median overall age of 47. This was significantly lower in women at 45, then men at 52 (p = 0.0000). The incidence of thyroid cancer increased from 1.43/ 100,000 to 3.61/100,000. This increase was in the mainly attributed to PTC, rising from 0.63 to 2.46/100,000. The number of deaths from the disease remained stable at 0.63–0.59/100,000. There was no survival difference between those under going total thyroidectomy versus thyroid lobectomy for PTC (hazard ratio 0.868, 95 % CI 0.598–1.26, p = 0.457). These results correlate with studies that demonstrate that although an increase in incidence of thyroid has been found, the number of patients dying from the disease has remained stable. This emphasizes the need for a new treatment paradigm of risk stratification in order to ensure maximum benefit for the patient.
8. Medullary thyroid cancer: outcomes and prognostic indicators within the Irish population P. Lennon, S. Deady, M.L. Healy, J. Kinsella, C.I. Timon, J.P. O’Neill St James Hospital Dublin, National Cancer Registry Ireland and RCSI Medullary thyroid cancer (MTC) accounts for approximately 5 % of all thyroid cancers, but represents 13.4 % of deaths attributed to
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 thyroid cancer. The RET proto-oncogene has been recognized as an integral part of MTC tumorigenesis. The aim of our study is to evaluate the prognostic factors and outcomes of patients diagnosed with medullary thyroid cancer in Ireland. A retrospective analysis of a national cancer database the National Cancer Registry in Ireland was examined for patients with a diagnosis of MTC between January 1998 and the June 2007. The Kaplan–Meier method was used to determine overall survival and factors predictive of outcome were determined by univariate and multivariate analysis by cox regression using Stata 13 software. Of a total of 45 patients, 25 were female and 20 were male. The median age was 52, 66.7 % presented at an advanced stage and 8 patients had metastases at diagnosis. The overall median survival was 6.63 years and the 1 and 5-year overall survival was 89.9 and 64.4 % respectively, with a 10-year survival for those with long-term followup available being 53.4 %. On univariate analysis age, stage (including T stage, cervical nodal metastases and distant metastases at diagnosis) and smoking status were statistically significant indicators of prognosis. T stage and age remained statistically significant on multivariate analysis. The poor overall survival in our series is disappointing but may represent a specific cohort of aggressive MTC or the older age of our patients. Further research is being conducted on the RET proto-oncogene within this cohort.
9. Infectious mononucleosis: frequently asked questions P. Lennon, M. Crotty, J.E. Fenton University Hospital Limerick and General Practice, Edmonton, Alberta Infectious mononucleosis (IM) is commonly seen both in the community and in the hospital setting. The aim of this review is to assist those that may have to navigate the sometimes-choppy waters of Infectious Mononucleosis in adolescents and adult population by examining the pertinent recent literature. A search was performed using Medline, Scopus, Google Scholar, the Cochrane Database of Systematic Reviews and the Cochrane central register of controlled trials. We gave priority to data from meta-analyses, reviews, and randomised controlled trials. IM is a non-genetic syndrome, defined by fever, pharyngitis, cervical lymphadenopathy and lymphocytosis. In the primary care setting, a clinical diagnosis alone may be sufficient to allow adequate management of a patient. In a small number of cases, where either the patient is pregnant or is in a high-risk group for HIV infection, further testing for CMV, HIV and other possible causes for Infectious Mononucleosis should be undertaken. Treatment of IM is in the main supportive with meta-analyses finding no support for acyclovir or steroids in routine cases. Metronidazole may provide an alternative treatment. Although often associated with IM, a recent Lancet editorial commented that that chronic fatigue syndrome is unlikely to be a consequence of EBV. Those wishing to return to contact sport at 3-4 weeks should have an ultrasound to ensure their spleen have returned to a normal size. IM is also associated with multiple sclerosis and Hodgkins lymphoma. This is a complex syndrome this review highights the need for ongoing research on this topic.
10. A preliminary study of the intracranial multilayer flow modulator and its ability to occlude cerebral aneurysms S. Sultan, E.P. Kavanagh A. Alves, I Wanke, D. Ruefenacht, N. Hynes
S167 Western Vascular Institute, Department of Vascular and Endovascular Surgery, University College Hospital Galway, Galway Clinic and NAMSA, Chasse-sur-Rhoˆne, France. Institute of Diagnostic, Interventional Radiology and Neuroradiology, University Hospital Essen, Germany. Neuroradiology, Swiss Neuro Institute, Clinic Hirslanden, Zurich, Switzerland. An estimated 6 million people in the United States have an unruptured brain aneurysm, or 1 in 50 people . The purpose of this study was to evaluate the ability to occlude cerebral aneurysms with the Cardiatis (Isnes, Belgium) intracranial multilayer flow modulator device, demonstrating local biocompatibility as well as device integration. The devices were implanted in the subclavian artery of 6 rabbit models, following induction of an aneurysm in the right carotid artery, collateral to the implanted segment of the subclavian. Device placement was performed 4 weeks after aneurysm creation, and for an implantation duration of 4 weeks. Gross examination and histopathological analysis showed the aneurysmal areas of all six specimens were obturated with an old mixed thrombus, showing the lines of Zahn. The devices were also markedly integrated into the arterial wall with no evidence of local intolerance, and no aneurysm rupture or leakage. Energy dispersive x-ray analysis of the specimens revealed that in all areas investigated in the tissues surrounding the device struts, there was an absence of nickel and titanium release. According to Wong et al. , the ultimate treatment goal for intracranial aneurysms is to reconstruct the vessel wall and correct the hemodynamic disturbance. A flow diverter has the ability to do this. These results demonstrate the basic mechanism of action of the multilayer flow modulator, its ability to modulate flow from turbulent to laminar, thereby encouraging organized thrombus formation. With initial clinical trials showing positive results, the intracranial multilayer flow modulator is a feasible treatment option for cerebral aneurysms. Studies using a larger cohort are necessary to further assess hemocompatibility, local and systemic safety and effectiveness. Conflict of interest/Disclosures: This study was sponsored by Cardiatis (Isnes, Belgium).
ANESTHESIA POSTER SESSION 11. Does the aging process have an effect on patients’ concerns and expectations in relation to chronic pain? M. Mc Loughlin, A. Imran, D. Harmon Department of Pain Medicine, University Hospital Limerick We explored the expectations and concerns of chronic pain patients younger than 65 years old and compared these to patients over 65 years. Patients attending the pain clinic for the first time pre-recorded their expectations through a questionnaire. At their first appointment, patients were asked by the physician if they had any concerns about their chronic pain and this data was recorded by the physician. Forty percent of these patients were older than 65 years and sixty percent were younger. The most common site of pain was the back for both younger and older patients. As was recently found at this pain clinic, patients’ chief expectation, regardless of age, was ‘‘some pain relief’’. Younger patients expected education about their condition
S168 and to be involved in a management plan, which was not deemed as important by older patients. A greater number of older people were concerned about falling than younger patients. Younger patients were more worried about side-effects from analgesia than older patients, and also more concerned about the adverse effect that pain was having on their career. Both older and younger patients were concerned about a lack of sleep. A greater number of younger patients stated that chronic pain was having an adverse effect on their mood. Identifying expectations and concerns of all patients, young and old can lead to more individual tailored treatment plans, greater adherence to treatment and increased satisfaction for both patients and physicians.
12. Preoperative anaemia in the elective orthopaedic surgical patient in University Hospital Limerick J.O. Connor, D. Harmon Department of Anaesthesia, Limerick University Hospital, Limerick Aims: The aim of this audit was to compare the approach of UHL to anaemia among elective orthopaedic patients in comparison to the NATA guidelines  and improve on any deficiencies in an attempt to decrease patient morbidity, blood transfusion and need for ICU stay. Methods: Retrospective data was collected on each patient who had an elective joint replacement surgery in UHL September 2014. Each patient’s blood test results were checked to see if they had a full blood count performed as close to 28 days prior to their surgery. If any patient met the WHO criteria for anaemia then further blood tests and/or referrals and/or prescription of various medications should have been performed as per the NATA algorithm in Figure 1. Results: 39 patients had primary joint replacements in Sept 2014 in Croom Hospital Limerick. 19 were male. 1 patient did not have a preop FBC and was excluded. 5 patients were anaemic pre-op (3 male). None of these patients had iron studies performed. Neither was any patient referred to a gastroenterologist or nephrologist. No patient was prescribed any medications to treat their anaemia. The mean number of days to evaluation of FBC pre-op was 28.7 days (range 1 day to 180 days preop). Conclusion: The majority of patients had an FBC performed 28 days prior to their surgery. 15.4 % of patients were found to be anaemic pre-op. Due to no local consensus on anaemia and lack of awareness of NATA guidelines, no further evaluation or management was planned to optimise these patients for surgery. Further education and discussion re NATA must take place to institute a local policy on preoperative anaemia.
13. Perioperative management of patients with opioid tolerance H. Misran, C. Trebuain, W. O’Brien, D. Harmon Department of Anaesthesia, University Hospital Limerick The perioperative management of patients with opioid tolerance is a particularly challenging aspect of anaesthesia. We present a 44-yearold chronic opioid consumer undergoing elective laparoscopic abdominal surgery with a minimum intravenous morphine intake equivalent to approximately 180 mg in 24 h.
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 This patient was known to the Chronic Pain Service for a history of chronic lower back pain and dependence on fentanyl transdermal patches and short-acting lozenges. Her past medical history included spina bifida occulta, ankylosing spondylitis, sacroiliitis, asthma and lumbar spinal fusion. Her primary concern was a fear of opioid withdrawal symptoms, contributing to her maladaptive overuse of fentanyl lozenges. Because she had refused neuraxial blockade, the pharmacological pain management plan included simple analgesics, opioid adjuncts, regional anaesthesia, wound infusion catheter techniques, and patient controlled analgesia with twice the standard morphine concentration. Additionally, she was reviewed pre- and post-operatively by the Acute Pain Service to monitor and wean opioid use, as well as to reassure and educate the patient and carers involved. While international1 and local2 guidelines have been published, there are few large-scale trials available on which to base such guidelines, specifically those targeting patients with opioid tolerance. Indeed much of what is known regarding this patient population exists merely in case reports, clinician’s experiences, and expert opinion. This highlights the difficulties encountered in managing perioperative pain in patients with opioid tolerance.
14. Continuous central venous oxygen saturation assisted intraoperative hemodynamic management during major abdominal surgery may improve outcome A. Mikor, D. Tra´sy, M.F. Ne´meth, S.Z. Kocsi, A. Osztroluczki, I. Kova´cs, G. Demeter, Z.S. Molna´r Department of Anaesthesiology and Intensive Therapy, University of Szeged, Hungary Background: Major abdominal surgery is associated with significant risk of morbidity and mortality in the perioperative period. Optimizing intraoperative fluid administration may result in improved outcome. Our aim was to compare the effects of central venous pressure (CVP), and central venous saturation (ScvO2)-assisted fluid therapy in patients undergoing high risk surgery. Methods: Patients undergoing elective major abdominal surgery and admitted to the intensive care unit were randomised into control, and ScvO2 groups. The target level of mean arterial pressure (MAP) was C60 mmHg. In case of MAP \60 mmHg patients received either a fluid or vasopressor bolus according CVP \8 mmHg in the control group and ScvO2 \75 % in the ScvO2 group. In the ScvO2 group\75 or [3 % drop of ScvO2 were also followed by interventions. For statistical analysis one-way ANOVA, independent sample T-test, Mann-Whitney test and Chi square test were used. Results: Patients in the ScvO2 group (n = 38) received more colloid as compared to the control group (n = 41) [279 (161) vs. 107 (250) ml/h; p \ 0.001]. Both groups received similar amount of crystalloid (1,126 ± 471 vs. 1,049 ± 431 ml/h; p = 0.46) and norepinephrine [37 (107) vs. 18 (73) mcg/h; p = 0.84]. In the ScvO2 group more patients received blood transfusion (ScvO2 group: 63 % vs. control group: 37 %; p = 0.018). There were more patients with complications in the control group, the difference was not significant (ScvO2 group: 10 vs. control group: 19; p = 0.07). Conclusion: ScvO2-assisted intraoperative haemodynamic support, resulted in fewer postoperative complications and seemed superior to CVP-assisted fluid management during major abdominal surgery. Conflicts of interest: Dr Molnar is the member of the PULSION Medical Advisory Board, and receives occasional honoraria for lectures.
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15. A survey of chronic pain patients’ experiences in the emergency department G. Fitzpatrick, S.O. Chonghaile, D. Harmon Beaumont Emergency Department and Department of Anaesthesia, Limerick University Hospital Objective: Chronic pain patients represent a unique challenge in the Emergency Department. Very little literature has been published regarding this group of patients. Our aim was to determine the attitude of patients with chronic pain to the Emergency Department in order to improve and streamline their future visits. Methods: A 2-year survey was carried out on Chronic Pain Patients regarding their Emergency Department Attendances. Patients attending the Pain Clinic in Croom Hospital, Co. Limerick were asked to complete a 20-part questionnaire regarding their experiences of visiting the Emergency Department in the preceding year. 41 questionnaires were completed. Results: Unbearable breakthrough pain was the main reason for visiting the Emergency Department. More than half (54 %) of those surveyed were not satisfied with the treatment received. Problems indicated included under-treatment of pain (57 %), a sense of being under undue suspicion of drug-seeking behaviour (33 %) and a perception that the patient themselves understood their condition better than the treating doctor (76 %). 69 % were offered paracetamol, NSAIDs, or time off work—all of which treatments could have been provided by their General Practitioner. Only 4 % were offered a nerve block. 71 % felt that the creation of personalised Patient Plans, consisting of an agreed plan between the patient, their pain specialist, and the Emergency Department, would expedite their trip through the Emergency Department. Conclusions: This survey provided many useful insights into Chronic Pain Patients attitude to the Emergency Department. Closer liaison with the Chronic Pain services and the patients themselves may improve the quality of care provided to patients in the future. 54 % are not satisfied with the treatment they receive in the Emergency Department. 57 % believe the ED doctor sees chronic pain as a mental issue. 28 % feet they have to over-emphasis their pain in order to get the Emergency Department doctor’s attention.
16. Epidural block assessment in an obstetric setting D. Burns, J. Shannon Department of Anaesthesia, University Hospital Limerick We surveyed a group of labour ward based midwives on in this regional maternity hospital with approximately 5,000 births per annum. The aim was to determine levels of training and practice with regard to the objective assessment of the performance of continuous infusion epidurals. A questionnaire of staff and review of patient charts took place both prior to and following training in this topic. The protocol in place at the commencement of this study did not include the requirement for assessment of the block performance by midwife staff. A new protocol which included this as standard practice was subsequently introduced. There were 22 responders to the initial survey. Overall the numbers with formal training in this topic was low at 9 % with all those trained having been trained in other centres. The rate of routine assessment was 27 % and non-routine (in cases of pain) being 50 %. The overwhelming number of responders ([95 %) indicated an interest in training on this topic. A survey of patient charts indicated that no such assessments were formally recorded. Following training and the introduction of a new protocol for epidural management, the self reported practice of the staff achieved
S169 close to 100 % compliance with the new protocol and an audit of patient charts also reflected this significant increase in use of and recording of objective assessments. The improvement in outcomes are expected to include earlier identification of inadequate block and more timely top ups of epidurals with an improvement in pain control.
ORTHOPAEDIC POSTER SESSION 17. Internal immobilisation versus external immobilisation for primary anterior shoulder dislocations—a systematic review and meta analysis I. Feeley, G. Rattan, J. Lunn, E. Sheehan Midland Regional Hospital, Tullamore and University of Limerick Introduction: The standard treatment of primary anterior shoulder dislocations has been internal rotation immobilisation with studies showing that this method has a high recurrence rate. Recent studies have been exploring the possible benefits of immobilising the shoulder in external rotation and comparing it to internal rotation. The objective of this review was to look at these various studies and assess the conclusions reached. Methods: A search of PubMed, Embase, The Cochrane Library and AMED was conducted to find studies comparing immobilisation in external and internal rotation and their efficacy in preventing recurrent shoulder dislocations. Results: Seven studies were included with a total of 672 patients were included. There were 330 patients in the internal rotation group and 342 patients in the external rotation group. There were 64 patients lost to follow-up. 145 of 301 (48.2 %) patients in the internal rotation group experienced a dislocation or subluxation. 106 of 307 (34.5 %) patients in the external rotation group experience a dislocation or subluxation. Meta analysis of the data showed a statistically significant increase in the relative risk for re-dislocation in those treated with internal rotation rather than external rotation [RR 1.433 (95 % CI 1.130–1.818)]. Conclusion: External rotation is a lesser utilised mode of immobilisation which shows potential for reducing the number of recurrent dislocations and subluxations post primary dislocation.
18. Knee flexion as a means to reduce blood loss post total knee arthroplasty S. Sasikumar, I. Feeley, D. Niall University of Limerick, Limerick and Midland Regional Hospital Introduction: Adjusting knee position post total knee arthroplasty has been mooted as a simple, cost-effective intervention to reduce blood loss. Recent studies have demonstrated that knee flexion 24–48 h post-surgery may lead to a decrease in markers such as hemoglobin loss, hematocrit and transfusion requirements. This systematic review assesses the literature to highlight current evidence of the effectiveness of knee flexion in reducing blood loss. Methods: The keywords ‘‘total knee arthroplasty’’, ‘‘total knee replacement’’, ‘‘blood loss’’, ‘‘post-operative management’’, ‘‘knee flexion’’ and ‘‘limb position’’ were applied to retrieve articles from various databases, regardless of their year of publication. Results: The search strategy revealed 7,310 articles, and six final manuscripts were used for the purpose of this systematic review.
S170 Outcome measures assessed in this review were difference in pre- and post-operative haemoglobin levels, haematocrit, estimated blood loss, number of blood transfusions and RBC count. Conclusions: Knee flexion in the post operative period reduces blood loss in total knee arthroplasty surgery. Published outcomes varied based on flexion regimes and sample size. Flexion at an angle of 70° or more, for 6 h or longer, is an effective means of reducing blood loss in the post-operative recovery of a TKA patient.
19. A systematic review assessing surgical versus conservative management of the true jones fracture J.A. Yates, G. Rattan, S. Sasikumar, I. Feeley Department of Surgery, Midlands Regional Hospital Tullamore This study assessed the outcomes of surgical versus conservative management in the treatment of the Jones fracture. A systematic review using four databases from their inception until September 2014 was undertaken. 6 studies were found that had both surgical and non-surgical groups. Statistical analysis was carried out using STATA 13.1 (Stata Statistical Software: Release 13. College Station TX: StataCorp LP). Six studies including 237 patients were found. 122 patients were treated conservatively while 115 had surgery. Patients treated conservatively had a significantly higher risk of developing nonunion at 1.22 (95 % confidence interval (CI) 1.10 to 1.36), a prolonged healing time, and a longer time to return to sports. Surgery significantly improved time to union in 3 of 4 trials found. There were more complications amongst patients undergoing conservative treatment. This review found in favor of surgical intervention of the Jones fracture due to the decreased nonunion rate, improved time to union, and fewer complications. There is a need for further randomized control trials to determine optimal operative treatment.
20. Factors contributing to patients’ non-attendance at orthopaedic and bone health clinics post hip fractures P.N. Stassen, F. Coughlan, J. Mahon, N. Maher, M. Casey, J.B. Walsh, R. Lannon, K. McCarroll Department of Surgery, Trinity College and St. James’s Hospital, Dublin Background: To try and identify in-patients who are likely to be nonattenders in follow up clinics with the aim of improving attendance rates and thereby reducing patient morbidity and improving their quality of life. Methods: A list of the hip fractures in St. James’ Hospital for 2013 and 2014 were cross-matched against both the bone health and orthopaedic follow up Out Patient Department (OPD) clinics to identify the Did Not Attends (DNAs). Data was collated for a number of parameters to identify the common factors, which may pre-dispose patients to becoming DNAs. Results: We collated and analysed data on parameters including: Patient medications, re-fracture rates, type of fracture and fixation, cognitive score. Bone health n = 51 (mean age = 81.5). Ortho n = 159 (mean age = 80.9). DNAs for the bone health clinic was 15.67 % (male = 3.9 %, female = 11.77 %).
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 DNAs for the orthopaedic clinic was 35.22 % (male = 18.64 %, female = 16.58 %). 62.5 % of DNAs at bone clinic were also DNAs at Ortho clinic. The vast majority of patients were seen perioperatively by an Orthogeriatrican. Conclusions: We recommend that the bone health and orthopaedic follow up clinics be held on the same day so that patients only have to make one visit to the hospital. We also recommend that patients (and their families/carers) are educated while in-patients as to the importance of attending the follow up clinics. Finally, an early identification system should be implemented, which would identify patients who are likely to be DNAs.
21. Systematic review of complications in spinal surgery: a comparison of retrospective and prospective study design C.L. Power, S. Henari, J. Street, B. Lenehan University of Limerick Graduate Entry Medical School and University Hospital Limerick, Department of Surgery, CNOSP Vancouver General Hospital, University of British Columbia This paper aims to systematically review the existing literature relating to complications of spinal surgery, in order to examine for a consensus of complications across papers and to evaluate the merits of prospective versus retrospective study design. The key words ‘‘spine surgery’’ and ‘‘complications’’ were chosen, and a MEDLINE search was performed for the years 1992–2012. We restricted our review by using only English language publications from core spine journals, focusing on adult, non-oncology patients. All abstracts were reviewed by two authors (SH and BL), with consensus reached for inclusion. In each publication we noted the site of surgery, study design, year of publication, duration of follow-up, complication type, procedure level and method of complication collection. All data was inputted on an Excel database. Our search revealed 985 papers, of which 226 met our inclusion criteria. Prospectively collected studies had a higher overall reported complication rate than retrospective studies. Twenty of 158 retrospective studies reported no complications or failed to mention them, while 6 of 68 prospective studies reported no complications or failed to mention them. Across articles there was no consensus of complications, and methodology often failed to establish a reporting system. This study identified a significant rate of complications relating to spinal surgery. We identified that prospective study design is more effective when accounting for these complications, representing a significant issue that is best studied prospectively with adherence to strict study controls.
22. Christmas tree related lower limb trauma—a festive case series of serious lower limb fractures P.M. McQuail, J.F. Baker, S. O’Flanagan, P. Keogh, P. Kenny Department of Trauma and Orthopaedics, James Connolly Memorial Hospital A number of celebratory seasons have acknowledged associated increases in trauma, with hand injuries and burns representing the majority in both the Eastern and Western World. Arguably the largest festive period in the Western world is Christmas. Despite this, there is an absence of literature documenting any associated increase in trauma specific with this period.
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 We report a series of severe lower limb injuries in the first week of December related to decorating the Christmas tree that accounted for a disproportionate share of the trauma admissions to a district hospital. We reviewed theatre logbooks and inpatient lists over the Advent period (typically December 1st until Christmas Day) in our institution. Injuries sustained when decorating the Christmas tree were identified and case histories reviewed. In the first 7 even days of Advent, trauma indirectly or directly relating to decorating the Christmas tree comprised 20 % (3/15; 2 male, 1 female) of all trauma admissions to the Trauma and Orthopaedic Unit. Furthermore, the injuries sustained were severe in grade; two patients sustaining an open Pilon fractures and one a closed medial sub-talar dislocation. Every year in the UK, approximately 1,000 people are injured by their tree, usually while fixing stars, lights or other decorations to the higher branches. However, this is a unique series of serious lower limb injuries as a result of decorating the Christmas tree in domestic settings and has not been described before in the literature. A safety campaign may be useful if the overall burden can be calculated.
S171 Background: Quadriceps tendon (QT) ruptures are significant injuries that are relatively uncommon. The diagnosis of QT ruptures are frequently missed or delayed. An association between the presence of a patella spur and QT ruptures has been suggested in the literature. Patients and methods: The Hospital Inpatient Enquiry system was used to gather data on all patients who sustained a QT rupture over a 5 year period from 2009 to 2013. A retrospective review of the medical notes and radiographs was undertaken. We reviewed 200 knee radiographs of patients without QT ruptures to establish the incidence of patella spurs in our normal population. Statistical analysis was performed using SPSS version 11.5 for Windows. Results: The records of 20 consecutive patients with 21 QT ruptures were reviewed. The average age was 60.9 years (range 44.9–82.1 years) and the majority were male (85 %). There was one bilateral QT rupture. Patella spurs were noted in 13 (62 %) patients which was significantly higher than patients without a QT rupture 19 % (p \ 0.05). Conclusion: We noted a significantly higher incidence of patella spurs in patients with QT ruptures compared to those without. The presence of a QT rupture should be ruled out in patients with a knee injury and a patella spur on the knee radiographs.
23. Diathermy awareness among surgeons-adequate or inadequate? P.M. McQuail, J.F. Baker, P. Kenny Department of Trauma and Orthopaedics, Connolly Hospital Blanchardstown Diathermy is an integral part of many modern surgical procedures. The basic principle of diathermy now is used in many permutations to yield advanced techniques in minimally invasive procedures. While diathermy is generally accepted as ‘safe’ in the United States, electrosurgery-induced injuries are among the commonest cause for malpractice lawsuits. The purpose of this study was to evaluate the awareness among surgeons of the principles, risks, precautions and appropriate use of diathermy. All surgeons employed from Senior House Officer (SHO) to Consultant grade in two teaching hospitals were surveyed. 85 surgeons were asked to complete an anonymous questionnaire which recorded level of training and addressed competence in principles, hazards, and precautions to be taken with diathermy. 8 Consultants, 5 Specialist Registrars, 19 Registrars and 13 SHO’s responded (71 % response). All but three subspecialties were represented. 82 % (37/45) had no formal diathermy training. Despite 89 % (40/45) of surgeons regarding diathermy as a safe instrument, 56 % felt they had inadequate understanding of the principles and failed to demonstrate an appropriate awareness of the potential risks. 51 % exhibited a dangerous lack of awareness in managing equipment not yielding the desired effect and 22 % were unaware of any patient groups requiring special caution. Only 42 % wanted formal training. This study found a lack of awareness of diathermy principles and hazards among surgeons. This puts patients and staff at potential risk of serious morbidity. An effort is needed to ensure surgeons across all grades are safe in their use of diathermy.
24. Is there an association between patella spurs and quadriceps tendon ruptures?
25. Upper limb surgeons—so you think you’re funny! a study of nominative determinism in orthopaedics P.M. McQuail, J.C. Kelly, K. O’Shea Department of Trauma and Orthopaedics, St. Vincent’s University Hospital, Dublin Nominative determinism describes how names can influence and determine life choices based on the name. Recent research demonstrates that nominative determinism can play a role in patient’s health and also determine career choices. Our objective was to ascertain whether a sub-speciality interest is an indirect marker of your usage level of humour that is, are those specifically interested in the humerus more humorous by nature. The ‘Richmond Humour Assessment Instrument’ (RHAI) was issued to Orthopaedic Surgeons of Specialist Registrar and Consultant level in a variety of sub specialties. A focal assessment of Upper limb surgeons was sought at the annual meeting of the Irish Hand Surgery Society. A comparative analysis was performed. 115 Questionnaires were issued with a 60 % response rate. Orthopaedic Surgeons with a sub-speciality interest in Upper limb surgery had an average score of 56.6/80 on the RHAI. The subspecialities found to be the least characteristically comical were Foot and Ankle and Spinal surgery, scoring averages of 53.5/80 and 55.9/ 80 respectively. Orthopaedic surgeons with a subspecialty interest in the humerus/ Upper Limb Surgery demonstrate high levels of humour usage on a daily basis. This comparison is significant when compared to their colleagues in spinal and foot and ankle surgery.
26. A case report of a bosworth fracture-dislocation ankle injury G.A. Kelly. D.I. Morrissey, M.E. O’Sullivan, S.R. Kearns
N. Svirkov-Vainberg, P. Ellanti P, A.R. Moriarity, Ni Fhoghlu, T. McCarthy Department of Trauma and Orthopaedics, St. James’s Hospital, Dublin
Department of Orthopaedic Surgery, University College Hospital Galway Acutely irreducible ankle fractures are uncommon and represent an orthopaedic emergency. Cases of irreducible ankle fractures with
S172 associated dislocation and entrapment of the proximal fibular fragment posterior to the tibia are known as a Bosworth Fracture. This fracture is a very rare injury in which closed reduction is difficult. Repeated attempts at closed reduction may cause further joint damage, while delays in reduction lead to further soft tissue damage. We report on a 44 year old female who presented with an irreducible Bosworth-type fracture. A CT scan was obtained pre-operatively to delineate the fracture fragment orientation and urgent ORIF was performed via a posterolateral approach. This case underlies that a good outcome can be achieved provided they are accurately recognized and promptly treated.
27. A case study of three abscesses of iliopsoas: variety in etiology, presentation and organisms G. Crozier Shaw, P. Magill Department of Orthopaedic Surgery, AMNCH (Tallaght) Hospital, Dublin Iliopsoas abscesses present with an inconsistent variety of clinical signs and symptoms and as such, can present a diagnostic challenge. Furthermore, delayed diagnosis can be dangerous. They are not uncommon yet it remains unclear why the iliopsoas muscle, in comparison to other tissues, is particularly prone to harboring abscesses. Certain theories exist such close proximity to bowel and rich vascularity yet these are unproven and often incongruent with clinical presentation. We present 3 cases that highlight these points: A 73-year-old man presented in septic shock and with unilateral L5 radiculopathy. He was diagnosed with a large iliopsoas abscess communicating with his total hip prosthesis. The organism cultured was staphylococcus aureus. He underwent percutaneous abscess drainage and two-stage revision of his hip replacement. It was not possible to clarify if the abscess was primary or secondary to an infected hip prosthesis. A 35-year-old healthy man sustained a ‘groin strain’ after a hyperabduction injury. He then developed a staphylococcus epidermidis iliopsoas abscess 5 days later. This spread into his native hip joint. He underwent two-stage primary hip replacement. A 29-year-old woman presented with low back pain 2 weeks postpartum. She had signs of systemic sepsis and was diagnosed with an iliopsoas abscess which grew streptococcus pneumonia. She was treated with intravenous antibiotics only. These cases highlight the variability of iliopsoas abscesses in terms of presentation, microbiology, severity and treatment. Our knowledge of their etiology is lacking.
28. The impact of ‘scoliosis awareness month’ on internet activity-hit or miss? P.M. McQuail, A. Canas-Martinez, J.C. Kelly, D. Moore, P. Kiely Department of Trauma and Orthopaedics, Our Lady’s Children’s Hospital, Crumlin and Our Lady of Lourdes Hospital, Drogheda Recent reports suggest that up to 66 % of American adults use the internet to source health-related information, with 64 % of those reporting that internet information impacted their medical decision making. National Scoliosis Awareness Month (NSAM) was launched in the United States (US) in 2008. To date, an evaluation of its effect in terms of internet search activity has not been performed.
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 Our objective was to assess the effects of the NSAM campaign on internet search activity, with scoliosis search activity serving as an indirect marker for scoliosis awareness. We then compared respective internet activity in Ireland with that in the US since the campaign’s inception. ‘Google Trends’ was employed to examine search trends for the term ‘‘Scoliosis’’, across all Google domains between January 2004 and July 2014 (10 years). Repeated measures ANOVA and Tukey post-hoc analyses were performed to assess for significant differences in activity. Activity in Ireland was compared with that in the US. No significant increase of online activity relating to scoliosis is generated in June despite the awareness campaign either in the United States or Ireland. Notably, an increase in awareness arose following news coverage regarding Richard III diagnosis of scoliosis from his skeletal remains. The NSAM campaign is proving ineffective in stimulating online activity and consequently scoliosis awareness. Conversely, these campaigns are documented to be hugely beneficial in breast cancer. A review of the most effective means of raising awareness for scoliosis is vital from both a clinical and economical perspective.
29. What Dr Youtube teaches patients about osteoporosis. Does it help or hinder? J.T. Cassidy, J.F. Baker Department of Orthopaedics, The Adelaide and Meath Hospital, Dublin and Galway University Hospital Introduction: The medical profession has been hesitant to embrace the internet as a medium for communication with patients. Nevertheless, patients increasingly utilize the internet as a source of medical information. Contemporary research has shown that the majority of online information (text) provided by orthopaedic societies is inaccesible to the average literacy level of the general public. Objectives: (1) To examine the quality of information available on YouTube regarding osteoporosis. (2) To investigate for a relationship between quality of information and number of views on YouTube. Methods: We searched ‘‘osteoporosis’’ on Youtube and examined the first 50 results. All videos in English were considered. To evaluate information quality we developed an osteoporosis online information content score. We also used the JAMA benchmark criteria which is widely used to evaluate online medical information in text format. Videos were additionally examined for authorship and potential financial bias. Results: Of the first 50 articles 46 were in English and four we in Spanish. Thirty-two videos targeted the general public and ten targeted healthcare workers. Five were produced by financially interested parties, 15 from academic individuals/institutions and twelve from practitioners. Four videos were of suitable quality for educating patients. There were no videos produced by recognised orthopaedic societies. Videos produced by financially interested parties were of significantly lower quality. Conclusions: The quality of osteoporosis information on YouTube variable which risks increased confusion amongst a vulnerable patient cohort.
30. Assessment of the quality and content of information on lumbar disc herniation on the Internet G.A. Kelly, J.F. Baker
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 Department of Orthopaedic Surgery, University College Hospital Galway The internet has become a major source of all types of information including health for members of the public. There are concerns about the quality, accuracy and reliability of medical information available online. The quality of information available with regards to Lumbar Disc Herniation is generally of poor quality and unreliable and this study was to determine if it has improved in line with the exponential increase in Internet-based information since the last time it was reviewed in 2005. We assessed the quality of information about Lumbar Disc Herniation on the first 25 websites returned by the 6 most popular search engines in August 2014. Each site was categorized by type and assessed for quality and validity using the DISCERN score, and a novel Lumbar Disc Herniation specific content score designed by the initial study in 2005. The presence of the Health on the Net Code (HONcode), a purported quality assurance marker, was noted. The Quality of information on Lumbar Disc Herniation available online is variable despite an exponential increase in the number of websites since 2005. Many websites omit basic information regarding treatment options, risks and prognosis. Commercial and Practice Based websites predominate. Patients need to be educated about appropriate Internet use and we have a potential role as clinicians to not only direct our patients to appropriate sites but also to help in developing content on the internet.
CLINICAL SESSION I 1. One-stage vs two-stage brachio-basilic arteriovenous fistula for dialysis access: a systematic review and a meta-analysis K. Bashar, D. Healy, S. Elsheikh, Leonard D. Browne, Michael T. Walsh, M. Clarke-Moloney, P.E. Burke, E.G. Kavanagh, S.R. Walsh Department of Vascular Surgery, University Hospital Limerick, Department of Acute Medicine, James Connolly Memorial Hospital, Dublin, University of Limerick and National University of Ireland, Galway Introduction: A brachiobasilic arteriovenous fistula (BB-AVF) can provide access for haemodialysis in patients who are not eligible for a more superficial fistula. However, it is unclear whether one or two stage BB-AVF is the best option for patients. Aim: To systematically assess the difference between both procedures in terms of access maturation, patency and postoperative complications. Methods: Online search for randomised controlled trials (RCTs) and observational studies that compared the one-stage versus the twostage technique for creating a BB-AVF. Results: Eight studies were included (849 patients with 859 fistulas), 366 created using a one stage technique, while 493 in a two stage approach. There was no statistically significant difference between the two groups in the rate of successful maturation (pooled risk ratio = 0.95 [0.82, 1.11], P = 0.53). Similarly, the incidence of postoperative haematoma (pooled risk ratio = 0.73 [0.34, 1.58], P = 0.43), wound infection (pooled risk ratio = 0.77 [0.35, 1.68], P = 0.51) and steal syndrome (pooled risk ratio = 0.65 [0.27, 1.53], P = 0.32) were statistically comparable. Conclusion: Although more studies seem to favour the 2-stage BVT approach, evidence in the literature is not sufficient to draw a
S173 final conclusion as the difference between the 1-stage and the 2-stage approaches for creation of a BB-AVF is not statistically significant in terms of the overall maturation rate and postoperative complications. Patency rates (primary, assisted primary and secondary) were comparable in the majority of studies. Large randomised properly conducted trials with superior methodology and adequate sub-group analysis are needed before making a final recommendation.
2. Complete pathologic response to neoadjuvant therapy for oesophageal cancers A. Zaborowski, H.M. Heneghan, A. Granahan, S. King, N. Ravi, J.V. Reynolds Department of Surgery, St James’s Hospital and Trinity College Dublin Background: Complete pathologic response (pCR) after neoadjuvant therapy for oesophageal and junctional cancers defines a unique cohort of patients. It appears to confer a survival benefit overall yet little is known about the long-term outcomes of these patients. Objective: To analyze long-term survival and disease recurrence patterns among patients who have achieved a pCR following multimodal therapy for oesophageal and junctional cancers [Neoadjuvant chemoradiotherapy (nCRT) prior to resection]. Patients and methods: Retrospective analysis of a prospectively registered 10-year cohort, with a minimum of 3 years follow-up. Results: From 2000–2010, 220 patients underwent surgery following nCRT, of whom 20 % (n = 44) achieved pCR (ypT0N0). Compared to those who achieved partial or no response (NR, n = 176), the pCR group were predominantly female (43 %) with squamous cell cancer (SCC 52 %). Patients achieving pCR had 5-year disease-free survival (DFS) and overall survival (OS) of 51.6 and 56.8 %, respectively, compared to 19.1 and 26.7 % in NR (p = 0.001). Disease recurrence was less frequent in pCR group (47.7 vs. 66.5 %, p = 0.021), and the patterns of recurrence varied significantly. Local recurrence alone was less common in the pCR group (9.1 vs. 20.5 %, p = 0.05). Systemic recurrence occurred in 25 % (lung, brain and liver were most common sites affected), while 13.6 % developed both local and distant disease. Time to recurrence or death was similar in both groups [12.0 vs. 12.5 months (p = 0.848), and 25.2 vs. 24.9 months (p = 0.953), respectively]. Conclusion: Complete responders to neoadjuvant treatment have significantly fewer recurrences, longer overall and 5-year DFS compared to partial or non-responders.
3. Evidence for varicose vein surgery in venous leg ulceration A. Elrasheid, H. Kheirelseid, Thomas Aherne, Khalid Bashar, Thamir Babiker, Peter Naughton, Daragh Moneley, Stewart R. Walsh, Austin L. Leahy Department of Vascular Surgery, Beaumont Hospital, Dublin Background: Venous leg ulcers affect 1–3 % of adults with a significant economic impact, utilizing 1 % of annual healthcare budgets in some Western European countries. Objectives: To determine the effects of intervention for incompetent superficial veins on ulcer healing and recurrence in patients with active or healed venous ulcers.
S174 Search methods: In October 2014, we searched Medline, CINAHL, EMBASE, Scopus, the Cochrane library and Web of Science without date or language restriction for relevant randomized or observational studies. Bibliographies of included studies were also searched for additional studies. Selection criteria: Observational studies or randomized controlled trials comparing intervention for varicose veins with compression therapy alone for venous leg ulcers were eligible. In addition, studies compared open to endovenous therapy for varicose veins in patients with leg ulcers and those compared treating saphenous and perforating veins to treating saphenous veins only were also included. Studies had to report at least one ulcer-related outcome (healing rate, recurrence or time to healing). Data collection and analysis: Details of potentially eligible studies were extracted and summarized using a data extraction table. Data extraction and quality assessment were performed independently by two review authors, and any disagreements resolved by consensus or by arbitration of a third author. Results: Intervention for superficial venous reflux improved ulcer healing (risk ratio = 1.11 [1.00, 1.22], 95 % CI, p = 0.04) and reduced recurrence (risk ratio = 0.48 [0.32, 0.67], 95 % CI, p \ 0.0001) compared to compression alone. Conclusion: This review provided low quality evidence to support intervention for varicose veins to improve outcomes for patients with venous leg ulcers. A well-structured RCT is required to investigate the role of endovenous ablation of incompetent superficial veins in improving venous leg ulcer outcomes compared to standard treatment (compression).
4. Is there a role for routine duodenal biopsy in all adult patients undergoing upper GI endoscopy? K.C. Ng, Y. Mihes, E. Myers, D.P. O’Leary, B. Waldron Department of General Surgery, Kerry General Hospital, Tralee Background: Coeliac disease (CD) is an enteropathy of the small bowel triggered by exposure to gluten in genetically predisposed individuals. Duodenal (D2) biopsy is essential in diagnosis of CD. Performing a routine D2 biopsy during oesophago-gastro-duodenoscopy (OGD) is controversial. The aim of this study is to determine the significance of performing routine D2 biopsy during OGD and to evaluate the contribution to the diagnosis. Method: This is a retrospective review of 555 patients who had D2 biopsies taken during OGD in 2013 in Kerry General Hospital. The histopathology results were correlated with the indications, the serology and patient’s demographics. Results: Of the 555 sets of D2 biopsies taken, 12 patients (2.2 %) were confirmed to have coeliac disease, 3 (0.5 %) were inconclusive, 532 (95.5 %) were normal, and 9 (1.6 %) were found to have other pathologies. 476 patients who had coeliac-type symptoms had D2 biopsies taken. All coeliac positive patients were found to be in this group (Table 1). None of the 77 patient who had reflux related symptoms as the indication for OGD were positive on serology or histology. 10 out of 12 patients with confirmed CD on D2 biopsies had positive serology. 11 patients had positive serology but negative on D2 biopsies. The negative predictive value of the serological test to exclude CD was 99 %. Conclusions: The decision to perform D2 biopsies should be symptom dependent and in particular, appears to have no yield in patients with reflux symptoms alone. Routine D2 biopsy in all patients undergoing upper GI investigation is not necessary.
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5. Genitourinary and gastrointestinal toxicity after radical radiotherapy for prostate cancer E.J. Redmond, K.S. Dolbec, A.S. Fawaz, H.D. Flood, S.K. Giri Department of Urology, University Hospital Limerick and Graduate Entry Medical School, University of Limerick Introduction: Radiotherapy is a common treatment option in the management of localised prostate cancer. Most initial side-effects resolve once the course of radiotherapy has finished, however troublesome long term side-effects may develop at an interval following treatment. These can result in multiple admissions or repeated procedures for the patient. The aim of this study was to investigate the burden of genitourinary (GU) and gastrointestinal (GI) toxicity among patients with prostate cancer who were treated with radiotherapy at our institution. Methods: The radiotherapy department database was used to identify all patients who underwent radiotherapy for prostate cancer from January 2006–January 2008. The patient administration system from each public hospital in the region was interrogated and all patient points of contact during 5 years of follow up were recorded. Individual patient charts were reviewed and factors which might influence outcomes documented. Results: A total of 112 patients were identified. The mean age at diagnosis was 66 (44–76) and the median PSA was 12.1 (3.2–38). The overall biochemical recurrence rate was 19 %. Thirty-five patients (31 %) required acute admission. Fifteen patients (13 %) were investigated for GU toxicity. Forty-seven patients (42 %) underwent investigation of GI side-effects and 44 % of these required argon therapy (21/47). Conclusion: This study found that a significant number of patients required investigation for possible GU/GI toxicity following radiotherapy. It is important that patients are counselled carefully in relation to these potential side-effects. The morbidity to patients and additional cost of managing such complications.
6. Accuracy of breast examination in a tertiary referral centre with a focus on clinically occult tumours C.J. Barter, P.W. Owens, E.J. Fahey, J. Ashraf, R. McLaughlin Department of Surgery, University Hospital Galway Breast cancer accounts for 31 % of all invasive cancers in Ireland, with over 2,700 patients newly diagnosed each year. Clinical breast examination (CBE) is a core element in the assessment of patients for breast cancer. As part of triple assessment, every patient attending this symptomatic breast unit undergoes a CBE and is scored using an internationally accepted ‘S1–S5’ clinical scoring system. CBE has been shown to have a sensitivity and specificity in the ranges of 54–58 % and 94–98 % respectively [1, 2]. Data was collected prospectively using a dendrite database from 2009–2014. 25,689 patients were assessed with 1,223 patients (4.8 %) being diagnosed with breast cancer. Of these, 254 (21 %) had a clinically normal breast examination. Our primary outcome demonstrates a sensitivity of 64 % and a specificity of 98 % for CBE in detecting breast cancer. Secondary outcomes include analysis of those with low CBE scores (S1 and S2). The performance of our CBE compares favourably with international standards. A proportion of patients with low clinical scores require imaging and biopsy for breast cancer detection.
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7. Development of a process by which a threedimensional reference standard of the human mesentery can be generated L.G. Walsh, D.J. Walsh, J.C. Coffey Centre for Interventions in Infection, Inflammation and Immunity (4i), Graduate Entry Medical School and Department of Surgery, University Hospital Limerick Introduction: Radiologic appraisal of the mesentery has been and remains a difficult field largely owing to classical inaccuracies in its descriptions. Deriving a process to accurately assess mesenteric anatomy on Computed Tomography (CT) and Magnetic Resonance (MR) potentiates profound enhancement of diagnostics and surgical planning. The primary aim of this study was to establish the first reference standard of the mesentery and radiologic correlates of this structure. Thus, by utilisation of modern graphic technologies, demonstrate the development of accurate three-dimensional models of the mesocolon and mesorectum with precise superimposition of that standard to radiologic correlates. Methodology: Three-dimensional models were created from crosssectional images obtained from the US National Library of Medicine’s (NLM) Visible Human ProjectÒ (VHP) and supplemental CT imaging. These images were imported into OsirisXÒ medical navigation software and the mesocolon and mesorectum digitally mapped and verified. Digital mapping involved the manual inputting of points representing three dimensions (i.e. x-, y- and z-coordinates). The resultant constellation of mapped points was exported to Cinema4DÒ where a ‘‘pointcloud’’ representing the mesocolon and mesorectum was generated. Following this, ‘‘pointcloud’’ data were exported for three-dimensional rendering through MimicsÒ thus representing a mesenteric standard of reference. The subsequent data were correlated with the associated cadaveric CT and MR imaging from the VHP. Results: Cadaveric referencing utilizing the VHP as a proxy yielded the generation of 43,152 points across 325 9 1 mm cryosections (mean points per slice = 132.78). Once mesocolic and mesorectal point data were collated in MimicsÒ; generation of a mesenteric standard of reference was possible. Through collation of this reference with associated CT and MR imaging, accurate recognition of the mesenteric components was achieved. Discussion: The VHP permitted the generation of a reference standard of the human mesentery with associated radiologic-correlated images. By mapping of data it was possible to develop an accurate three-dimensional model of the mesentery thus generating the first documented mesenteric standard of reference and further potentiating an enhanced understanding of mesenteric anatomy.
8. Medical specialty choice: does personality matter? M.F. Duignan, S. Lydon, P. O’Connor, T.P. McVeigh, G. Offiah, D. Byrne School of Medicine, NUI Galway, Department of Psychology, Trinity College and Beaumont Hospital Introduction: Interest in the ‘‘non-cognitive’’ traits and abilities of physicians, such as professionalism, personality, empathy, and values, has increased in recent years1. Research has identified relationships between personality and acceptance into medical school2, success in medical school3, clinical performance4,5,6, and physician wellbeing7,8. Aims: The aim of this study was to examine the differences in personality traits between doctors and medical students across gender, level of training and medical specialty.
S175 Methods: The validated NEO Five Factor Index13 (NEO-FFI) questionnaire was used to assess personality. This instrument consists of 60 items which assess neuroticism, extraversion, openness agreeableness, and conscientiousness. Medical students were invited to participate during lectures, and postgraduate trainees and senior physicians were invited by email. Results: Two hundred physicians and 134 medical students completed the questionnaire. Post-internship doctors scored significantly higher on conscientiousness (p = 0.001) than those pursuing basic medical training. Among those pursuing basic medical training, females scored significantly higher than males on agreeableness (p \ 0.001) and conscientiousness (p = 0.001. Among those pursuing basic medical training, those interested in person-focused medical specialities scored significantly higher on extraversion (p \ 0.001), conscientiousness (p \ 0.001), and lower on neuroticism (p = 0.005) than those who had no strong preference. Respondents did not comprise a homogenous group. Standardized scores on all NEO-FFI dimensions spanned from the absolute minimum to the maximum possible. Conclusions: These results suggest that there is no unique personality profile associated with medical practice, or medical speciality. Instead, it appears that medical school may shape personality.
9. Comparative effectiveness of adrenal sparing radical nephrectomy and non-adrenal sparing radical nephrectomy in clear cell renal cell carcinoma: observational study of survival outcomes L.G. Walsh, G.J. Nason, C.E. Redmond, N.P. Kelly, B.B. McGuire, V. Sharma, M.E. Kelly, D.J. Galvin, D.W. Mulvin, D.M. Quinlan, H.D. Flood, S.K. Giri Department of Urology, University Hospital Limerick, St Vincent’s University Hospital, Dublin and North Western University, Feinberg School of Medicine, Chicago, Illinois, USA Objective: To compare the survival outcome of patients treated with adrenal sparing radical nephrectomy (ASRN) or non- adrenal sparing radical nephrectomy (NASRN) for clear cell renal cell carcinoma (RCC). Methods: In this observational multi-centre study, only patients with pathologically confirmed clear cell RCC between January 2000 and December 2012 were included. Exclusion criteria included patients undergoing cyto-reductive nephrectomy and nodal involvement. 579 patients (ASRN, n = 380 and NASRN, n = 199) who met our inclusion and exclusion criteria. Patients were categorised by risk groups (all stage, early stage and locally advanced RCC). Overall survival (OS) and cancer specific survival (CSS) for all stage, early stage and locally advanced RCC following ASRN and NASRN. Survival analysis was performed using univariate Kaplan–Meier curves and multivariable Cox Proportional Hazards regression. Results: Median follow-up was 41 months (range 12–157). On univariate analysis, there were significant benefit in OS (ASRN vs. NASRN = 79.5 vs. 63.3 %; p = 0.001) and CSS (84.3 vs. 74.9 %; p = 0.001) differences favouring ASRN for all stage group. On multivariate analysis, after adjusting for age, gender, stage, grade, tumor necrosis and vascular invasion, NASRN was associated with worse OS and CSS. Only 1.9 % patients had adrenal involvement. Conclusions: This observational study with follow-up to 13 years suggests ASRN leads to better survival than does NASRN. Thus ASRN should be performed in all patients undergoing radical nephrectomy for clear cell RCC unless contra-indicated.
10. The efficacy of percutaneous tibial nerve stimulation (PTNS) for the treatment of urge faecal incontinence S.M. Abd Elwahab, M. Majeed, M. Hannon, P.S. Waters, M. McCourt, E.J. Andrews Department of Surgery, Cork University Hospital Faecal incontinence is a common multifactorial disorder affecting between 1–7 % of the population. Percutaneous tibial nerve stimulation (PTNS) is a minimal invasive treatment that involves peripheral neuromodulation performed by inserting a needle electrode near the posterior tibial nerve. PTNS efficacy has been established for urinary incontinence, however, its role in faecal incontinence is less clear. The aim of the study was to assess the efficacy and outcomes of PTNS in treatment of urge faecal incontinence (UFI). An analysis of a prospectively maintained database of all patients undergoing PTNS for UFI between 2011–2014 was performed. Data was collated from hospital databases and patient charts. Evaluation of UFI was performed at baseline and post treatment. Statistical analysis was performed using Minitab V18 with p \ 0.05 considered significant. Thirty patients (27 females, mean age 60.1 years) were included in the analysis. 30 % of patients had a sphincter defect on endoanal ultrasound. 14 patients had a previous obstetric related procedure such as episiotomy or forceps delivery. Average anal resting and squeeze pressures at were 34.3 and 48.9 respectively prior to commencing treatment. Continence was improved in 24 of 30 patients. Average St Mark’s incontinence score pre-PTNS was 18 (14–21). There was a significant reduction in the average St Marks score post-PTNS 13 (4–21, p \ 0.05). There were no complications encountered with the procedure. At long term follow-up four patients required sacral nerve stimulation and two patients required a resection rectopexy. This preliminary study demonstrates that PTNS is an effective and well tolerated adjunct in the treatment of UFI.
11. The use of inflammation-related markers to predict outcome in rectal cancer C. Reid, C.A. Fleming, H.M. Mohan, K. Schmidt F. Cooke, South Eastern Rectal Cancer Network Department of General Surgery, Wexford General Hospital, South Eastern Rectal Cancer Network, University Hospital Waterford Background: The clinical significance of systemic inflammatory response (SIR) for outcome prediction in rectal cancer is currently under debate. Neoadjuvant therapy (NAT) is a pivotal aspect of management in rectal cancer to downstage disease and improve outcome1. In this study we aimed to analyse the usefulness of acute phase reactants to predict responses to NAT and other outcomes in rectal cancer. Methods: We analysed prospectively maintained data of rectal cancer patients treated in the South East of Ireland from 2010–2014. We identified patients who had received NAT and proceeded to surgical excision. Basic demographics, radiological and pathological features were tabulated. Neutrophil–lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR), serum albumin (SAL) and CEA levels within 7 days prior to NAT were calculated. Tumour response to NAT was estimated based on tumour regression grading (TRG) system of the American Joint Committee on Cancer (AJCC) 7th Ed. Circumferential resection margin (CRM) was graded using AJCC scoring (R status). Statistical analysis was performed using SPSS (version 21). Results: During the study period, 203 patients with rectal cancer were managed by the South Eastern Rectal Cancer Network. Mean age at presentation was 66.9 years (22–89). 61.7 % of patients were male and 39.3 % female. 130 patients (64 %) underwent surgery with curative
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 intent of which 90 % (n = 117) received NAT. 14.3 % (n = 17) achieved CPR following NAT, 26.1 % (n = 31) TRG1, 27.7 % TRG2, 31.9 % TRG3. 80.7 % achieved an R0 resection (8.4 % R1 and 2.5 % R2). Elevated NLR was significantly associated with positive lymph nodes post NAT (p = 0.027) and lower chance of achieving R0 resection (p = 0.009). Low SAL was predictive of not achieving an R0 resection (p = 0.004) and elevated CEA was most predictive of positive post NAT lymph node positivity (p = 0.003). Conclusion: While inflammatory markers are predictive of CRM resection status and lymph node positivity post NAT they alone do not predict overall tumour response to NAT and downstaging. Further research in this area is warranted.
12. Validation and assessment of a technology familiarity score in patients attending a symptomatic breast clinic C. O’Brien, J. Kelly, B. Cotter, E. Lehane, M.A. Corrigan Cork Breast Research Centre and Catherine McCauley School of Nursing and Midwifery, Cork University Hospital Introduction: New media (computers, mobile phones and the internet) has the potential to transform the healthcare information needs of patients with breast disease (1). However patients’ current level of use and their willingness to accept new media for education and communication remain unknown. Methods: This was a single centre clinic-based prospective crosssectional study. A previous developed instrument was modified, validated and tested on patients attending a symptomatic breast clinic (2). Results: The instrument was evaluated on 200 symptomatic breast patients. The commonest outlets for education were staff (95 %), leaflets (69 %) and websites (59 %). Websites are more likely to be consulted by younger patients (\47 years) and patients who were working, students or homemakers (p\0.05). Patients rated usefulness of information media in this order: (1) print (2) phone (3) website (4) email (5) text (6) apps. First time patients are more likely to find text messaging and emailing useful (n \ 0.05). Younger patients (\47 years) are more likely to find text messages, apps, websites and email useful (p \ 0.05). Urban patients are more likely to find websites and email useful (p \ 0.05). Patients with higher education were more likely to favour apps, websites and email (p \ 0.05). Smartphone owners were significantly more likely to rate text messaging, apps, websites and email as useful media (p \ 0.05). Conclusion: This study demonstrates that new media technology use among breast patients is expanding as expected along generational trends. As such its’ further integration into healthcare systems can potentially ameliorate patient education and communication. Disclosures: Supported by Aid Cancer Research (ACT) Cork.
CLINICAL SESSION II 13. The use of needle catheter tipped feeding jejunostomy tubes in cancer patients and the varying degrees of complications that can occur post operatively S. Tarrant, I. Tiedt, C. O’Neill, N. Mccawley, M. Arumugasamy, Prof P. Broe Beaumont Hospital
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 As with any invasive procedure the operative insertion of a jejunostomy feeding tube carries a wide range of risks that can occur after the procedure. We examined the frequency, causes, variation, severity and how the complications that did occur were resolved with the aim of identifying areas in which our standard of care can be improved. This was a retrospective study of 35 patients both gastric and oesophageal who were treated under 2 surgeons within the upper gi cancer service in Beaumont Hospital in 2013. Out of the 35 patients involved in the study, 29 had jejunostomy tunes inserted. Out of this number, 31 % resulted in complications compared to 24 and 37 % and in 2012 and 2011 respectively. Out of the 9 patients who experienced complications 11 % of these were major and 88 % were minor. Those with major complications are those who required either re-operation or intervention. The minors are those that either resolved spontaneously or were treated conservatively on the ward. The most common minors were the tube falling out, pain and infection which all accounted for 22 % each. Any invasive procedures carry risks and it is up to us as clinicians to minimise these risks and to innovate remedies to such risks. The most common minor complications such as infection and the tube falling out can perhaps be remedied by an alternative surgical technique or fastening device and to ensure on-going follow up so that the risk of it falling out or becoming infected are prevented rather than treated.
S177 Department of Academic Surgery and Breast Radiology, Cork University Hospital Digital mammography is an emerging imaging technology in breast cancer. This study compared the ability of contrast enhanced digital mammography (CEDM) to Digital mammogram (DM) in accurately predicting the radiological T stage of breast cancers. A retrospective review of CEDM was conducted correlating preoperative imaging size with final pathological evaluation. Newly diagnosed breast cancer patients imaged with CEDM between June 2011 and March 2013 were included in the analysis, with a median tumour size 25 mm (1–110). Predicted tumour size in each modality was compared to actual pathology size and was considered concordant if imaging size was within ±1 cm of pathology size. Eighty-seven patients in total had CEDM performed. The median age was 50 years (37–73). Forty-six patients were subsequently diagnosed with breast cancer on core biopsy. Of the forty-six cancers imaged with CEDM, 44 had suspicious enhancement giving a sensitivity of 95.7 % (95 % CI 85.2–99.5 %). When compared to pathology size CEDM was concordant in 16 of 34 (47.1 %) of cases, while DM was only concordant in 11 of the 34 (32.4 %) cases which was statically significant (p = 0.027). CEDM is a more accurate predictor of tumour size in breast cancer. Further research is ongoing to evaluate the role of CEDM in reducing rates of repeat surgery for margins in breast conservative surgery.
14. An audit of culturally sensitive service provision S. Akasha, D. Nally, R. McLaughlin, M.J. Kerin, C. Malone, K. Sweeney Department of Surgery Galway University Hospitals Background: Delivery of patient centred health care can be limited by cultural differences. As Irish society becomes more multicultural, these differences pose a challenge to those attending and offering breast care services. Previous research has shown that women of different ethnic groups have difficulty communicating with breast clinic staff1 but there is insufficient research on this subject. Aim: To assess experience and satisfaction of patients attending the Symptomatic Breast, UHG with specific reference to cultural, ethnic and religious preferences. Methods: A questionnaire was drafted from previously validated studies, tested and amended before distribution to patients attending the Symptomatic Breast Unit, Galway University Hospital. Results: 113 patients were surveyed. The mean age of patients surveyed was 41.3 years. 96.5 % were female. 12.4 % did not have English as a first language and 10.6 % reported difficulty expressing themselves. Overall, 70 % were extremely satisfied with their experience. Only 2 of those surveyed were extremely dissatisfied with their experience, one cited waiting time as a reason for dissatisfaction, the other failed to explain. There was no correlation between ethnicity, English as a first language or religion and level of satisfaction. Conclusion: Breast care services must be sensitive to cultural differences of the patients attending and acknowledge the communication challenges posed by foreign languages. The Symptomatic Breast Unit in GUH is performing particularly well in this respect.
15. Contrast enhanced digital mammography as an adjuvant in predicting breast cancer size A. McGuire, D.P. O’Leary, M. Ryan, Z. Khan, M. Corrigan, H.P. Redmond, N. Relihan
16. What’s dominating surgical research? A review of the design of all trials published in the top four surgical journals by impact factor in one calendar year A. Lawlor, S.P. Murphy, C. Rice, L. Kieswetter, C. O’Rourke, J.E. Fenton, J.C. Coffey Graduate Entry Medical School, University of Limerick and University Hospital Limerick Background: Surgical research methodologies have undergone great change in the past two decades. The push for more robust analysis of surgical techniques and outcomes has resulted in an increased focus on experimental research and the publication of RCT’s in particular. Surgical research was once a landscape dominated by retrospective reviews and case series. Retrospective observational research is cheaper, less difficult and requires a shorter timescale than prospective trials and is therefore always likely to dominate both medical and surgical publications. We review the current landscape of surgical research to see if this push has resulted in a significant proportion of experimental research being published in the top four surgical and colorectal journals by impact factor. Methods: All trials published online in the calendar year 2013 in The Annals of Surgery, British Journal of Surgery, JAMA Surgery (previously the Archives of Surgery) and Surgery. 700 trials which reported on human patients or human tissue were included in this review. Results: Trials were initially analysed as observational or experimental. 85 % of published trials were observational and 15 % were experimental. 60 % of experimental trials were RCT’s. The British Journal of Surgery had the highest proportion of RCT’s (18.49 %) while JAMA Surgery had the lowest (3.94 %). Of the observational research 16.68 % was prospective. Retrospective cohort studies were the most common observational method used (28.24 %) followed by large database reviews (20.0 %) with case control studies the least common study design (5.38 %). Conclusions: While retrospective observational research dominated in our review, prospective research, in the form of RCT’s and cohort
S178 studies, made up a larger proportion of publications than expected. Randomised controlled trials in surgery have been increasing in frequency in recent years paving the way for more systematic reviews and meta-analysis. Disclosures: Funded by the MELG (Medical Education Liaison Group) Mid-West.
17. The reporting of ethical approval and informed consent in the top five surgical and colorectal journals by impact factor S.P. Murphy, C. Rice, A. Lawlor, L. Kieswetter, C. O’Rourke, J.E. Fenton, J.C. Coffey Graduate Entry Medical School, University of Limerick and University Hospital Limerick Aims: Medical research involving human subjects must follow ethical standards as outlined in the Declaration of Helsinki of the World Medical Association. The aim of this study was to assess the frequency of reporting of informed consent and regional ethical committee (REC) or Institutional Review Board (IRB) approval in all reports of studies published in the top five surgical and colorectal journals by impact factor. This is the largest review of its kind in surgery. Methods: All clinical research articles published online in the calendar year 2013 in The Annals of Surgery, British Journal of Surgery, JAMA Surgery (previously the Archives of Surgery), Surgery and Disease of the Colon and Rectum. A total of 1,315 articles were reviewed. 471 studies did not meet the inclusion criteria leaving 844 studies included in this review. Results: Of the 844 studies reviewed, 524 (62.09 %) reported receiving REC/IRB approval. There was some variation of reporting between the journals (56–68 %) which trended with impact factor. There was significant variation in reporting REC approval between study types (p \ 0.05) with experimental studies reporting more often than observational studies and prospective more often than retrospective. Reporting of informed consent was confined to prospective studies, resulting in a 61.24 % reporting rate. Articles which did not report REC approval were associated with not reporting informed consent (p \ 0.05). Conclusions: This is the largest review of its kind in surgery. It shows that reporting of ethical considerations in the top five surgical journals by impact factor is inadequate. Many studies that fail to report on ethical approval and informed consent continue to be published making evaluation of research integrity difficult for readers. Disclosures: Funded by the MELG (Medical Education Liaison Group) Mid-West.
18. Randomised controlled trials in surgery. A review of the categories, surgical sub-specialty and patient numbers of all RCT’s published in the top four surgical and colorectal journals by impact factor in one calendar year A. Lawlor, S.P. Murphy, C. Rice, L. Kieswetter, C. O’Rourke, J.E. Fenton, J.C. Coffey Graduate Entry Medical School, University of Limerick and University Hospital Limerick
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 Background: Surgical research methodologies have undergone great change in the past two decades. The push for more robust analysis of surgical techniques and outcomes has resulted in an increased focus on experimental research and the publication of RCT’s in particular. We review the general topics under investigation in all RCT’s published in the top four surgical and colorectal journals by impact factor. Methods: All trials published online in the calendar year 2013 in The Annals of Surgery, British Journal of Surgery, JAMA Surgery (previously the Archives of Surgery) and Surgery. 700 trials which reported on human patients or human tissue were identified, 66 of which were RCT’s and were included in this review. Results: 12,893 patients were enrolled in 66 RCT’s published in the top four surgical and colorectal journals in 2013. The mean number of patients enrolled was 195, the median was 105 and the range was 5–1,143 patients. The majority (57.58 %) were upper and lower gastrointestinal studies with vascular surgery accounting for 12 and 30.3 % in the Other category (ENT, Plastics, Cardiothoracic, Breast and Neuro). 40.91 % of studies investigated surgical practice via comparison of two procedures while 24.24 % focused on specific outcomes of a single procedure. 13.64 % investigated surgical materials, 13.64 % made up the other category (pharmacological interventions and education) while 7.58 % examined perioperative issues. Conclusions: Not surprisingly GI surgery dominated the RCT’s in these particular journals. The majority of RCT’s focused on comparing two surgical procedures or examining specific outcomes of a single procedure. The majority of trails enrolled adequate patient numbers for power. Disclosures: Funded by the MELG (Medical Education Liaison Group) Mid-West.
19. Does tumour biology impact upon surgery type and complete pathological response after neoadjuvant chemotherapy in breast cancer patients with axillary nodal metastases? M.R. Boland, A.J. Lowery, D. Evoy, J. Rothwell, J. Geraghty, C. Quinn, G. Gullo, J. Walshe, J. Crown, A. O’Doherty, E.W. McDermott, R.S. Prichard Department of Breast Surgery, Pathology, Oncology and Radiology, St Vincent’s University Hospital Few studies have focussed on effects of tumour biology on extent of surgery and rates of pathological complete response (pCR) in breast cancer patients with nodal metastases who undergo neoadjuvant chemotherapy (NAC). The aim of this study was to examine the impact of different biological tumour characteristics on extent of breast surgery, nodal burden and rates of axillary pCR in breast cancer patients with nodal metastases who undergo NAC. A retrospective review of a prospectively maintained database identified breast cancer patients with positive axillary fine needle aspiration cytology between 2007–2012. Patients who underwent NAC and subsequent axillary lymph node dissection (ALND) were recorded and tumour characteristics analysed. Extent of surgery and rates of pCR after NAC by biologic subtype were compared. 111 patients with breast cancer and nodal metastases underwent NAC and subsequent ALND. With regard to tumour biology, 58 patients (52.3 %) were [ER+HER2-], 31 patients (27.9 %) were [ER+HER2+], 16 patients (14.4 %) were [ER-HER+] and 6 patients (5.4 %) were [ER-HER-]. Axillary pCR was significantly higher in the [ER-HER+] group compared to the [ER+HER2+] and [ER+HER2-] groups (87.5 vs 48.4 vs 12.1 %; p \ 0.001). Tumour biology did not affect extent of surgery. Nodal burden (Mean positive nodes) was significantly lower in the [ER-
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 HER+] group compared to the [ER+HER2-] group (0.19 vs 7.46; p \ 0.001) and [ER+HER2+] group (0.19 vs 1.96; p = 0.01). HER2 positivity is associated with increased rates of axillary pCR and reduced nodal burden after NAC. Patients with HER positivity could be amenable to less aggressive axillary surgery post NAC.
20. 20 year experience of liver transplantation in a single centre N.J. O’Farrell, N. Saeed, M. Sheehan, A. Cooney, J. Geoghan, D. Maguire, E. Hoti Liver Transplant Unit, St Vincent’s University Hospital, Dublin Introduction: Liver transplantation is a life-saving procedure, performed in a single-centre in Ireland. The aim of this study was to examine a nation’s 20-year experience with liver transplantation. Methods: Data were collected from a prospectively maintained database between January 1994 and December 2013. Changes in trends between different time-periods were evaluated using Mann– Whitney U and Chi square tests. Survival analysis was performed using Kaplan–Meier curves. Results: A total of 828 cadaveric orthotopic liver transplantations were performed. There was a twofold increase in the number of transplantations between the first and second half (277 versus 551 patients, respectively) of the study. Seventy-eight (10.7 %) patients required a first regraft, 16 (2 %) a second regraft and five (0.68 %) a third or more regrafts. Retransplantation rates were consistent throughout the 20-year experience (p = 0.184). The most common indication for retransplantation was hepatic artery thrombosis (35.7 %), followed by chronic rejection (23.8 %). There was a significant decrease in in-hospital mortality (p = 0.002) between the periods 1994–2003 (15.5 %, 43/277) and 2004–2013 (8.3 %, 46/551). Overall median patient survival was 13.8 years, with a significant increase in survival rates demonstrated in the second half of the study (p = 0.005). Conclusions: Over the 20-years examined, we have demonstrated a significant increase in the number of liver transplantations performed, with an associated improvement in post-operative mortality and longterm survival rates.
21. Long-term outcomes after multimodal therapy for oesophageal cancer H.M. Heneghan, A. Zaborowski, A. Granahan, S. King, N. Ravi, J.V. Reynolds Department of Surgery, Trinity Healthcare Sciences Building, St. James’s Hospital Background: Multimodal therapy [Neoadjuvant chemoradiotherapy (nCRT) prior to resection] is increasingly the standard of care for locally advanced oesophageal and junctional tumours. Tumour regression at the primary site is considered a proxy of survival benefit, but long-term outcome data is rarely reported. Objective: To analyze long-term outcomes following multimodal therapy for oesophageal and junctional cancer, and the impact of tumour regression on survival with multivariate analysis. Patients and methods: Retrospective analysis of a prospectively registered 10-year cohort, with a minimum of 3 years follow-up. Results: Between 2000–2010, 265 patients underwent multimodal treatment for oesophageal/junctional cancer (76 % males, mean age 58.7 years, 71 % adenocarcinoma). 45 (17 %) did not progress to
S179 surgery due to disease progression or decreased performance status. At a median follow-up of 56 months (range 24–174), 50 (22 %) had a complete pathologic response (pCR) to nCRT. The overall median survival was 28 months, and the 5-year survival was 28.1 %. The overall 5-year survival of patients achieving a pCR was 52 % compared with 26 % in non-pCR patients (p = 0.015). Histomorphologic tumor regression grades (TRG) was not associated with pre-CRT cTN stage but was significantly associated with ypN stage (p \ 0.001). On multivariate analysis, ypN status (p = 0.048) and R0 resection were independent predictors of overall survival, but not TRG (p = 0.611). Conclusion: Achieving a node-negative (ypN0) and R0 resection status are the major determinants of outcome following neoadjuvant chemoradiotherapy for oesophageal and OGJ cancers. A pCR confers survival benefit, but TRG is not an independent predictor of survival.
22. Initial experience with use of a synthetic mesh in patients undergoing tissue expander breast reconstruction A.T. Manning, S. Sharma, P.A. Cronin, M. Barry, M.R. Kell Department of Surgery, Mater Misericordiae University Hospital, Dublin Background: Tissue-expander (TE) followed by permanent implant insertion is now the most common form of breast reconstruction for patients undergoing mastectomy. The use of Acellular Dermal Matrices (ADM’s) for reinforcement at time of TE insertion is associated with higher likelihood of seroma formation, infection and reconstructive failure. TIGRÒ Matrix Surgical Mesh is a fully absorbable and completely synthetic alternative to ADM’s. We report on our initial experience with use of TIGRÒ Matrix in patients undergoing breast reconstruction with TE insertion. Methods: Patients undergoing breast reconstruction with TE insertion in which TIGRÒ Matrix Surgical Mesh was used for reinforcement were identified and data prospectively collected. Patient demographics, indications for surgery, length of hospital stay, perioperative and post-operative complications were identified. Results: 10 patients were identified who underwent unilateral (n = 8) or bilateral (n = 2) breast reconstruction in which TIGRÒ Matrix was used. Median length of post-operative hospital stay was 3 days. There were no peri-operative seromas or wound infections, and at early follow there have been no cases of reconstructive failure. Conclusions: Our initial experience with the use of a fully absorbable fully synthetic mesh for reinforcement following TE insertion has been positive with no post-operative complications identified. Although longer follow-up is required, TIGRÒ Matrix Surgical Mesh may be a useful accessory to expander-implant based breast reconstruction.
23. The accuracy of urgent pre-operative imaging in correctly pinpointing the pathology in patients undergoing emergency abdominal surgery at a busy acute surgical unit M. O’Sullivan, O.S. Mansour, D.J. Waldron, J.C. Coffey Department of Surgery, University Hospital Limerick Aim: To establish the accuracy of emergency imaging in diagnosing acute abdominal emergencies requiring surgery. Methods: A retrospective analysis was performed on a consecutive series of abdominal emergencies (appendicectomies) requiring
S180 surgery in University Hospital Limerick over a 4 month period. Data was collected regarding: type of surgery, radiological findings and histopathology reports. Results: Over 100 (n = 138) consecutive surgical interventions were identified between June and October 2014. 39 % (n = 54) underwent pre-operative imaging. Of these, 24 % (n = 13) had a pre-operative US Pelvis reported as normal. Histologically 8 had appendicitis, 1: faecolith without inflammation, 1: normal appendix. 3 patients underwent laparoscopy without appendicectomy. 16 % (n = 9) patients underwent a CT which was reported as appendicitis with one suggesting evidence of an abscess. Histologically this one was found to be perforated. 4 of the others were appendicitis, 1: gangrenous, 3: perforated. 4 % (n = 2) had CTs initially reported as colitis and ileitis without evidence of perforation. Histologically both were perforated appendicitis. Of note both CT reports were amended on further review by the radiology team. Conclusions: One must have a high index of suspicion regarding the correlation of imaging with the underlying pathology. Thorough discussion with radiology, together with clinical judgement is the best way to manage the acute abdomen.
24. Evaluation of nurse led discharge (NLD) protocol on a surgical dayward R. Sheeran, E. O’Malley, B. Moloney, F. Orefuwa, C.G. Collins Portiuncula Hospital, Ballinasloe Background: Identifying when a surgical day case patient is suitable for discharge has traditionally been the responsibility of the attending surgeon. With well organised pathways and a well-defined protocol nursing staff have become increasingly important in determining suitability for discharge. Aim: To analyse the outcomes of NLD in a surgical day service. Methods: This retrospectively analysed all day case procedures using NLD protocol between January 2013 and June 2014. NLD protocol guides discharge by scoring the patient based on postoperative progress. NLD scores were compared to highest early warning scores (EWS). Patients successfully discharged were followed up by telephone after 48 h. Results: 128 day cases were reviewed. 109 (85.2 %) patients were successfully discharged and 19 (14.8 %) stayed overnight. Procedures requiring admission included laparoscopic cholecystectomy (13 of 45) and hernia (inguinal and umbilical) (5 of 23) repairs. Complications included pain (52.6 %), nausea (21 %), vomiting (15.8 %), urinary retention (10.5 %). Mean highest recorded EWS score was 1.89 (±1.89) including 15 patients with score 3 or less for entire admission despite postoperative surgical concerns identified by NLD protocol. No major complications were elicited with the 48 h telephone follow up. Conclusion: NLD identifies patients suitable for same day discharge. EWS is less reliable. NLD allows nurses to confidently and safely discharge patients who do meet the criteria, improving patient care in day case surgery.
CLINICAL SESSION III 25. Can ‘hotspotting’ prove to be a useful tool to reduce ED attendance in the general hospital setting? E.J. McGovern, J. Bolger, P. Coyle, R.M. Waldron, D. Courtney, A. Jackson, K. Barry Department of Surgery, Mayo General Hospital
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 Introduction: As acute hospital services are rationalised, there is increasing strain put on existing emergency services. Previous work has identified groups who put excessive strain both on ED and outpatient services. These can be classified as ‘frequent users’ (4–7 attendances per year) and ‘super users’ (C8 attendances per year). Hotspotting allows the identification of areas with disproportionate numbers of frequent and super users, allowing focussed allocation of community resources. This leads to significant cost savings and eases the burden on acute services. All hotspotting to date has focussed on large urban centres. Aims: To determine if hotspotting may be of use to identify disproportionate ED use in the general hospital setting. Methods: ED attendances from 1st July 2013–30th June 2014 were logged. Frequent users and super users were isolated. Addressed were cross referenced against national census data to determine number of users per 500 population in geographically distinct regions. These were plotted using Google mapping software. Results: There was a large difference in attendances based on geographical area. Numbers of frequent users ranged from 1.00/500 population to 4.88/500 population. Four out of nineteen areas had C4 frequent users per 500 population. There was no correlation between number of users and distance from MGH (r2 = 0.03). Conclusion: There are a number of geographically distinct hotspots for frequent users of ED services for our catchment area. Use of services is not linked to proximity to service provision. These data will allow future planning of community interventions to potentially decrease unnecessary ED attendance.
26. Differences in metastatic patterns between luminal B and HER2 over expressing breast cancers and changes since the introduction of trastuzumab A. McGuire, A. Lowery, J.A.L. Brown, M.J. Kerin Discipline of Surgery, School of Medicine, University Hospital Galway Background: There is accumulating evidence that breast cancer subtype determines the timing, pattern and outcome of metastatic disease. The aim of this study was to assess the natural history of Her2 +ve breast cancer subtypes (Her2overexpressing and Luminal B), with specific emphasis on relapse patterns before and after the use of Trastuzumab. Methods: Analysis of Her2-positive breast cancers treated at a tertiary referral unit from 1992–2014. Disease free survival (DFS) and patterns of relapse were compared between luminal B and the HER2 overexpressing subtypes before and after the introduction of Trastuzumab. Results: 480 patients were included (296 Luminal B and 184 HER2overexpressing). In patients who did not receive trastuzumab, the 2 yr DFS in the Her2-overexpressing group was significantly reduced compared to the Luminal B group (37.3 vs 43.4 %). There was no difference in DFS between the subtypes when patients received trastuzumab (56.3 % luminal B vs 56.2 % Her2). There was no significant difference in the rate of distant metastasis between Luminal B tumours (n = 38, 13.9 %) and the Her2 overexpressing tumours (n = 21, 12.4 %) (p = 0.6). However the pattern of metastases sites differed between the subtypes; luminal B tumours had higher rates of bone as the first site of relapse (n = 23, 30 %) compared to Her2 overexpressing tumours (n = 6, 10.4 %), which were twice as likely to metastasise to the brain (n = 7, 12.1 %). Conclusion: Her 2 positive breast cancer exhibit distinct patterns of recurrence according to molecular subtype. Insights into the preferences for different metastatic sites will provide exciting avenues for future research.
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27. The Effect of obesity on the clinicopathological characteristics of colorectal cancer: a systematic review and meta-analysis J.G. Solon, J.P. Burke, G. Handelman, D.C. Winter Centre for Colorectal Disease, St Vincent’s University Hospital, Dublin Introduction: Obesity is associated with both adenoma formation and colorectal cancer development. The effect of obesity on the clinicopathological characteristics of and survival from colorectal cancer remains unclear. Methods: A comprehensive search for published studies examining the effect of obesity on colorectal cancer clinicopathological characteristics and survival was performed. Random effects methods were used to combine data. Results: Data were retrieved from 21 studies describing 44,782 patients with 19 % of patients having a BMI [30. Obesity related colorectal cancer was not associated with male sex (OR (odds ratio): 0.944, 95 % CI (confidence interval): 0.855–1.043, P: 0.258), advanced T stage (T4) (OR: 0.920, 95 % CI: 0.771–1.096, P: 0.350) or poor differentiation (OR: 1.001, 95 % CI: 0.923–1.085, P: 0.989). There was a small increase in distal tumor location (OR: 1.161, 95 % CI: 1.094–1.231, P \ 0.001) and node positivity (OR: 1.124, 95 % CI: 1.007–1.255, P: 0.037) in patients with obesity. Obesity associated colorectal cancer did not affect cancer related mortality (OR: 1.487, 95 % CI: 0.926–2.389, P: 0.101), cancer recurrence (OR: 1.012, 95 % CI: 0.953–1.075, P: 0.691) or all cause mortality (OR: 0.939, 95 % CI: 0.839–1.051, P: 0.274). Conclusions: Based on these data, obesity associated colorectal cancer is associated with distal tumor location and nodal positivity which does not effect survival. Obesity in the setting of colorectal cancer may not be an adverse prognostic feature.
28. Vascular endothelial growth factor (VEGF) expression in a Wistar rat model following induced acute limb ischemia O.P. Godkin, A. Potempa, O. Budzak, A. Kosican, S. Toth, P. Stasko Department of Vascular Surgery, VUSCH, Cardiovascular Institute, Ondavska Kosice, Slovak Republic, Wexford General Hospital and Department of Histology and Embryology Srobarova, Kosice, Slovak Republic Introduction: Acute limb ischemia (ALI) is a vascular that threatens limb viability. We categorize ALI according to Rutherford’s classification. In many cases however the boundaries between stages are particularly ambiguous especially those of stage IIB and III. Differentiation of these stages may be accomplished by using both histopathological and immunohistochemical methods to determine limb viability. Objectives: The aim of this work is to evaluate ischemia-reperfusion damage of skeletal muscle by changes in VEGF following induction of acute limb ischemia. Methods: Ischemia was induced by cross clamping the abdominal aorta for 1 h in 35 male Wistar rats, followed by 3, 6, 12, 24, 48 and 72 h reperfusion. According to these time intervals, the animals were divided into 8 time-dependent groups (I1R3, I1R6, I1R12, I1R24, I1R48, I1R72, and K-control). Gracilis muscle sample was taken from each animal and underwent Hematoxylin-Eosin staining and VEGFimmunohistochemical examination.
S181 Results: Maximum increase of blood vessels inthe samples stained with Hematoxylin–Eosin were determined after 6 h of reperfusion, while a significant increase occurred between 3 and 6 h reperfusion (35.71 %, p \ 0.01). The minimal number of blood vessels was observed after 72 h of reperfusion, with significant reduction between 6 and 72 h (29.12 %, p \ 0.01). We determined the minimum number of immunoreactive vessels in the control group, with a maximum increase in I1R12 by immunohistochemical quantification of VEGF. Muscle fibre of sarcoplasm immunoreactivity (VEGF) was minimum in the control group, with maximum values observed in I1R24. A significant increase in VEGF-immunoreactivity of sarcoplasm fibres occurred between control group and I1R12 (p \ 0.05). Conclusions: The results of the experiment can be used to quantify the ischemia-reperfusion period, which is characterized by increase in VEGF immunoreactivity factor in regeneration of damaged or atrophied muscles.
29. The biopsychosocial impact of vesicovaginal fistula repair; a cross-sectional analysis L.M. Houlihan, M. Lynch Department of Surgery and Obstetrics, Kitovu Hospital, Masaka, Uganda Objective: Great efforts have been made in recent years to increase the availability of vesicovaginal fistula (VVF) repair so as to holistically improve affected women’s quality of life. This research aims to collect, identify and qualitatively analyse post-operative VVF data, including long-term clinical, psychological and social outcomes of vesicovaginal fistula repair. Design: Cross sectional study using a questionnaire designed by the researchers to identify and qualitatively assess the post-operative biopsychosocial implications of VVF repair, on women previously suffering with multiple fistula afflictions. Setting: Interviews took place during the VVF Outpatient Clinics over a 4 month period in Kitovu Hospital Masaka Uganda. Study population: 43 women post repair who attend VVF Outpatient Clinic. Methods: The women who attended the VVF Outpatient Clinic completed the comparative questionnaire, either by themselves or via a translator. This data was qualitatively analysed by the article’s researchers from a pre and post-operative perspective. Main outcome measures: The biopsychosocial outcomes were measured to assess holistic improvement in the patient’s quality of life. Results: Patients who underwent repair experienced an overall marked improvement in all aspects of their lives, most prominently where 98 % of women experienced a post-operative improvement in urinary incontinence, depression, shame and social isolation. This study also identified a 42 % decrease in the formerly widespread social stigma associated with women who had a fistula. Conclusions: The results reflect positively on the impact, which repair has on these women’s quality of life, as well as on the education and campaign efforts pioneered by the medical and lay community. VVF repair undoubtedly holistically improves these women’s lives.
30. Weight loss in oesophageal and gastric cancer patients; can we mitigate the risk? S. Tarrant, C. O’Neill, N. McCawley, M. Arumugasamy, P. Broe
S182 Department of Upper GI Surgery and Dietetics, Beaumont Hospital Patients with gastric and oesophageal malignancy are predisposed to weight loss during their post-operative recovery phase which may have deleterious consequences for their recovery. We examined whether patient weight loss pre-operatively was a risk factor for predicting likelihood of clinically significant* weight loss in the post operative phase and whether prolonged length of jejunostomy supplemental feeding may mitigate this risk. We maintained a prospective database of upper gastrointestinal malignancies at our centre Beaumont hospital in 2013. This identified 35 cancer patients who underwent oncological resection. Of these, 29 had surgically placed jejunostomy tubes, 18 at gastrectomy and 17 at oesophagectomy. 66 % of patients reporting weight loss pre-oesophagectomy and 42 % of patients reporting weight loss pre gastrectomy also experienced weight loss in their post operative recovery. Moreover, 58 % of the oesophagectomy patients and 55 % of the gastrectomy patients experienced weight loss of clinical significance at the time of their first outpatient appointment 4 weeks post discharge from hospital. In our centre, only 20 % of all patients received supplemental enteral nutrition via their jejunostomy for greater than 20 days. We have identified high rates of clinically significant weight loss in our oncology patients. We propose that identifying patients at high risk of clinically significant weight loss would allow for initiation of prolonged post operative enteral nutrition supplementation which may lead to a reduction in weight loss and subsequent sequelae.
31. Impact of a clinical-decision making module on the attitudes of surgical trainees in Ireland N.R. Bhatt, E. Doherty, E. Mansour, O. Traynor, P.F. Ridgway Department of Surgery, Adelaide and Meath Hospital, Dublin and RCSI Introduction: Decision-making, a cognitive non-technical skill, is a key element for clinical practice in surgery (1). Importance of active teaching of these skills has been recognised recently due to changes in the structure of surgical training programs in United Kingdom and Ireland, and the new working time legislations (2). The Royal College of Surgeons in Ireland conducts a clinical decision-making (CDM) module for basic surgical trainees each year. The aim of this paper was to determine the impact of a CDM module on attitudes of surgical trainees. Methods: Three standardised 2-h workshops for three trainee groups were delivered. The trainees were assessed by an anonymous questionnaire before and after the module. Change in attitude of the trainees was determined by comparing Likert scale ratings using the Wilcoxin Signed rank test. Results: Fifty-seven newly appointed basic surgical trainees attended these workshops. A statistically significant rise in the proportion of candidates recognising the importance of being taught CDM skills (p = 0.002) revealed the positive impact of the module, as did the increased understanding of different aspects of clinical decision making like shared decision making (p = 0.035) and different styles of decision making (p = 0.013). Conclusion: Our cohort of surgical trainees perceived non-technical skills’ workshops as useful. The changes in their attitudes towards CDM reflected the improved comprehension of trainees after the module. Therefore it might be worthwhile to introduce such modules as a part of surgical curricula and train the novice surgeons in the core competency of CDM.
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
32. Surgeon and pathologist assessment of acute appendicitis: how accurate are we? P.N. Stassen, D. Mullan, H. Mohan, C. Fleming, J. Foley, A. Heeney, K. Schmidt, K. Mealy Department of General Surgery, Wexford General Hospital Background: Appendicitis is a common surgical emergency. Increasingly, a laparoscopic approach is used. Removal of a normal appendix is no longer routinely advocated, especially using a laparoscopic approach. However, this relies on accurate diagnosis of a normal appendix by the operating surgeon. This study aimed to compare surgeon and pathologist assessment of appendicitis in Wexford General Hospital over a 14-year period. Methods: An audit was performed on all appendix specimens removed at open appendicectomy over a 14 year period, using the prospective Lothian Surgical Audit system and pathology reports. Open appendicectomy was selected to examine, as the routine practise at our institution is to remove a normal appendix at open appendicectomy. Statistical analysis was performed using SPSS, version 21. Results: A total of 1,068 open appendicectomies were performed for clinically suspected appendicitis. The mean age at presentation was 22.8 years (range 7–55), with a 1:3 female to male ratio. 39 % were performed on paediatric patients. 96.1 % (n = 1,034) of appendicectomies were performed acutely, and 3.9 % (n = 42) were interval appendicectomies. Intra-operatively an impression of acute appendicitis was made in 90 % cases (n = 934), compared to 78.8 % (n = 816) on pathological analysis. (p \ 0.001). The remaining pathologies showed 2.9 % carcinoid and 15.1 % normal appendix. In 43 cases (4 %) a normal appearing appendix had evidence of appendicitis. On correlation of intra-operative impression of acute appendicitis and final histological analysis weak association was observed between the two groups (Pearson correlation coefficient, r = 0.132). Conclusion: The results of this study highlight the discordance between histological evidence of acute appendicitis and intra-operative impression. Therefore other clinical variables and not macroscopic appearance alone should be used when deciding to perform appendicectomy.
33. Should all trauma patients undergo routine whole body computed tomography on admission: a systematic review and meta-analysis K.C. Chong, S. MacCormick, K. Bennet, D. Mockler, D.B. O’Connor, K.C. Conlon Professorial Surgical Unit and Pharmaco-Epidemiology Department, Trinity College Dublin and Tallaght Hospital Dublin Trauma is a leading cause of death. Early in-hospital trauma care with accurate diagnostic work-up is crucial for survival. Conventional imaging includes plain films, FAST scan and selective CT. Wholebody computed tomography (WBCT) has been shown to improve outcomes in major trauma but remains controversial and has not been incorporated into ATLSÒ guidelines. We assessed the evidence for performing WBCT in trauma. Systematic literature search of Medline and Embase databases was performed (1990–July 2014). Studies reporting outcomes in trauma patients undergoing WBCT on admission compared to patients undergoing non-WBCT were. Studies were assessed for quality using Newcastle-Ottawa scale (NOS 1–9). Studies exclusively reporting head trauma were excluded. Pooled estimation for proportion of
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 excess mortality in non-WBCT was computed using random effects model. The search yielded 1,422 titles and 16 studies (retrospective and prospective non-randomized series) involving 30,441 patients were analysed. There was significant heterogeneity between studies. All selected studies involved patients with major trauma (Injury severity score [16) and there was no significant difference in ISS between WBCT and non-WBCT groups. Time in emergency department and time to surgery was reduced for WBCT patients in some studies. Six high-quality studies (NOS [7), including 25,709 patients reported mortality. Non-WBCT mortality rate was significantly higher compared to patients receiving WBCT. Range 0.5–15.4 %, pooled ES 0.26 (95 % CI 0.17–0.24). WBCT has a survival advantage over non-WBCT and its use can be justified during the initial assessment and resuscitation of major trauma patients. (Level 3 evidence) A randomized trial of WBCT in trauma is warranted.
34. Carotid artery stenting—cervical approach vs. femoral approach—11 years experience N. Elsafty, W. Tawfick, S. Sultan Western Vascular Institute UCHG, School of Medicine, NUIG, Galway Clinic, RCSI Introduction: Randomized-control trials have been inconsistent in proving superiority of carotid artery stenting (CAST) to carotid endarterectomy (CEA). CAST has been associated with a higher risk of stroke. Studies suggest access technique in CAST may be pivotal in reducing peri-operative stroke. Aims: To compare CEA to trans-femoral carotid artery (F-CAST) and trans-cervical carotid artery (C-CAST) regarding clinical success, efficacy in decreasing morbidity and mortality. Composite primary endpoints included stroke, MI and death. Secondary endpoints included patency and re-intervention rates. Methods: A retrospective parallel group observational study over 11 years with 51 CEA and 45 CAST patients. Multiple logistic regression was used to control for co-morbidity and anatomical high risk factors. Propensity scoring was used to adjust for baseline characteristics and selection bias, by matching co-variables. Results: 45 CAST procedures (33 F-CAST and 12 C-CAST) and 51 CEA cases adjusted for baseline characteristics and matching covariables were compared. Mean age was 68.3 years with equivalent demographics between the 3 groups. One (3 %) patient in the F-CAST group suffered a peri-operative stroke with no stroke in either group. There was one (1.9 %) peri-operative MI in the CEA group and none in either CAST group, p 0.361. 30 day mortality was 0 in all 3 groups. 5 year stroke free survival was 93.3 % in CEA, 87.9 % in F-CAST and 92.9 % in C-CAST. 5 year re-stenosis and reintervention rates was equivalent in the 3 groups. Conclusion: CAST technology is still suboptimal however, C-Cast provides a safer option with significantly less risk of peri-operative stroke and combined post-operative stroke/MI/death.
35. Examining the role of the ‘‘letter to the editor’’ J. Fay, C. O’Rourke, J.C. Coffey, J.E. Fenton GEMs, University of Limerick, Department of General Surgery and ENT, Limerick
S183 The letter to the editor plays an important role in literature. Letters to the editor afford an opportunity to take a position for or against an issue or simply to educate readers on a topic. The aim of this study was to identify the role and theme of letters to the editor published in five leading general surgery journals. All letters to the editor published in; Annals of Surgery (AOS), Journal of American College of Surgeons (JACS), Surgical Endoscopy (SE), Surgery and Diseases of the Colon + Rectum (DCR), for the year 2013, were examined along with the individual journal guidelines for the submission of such letters. 36 different countries produced a total of 190 letters for the year 2013. Surgical Endoscopy was the highest contributor with 34.2 % of total letters, 95.4 % of which were related to original journal articles. JACS contributed 24.2 % of total letters (100 % related to original journal articles). AOS contributed to 15.7 % of total letters (96.7 % were directly related to original journal articles). DCR contributed 16.8 % of total letters published (100 % directly related to original journal articles) and was also the only journal that published the author’s response directly with the letter. Surgery published the least amount of letters only contributing 8.9 % of the total letters. (94.1 % directly related to original journal articles). 2 journals published diagrams and tables with letters. Overall, 97.4 % of all letters were directly related to original content. Of these 36.8 % disagreed and 19.5 % agreed with the journal content, with 24.2 % responding indifferently the rest clarifying or ignoring authors views. Letters to the editor allow the opportunity of post-publication peer review and sharing the latest advances in clinical research. Some journals utilise this tool more than others, with some using strict inclusion criteria’s with other allowing a more flexible approach the letter to the editor. This study identifies a clear lack of letter indexing in high impact general surgery journals.
36. Supervised exercise therapy (SET) for intermittent claudication: factors that determine compliance and outcomes S. Carr, E.A.H. Kheirelseid, T. Aherne, D. Moneley, A. Leahy, P. Naughton Department of Vascular Surgery, Beaumont Hospital, Dublin Supervised exercise therapy (SET) has significant benefit in improving walking time and distance in people with peripheral vascular disease (PVD). This study aims to assess the usefulness of SET in our cohort of patients and to determine factors predicting compliance and outcomes of SET. A retrospective analysis of a prospectively updated database of the patients assigned to a SET programme for the treatment of PVD was undertaken. Data was gathered from medical notes and through phone interviews. SPSS was used for statistical analysis. Ninety-eight patients underwent SET during the study period. Their mean age (±SD) was 69.2 (±10.12) and 82 % were males. Median follow up of 25.1 months (IQ range 17.0–31.6). SET significantly improved the quality of symptoms as described per patients (p = 0.001). Factors like Level of Claudication (p = 0.042) and educational level (p = 0.007) were found to affect the outcome of SET programme. On multivariate analysis (logistic regression) only history of hypertension was identified as predictor of outcome after SET (p = 0.045). In addition, smoking history (p = 0.021), hypercholesterolemia (p = 0.020) and history of ischemic heart disease (p = 0.029) significantly affect compliance. Using linear regression, smoking history (p = 0.024) and quality of symptoms (p = 0.018) were identified as predictors of compliance to SET.
S184 SET is effective in improving quality of symptoms in our cohort of patients. SET compliance is the most important factor in achieving maximum benefit and SET compliance can be determined by patient’s compliance with other aspects of optimal medical treatment.
SESSION 5 PLENARY SESSION 37. The approach to involved anterior margins after breast conserving surgery; whether or not to re-excise L.O. Connell, S. Walsh, C.X. Cheung, Z. Al Hilli, J. Rothwell, D. Evoy, J. Geraghty, C. Quinn, A.O. Doherty, E.W. McDermott, R. Prichard Department of Breast-Endocrine-General Surgery, St Vincent’s University Hospital, Dublin Involved radial margins after breast conserving surgery routinely undergo re-excision. However, appropriate management of involved anterior margins (IAM) remains a topic of controversy. It has been suggested that re-excision of IAM yields low rates of residual malignancy and may only be necessary in selected patients.(1,2) The aim of this study is to examine the management of involved anterior margins after breast conserving surgery at SVUH and to analyse the rate of residual disease in re-excised anterior margins. A retrospective review of all patients having breast conserving surgery at St Vincents University Hospital from January 2008 to December 2012 was performed. Data collected included patient demographics, tumour characteristics, margin positivity, re-excision rates and definitive histology of the re-excision specimens. An involved margin was defined as \2 mm. A total of 930 patients were included with an average age of 65 (29–94). Of these, 121 (13 %) had an IAM. Further re-excision of the anterior margin was carried out in 37 (30.6 %) and a further 16 (13.2 %) proceeded to mastectomy. Residual disease was found in 18.5 % (7/36) of those who underwent re–excision and 7/16 (43.75 %) of those who underwent mastectomy. Overall, 11.57 % (14/121) of patients with IAM were subsequently found to have residual disease. There is currently no consensus regarding the management of IAM. These findings suggest that further research is warranted to identify those patients with IAM who may benefit from further surgery.
38. Can inflammatory markers be used to predict complete pathological response in rectal cancer C.A. Fleming, C. Reid, H.M. Mohan, K. Schmidt, F. Cooke South Eastern Rectal Cancer Network, Wexford General Hospital Background: The management of rectal cancer patients who achieve complete tumour response (CPR) to neoadjuvant therapy (NAT) is a current source of debate1. Some advocate ‘‘watch and wait’’ programmes. Central to this approach is accurate diagnosis of complete response pre-operatively. We sought to identify if baseline inflammatory markers act as an adjunct to MRI for prediction of CPR. Methods: We analysed prospectively maintained data of rectal cancer patients treated in the South East of Ireland from 2010–2014. We identified patients who received NAT and achieved radiological or pathological CPR. Basic demographics, radiological and pathological features were tabulated. Neutrophil-lymphocyte ratio (NLR), platelet-
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 lymphocyte ratio (PLR), serum albumin (SAL) and CEA levels within 7 days prior to NAT were calculated. Tumour response to NAT was estimated based on tumour regression grading (TRG) system of the American Joint Committee on Cancer (AJCC) 7th Ed. Association between post-operative CPR and raised inflammatory markers was analysed. Statistical analysis was performed using SPSS (version 21). Results: 203 patients with rectal cancer were managed by the South Eastern Rectal Cancer Network. 24 patients achieved radiological (MRI) or pathological CPR. Mean age was 67.1 years (range 59–80), a 1:3 female:male ratio was observed. 62.5 % (n = 15) of patients were tumour stage 3 on pre-NAT MRI, 12.5 % (n = 3) were T4. All patients received chemo and radiotherapy. NLR (p = 0.43), PLR (p = 0.34), SAL (p = 0.64) and CEA (p = 0.32) alone were not predictive of CPR. In this sample group 7 patients (29.2 %) had CPR on MRI but remnant disease following surgical excision (4 = T3, 3 = T2). Correlation of post-NAT MRI and post-operative histological specimen was not significant in this small sample size (p = 0.235). However when raised NLR is considered with post-NAT MRI CPR it is significantly associated with histological CPR (p = 0.042). Conclusion: Raised NLR and complete pathological response on post-NAT MRI is more predictive than MRI alone for histological CPR in rectal cancer patients following NAT.
39. Informing consent: health literacy and perception of risk in a high-risk cancer clinic E. Rutherford, J. Kelly, E.A. Lehane, B. Cotter, M.A. Corrigan School of Medicine, University College Cork, Breast Cancer Research Centre, CUH, Wilton, Cork and Catherine McAuley School of Nursing and Midwifery, Brookfield, University College Cork supported by Aid Cancer Treatment Cork Background: Although accounting for fewer than 15 % of total breast cancers, the risk of hereditary breast cancer is a significant concern to relatives of breast cancer patients. Health literacy has been identified as a priority for healthcare providers across Europe (1). Aims: This study sought to determine the correlation between health literacy and the perception of breast cancer risk, including perceptions of BRCA mutations. Methods: A cross-sectional study of a family history clinic population (n = 86) was carried out, consisting of a patient survey and a validated health literacy assessment. Patients’ risk perception was assessed in four categories: 1. 2. 3. 4.
Personal lifetime risk Personal 10 year risk Lifetime Ten year risk of the average woman of the same age
Knowledge of BRCA prevalence and risk of being a mutation carrier was also assessed. Scores were compared to actual risk as calculated by the IBIS system. Bivariate correlation analysis was employed to explore possible correlation between risk perception and health literacy. Results: The majority of women overestimated risk in all categories (83.5–100 %). Follow up patients displayed an improvement of 2–4 % in risk accuracy (this did not reach statistical significance, p = 0.185–0.726). Mean inaccuracy scores remained high for each category- between 21–30 %. More than 37 % of patients recorded test scores that indicated the possibility of limited literacy. Inadequacy of health literacy correlated with risk inaccuracy across both personal ten-year (rs = 0.224, p = 0.039) and general 10-year population estimations. (rs = 0.267, p = 0.013). Accuracy of estimation of BRCA mutation population
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 prevalence was also associated with improved health literacy scores (r = 0.399, p \ 0.001). Conclusion: A high degree of inaccuracy in risk perception exists amongst women with a family history of breast cancer, even after specialist consultation. Low levels of health literacy correlate with a higher degree of inaccuracy. Targeted patient educational interventions need to be sympathetic to patient literacy status.
40. Analysis of adipose tissue distribution and patient outcomes in colon cancer patients E.P. O’Connell, M. Twomey, D.P. O’Leary, M. Maher, H.P. Redmond Department of Surgery and Radiology, Cork University Hospital Introduction: Visceral adipose tissue is a metabolically active substance associated with raised inflammatory cytokines. In particular, interleukin 6 (IL-6) is strongly related to visceral obesity and has been linked to a number of diseases including colon cancer. Aim: To accurately quantify adipose tissue levels in colon cancer patients and determine if an association exists between visceral obesity, patient outcomes and cytokine levels. Methods: Pre-operative cytokine levels were measured in colon cancer patients undergoing curative resection for colon cancer between 2009 and 2012. Visceral, subcutaneous and total fat levels were quantified in each patient through measurement of lumbar fat on pre-operative CT scans. The ratio of visceral to total fat and the ratio of subcutaneous to total fat were calculated for each patient. Results: 26 patients were included in the analysis. Fat distribution patterns were markedly different between male and female patients. Male gender was significantly associated with a high visceral to total fat ratio (p = 0.02) while female gender was significantly associated with a high subcutaneous to total fat ratio (p \ 0.01). High levels of adiposity were significantly associated with early post-operative complication (p = 0.032). Visceral adiposity was associated with serious complications including anastomotic leak and wound infections (p = 0.018). In contrast with previous studies IL-6 levels tended to be higher in those with low levels of visceral fat although this finding was non-significant. Conclusions: A complex relationship exists between cytokine levels, adiposity and outcomes in colon cancer patients. This study identifies an association between visceral adiposity and early post-operative complications.
41. Preoperative short course radiotherapy with long interval surgery in a series of high risk patients with locally advanced rectal cancer M. Flanagan, V. Brennan, I. Reynolds, B. O’Neill*, D.A. McNamara Department of Colorectal Surgery and St. Luke’s Radiation Oncology Centre, Beaumont Hospital Background: Preoperative radiotherapy improves local control for rectal cancer. Short course radiotherapy (SCRT) followed by early surgery has oncologic results similar to long course chemoradiotherapy (LCCRT) and delayed surgery, with no reported difference in acute or late toxicity1,2. Standard SCRT protocols do not result in downstaging so patients with a threatened margin usually receive LCCRT. We report a consecutive series of patients treated with SCRT in whom surgery occurred at a delayed interval instead of the standard 7 days.
S185 Methods: Patients unsuitable for standard SCRT or LCCRT between 2008 and 2014 were considered for short course radiation followed by a prolonged interval to surgery. Every patient was discussed by a multidisciplinary team at least twice. Each patient received 25 Gy in 5 fractions. Data including demographic information, type of surgery, MRI and pathological stage, Mandard tumour regression grade (TRG) and post-operative complications were prospectively recorded in a Dendrite database. Results: 9 patients of median age 72 (65–85) years were treated with this protocol. The median interval to surgery following completion of radiation was 60 (13–94) days. Co-morbidity was the commonest indication with all patients ASA grade [2. All patients with an anastomosis had a post-operative gastrograffin enema. A leak rate of 20 % was observed compared to 12.8 % in patients receiving our standard protocol LCCRT. There was no all-cause mortality in this cohort of patients at 30-day follow up compared to 1.9 % of those received LCCRT during the same time period. One patient had a complete pathologic response. One patient had a positive distal resection margin: all other radial, proximal and distal margins were negative. Conclusion: Patients treated with a short course long interval to surgery protocol were older and had worse ASA grades than patients receiving standard LCCRT protocols. This small series suggests this protocol is oncologically safe and results in similar early surgical outcomes when compared to those who received LCCRT protocols. It may have a role in treating patients who require preoperative chemoradiotherapy where standard protocols prove difficult.
42. Laparoscopic Heller myotomy: effect of age on perioperative outcomes B.C. Murphy, T.J. Murphy Department of Oesophago-Gastric Surgery, Mercy University Hospital, Cork Introduction: Laparoscopic Heller Myotomy is the current treatment of choice for oesophageal achalasia with type I and III subtypes. Pneumatic dilatation is associated with inferior outcomes compared to surgery. Despite this, less invasive treatments such as pneumatic dilatation and botox injections are often chosen in the elderly. Our preference is to treat type I and III oesophageal achalasia with a laparoscopic Heller Myotomy regardless of age. Aim: To assess the effect of age on peri-operative outcome of patients undergoing laparoscopic Heller Myotomy as a treatment for achalasia. Methods: Peri-operative data were retrospectively collected on patients undergoing laparoscopic Heller Myotomy from 2011 to 2014. Patients were classified into two groups: group 1 (age B70) and group 2 (age C70). Results: Heller myotomy was performed on 28 patients, 22 in group 1 (79 %) and 6 in Group 2 (21 %). The mean age was 44 and 76 years, respectively. There were no 90-day operative mortality nor open conversions. There was one mucosal tear in group 1, which was repaired intra-operatively. There were no peri-operative complications in group 2. The mean length of stay in group 1 was 1.86 days post-op (range 1–3), and 2 days post-op in group 2 (range 1–3). 30 day re-admission was 0 % for both groups. There was no difference in Eckardt dysphagia scores between the two groups at the first post-operative visit. Discussion: There were no differences in peri-operative outcomes between the two groups. Laparoscopic Heller Myotomy, therefore, is a safe and feasible treatment of Type I and III achalasia in patients of all ages.
43. Untangling the role of protein kinase C in breast cancer downstream of growth factor and adhesion signalling Mary McCumiskey, Catriona Dowling, Susan Dwane, Shona Tormey, Tara Dalton, Patrick A. Kiely Department of Life Sciences, University of Limerick, University Hospital Limerick and Graduate Entry Medical School Recent studies have revealed a correlation between higher RACK1 expression levels and shorter overall survival times of breast cancer patients. RACK1 is a 37 kDa protein with 7 WD repeat sequences which functions as a 7-sided Beta-propeller to shuttle proteins around the cell to their site of function. The scaffolding properties of RACK1 make it essential for integrating these signaling events and RACK1 stabilizes enzyme activity keeping specific pools of proteins in the ‘active’ state, thus facilitating the establishment and maintenance of signalling pathways. Suppression of RACK1 expression in MCF-7 cells severely disrupts cell adhesion and cell migration and has a dramatic effect on the overall activity and substrate specificity of enzymes such as PP2A and Src. PKC is a family of serine/threonine kinases, consisting of at least 9 different isoforms. Isoforms of the PKC family have been implicated in the regulation of cell proliferation, differentiation and survival. Their activity is mediated by several factors including calcium, phorbol esters, and by binding to RACK1. PKC’s have a wellestablished role in cancer but their contribution to breast cancer in the context of transmitting signals from the ECM through integrin and IGF-I signalling pathways remains neglected. In this pilot study, we are looking at protein kinase C (PKC) expression and it’s interaction with RACK1 in breast cancer downstream of growth factor and adhesion signalling. Using qRT-PCR, we have determined the expression profile of PKC’s in breast cancer tissue of various breast cancer subtypes, and compared this to the expression profile in normal breast tissue. Combining this with patient data, we are correlating PKC expression with patient prognosis. Our work suggests that PKC expression may have potential use as a biomarker for prognosis and as a target for novel therapeutic agents.
44. Identification of TTBK1 as a novel RACK1 binding partner in breast cancer S. Hayes, M. Kiely, M. McCumiskey, S. Tormey, T. Dalton, P.A. Kiely Department of Life Sciences, and Materials and Surface Science Institute, Stokes Research Institute, Graduate Entry Medical School, University of Limerick and Department of Surgery, University Hospital Limerick Increasing our knowledge of the mechanisms regulating cell adhesion and proliferation in breast cancer cells is central to understanding tumour progression and metastasis. RACK1 is a scaffolding protein with 7 WD repeats that mediates crosstalk between growth factor and adhesion receptor signalling and is a well-documented binding partner of PP2A. RACK1 plays a critical role in determining how PP2A functions in signalling pathways by modulating the activity and substrate specificity of PP2A, while regulating its distribution to specific cellular locations. A mass spectrometry screen of the RACK1/PP2A complex in breast cancer cells cultured in 3-Dimensional conditions identified 66 novel binding partners of the complex, a diverse group of proteins found in a variety of cellular locations. One of the proteins identified
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 was Tau-Tubulin Kinase 1 (TTBK1). TTBK1 is a serine/threonine/ tyrosine kinase and is a member of the casein kinase 1 superfamily, which has the ability to control tubulin activities, phosphorylate tau proteins and induce tau aggregation in human neuronal cells. We have found that the gene coding for TTBK1 is over-expressed in cancer cell lines and 70 % of the breast cancer patients we analysed. We established that in MDA-MB-231 cells, TTBK1 is found in the membrane fractions where it co-localises with RACK1. We used siRNA to knockdown TTBK1 in these cells and showed that TTBK1 plays a role in the regulation of IGF-1 mediated MAP Kinase activation. Using a Real Time Cell Analysis platform, we showed that TTBK1 is required for cell adhesion and proliferation in these cells. Taken together, this work suggests that TTBK1 has a role to play in breast cancer and that TTBK1’s function is mediated in part by the interaction with RACK1. Future work in this space is directed at understanding the mechanism by which TTBK1 binds to RACK1 and may reveal the potential for the RACK1/ TTBK1 interaction to be used as a novel therapy or diagnostic marker in triple negative breast cancer.
45. PI3K pathway as a novel target in androgen-driven aromatase inhibitor resistant breast cancer A. Ali, L. Creevey, F. Bane, W.A. Marzuki, A.D.K. Hill, L.S. Young, M. McIlroy Endocrine Oncology Research Group, RCSI and Department of Surgery, Beaumont Hospital, Dublin The gold standard treatment for post-menopausal breast cancer is aromatase inhibitor (AI) therapy. Unfortunately, resistance is inevitable in about 30–60 % of these patients. Research from our lab previously identified a transcription factor, HOXC11, to be associated with breast cancer resistance and metastases. Prosaposin (PSAP) was identified as putative HOXC11 target gene in AI resistant setting. PSAP is a secreted protein that also plays a role in metastatic prostate cancer in ligand dependent and independent fashion (1,2). We have previously shown PSAP is an androgen responsive gene that can upregulate androgen receptor (AR) expression in a ligand dependent manner in AI resistance. An AR antagonist was effective at slowing down cell proliferation in AI resistant cells in vitro. PSAP can also potentially act in a ligand independent fashion by binding to G-protein-coupled receptor 37 (GPR37) and this current study is focused on evaluating the role of PSAP in PI3K pathway activation via GPR37 in the development of AI resistance. Treatment of cells with recombinant PSAP (rhPSAP) resulted in increasing expression of p-AKT in a dose-dependent manner. To target this pathway of resistance, we used a PI3K/mTOR inhibitor BEZ235 on our AI resistant cells. Functional studies with BEZ235 treatment showed significant reduction in cell motility and cell proliferation. Treatment of AI resistant cells with BEZ235 showed decreased expression of p-AKT, with little or no effect on AR expression. These findings suggest that with combination treatment regimens including AR antagonists and PI3 K inhibitor this may ensure sustained response to AI therapy.
46. Investigation of exosome-encapsulated microRNAs as potential circulating biomarkers of breast cancer D.P. Joyce, M. Higgins, C.L. Glynn, J. Brown, E. Holian, P. Dockery, M.J. Kerin, R.M. Dwyer
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 Discipline of Surgery, School of Medicine, National University of Ireland Galway Introduction: Exosomes are membrane-derived vesicles that are actively secreted by cells. They have been implicated in cell-to-cell communication, with recent studies suggesting exosome-mediated trafficking of microRNAs between cells. The aim of this study was to identify the panel of exosome-encapsulated microRNAs secreted by breast cancer cells in vitro, and to apply these findings to circulating levels in breast cancer patients. Methods: Cell-secreted exosomes were isolated from 4 breast cancer cell lines and characterized using Transmission Electron Microscopy (TEM) and Western Blot analysis. MicroRNA array analysis targeting 2,089 miRNAs was performed to identify the panel of miRNAs that was secreted within exosomes, with targets of interest validated using RQ-PCR. The presence of these miRNAs in the circulation of patients with breast cancer was also investigated. Results: TEM analysis of secreted exosomes revealed vesicular bodies of 40–100 nm in size. Immunoblotting confirmed the presence of the exosome-associated protein CD63. Greater than 320 miRNAs were secreted within exosomes from each cell line. Exosome-mediated transport of miRNAs was demonstrated using confocal microscopy. miR744-5p, which was found to be secreted within exosomes, was detectable in the blood of breast cancer patients and healthy controls. Preliminary analysis supports an association between this miRNA and tumour epithelial subtype. Conclusions: A distinct panel of miRNAs are selectively packaged into exosomes and secreted by breast cancer cells. This transfer of functional miRNAs between cells may play an important role in intercellular communication in the tumour microenvironment, and have implications in their use as circulating biomarkers of disease.
47. Co-delivery of pro-angiogenic agents as a treatment strategy for peripheral vascular disease C.C. Herron, C. Hastings, C.O. McDonnell, F.J. O’Brien, G.P. Duffy Tissue Engineering Research Group, Department of Anatomy, RCSI and Department of Vascular Surgery, Mater Misericordiae University Hospital, Dublin Introduction: A combination of pro-angiogenic agents is proposed to increase collateral vessel formation in critical limb ischaemia when compared to single agent use. The use of sophisticated drug delivery systems such as hydrogels to allow for a sustained release of the proangiogenic agents may help to augment their effects. Aim: To assess the efficacy in vivo of a novel combination of proangiogenic agents, desferrioxamine (DFO) and human mesenchymal stem cells (hMSCs) in a chitosan based hydrogel to increase collateral vessel formation in a hindlimb ischaemia model. Methods: 40 athymic mice underwent ligation of the common femoral artery to induce critical limb ischaemia. This was followed by injection with either chitosan gel alone, chitosan gel with DFO, chitosan gel with hMSCs or chitosan gel with DFO and hMSCs. Limb perfusion was assessed weekly via laser Doppler imaging and at 28 days histological analysis was undertaken and treatment and nontreatment limbs were compared for collateral vessel number. Results: Laser Doppler Imaging measures actual perfusion to the limbs. At day 28 animals who received chitosan gel alone had an average recovery of 54.86 %. This compares to a recovery of 28.65 % in the chitosan gel and hMSC group, 34.87 % in the chitosan gel with hMSC and DFO group. The recovery in the chitosan gel with DFO alone group was 37.13 %. Conclusion: We have demonstrated a novel combination pro-angiogenic in an in vivo model of critical limb ischaemia.
48. Investigation of the role of STAT3 signalling in obesity-associated adenocarcinoma of the oesophagus K.E. O’Sullivan, M.C. Cathcart, E. O’Regan, J. Michaelson, N. Gilmartin, A. Cannon, G. Moore, J. Lysaght, J.N. O’Sullivan, J.V. Reynolds Institute of Molecular Medicine, St James’s Hospital, Dublin Strong epidemiological evidence links obesity with the development of oesophageal adenocarcinoma (OAC). The inverse relationship is seen in squamous cell carcinoma (SCC). The molecular mechanisms underpinning phenomenon are unknown. This study examines the potential role of the STAT3 signaling pathway. A series of co-culture experiments with OE33 (OAC) and OE21 (SCC) cells were carried out with visceral (vACM) and subcutaneous (sACM) adipose conditioned media. PhosphoSTAT3 quantification was performed on Tyr705 pSTAT3 assay (MesoScale Discovery). Both OE33 and OE21 cells demonstrated a rapid increase in pSTAT3 post ACM exposure (p = 0.02 and \0.0001 respectively). Obese vACM resulted in a significantly greater increase in pSTAT3 than non-obese vACM (p = 0.04) in OE33 cells only. Furthermore, vACM treatment resulted in higher pSTAT3 levels in OE33 cells compared with sACM (p = 0.02). Quantification of total STAT3 in snap frozen obese and non-obese OAC and SCC tissue was then performed (n = 10 per subtype). Greater total STAT3 was demonstrated in obese OAC patients compared with non-obese (p = 0.01). Immunohistochemical staining for pSTAT3 and IL-6R was performed on tumour tissue from 154 patients with OAC and SCC in tissue microarrays. Survival analysis revealed a protective effect with increased pSTAT3 expression in OAC (HR 0.74, p = 0.02) and the inverse in SCC (HR 3.7, p = 0.08). We have elucidated divergence in OAC and SCC in response to adiposity in vitro. These results are mirrored by in vivo survival analysis. These findings indicate pSTAT3 activation plays a role in obesity-associated OAC, making it a potential therapeutic target to augment existing therapies. Disclosures: Funding: Irish Cancer Society Research Scholarship CRS120SU.
SESSION 6 SCIENTIFIC SESSION 49. Management of infected pancreatic necrosis: a 5 year experience O. Ahmed, G. McEntee Department of Hepatobiliary and Pancreatic Surgery, Mater Misericordiae University Hospital Until recently, a diagnosis of infected pancreatic necrosis warranted necrosectomy, which was associated with high morbidity and mortality rates greater than 20 % (1). Pre-operative percutaneous drainage delayed the need for necrosectomy until improved outcomes (2). In 2008 this institution changed its approach to the management of such cases opting instead for percutaneous drainage with selective deferred necrosectomy. A total of 37 patients with infected pancreatic necrosis from January 2008 to December 2013 were included. The acute physiology and chronic health evaluation (APACHE) and sequential organ failure assessment (SOFA) scores were calculated on admission, before any surgical or radiological intervention. The median initial APACHE and SOFA scores were 10 (range 0–18) and 3 (range 0–10). All 37 patients underwent radiologically guided drainage and a selective necrosectomy was performed on 16 of these where the
S188 infection did not completely resolve; n = 3 (2008), n = 4 (2009), n = 4 (2010), n = 1 (2011), n = 3 (2012), n = 1 (2013). 21 patients did not require surgery and were managed with pancreatic drain insertion, optimal nutritional and critical care interventions. Overall mortality was 8 % (n = 3). This study demonstrates that radiological guided drainage of infected pancreatic collections can, in most cases, prove curative and, if not, facilitate delayed surgical intervention with improved outcomes.
50. Lipopolysaccharide (LPS)-induced tolerisation of colorectal cancer cells increases their metastatic potential in vitro and in vivo D. Hechtl, J.H. Wang, H.P. Redmond Academic Surgical Research Department, University College Cork and Cork University Hospital Introduction: Endotoxin tolerance (ET) is a refractory state in which, immune cells show unresponsiveness to repeated LPS stimulation. Inflammation increases the incidence of tumour recurrence and metastases despite curative surgery in colorectal cancer. Toll-like receptor 4 (TLR4), which binds LPS, has an essential role in initiating the inflammatory cascade and ET. This interaction between LPS and TLR4 evoke cardinal effects in tumour progression. Aim: To investigate whether LPS pre-treatment influences human or murine colorectal cancer cells adhesion, proliferation and invasion in vitro. Also we evaluated LPS pre-treatment effects on murine colorectal tumour cells in vivo. Methods: Human (SW620, SW480) and murine (CT-26) colorectal cancer cells were pre-stimulated with LPS (100 ng/ml) to induce tolerisation. Non-tolerised and tolerised cells were then assessed for cytokine profile, adhesion, invasion and viability. For in vivo experiments, CT-26 cells were either inoculated into the flank of BALB/c mice (n = 24) to assess primary tumour growth or (n = 24) underwent intra-splenic injection of CT-26 cells to observe metastatic growth in the liver. Results: Following LPS treatment SW620 cells demonstrated reduced (p = 0.002) interleukin-8 and vascular endothelial growth factor release, confirming that LPS pre-stimulation induced tolerisation in these cells. Furthermore, LPS pre-treatment of SW480, SW620 and CT-26 cells resulted in increased (p = 0.046) proliferation, adhesion and invasion in vitro. Similarly, LPS pre-stimulation of CT26 cells in BALB/c mice exhibited marked primary and metastatic tumour growth. Conclusion: These results suggest that endotoxaemia as a result of surgery or sepsis may play a critical role in colorectal cancer cell growth in the perioperative period.
51. Morphine potentiates the action of 5-fluorouracil, possibly through inhibition of autophagy D. Brinkman, T. O’Donovan, S. Mckenna, J.H. Wang, H.P. Redmond Department of Surgery, Cork University Hospital, Cork Cancer Research Centre Introduction: Morphine is used regularly for pain management. Its action on the growth of various cancers has been researched with varying results. 5-fluorouracil (5-FU) is commonly used in chemotherapeutic regimens for colon cancer, and the combination can be given in clinical practice. Autophagy is a cell survival mechanism that
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 can occur when stress is applied: by digesting non-essential organelles, the cell can continue to fuel essential processes. We wished to investigate the effect of the combination of the two drugs on tumour growth and determine whether this effect was due to a change in autophagic flux. Method: Human colon cancer cell lines (SW480 and SW620, primary and metastatic respectively) were treated with varying doses of 5-FU alone, morphine alone and a combination of both for various time points in vitro. Morphology by cytospin, autophagosome levels by ‘‘Cyto-ID’’ assay and recovery from treatment by modified colonogenic assay were assessed. Results were analysed for significance using paired samples t-tests in SPSS 20 (IBM). Results: Morphine alone had little effect compared to control, increasing autophagosome levels and decreasing apoptosis slightly but not significantly. 5-FU alone increased autophagosome levels and significantly reduced the colony count. 5-FU and morphine in combination had a significantly increased effect in suppressing tumour colony growth/recovery (p = 0.002–0.009) and decreased autophagosome levels compared to 5-FU alone. Conclusion: Morphine in combination with 5FU potentiates the chemotherapeutic’s effect. Further study is required to confirm the effect is due to the suppressed survival mechanism, autophagy.
52. Molecular cues to angiogenesis in the chick extraembryonic membrane following cadmium exposure A. Kaskova-Gheorghescu, J. Duess, J. Thompson School of Medicine and Medical Science, University College Dublin, St Vincent’s Dublin, National Children’s Research Centre, Our Lady’s Children Hospital Crumlin Vascular endothelium is an important target of cadmium (Cd) toxicity. It was noticed that exposure to Cd can alter the expression of VE-cadherin and VEGF in in vitro assay. This study represents a novel investigation of Cd on molecular factors associated with vessel growth, branching and endothelial integrity utilizing the in vivo chick embryo model. Embryos incubated for 60 h to stage 16–17 were explanted according to Dugan’s method and treated with 50 lL of 50 lmol CdAc vs. NaAc. Embryos were dissected from their extra-embryonic membranes (EEM) and distributed for either mRNA (VEGF-A, VEGF-R2, Ang-2, and VE-cadherin) or protein analysis (gallinaceous VEGF-A ELISA) at 1, 4, 8 and 24 h after the treatment. Concentration of VEGF-A in the EEM was significantly reduced in the Cd treated group when compared to the NaAc treated controls. Similarly, the relative mRNA expression levels of VEGF-A, VEGF-R2, and VEcadherin were significantly reduced decreased in Cd group, however Ang2 was found to be increased in the Cd group compared to controls. Our results demonstrate that Cd exposure clearly impairs vascular development by disrupting tube formation (VEGF-A, VEGF-R2). Further, Cd disrupts cell-cell junctions and endothelial integrity (VEcadherin) leading to increased permeability and haemorrhage. This study demonstrates for the first time the up-regulation of Ang-2, an important cue in vessel disassembly, following exposure to this toxic agent.
53. Evolution of a research field—a microRNA example M.C. Casey, J.A.L. Brown, M.J. Kerin, KJ Sweeney Discipline of Surgery, Galway University Hospital
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 Onset of the digital age revolutionised the manner in which scientific knowledge is produced. With expanding scientific production and unprecedented access to information, the requirement of a means of assessing and analysing research output is essential. Here we utilised bibliometric parameters to quantitatively analyse miRNA research yield, from time of discovery in 1993 to December 2013, outlining the progression of this novel research field. Data were retrieved from the Web of ScienceTM (WoS) Core Collection database (Thompson Reuters), searching the terms ‘‘miRNA’’ and ‘‘microRNA’’ and analysed using WoS data tools. Publications of all languages and formats were accepted. The number of items identified summates 26,177 publications. From time of first publication, yearly output increased exponentially, with 62 % of all items published within the years 2011 to 2013 (n = 16,348). The United States contributed most to the literature (n = 11,056), followed by the Peoples’ Republic of China (n = 5,584). 69 % of all published material were original articles (n = 18,111), with only 13 % review articles (n = 3,314). Of all research categories, biochemistry molecular biology comprised 24 % of publications (n = 6,163), followed by oncology, with 15.5 % of publications (n = 4,070). PLoS ONE published miRNA material most prolifically (n = 1,589), followed by Nucleic Acids Research and PNAS (n = 451). A total of 837,898 citations were identified, with PNAS publications cited most frequently (6 % total citations). Considering the ongoing remodelling of scientific research, bibliometric analysis proves informative, revealing publication trends, citation patterns and research distribution, enabling researchers to produce targeted scientific outputs.
54. Recruitment of AIB1 as a result of HER-2 overexpression confers resistance to aromatase inhibitor therapy E. Burke, D. Vareslija Endocrine Oncology Research Group RCSI More than 75 % of breast cancers express estrogen receptor (ER) and/ or progesterone receptor (PR). Successful therapies such as Tamoxifen and aromatase inhibitors are currently used in the clinic to treat ER-positive patients. Despite their success, a large portion of patients that initially respond to treatment acquire resistance to disease and tumours ultimately acquire the ability to grow in the presence of therapy. Previously, the steroid receptor co-activator, Amplified In Breast Cancer 1 (AIB1) has been shown to have a role in promoting cell proliferation, migration, invasion and metastasis by signalling through ER, as well as activating growth factor pathways. The aim of this study was to investigate whether the presence of an active growth factor signalling pathway may be in fact up-regulating the AIB1 signalling pathways in response to endocrine treatment. Utilising patients that had recurred on adjuvant endocrine therapy, this study demonstrated that in Her2-positive patients AIB1 expression increased as determined by Immunohistochemistry. However, in patients that were Her2-negative AIB1 expression remained largely reduced. This increase was not evident in the endocrine sensitive cell lines which were either Her2-postive or Her2-negative. The findings of this study suggest that active growth factor pathways can stimulate tumour progression either in concert with ER signalling or independently by utilising AIB1 pathways that promote the aggressive phenotype. Given the current evidence that there is receptor switching between primary and metastatic disease, combining endocrine therapy and a growth factor inhibitor in ERpositive patients would be beneficial in attenuating aggressive disease.
55. Protein biomarkers; HOXC11 and S100b, for the prediction of recurrence and response to endocrine treatment in breast cancer S.E. Kelly, C. Byrne Endocrine Oncology Research Group, Department of Surgery, RCSI, Dublin The advent of molecular profiling has allowed for classification of breast cancer, a highly heterogeneous disease, into subtypes based on levels of cellular gene expression. This advancement has driven the pursuit of personalized breast cancer treatment. Although the development of targeted therapies (including endocrine therapy), has led to great improvement in breast cancer treatment, tumour resistance and thus recurrence remains an elusive clinical problem. In this project, immunohistochemistry was undertaken to stain tissue microarrays containing breast cancer samples from 560 patients, to assess tumour nuclear expression of the developmental transcription factor homeobox C11 (HOXC11). Using the Stata program, the HOXC11 profile of this patient cohort was compared with the pre-existing patient database, containing information including; receptor status, time to recurrence and endocrine treatment of patients. It was found that HOXC11 positivity is predictive of reduced disease-free survival/recurrence, particularly in the context of endocrine treatment-resistant breast cancer. Furthermore, HOXC11 was found to directly associate with positive nodal status and steroid receptor coactivator-1 (SRC-1), a key mediator of disease recurrence. Enzyme-linked immunosorbent assay (ELISA) was used to determine breast cancer patients’ (n=8) preoperative and post-recurrence serum levels of S100b, a protein which is expressed in endocrine treatment-resistant breast cancer cells under the regulation of HOXC11 and SRC-1. It was found that S100b serum levels were elevated in all samples, which adds to evidence that S100b offers potential as a biomarker of disease progression/recurrence. These results show HOXC11 and S100b to be biomarkers of disease recurrence with considerable clinical potential.
56. Do genes involved in DNA repair harbour breast cancer susceptibility loci? R.J. Mulligan, T.P. McVeigh, K.J. Sweeney, J.B. Weidhaas, N. Miller, M.J. Kerin Discipline of Surgery NUI Galway 7 Breast Check Western Unit & Yale University Introduction: A large proportion of the heritability of breast cancer remains unexplained. Discovery efforts have largely focused on genes involved in maintenance of genomic integrity. Polymerase (Pol)-k gene encodes for Pol-k protein, which acts in dsDNA repair by resynthesis of missing nucleotides during non-homologous end joining, and by base excision repair. A variant in Pol L; rs3730477 (G[A); leads to an amino acid translation (Arg438Trp). In vitro work to date has shown that this variant may affect dsDNA repair. Aim: The aim of this study was to investigate the role of POL-k variant in breast cancer risk and phenotype. Methods: A case–control study was undertaken. Cases were recruited via symptomatic and screening breast units. Cancer-free controls were recruited from the community. Germline DNA was extracted from blood/buccal swabs using ethanol precipitation. Genotyping was performed using a Taqman-based platform. Data was analysed using SPSS v22.
S190 Results: DNA samples from 235 cases and 268 controls were genotyped for the POL-k variant rs3730477. Minor allele frequency (MAF) in the entire cohort was 0.17, with no significant difference noted between cases and controls, or between molecular subtype or grade of breast cancer. Conclusion: The POL-k variant rs3730477 was identified in the Irish patient population, but frequency of the minor allele did not vary between cases and controls. Expression of this particular variant does not appear to alter disease risk or phenotype. Larger scale studies may be required to confirm the role of this POL-k as a breast cancer susceptibility gene.
57. A 5-year review of the correlation between primary tumour and lymph node response following neoadjuvant therapy in breast cancer C.A. Fleming, K.M. McCarthy, T.J. Browne, M.J. O’Sullivan, H.P. Redmond, M.A. Corrigan Breast Research Centre, Cork University Hospital. Supported by Aid Cancer Research Cork Background: Neoadjuvant therapy (NAT) offers a unique opportunity to assess tumour response to systemic agents. However a discrepancy may exist between the response of the primary tumour and involved nodes. This study sought to assess the frequency of response discordance post NAT. Methods: All consecutive node positive patients receiving NAT at the Southern Breast Cancer Centre at Cork University Hospital from 2009–2014 (inclusive) were identified through a prospectively collected database. Basic demographics, and radiological and pathological features were tabulated. Nodal response were estimated from pathological response to treatment measurements. Statistical analysis was performed using SPSS. Results: A total of 108 node positive patients had completed surgery and were eligible for inclusion. Median age was 50 years (range 20–27), all patients underwent axillary clearance and 62 % underwent mastectomy. Statistical significance was seen in improvement of tumour grade following NAT (p \ 0.01) with a 40 % average reduction in tumour size. There was an overall positive correlation between tumour and lymph node (LN) response following NAT (Spearman correlation coefficient r = 0.463, p \ 0.001). Twenty one patients achieved a LN complete pathological response (CPR) with 81 % having a CPR in tumour also. A CPR in the tumour occurred in 20 patients and predicted complete nodal response in 85 % of cases. Conclusion: Fifteen percent of primary tumours with CPR had persistently positive LN’s. This represents a significant discordance between the primary tumour and the LN, representing a concern for the potential lack of response of occult systemic metastasis. A biomolecular analysis of these is being determined.
58. Tamoxifen drives AIB1 recruitment to oestrogen receptor response genes in HER2 positive breast cancer cells M.D. Ryan, F.T. Bane, A.D.K. Hill, L.S. Young School of Medicine, Department of Surgery and Endocrine Oncology Research Group, RCSI and Department of Surgery, Beaumont Hospital, Dublin
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 AIB1 (Amplified in Breast Cancer 1) is a steroid receptor co-activator with various functions in both physiological and pathophysiological states1. Previous studies have shown the relationship between high levels of AIB1 and poor response to tamoxifen in patients with HER2 overexpressing tumours2. The mechanism which underlies this link is not well understood at this time. In this study, the level of HER2 overexpression of a previously transfected MCF7 breast cancer cell line was quantified. These overexpressing cells were then used to examine the role of the HER2 receptor in tamoxifen driven endocrine resistance using molecular studies to study the interactions between AIB1 and the oestrogen receptor a at the proteomic and genomic levels. Using chromatin immunoprecipitation, tamoxifen was shown to act as a partial agonist in the presence of HER2, allowing partial binding of AIB1 to oestrogen response sites. This allows for transcriptional activity to occur in the absence of steroidal impulses, in contrast with its usually antagonistic action. The drug was also seen to increase the levels of AIB1 binding to the oestrogen receptor and thus increase transcriptional activity, which may contribute to the development of endocrine resistance in vivo. This study would suggest that AIB1 would be a good prognostic biomarker for tamoxifen response and could also possibly act as a good target for treatment of endocrine resistant breast cancers.
59. Investigating the role of microrna-associated single nucleotide polymorphisms in breast cancer R.J. Mulligan, T.P. McVeigh, K.J. Sweeney, J.B. Weidhaas, N. Miller, M.J. Kerin Discipline of Surgery NUI Galway, Breast Check Western Unit, Yale University Introduction and aims: Micro (mi)RNAs are small non-coding RNA molecules that exert post-transcriptional effects on gene expression by binding with cis-regulatory regions in target messenger (m)RNA. miRNAs play a crucial role in regulation of a host of biological pathways. Functionally relevant Single nucleotide polymorphisms (SNPs) in miRNA precursors may alter miRNA function and may modify cancer risk. SNPs associated with mir146a and mir196a2 have been shown to modify breast cancer risk and age of onset. The aim of this study was to investigate the role of variants associated with mir196a2 (rs11614913) and mir146a (rs2910164) in breast cancer in an Irish sample. Methods: A case–control study was undertaken. Cases were recruited from symptomatic and screening breast units and cancer-free controls from the community. Patients with high-risk mutations in BRCA1/ BRCA2 were excluded from analysis. DNA was extracted by crystallisation precipitation from blood/buccal swabs and genotyping was performed using a Taqman-based platform. Data was analysed using SPSS v22. Results: A total of 719 (427 cases, 292 controls) patients were genotyped for mir146a-variant, and 635 (351 cases, 284 controls) for mir196a2-variant. Both variants were identified, with minor allele frequency of 0.2 for mir-146a-variant, and 0.56 for mir196a2-variant. Expression of the variants did not differ significantly between cases and controls (p = 0.189, mir-146a; p = 0.931, mir-196-a-2, X2). Cases expressing the mir-146a-variant were affected at a significantly younger age than wild-type cases (57 ± 12 vs 55 ± 11, p = 0.04, t-test). Conclusions: A single nucleotide polymorphism in the mir-146a2 precursor is associated with younger age of onset of breast cancer in Irish patients.
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210
60. A case control study examining the association of Smad7 and TLR single nucleotide polymorphisms on colorectal cancer risk in ulcerative colitis F. Reilly, J.P. Burke, G. Lennon, D.A. McNamara, E.W. Kay, G. Cullen, G.A. Doherty, H. Mulcahy, J.M. Hyland, S. Martin, D.C. Winter, K. Sheahan, P.R. O’Connell School of Medicine and Medical Science, UCD; Centre for Colorectal Disease, St. Vincent’s University Hospital; Department of Colorectal Surgery and Pathology, Beaumont Background: Ulcerative colitis (UC) is characterized by chronic mucosal inflammation, and an increased risk of colorectal cancer. Smad7, TLR2 and TLR4 modulate intestinal inflammation and their polymorphisms affect the risk of sporadic colorectal cancer development. The current study examines the association between single nucleotide polymorphisms (SNPs) in smad7, TLR2 and TLR4 and colorectal cancer development in patients with UC. Methods: DNA was extracted from formalin-fixed, paraffin-embedded tissue from 90 patients with UC who had undergone panproctocolectomy between 1985–2013; 30 with UC associated colorectal cancer and 60 control UC patients. Control cases were matched 2:1 for age at diagnosis of colitis, duration of disease and gender. Genotyping was performed for the smad7 rs4464148, rs11874392, rs12953717, and rs4939827 SNPs, the TLR2 rs5743704 and rs5743708 SNPs and the TLR4 rs4986790 and rs4986791 SNPs. Results: 63/90 (70 %) of patients were male and the mean age at diagnosis of UC was 38.6 ± 1.6 years. The mean time to the diagnosis of UC associated colorectal cancer was 13.5 ± 1.9 years. The 5-year recurrence free and cancer specific survival rates were 76 and 88 % respectively. All 8 SNPs were in Hardy–Weinberg equilibrium. None of the 8 SNPs assessed in smad7, TLR2 or TLR4 were associated with the development of UC associated colorectal cancer at an allelic or genotypic level. Conclusions: These data do not support an association between polymorphisms in smad7, TLR2 or TLR4 and the development of UC associated colorectal cancer.
SESSION 7 ENT/HEAD & NECK SESSION 61. Anaplastic thyroid carcinoma in Ireland
S191 analysis age, gender, metastases at diagnosis, surgery, radiotherapy, and multimodality treatment were statistically significant indicators of prognosis, and metastases at diagnosis remained statistically significant on multivariate analysis. These results correlate with the ATA guidelines where, when possible multimodality therapy offers a statistically significant survival advantage to select group of patients.
62. ‘‘Throat awareness’’ is a variation of normal: a retrospective chart review of so-called ‘‘globus’’ patients C. Byrne, K. Gullane, J. Doody, C. O’Rourke, J.E. Fenton Department of Otolaryngology and Head and Neck Surgery, University Hospital Limerick Objective: To determine whether so called ‘‘globus pharyngeus’’, as an isolated condition, has any discernable pathological findings on investigation with flexible nasoendoscopy. Previous studies have attempted to define this condition but there appears to be little or no agreement in the literature on the diagnosis or pathogenesis of ‘globus’. Methods: A retrospective case review of 100 patients in an ear, nose and throat clinic between 2007 and 2013. All patients had undergone nasoendoscopy and been given a diagnosis of ‘globus’. Exclusion criteria included those patients who were smokers, had a known diagnosis of malignancy or gastroesophageal reflux disorder, or presented with atypical symptoms. Results: 100 patients underwent flexible nasoendoscopy, of which only 5 had abnormal findings. None of these abnormal findings were of malignant nature. Conclusion: ‘Globus pharyngeus’ is a subjective condition that has not been shown to have consistent pathological findings or an underlying upper aerodigestive tract malignancy. This notion was supported by this comprehensive chart review. Given that the phenomenon is entirely subjective and no pathology is discerned, we conclude that this sensation is a variation of normal. The term ‘globus’ or ‘globus pharyngeus’ needs to be revised, with the introduction of a new, clarifying terminology to accurately describe the very specific clinical phenomenon described in our chart review.
63. Racial variations in thyroid cancer presentations and outcomes
P. Lennon, S. Deady, M.L. Healy, J. Kinsella, C.I. Timon, A.J. Hill, J.P. O’Neill
E. Keane, E. O’Cathain, T.K. Subramaniam, H. Rowley
St James Hospital Dublin, National Cancer Registry Ireland and RCSI Anaplastic thyroid cancer is a devastating disease with median survival between 1.2 to 10 months. The disease accounts for as little as 0.9–1.6 % of total thyroid cancer cases, but may account for up to half of all thyroid cancer mortality. The aim of our study is to evaluate the prognostic factors and outcomes of patients diagnosed with anaplastic thyroid cancer in Ireland. We carries out a retrospective analysis of the Irish national cancer database between 1st of January 2000 and the 31st December 2010. The Kaplan–Meier method was used to determine overall survival and factors predictive of outcome were determined by univariate and multivariate analysis by cox regression using Stata 13 software. Of a total of 64 patients, 40 were female and 24 were male. The median age was 69, and 27.5 % of patients had distant metastases at diagnosis. The overall median survival was 2.3 months and the 6 months, 1, 2, and 5 year overall survival was 23.4, 12.5, 6.25 and 4.69 % respectively. On univariate
RCSI Objective: The incidence of thyroid cancer is increasing worldwide. There is conflicting evidence as to why, however, the majority of the available data suggest that it is not simply due to enhanced diagnostic practices but a true increase with more patients being affected. The aim of this study is to assess racial variation in thyroid cancer to assess the at-risk population. Methods: A systematic review of the literature regarding racial groups in thyroid cancer was undertaken. Due to lack of cohesiveness of the data, a narrative systematic review of 8 retrospective cohort studies was undertaken. Results: Eight retrospective cohort studies which analysed adult patients (aged[18) with histologically confirmed thyroid cancer were identified. A total of 611,777 patients were included. There was considerable heterogeneity in the reporting of the data. The analysis suggest that there are variations between racial groups which are also
S192 dependent on gender, white patients have a slightly higher male population when compared to their counterparts, with Asian females having a higher proportion. Black and white patients have a higher proportion of follicular cancer. Hispanics were younger at the age of diagnosis. The outcomes in terms of stage, size and survival tend to be greatly affected by socioeconomic status. Conclusions: Following our analysis, we recommend a more concise manner of reporting with individual level risk factors being taken into consideration. Our data does, however, suggest that socioeconomic status has significant impact on the outcomes for these patients and steps must be taken to close this gap.
64. Preliminary comparative observational study of the effects of gelorevoice throat lozenges on the symptoms of globus pharyngeus R. Woods, T. Subramaniam, C.I. Timon Department of Otolaryngology, Royal Victoria Eye and Ear Hospital, Adelaide Road, Dublin Objective: Globus accounts for approximately 5 % of ENT referrals, however, once an underlying cause is outruled, it remains difficult to treat. GeloRevoice Lozenges act to form a special hydrogel complex, containing hyaluronic acid, which adheres to mucous membranes and forms a protective film over irritated areas. We evaluate the effect of GeloRevoice Lozenges on symptoms of globus. Methods: Patients with ongoing symptoms of globus after previous acid suppression therapy were given 4 weeks of treatment with GeloRevoice Lozenges. The validated Glasgow–Edinburgh Throat Scale scoring system was used pre and post treatment to evaluate for improvement in symptoms. Paired t-tests were carried out. Results: 23 patients completed the study (15 female, 8 male). Average age was 48.3 years. 18 patients reported full compliance with therapy and so were included in the results. No side effects were reported. The lozenges significantly improved the symptoms of ‘feeling of something stuck in the throat’ (p = 0.03) and ‘discomfort/ irritation in the throat’ (p = 0.04). Seven further symptoms were improved and two symptoms disimproved, but none of these were statistically significant. Conclusions: This preliminary study indicates that there may be benefit from the use of GeloRevoice for symptoms of globus. Findings may be due to placebo effect. Lack of statistical significance for some results may be due to small sample size and so further patients should be recruited to determine whether there is significant improvement from this medication. Placebo-controlled trials would be ideal, however no placebo is currently on offer for this medication.
65. Post radiotherapy hypothyroidism; hyposurveillance? E. O’Reilly, S. Brennan, C. Timon, J. Kinsella Department of Otolaryngology, Head and Neck Surgery, St James Hospital, Dublin Introduction: Hypothyroidism post neck radiotherapy has been well documented, with a 27 % risk of developing hypothyroidism post radiotherapy for neck cancer. The median time to diagnosis was 1.8 years1. A case of profound hypothyroidism detected 7 months post radiotherapy has highlighted the potential dangers of under surveillance. Hypothyroidism causes severe fatigue, impairs immune responses and if left untreated may result in myxoedema coma which
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 can prove fatal. High risk groups include those with previous surgery, high doses of radiation and a family history. Objective: The aim of this study to determine the frequency of Thyroid Function Tests (TFTs) and to document the prevalence of hypothyroidism in a post-radiotherapy cohort. The cohort would also be stratified to highlight patients at increased risk who may benefit from more intensive surveillance. Methods: The SJH online head and neck cancer registry was searched to find a cohort of 40 patients whom had previous radiotherapy, with or without surgery. TFT results were then sought, as were diagnoses of hypothyroidism. Patients with ongoing radiotherapy or thyroidectomy were excluded. Results: In total 40 patients were included; 18 had TFTs, of which 10 were treated hypothyroid, while 2 had untreated subclinical hypothyroidism. Conclusion: Hypothyroidism is a common complication post radiotherapy in head and neck cancer patients. The role of TFTs post therapy is well documented and monitoring protocols are in place, however there is a clear roll for increased surveillance particularly in high risk groups.
66. Rapid access clinics in ENT: University Hospital Waterford experience F. Alsabah, W. Hasan, E. Lang, L. Skinner, D. Smyth, M. Donnelley Otolaryngology, Head and Neck Surgery Department, University Hospital Waterford Introduction: Rapid Access Clinics provide important access to specialist care for patients referred by General Practitioners (GPs), Emergency Departments (ED) and doctors on non-ENT hospital wards. The aim is to enable prompt diagnosis and management of acute conditions, within an optimum environment containing appropriate clinical and staff resources. To avoid overburdening our rapid access ENT service and to maintain efficient referral system we audited 29 consecutive clinics. Method An audit of 29 consecutive rapid access ENT clinics between 11th June and 27th August 2013 in University Hospital Waterford. This included patient’s numbers, referral source, presenting complaints, diagnosis and outcomes. Results: 142 patients were audited. 54 patients were referred by GPs, 71 by EDs, 7 patients from previous rapid access clinics; data was missing in 10 patients. Nasal Trauma, Otalgia and Otorrhea were commonest presenting complaints. Otitis externa and Nasal Fractures were the commonest two findings followed by patients with Normal ENT exams. 94 patients were discharged, 36 patients required ENT OPD follow up, 9 patients were brought back to Rapid access clinic for further assessment and 3 patients were booked for surgery directly. Conclusion: Open rapid access Emergency services are likely to result in overburdening staff and resources. On the other hand, controlled rapid access clinics showed to be an efficient referral system in identifying patients who require prompt diagnosis and management. It also helped reducing the pressure on ENT OPDs from referrals of patients with minor ENT problems.
67. A comparative audit of FNA thyroid indications, results and needles used C. O’Rourke, T. Kelly, C. Hogan, J. Fenton University Hospital Limerick
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 Aim: Comparing the use of spinal needles versus other needles for fine needle aspiration (FNA) of thyroid nodules to obtain better specimens for adequacy and cytological diagnosis. Methods: This study is an observational analysis with planned data collection, comparing the use of three different needles (3 different radiologists) in obtaining FNA thyroid samples. All investigations were carried out in the University Hospital Limerick over a 6 month period. Results: 90 samples were included. 40 were solid, and 50 were complex cysts. There was no significant difference between the sizes of needle in the adequacy of the samples obtained. 17 nodules were inadequately sampled in total. 65 % of these were in nodules less than 1 cm in greatest dimension. There was no difference in yield among the three radiologists (chi2 test, p = 0.5192). No significant complications were encountered. Conclusion: Needles of varying gauge can be used to obtain adequate fine-needle aspiration biopsy samples from thyroid nodules. Experienced physicians can perform fine-needle aspiration biopsy with equal proficiency.
68. Difficult access to the cochlea in cochlear implantation C. Wijaya, P. Walshe, F. Glynn, L. Viani National Cochlear Implant Program, Cochlear Implant Department, Beaumont Hospital Intro/objective: Cochlear implantation is now being performed on a wide variety of patients. Many patients have had previous surgery of the ears, and others have congenital anomalies of temporal bone. Our objectives were to describe operative approaches of such patients and the results achieved. Methods: We describe a portfolio of operative approaches to access the cochlea in difficult ears. Result: All patients underwent cochlear implantation, and quality of life evaluation after cochlear implantation with Category of Auditory Performance (CAP) and Speech Intellegibility Rating (SIR) scores were excellent. Conclusion: Careful pre-cochlear implantation planning via multiple clinical modalities ensures a safe operative approach and optimal post-operative outcomes.
69. Sublingual immunotherapy for grass pollen induced rhinoconjunctivitis. An initial experience T. Subramaniam, P. Lennon, R. Kaulsay Clontarf Allergy Clinic, Dublin Introduction: Grass pollen induced allergic rhinoconjunctivitis is vast becoming a health concern in the developing world due to impact on patient’s quality of life. There have been several advances in the management this immune disorder. Of interest is the approval of pre and post seasonal sublingual immunotherapy for the management of grass induced allergic rhinitis. Objective: To evaluation efficacy of sublingual immunotherapy for grass induced allergic rhinitis. Methods: We identified a 30 patient cohort for a retrospective assessment via a telephone questionnaire using the SNOT 22 for symptoms assessment pre and post seasonal sublingual immunotherapy.
S193 Results: The male to female ratio was 2:3 with an average of 33. The mean total SNOT 22 score pre therapy is 53.4 and us 21.67 post therapy, noting a decrease of 31.73 (95 % confidence interval of 25.07 and 38.4). This is statistically significant with a P value of less than 0.00001. Conclusion: Sublingual immunotherapy for grass induced allergic rhinitis provides sufficient symptoms relief following a subjective assessment using the SNOT 22 questionnaire.
70. Is day case septoplasty safe or just efficient? GUH retrospective review S. Jaber, O. Young Galway University Hospital Background: In the current harsh economic climate, surgeons are under pressure to increase volume of day case procedures in order to reduce length of stay, reduce waiting lists and costs. Septoplasty has been identified as a potential Day Case procedure internationally and by the HSE in it’s ‘‘Basket of 24’’ procedures. The aim of this study is to assess the feasibility and safety of day-case septoplasty. Materials and methods: Retrospective review of day-case septoplasties in Galway University Hospital for a single surgeon from July 2011 to August 2014. Data on patient demographics, surgical technique and surgeon grade were collected. Questionnaires were also compiled from all ENT teaching hospitals in Ireland and practice guidelines were compared. Results: Sixty-one patients underwent septoplasty under GA in our Surgical Dayward during this time period. One patient was readmitted with epistaxis, giving an overall readmission rate of 1.6 %. The operators included one consultant and three registrars. Conclusion: Our study demonstrates that septoplasty can be performed in a safe and efficient manner with a low re-admission rate provided patients are selected appropriately.
71. The role of adjuvant radiotherapy in the management of recurrent pleomorphic adenomas of the parotid: a systematic review and meta-analysis of the literature P. Lennon, A. White-Gibson, S. Brennan, J. Kinsella, C.I. Timon, J.P. O’Neill St James Hospital Dublin, St. Luke’s Hospital Rathgar and RCSI Adjuvant radiotherapy in recurrent pleomorphic adenomas of the parotid remains controversial. The aim of this study is to undertake a systematic review and meta-analysis, in order to establish its efficacy and safety in this cohort. We searched the English language literature between 1985 and 2014. Inclusion criteria included observational studies on the treatment and outcome of RPA. Exclusion criteria included the use of radiotherapy for residual tumors, use in the immediate post-operative setting, case reports, papers with no clear results, and pleomorphic adenomas not arising from the parotid. The first and second authors selected the studies by consensus. 522 abstracts were studied. Data was available from 16 retrospective studies, on a total of 624 patients, 72.6 % of whom were treated for their first recurrence. The average median follow-up after treatment of a recurrence was 9.7 years, 60.8 % of patients were female and the average median age was 45.3 years. The risk of a further recurrence in patients treated with surgery and adjuvant radiotherapy ranged
S194 from 0–44.4 % (median 11.3 %), whilst the risk of re-recurrence in the surgery-only cohort ranged from 0–51.9 % (median 20.5 %). The pooled relative risk of a further recurrence in the radiotherapy cohort was 0.41 (95 % CI 0.29–0.58, Fishers exact p-value 0.0001). This data supports the use of radiotherapy in RPA to decrease the risk of re-recurrence. Possible confounders include age, multinodular recurrences and parotidectomy as initial treatment. We must also be cognizant of the risk of secondary malignancies and the morbidity associated with radiotherapy.
72. 14 year retrospective multicentre review of lip malignancies a single surgeon experience: management and outcome
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 institute were excluded. US was performed in this institution on 172 of these patients. Of these, 61 patients were diagnosed with a nodule C4 cm. Malignancy rates were similar in those patients with nodules C4 cm and those without (16/61, 26.6 % versus 27/109, 24.7 %). Of the 61 patients with large nodules 57 (93.4 %) had preoperative FNAC. The majority of these were classified as Thy2 (26/57, 45.6 %). The remainder were classified as Thy 1 (5.26 %), Thy3 (36.84 %), Thy4 (3.51 %) and Thy 5 (8.77 %) Of the patients with a benign diagnosis on FNAC, 27/29 (93.1 %) had a benign diagnosis on final histology. This study does not show an increased rate of malignancy in patients with thyroid nodules measuring [4 cm. Furthermore FNAC accurately predicted a benign final diagnosis in 93.1 %. This suggests that patients with a nodule measuring C4 cm, and a FNAC Thy1 or Thy2 may be safely managed with surveillance, thus sparing them from invasive surgical intervention.
F. O’Duffy, E. O’Reilly, C.I. Timon St James Hospital, Department of Head and Neck Surgery, Dublin Lip cancers represent 15–20 % of all malignancies of the oral cavity1. We undertook a retrospective analysis of patients undergoing treatment under a single surgeon over a 14 year period. Factors examined included patient demographics, location, type of surgery, pathology, surgical margins, locoregional disease, adjuvant therapy, prior/subsequent excision, in-patient stay, duration of follow-up and prior or subsequent second primary. To date 29 patients have been identified. Wide local excision with Karpandzic flap reconstruction provided the mainstay of surgical management. 27 % of those patients had previous surgical excision at the same location. The dominant cancer type was squamous cell carcinoma (SCC) in men with melanoma and adenocystic also identified. Known risk factors for skin SCC where inconsistently recorded in the medical notes with only 3 patients having a history of sun exposure recorded. In part, due to the location of lip malignancies most are found at early stages and this was confirmed in our study with only a single T4 malignancy treated over the 14 year period. Promt diagnosis and complete surgical excision with clear margins at first operation is the corner stone for successful oncological and cosmetic management for this patient group.
73. Is four the magic number? A retrospective analysis of radiological findings and final histology in four years of thyroid surgery in a tertiary institute S. Casey, S.M. Walsh, A. Heeney, D. Evoy, E. McDermott, R.S. Prichard Department of Breast and Endocrine Surgery, St Vincent’s University Hospital, Dublin Thyroid nodules are investigated with ultrasound (US) and fine needle aspiration cytology (FNAC), the results of which dictate surgical management. Patients with thyroid nodules greater than 4 cm are traditionally offered thyroid lobectomy, regardless of FNAC result. The aim of this study was to examine malignancy rates in the final histology of patients who underwent thyroid surgery for nodules C4 cm. A retrospective review of thyroid surgery carried out in St. Vincent’s University Hospital between January 2007 and December 2011 was performed. Ultrasound findings, initial FNAC and final histopathology were reviewed. There were 440 thyroid surgeries performed during the specified timeframe. Patients who did not have an US performed in this
74. Sphenopalatine and anterior ethmoidal artery ligation for epistaxis: the clinical experience of a tertiary referral centre A.M. McDermott, E. O’Cathain, J. Doody, D. Coakley, G. O’Leary, P. O’Sullivan, P. Sheahan Department of ENT, South Infirmary Victoria University Hospital, Cork Objective: Sphenopalatine artery (SPA) ligation is a commonly employed surgical intervention for control of epistaxis refractory to conservative measures. This objective of this study was to evaluate the clinical experience of SPA ligation for control of epistaxis at our institution. Methods: Retrospective review of all patients undergoing SPA ligation for epistaxis control at our institution between October 2008 and July 2014. Clinical and operative parameters were reviewed from case notes and collated. Data analysis was performed using Minitab V15.0. Results: Forty-two patients (34 males) underwent SPA ligation during the study period. Mean age was 62.6 years. 38 % (n = 16) of patients were on oral anticoagulation or antiplatelet therapy. Forty patients presented as emergencies and had undergone nasal packing at initial presentation (14 bilateral), with 31 undergoing two or more preoperative nasal packings. Two patients underwent SPA ligation as semi-elective procedure for recurrent epistaxis.. SPA ligation was accomplished successfully in all patients. Twelve (29 %) underwent concomitant septoplasty, and 10 (24 %) underwent concomitant intraoperative nasal packing. Postoperatively, 38 patients (90 %) had no further bleeding. Persistent epistaxis was treated in 3 patients by further nasal packing on the ward, and in one patient by internal maxillary artery ligation in theatre. Over a quarter (26 %) of patients required a blood transfusion. Mean length of hospital stay was 5.2 ± 3 days. There were no complications. Conclusion: SPA ligation is a simple, effective and safe minimally invasive approaches for surgical control of refractory epistaxis in our institution.
75. Presentation and management of laryngomalacia in children above age 1 at a tertiary referral centre: a retrospective review T.S. Ahmed, C.G. Jephson
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 Department of Paediatric Otolaryngology, Great Ormond Street Hospital, London Classical laryngomalacia is characterised by inspiratory indrawing of the supraglottis and in most children is self-limiting during the first year of life. A small proportion of children have symptoms beyond this which can significantly impact upon respiratory health, feeding and growth. This study aims to define the characteristics and management of children at our institution undergoing surgical treatment for laryngomalacia beyond the age of 12 months. All children undergoing surgery for laryngomalacia above age 12 months over a 19 year period (1995–2014) were identified from an electronic database. A retrospective chart review was performed and data including demographics, comorbidities, presenting features and post-operative courses were extracted. 17 children were identified who underwent surgery within this age group. The mean age at operation was 75.2 months (SD 56.9), the oldest child being age 17. Neuromuscular problems were frequent, particularly cerebral palsy and global developmental delay. Three common presentations were identified: persistent stridor; sleep-disordered breathing with obstructive sleep apnoea; and reduced exercise tolerance with exertional dyspnoea. Surgical procedures performed included aryepiglottoplasty and excision of redundant arytenoid mucosa using ‘cold steel’ instruments. Unilateral procedures were performed in seven cases. No complications were recorded. Laryngomalacia beyond the age 1 is unusual but being increasingly recognised. Children often have associated neuromuscular problems. Disease is more likely to be at arytenoid level and presentation may be non-classical, but in carefully selected individuals aryepiglottoplasty can be a safe and effective intervention. Unilateral or staged procedures are useful where there are concerns about precipitating post-operative aspiration.
76. Differentiated thyroid cancer: assessment of clinical practice in a tertiary referral centre P.W. Owens, E.J. Fahey, A.J. Lowery, D.S. Quill, M.J. Kerin Department of Surgery, University Hospital Galway International best practice guidelines provide well-defined recommendations for the management of differentiated thyroid cancer (DTC) measuring B1, [4 cm and for those with defined risk factors1. However, the extent of surgery and requirement for radioiodine remnant ablation (RRA) are less clearly defined for tumours 1–4 cm in size. Guidelines recommend a ‘‘personalised decision making’’ approach for this cohort, with therapeutic decisions based on patient preference, recurrence risk and multi–disciplinary discussion. This study aims to assess adherence to guidelines and investigate treatment patterns in the ‘‘personalised decision making’’ cohort for thyroid cancers treated at a tertiary referral centre in the West of Ireland. Data was obtained from a prospectively maintained thyroid cancer database. 92 out of 97 patients (95 %) treated for DTC between 2009 and 2014 were managed in accordance with guidelines (Table 1). Out of those not adherent, three were over treated with discordant total thyroidectomy, while two were under treated with discordant lobectomy only. 28 patients (29 %) had tumour characteristics requiring ‘‘personalised decision making’’, of which 26 underwent total thyroidectomy rather than lobectomy. Similarly for RRA, 39 out of 41 patients (95 %) in the ‘‘personalised decision making’’ group were treated with radioactive iodine. Management of thyroid cancer at our institution closely adheres to guidelines, with a trend towards more aggressive management in those where personalised decision making is required.
SESSION 8 CLINICAL SESSION IV 77. Unplanned second operations in breast surgery: a single centre experience D.O. Connor, D. Nally, R. McLaughlin, M. Kerin, C. Malone, K. Sweeney Department of Surgery, Galway University Hospitals Background: Breast surgery is considered to be relatively safe and clean but is not without risks which can be underestimated. Complications can increase length of stay, associated costs and can delay further planned treatment. There are also possible oncological ramifications1. Aim: This study aimed to quantify the rate of surgery for complications in breast surgery, to determine the nature of the complication and to determine the outcomes of those undergoing second surgeries. Method: A retrospective audit was performed of all patients requiring an unplanned second operation in a large tertiary referral centre with both screening and symptomatic units. The study period was Jan 2008 to December 2012. Results: 7434 breast operations were performed during the period. (4,715 for benign disease; 2,719 malignancy) 87 patients underwent an unplanned second surgery (1.84 %) 70 of these patients had malignant breast disease. There were 49 infectious complications, 28 haematomas, and 12 operations for tissue necrosis. Some patients had a combination of complications. The median follow up was 59 months. 2 patients of the 70 with malignancy had disease recurrence. Conclusion: In this series breast surgery is associated with a low rate of unplanned second operation. The most common complication was evacuation of haematoma. Further follow up and larger numbers are required to assess impact on oncological outcomes.
78. The impact of biliary pancreatitis: real-world experience versus the guidelines M. Kelly, D.B. O’Connor, A. Gillis, K. Utley, M. Egan, G. Fitzpatrick, P.F. Ridgway, K.C. Conlon Professorial Surgical Unit, Trinity College Dublin and Department of Anaesthesia and Critical Care, Tallaght Hospital The aim of this study was to audit outcomes for patients with acute biliary pancreatitis admitted to a single-center compared to recently updated IAP/EPC evidence-based guidelines. A retrospective analysis was performed on consecutive patients from a prospectively maintained pancreatitis database between January 2010 and December 2013. Data recorded included IMRIE score and CRP on admission, radiological imaging, ERCP, length of stay (LOS), ICU, mortality rate, rate of laparoscopic cholecystectomy and timing of cholecystectomy. A total of 97 patients (68 females) had confirmed biliary pancreatitis. This accounted for 35 % of all acute pancreatitis admissions during the study period. IMRIE score was available for 82 (84.5 %) of which 11 (13.4 %) were predicted severe (IMRIE [3). Median LOS was 9 days (3–110). Eight (8.2 %) were admitted to ICU. There were 3 (3.1 %) in-patient deaths. IMRIE score (p = 0.005) and CRP 150 (p \ 0.001) predicted LOS. Radiology utilized: Abdominal US in 77/97 (80 %, median day 2), CT in 52 (53.6 %, median day 5), MRCP in 62 (64 %) and Endoscopic US in 9 (9.3 %). ERCP was performed in 48/97 (49.5 %, median day 5). Laparoscopic
S196 cholecystectomy was performed in 68/76 (89.5 %) of available patients to date (excluding deaths, patient refusal and patients undergoing ERCP only due to co-morbidities). Median time to cholecystectomy was 59 days and 23/76 (30.2 %) underwent cholecystectomy during their index admission. We demonstrated compliance with guidelines regarding prognostication, diagnostic imaging and biliary tract management. However, only 30 % received cholecystectomy within the preferred time to reduce the risk of recurrent pancreatitis/biliary events and this should be addressed with adequate resource allocation.
79. Determining the prevalence of sarcopenia in chronic pancreatitis using CT: a pilot study in an Irish cohort D.B. O’Connor, C. Purcell, M. Egan, R. Ryan, O. Griffin, S. Duggan, K.C. Conlon Professorial Surgical Unit, Trinity College Dublin, Tallaght Hospital and St. Vincent’s University Hospital, Dublin Chronic pancreatitis (CP) is a progressive inflammatory disease leading to malnutrition and nutrient deficiency. Recent studies have highlighted the high prevalence of osteopathy in CP. Sarcopenia is a loss of skeletal muscle mass with a strong association with osteopathy. It is associated with increased morbidity and mortality in gastrointestinal malignancy. The aim of this study was to determine the prevalence of sarcopenia in a cohort of CP patients using computed tomography (CT). Patients were identified from a prospectively maintained CP database including metabolic, biometric, and quality of life (QOL) data. Patients who had a CT scan within 12-months of their data collection were selected for analysis. Skeletal muscle mass was measured using consecutive CT axial images at L3 vertebral level. CT images were analyzed using SliceOmatic Ò (Tomovision), validated software for body composition analysis. Sex specific cut offs for sarcopenia were used. CT scans were analysed for 29 patients (17 male, 12 female, median age 43 (25–70). Median body mass index (BMI) was 25.6. BMI was \18 in 6 and [30 in 7 patients. Osteopathy was present in 22/29 patients (9/29 osteoporosis, 13/29 osteopenia). The overall prevalence of sarcopenia was 52 % (15/29). Sarcopenia was present in both underweight and obese patients. There was a trend towards osteoporosis and lower QOL in sarcopenic patients but this did not reach significance. This preliminary study has shown a high prevalence of sarcopenia in CP, independent of BMI. Further studies are warranted to determine wider prevalence and prognostic impact.
80. Do urgent cardiac cases utilise more resources than elective? A single unit audit
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 Results: There is a significant increase in urgent cases from 2010 to 2013 and a drop of electives during the same period. No significant difference in the length of stay between elective and urgent cases was identified. Conclusion: Our audit clearly demonstrates that urgent cases can be performed with little impact on resources. It also highlights that in our cohort of population urgent cases are increasing as compared to electives.
81. Epidemiological study of soft tissue sarcomas in Ireland Nikita Bhatt, Sandra Deady, Amy Gillis, Alexia Bertuzzi, Aurelie Fabre, Eric Heffernan, Charles Gillham, Gary O’Toole, Paul F. Ridgway Department of Surgery, Adelaide and Meath Hospital, Tallaght, Dublin Introduction: Soft tissue sarcomas (STS) account for 1 % of adult and 7 % of pediatric malignancies (1). Histopathology and classification of these rare tumors requires further refinements (2). The aim of this paper is to describe the current incidence and survival of STS from 1996–2010 in Ireland and compare these with comparably coded international published reports. Materials and methods: This is a retrospective, population study based on the data from the National Cancer Registry of Ireland (NCRI). The Age Specific incidence Rates (ASR) for STS and the survival rates for STS in Ireland were obtained. The incidence of STS based on gender, age, anatomical location and geographical distribution was obtained. International data was retrieved from the RARECARE group. Results: The annual mean ASR in Ireland was 4.55 ± 0.393 per 100,000 person-years. The average survival rate of STS for this period in Ireland was 55.7 %. This was lower than the European rate of 58 %. The ASR in Ireland was comparable to other international reports as were the incidence trends based on various factors. The survival rate for STS in Ireland was lower than international survival rates including European rates. Conclusion: STS in Ireland has significant differences with regards to incidence and survival trends between Ireland and other European countries, which could be real or attributed to coding discrepancies. The survival rates of STS in Ireland are lower as compared to international reports, which needs more work.
82. The impact of social work intervention in alcoholinduced pancreatitis in Ireland: a single centre experience
M. Tarazi, M.N. Anjum, B. Philip, K. Doddakula
C. Beagon, N.R. Bhatt, S.M. Donnelly, M. Egan, A.P. McKay, B. Mehigan, K.C. Conlon, P.F. Ridgway
Department of Cardiothoracic Surgery, Cork University Hospital Objective: Literature supports that elective cases perform better by utilising minimal resources. Significant increase of urgent cardiac cases in the recent years have provoked us to perform an audit to evaluate if the traditional wisdom is applicable in today’s practice. Methods: 1,203 patients undergoing elective and urgent coronary artery bypass grafting from 2010 to 2013 were included. Data was acquired from the theatre register and Patient Analysis Tracking System (PATS). Length of stay was considered as the marker for resource utilization. Emergency and salvage patients are excluded.
Social Work Department, at the Adelaide and Meath Hospital, Tallaght and Trinity College Introduction: The recurrence rate for alcohol-induced pancreatitis can be up to 48 % (1). Aggressive alcohol abstinence intervention has shown to decrease recurrence. Hence, social work interventions to reduce alcohol dependence play a vital role in the management of these patients but current management remains largely symptomatic (2). The aim was to investigate the impact of social work intervention in its current form in a tertiary centre Ireland preventing readmission for patients with alcohol-induced pancreatitis.
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 Methods: A retrospective cohort study on patients admitted with acute alcohol-induced pancreatitis (identified by the hospital identification system) to a tertiary hospital over 3 years (January 2009 to December 2012) was performed. Demographic data of this cohort, details of their hospital admissions (first admission and relapse if any) and the impact of social work intervention were recorded. Results: The relapse rate in the cohort of 160 patients with alcoholinduced pancreatitis was 28.1 %. Social work intervention in its current form did not demonstrate a statistically significant difference to the chance of relapse in patients with alcohol-induced pancreatitis (p = 0.229, Anova). The employment status was a significant risk factor for relapse (p = 0.027, Anova). Conclusion: The study has shown that current social work intervention for alcohol-induced pancreatitis patients in Ireland is ineffective in preventing relapse. Long-term prospective studies may be required to formulate and better implement more efficacious social work interventions, which may help reduce recurrence in alcoholinduced pancreatitis patients.
83. Risk of colon cancer after acute uncomplicated diverticulitis: is colonoscopy really necessary? An Irish perspective A. Moorthy, E. O’Connor, H. Al-Chalabi, N. Ravi, J.V. Reynolds Department of Surgery, Trinity Centre, St James’s Hospital, Dublin Introduction: It has long been recommended that patients undergo follow up colonoscopy to exclude colon cancer after an episode of acute diverticulitis. The role of colonoscopy following an episode of acute uncomplicated diverticulitis remains controversial. Our aim was to evaluate the need for colonoscopy after an episode of acute uncomplicated diverticulitis, diagnosed both clinically and by Computed tomography scan (CT). Methods: Patient records were analysed retrospectively from a prospectively maintained database. Inclusion criteria were patients diagnosed with clinically and radiologically confirmed uncomplicated acute diverticulitis at any point during admission between 2007–2012. CT, colonoscopy and histology reports were examined. Results: A total of 97 patients met our inclusion criteria. The 97 patients comprised 53 (54.6 %) women and 44 (45.4 %) men with a median age at diagnosis of 66 and 53 years respectively. Of this patient cohort, 88 (90.7 %) of the 97 patients had undergone routine colonoscopy. Colonic polyps were present and biopsied in 13 (13.4 %) of patients. 9 (9.3 %) had hyperplastic polyps and 3 (3.1 %) had low grade adenomas. Only a single patient (1.14 %) in our study was found to have a histological diagnosis of colonic malignancy. The yield of colonic neoplasia at any stage in our study (1.14 %) was equivalent to that detected by screening programmes in asymptomatic individuals among an international standards (0.8–1.1 %). In addition, our result compares to a calculated estimated prevalence of 1.4 % among Irish adults older than 65 years (by the end of 2010). Conclusions: Unless colonoscopy is part of a screening programme, routine colonoscopy following an episode of CT-diagnosed acute uncomplicated diverticulitis is unnecessary in the absence of other alarming clinical signs of Colorectal Cancer.
84. The role of the general hospital in the era of run through surgical training Donald Courtney, Jarlath Bolger, Ronan Waldron, Peter Coyle, Emma Jane Mcgovern Claire Connellan, Waquer Khan, Kevin Barry
S197 Department of Surgery, Mayo General Hospital Introduction: Surgical training in Ireland has undergone major changes in recent years. Previously trainees would spend 2 or 3 years in basic training followed by a period of research and clinical registrar posts prior to progressing to higher surgical training. Trainees now commence core surgical training for 2 years and may progress directly to higher surgical training. It is imperative that trainees gain adequate exposure to operative procedures and management of surgical emergencies before progressing to higher training. MGH is an affiliated training hospital for the RCSI and typically has an annual intake of core trainees and higher surgical trainees. Aim: To assess training opportunities for core surgical trainees in MGH. Methods: HIPE data, theatre log books and chart reviews were conducted for the month of July 2014. All emergency and elective admissions and procedures were recorded. Procedures were classified as complex major, major, intermediate and minor operations. The involvement of higher surgical trainees and core surgical trainees in procedures was recorded. Results: There were 354 elective admissions and 139 emergency admissions in July. There were 44 complex major or major procedures. There were 38 intermediate, 97 minor procedures and 180 diagnostic endoscopy. Twenty seven percent (n = 37) of emergency admissions required operative intervention. Conclusions: General hospitals offer a wide range of both emergency and elective procedures. This offers excellent opportunities for junior surgical trainees to gain exposure to the basics of surgery including a large volume of minor operations and endoscopies. General hospitals should play a prominent role in run-through surgical training.
85. Competency in scrotal examinations—a survey of newly qualified doctors N.P. Kelly, J.C. Forde, S.K. Giri, H.D. Flood Department of Urology, University Hospital Limerick Testicular cancer awareness has increased following a number of high profile public information campaigns, emphasising early detection and early presentation to a doctor. However, given its personal and intimate nature, teaching scrotal examination technique to medical students is difficult, in comparison to abdominal or chest examinations, for example. We aimed to assess opinions from newly-qualified doctors of the quality of scrotal examination training in medical school. An online survey was created using SurveyMonkeyTM and distributed to 475 Interns in the Republic of Ireland (ROI) between October and December 2012. In total, 179 responses were received (response rate = 37 %). Overall, 67 respondents were male (37.4 %). 164 respondents (91.4 %) completed medical school in ROI. Only 101 (56.4 %) had formal scrotal examination (SE) training during medical school. Training methods used included demonstration models (50 %), human volunteers (19 %) or both (21 %). The majority of respondents felt that SE training was inadequate in medical school (74.9 %) and that they did not feel competent in performing (SE) on graduating (73.2 %). Of note, 175 respondents (97.8 %) do not routinely examine the scrotum when examining a male abdomen. Testicular self-examination is not practiced by almost 33.3 % of male respondents. Scrotal examination is poorly taught in medical schools with many new graduates not competent in the technique. This could compromise a doctor’s ability to educate patients in testicular selfexamination. More importantly, this lack of competence is likely to
S198 compromise a doctor’s ability to diagnose important scrotal conditions such as torsion and cancer.
86. 10 year experience of thoracic endovascular aortic repair Z. Ahmed, S.M. McHugh, A. Elmallah, N. Hamada, M.P. Colgan, A. O’Callaghan, S.M. O’Neill, P. Madhavan, Z. Martin St James’s Vascular Institute, St James’s Hospital Introduction: Endovascular repair has revolutionized the treatment of thoracic aortic disease. We report our 10 year experience using this treatment. Methods: A prospectively held database (Vascubase) was interrogated and all patients who underwent thoracic stenting for aortic disease between 2005 and 2014 were identified. Results: 56 patients (mean age = 63 years; 55.3 % male) underwent endovascular treatment for various thoracic patholgies: fusiform aneurysm (n = 16), sacular aneurysm (n = 5), traumatic dissection/ transection (n = 10), non-traumatic dissection (n = 9), pseudoaneurysm (5), deep penetrating ulcer (n = 10) and coarctation (n = 1). 24 (42.8 %) were emergency cases. 4 patients out of the total had thoracoabdominal aneurysms. The majority of patients were ASA III or higher (78 %). All patients received self-expanding endoluminal graft. 9 patients required rerouting through open bypass before the endovascular treatment. Technical success was 100 %. Thirty-day mortality was 7.1 % (4/53). 4 patients developed major haemothorax requiring open exploration and washout/drainage. Spinal cord ischemia occurred in 2 patients (3.8 %). 2 patients had Type I endoleaks requiring reinterventions and 4 patients had Type II endoleaks which were manged conservatively. Mortality and morbidity predictors were extremes of age and presence of other significant co-morbidities. Emergency cases included transfers from 9 different hospitals from all regions of the country and included both regional and teaching hospitals. Conclusion: Endovascular repair is a safe and effective treatment option which enables patients to be treated with lesser morbidity and mortality. Transfer of patients with acute pathology to a tertiary centre can safely be performed with good outcomes.
87. Changing trends of acute pancreatitis—St. Luke’s Hospital in comparison to the Irish population Umair Muhammad, Awan Faisal, Elfaedy Osama, Pretorius Fredrick, Balfe Paul Department of Surgery, St. Luke’s Hospital, Kilkenny Objective: Analyze and compare trends in incidence, aetiology and profile of acute pancreatitis at St. Luke’s Hospital Kilkenny in comparison to Irish population and its implications on health system. Methods: Acute pancreatitis admissions (ICD-10 Code K85) were identified for years 2005–2013 at St. Luke’s Hospital and for all hospitals in Ireland using HIPE data. These were categorized into biliary tract-related (Code K85.1), alcohol-related (Code K85.2), others (Code K85.8) and unspecified (Code K85.9). Chi Square test was used to analyze the data. Results (comparative national rates in parentheses): There were 769 admissions at St. Luke’s Hospital Kilkenny, which constituted about 5.88 % of the 13,070 admissions nationwide. Majority were male 55.2 % (59.99 %). Gallstones were still the dominant aetiology,
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 43.43 % (20.82 % in the last 5 years). Alcohol-induced increased significantly over the period from 8.91 % in 2005 to 10.08 % in 2013 (3.9–4.1 %). The average age at presentation was 53.56 years (50.7 years) with an average length of stay of 5.7 days (8.9 days). The incidence has significantly increased from 48.25 in year 2005 to 55.25 in 2013 per 100,000 population (26.73 in 2005 to 36.99 in 2013 per 100,000 population). However, there was no significant increase in mortality rates: 6.29 in 2005 to 7.40 in 2013 per 100,000 population nationwide. Conclusions: Study highlights the changing trends in incidence, etiology and patient profile. The increasing incidence of alcohol-related pancreatitis has major implications for an already overstretched health service. IMRIE score is widely used throughout Ireland. This is a good prognostic score for gallstone-induced pancreatitis. However, with the increasing trend of alcohol induced pancreatitis it may not be a significantly robust predictor of severity. The study also points to the importance of recording the IMRIE score as part of the HIPE dataset (not currently the case).
88. Feeding jejunostomy tubes in cancer patients; not without risk? S. Tarrant, I. Tiedt, C. O’Neill, N. McCawley, M. Arumugasamy, P. Broe Department of Upper GI Surgery Dietetics, Beaumont Hospital, Dublin The operative insertion of a jejunostomy feeding tube in patients undergoing major upper gastrointestinal (GI) resections is not without risk. We examined our use of jejunostomy feeding tubes and the frequency and aetiology of complications that occurred with the aim of identifying areas in which our standard of care can be improved. We analysed a prospectively maintained database of 29 patients with both gastric and oesophageal malignancy who had a surgically placed xylem TMjejunostomy feeding tube placed during their resection at a single centre in 2013. Overall, 9 patients (31 %) experienced a complication attributable to their jejunostomy feeding catheter; 11 % of these were major requiring re-intervention either operatively or with interventional radiology and 88 % were minor complications that either resolved spontaneously or were treated conservatively on the ward. The most common minor complications were the tube falling out, pain and catheter site infection. Nutritional supplementation is accepted as an important adjunct to recovery in oncology patients undergoing major upper GI resections, but as with any invasive procedures it carries risk. To address these high rates of complications, we propose to initiate catheter care patient education at ward and out-patient level and to introduce a catheter care bundle into our enhanced recovery programme to allow timely identification of catheter related problems.
SESSION 9—ANESTHESIA SESSION 89. Narrative and pain medicine M. Elhadi, D. Doltani, H. Misran, D. Harmon Department of Pain Medicine, University Hospital Limerick Narrative influences pain but it also provides for intervention in a new and integrative model of pain. This model seeks to account for the
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 uncertainties intrinsic to pain as the experience of a brain based, culturally infected and narrative driven human consciousness. Narrative medicine complements standard western biomedicine. It is medicine practiced with narrative competence. It is a form of knowing. It is complementary to traditional data-driven, high tech, medical knowledge. It requires training to acquire narrative competence. All pain patients have personal stories to tell about their pain. Many patients believe the discredited story that pain holds a one-one relationship with tissue damage. Through case illustration we will outline the role of narrative in pain medicine.
90. Perceived injustice in chronic post surgical pain patients A. Imran, D. Doltani, D. Harmon Department of Pain Medicine, University Hospital Limerick Chronic post-surgical pain (CPSP) is a recognized adverse consequence of surgery. The prevalence of CPSP varies with different surgeries. Overall between 10 and 30 % of surgical patients report persistent pain at 1 year postoperatively. Chronic pain is associated with a significant effect on quality of life and increased health care utilization. Perceptions of injustice are likely to arise when an individual is exposed to situations that are characterized by a violation of basic human rights, transgression of status or rank, or challenge to equity norms and just world beliefs. Experience of irreparable loss is also likely to give rise to the perception of injustice. Emerging evidence suggests that appraisal of pain and disability in terms of injustice related themes contribute to adverse pain outcomes. Research also supports the use of assessment measures of perceived injustice in the routine assessment of individuals with pain conditions. We designed a prospective observational study to systematically assess the injustice experience of chronic post surgical pain patients. This has not previously been studied. After ethics committee approval and informed written consent, we enrolled 100 adult chronic postsurgical pain patients attending the UHL pain clinic first time. We asked them to fill the Injustice Experience Questionnaire (IEQ). Raw injustice experience scores was collected from IEQ and percentile score for each patient was obtained using IEQ manual. We will report the injustice experience scores in chronic post surgical pain patients. Results indicate new avenues of treatment in these patients.
S199 Headache Society criteria) (2). They had a formal interview and a data collection sheet was completed. The study objective was to determine the characteristics of symptoms, physical signs and previous history among these patients, including previous tests and procedures. We feel that the result of this study will show that a large number of patients with symptoms and signs suggestive of cervicogenic headache have a number of unnecessary imaging scans and lumbar punctures.
92. Case series of perceived injustice in chronic pain H. Misran, D. Harmon Department of Pain Medicine, Univeristy Hospital Limerick, Limerick Perceived injustice has been identified as a significant barrier in the treatment of pain and depressive symptoms following musculoskeletal injury1. We present several case reports highlighting the detrimental effects of perceived injustice on outcome and the difficulties in the successful management of chronic pain. The first patient presented with a 3 year history of neck pain following an injury during the delivery of her first child in a maternity hospital. She reports a complicated labour, conflicting medical advice, and a long medicolegal process that has exacerbated her pain and mental health. The Injustice Experience Questionnaire and an Injustice Logbook completed by the patient accounts for each incidence of injustice observed. Audio recordings of consultations with the second patient describe clearly the feelings of anger and suffering following an injury inflicted by someone else. She highlights in feelings of abandonment, unfairness, as well as loss of mobility which has impacted greatly on her quality of life. Multidisciplinary approach to treatment is ongoing, though her pain remains unchanged. Research on perceived injustice has focused primarily on victims of whiplash following road traffic accidents, where injustice is a significant predictor of post-traumatic stress disorder and augments the relationship between pain severity and depressive symptoms1. There is no specific treatment targetting perceptions of injustice specifically. High levels of perceived injustice in these cases predict treatment difficulty and a guarded prognosis.
93. Patent blue V anaphylaxis—a typical presentation K. Doody, E. McGloughlin. S. Mahdy
91. Cervicogenic headache: a prospective study of patient characteristics and medical care M. Alhomary, H. Misran, D. Harmon Department of Anaesthesia, Pain and Intensive Care Medicine, University Hospital Limerick Cervicogenic headache is a common cause of headache, with an incidence as high as 13.8 % among patients with headache disorders (1). Although there are clear clinical diagnostic criteria that aid in the identification and diagnosis of cervicogenic headache, it is still underdiagnosed with many patients undergoing multiple diagnostic tests such as CT scans and MRI of the brain, as well as unnecessary lumbar punctures we believe. Early diagnosis of cervicogenic headache is of paramount importance, as it facilitates prompt management and will improve patients’ outcome and satisfaction. We performed a prospective study on a cohort of 50 consecutive adult patients presenting to our pain clinic with a diagnosis of cervicogenic headache (International
Department of Anaesthesia, University Hospital Limerick Introduction: Patent Blue V dye is regularly used in assessing lymphatic system in the context of tumour evaluation for breast cancer and malignant melanoma. It has been associated with anaphylaxis with an incidence ranging from 0.24 % to 2.21. Case description: This was a case of life threatening anaphylaxis without many of the initial cardinal signs of anaphylaxis in a 34 year old female undergoing groin lymph node biopsy. Following intradermal injection of 2.5 ml patent blue dye the patient developed severe hypotension (50/30 mmHg) and tachycardia (125 bpm) unresponsive to initial boluses of phenylephrine and fluids. At this time unusually no other cardinal signs of anaphylaxis were evident clinically. The patient’s airway pressure remained within normal limits and there was no difficulty ventilating the patent and there was no evidence of bronchospasm, angioedema or urticaria. The patient required repeated boluses of 100 lg IV adrenaline which caused a slight improvement in BP and was then commenced on an adrenaline/phenylephrine infusion to maintain BP.
S200 The patient subsequently developed a rash near the site of injection and was also treated with IV chlorphenamine 10 mg and hydrocortisone 200 mg IV. This case was atypical given the severity of the patient’s hypotension and requiring a continuing inotropic infusion to maintain BP and the lack of other signs initially indicating a possible case of anaphylaxis. Only one similar case has been described in the literature2. It is therefore vitally important both surgeons and anaesthetists are aware of this possible presentation. Post operative investigations were all normal except for raised tryptase levels and the patient was sent immunology testing for confirmation of diagnosis.
94. Who Accompanies patients to the chronic pain clinic? D. Doltani, A Imran, D. Harmon Department of Pain Medicine, University Hospital Limerick Chronic pain affects about 13–46 % of the adult population. Good communication is paramount in the doctor-patient relationship and in patient outcomes. Patients attending the pain clinic are often elderly patients. They are often accompanied to consultation and these accompanying people are relevant in the communication process. We sought to characterize who attends with patients to the pain clinic. We also wished to determine the accompanying persons influence on the doctor-patient interaction. The role of accompanying person with patients in chronic pain clinic and accompanying persons influence on patient–doctor relationship has not been studied previously. We designed a prospective observational study. Local ethics committee approval followed by written informed consent was obtained. Patients attending the pain clinic for the first time and review patients were included (n = 200). Previous studies have found that approximately one third (30.4 %) of patients were accompanied during visits to their general practitioners. Children and patients older than 75 years most frequently had another person with them. We will present demographic data of patients and their accompanying adults. We will report the accompanying persons influence on the doctorpatient interaction in the pain clinic. Good communication is paramount in the doctor-patient relationship and in patient outcomes. This study results will help the pain clinician in communication aspects with patients and accompanying people.
95. Surviving maternal sepsis: are we there yet? R. Irwin, J. Shannon Department of Anaesthesia, Limerick University Hospital Summary: Sepsis is the leading cause of direct maternal death as per the most recent CEMACH Confidential Enquiry into Maternal and Child Health report. The 2003–2005 triennial CEMACH report recommended the routine use of the MEOWS modified early obstetric warning system, which is an early warning system adapted for the obstetric population1. In Ireland, this has led to the introduction of the IMEWS Irish Maternity Early Warning System. The aim of this study was to identify the incidence of sepsis in our population and to audit our compliance of the ‘sepsis six bundle’ upon identification of a septic patient. Patient data was collected concurrently over a 3 month period from our Regional Maternity Hospital. Septic patients were identified by means of the newly introduced IMEWS. Those triggering SIRS
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 criteria with suspected infection after medical review were included in the audit. The IMEWS prompts the ‘sepsis six’: to take appropriate cultures, FBC with lactate, and start urine output monitoring, followed by fluid resuscitation, maintenance of oxygenation and commencement of IV antibiotics. The adherence to the timely application of this sepsis bundle was assessed. Major contributors to poor adherence to sepsis guidelines are many fold and include failure to recognise sepsis, lack of familiarity or lack of awareness of the sepsis guideline2. A number of preventable deaths cited by CEMACH occurred due to failure to recognise women who were at high risk of maternal complications.1 The IMEWS introduction allows for easier identification of the deteriorating obstetric patient as well as prompting timely interventions.
96. A systematic review of undergraduate ultrasound education in medical schools M. Creaney, H. Misran, S. Keane, B. Rosenbloom, C.M. Nix Department of Anaesthesia, Intensive Care and Pain Medicine, University Hospital Limerick Introduction: Point of care ultrasound (POCUS) is ultrasonography performed at the patient’s bedside in real-time by a health care provider. Recognizing the potential of POCUS in future practice, medical schools worldwide have developed ultrasound curricula. In 2011, the University of South Carolina published their undergraduate medical school ultrasound curriculum1. Since then the American Institute for Ultrasound in Medicine (AIUM) has developed an online portal where undergraduate programs can list and share their curricular initiatives2. As of January 2014, there are 178 programs listed. Our aim was to conduct a systematic review to discover from the recent published literature what type of ultrasound education undergraduate students are receiving and whether the effectiveness of this type of education is being evaluated. We wished to determine how best to teach ultrasound at the undergraduate level. Methods: We conducted a systematic search for articles published since 1990 using the following MeSH terms: medical students, education OR teaching, ultrasound. We searched the following databases: Medline, Cochrane, Ebscohost, Embase and Psychinfo. Results: This yielded 290 articles of which 138 remained for analysis once we applied our exclusion criteria. We created charts to extract quantitative and qualitative data from these articles to answer the review questions. Conclusions: Most of the literature in this field is descriptive. Published formal evaluation of the effectiveness of these programs is scarce. The authors recommend evaluation of the effectiveness of integrated ultrasound curricula. This will allow undergraduate medical educators to design ultrasound curricula that serve medical students well in their future practice. Disclosure: CM Nix will coordinate 2015 ultrasound pilot project for UL Medical School.
SESSION 10 ORTHOPAEDICS SESSION I 97. Assessing the accuracy of measuring leg length and knee genu varum/valgum angle using a new markerless motion analysis system in orthopaedics R. Hurley, A. Devitt
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 Orthopaedic Surgery Department, Galway University Hospital, Galway New marker free motion analysis systems are being used extensively in the area of sports medicine and physiotherapy. The accuracy and validity of use in an orthopaedic setting have not been fully assessed for these newer marker free motion analysis systems. The aim of this study is to compare leg length and varus/valgus knee measurements performed by leg measurement X-ray, and performed using the new marker free motion analysis system (Organic motion biostage). Patients attending the orthopaedic department for total knee replacements were recruited. They underwent radiological leg measurement X-ray, clinical leg measurement, and finally assessment using the organic motion biostage system. These were analysed using the motion monitor software, microsoft excel and minitab 16. For 23 patients assessed, all methods showed a statistically significant result (p \ 0.05) using paired t-tests. This rejects the null hypothesis-indicating that organic motion does not have the accuracy currently to measure leg length or knee varus/valgus angle. Results indicate that the organic motion biostage system—a new marker free motion analysis system, is not feasible currently as a method of accurately measuring leg-length. Given the current modelling methods used by this new system there are limitations, that if addressed may yet allow the system to become a useful clinical tool. These authors feel it still has applications in orthopaedics as a useful, quick, and easy to use method of motion analysis and functional screen in orthopaedic patients, and warrants further investigation.
98. Pain and functional outcomes with tourniquet use in total knee arthroplasty A. Abdulkarim, K.E. Krause, E. Sheehan Midland Regional Hospital Tullamore and University of Limerick Introduction: Tourniquets have been used for many years during total knee arthroplasty as a means of achieving a bloodless field for better visualization and cement-bond inter-digitation. Controversy has surrounded the necessity for a tourniquet in past years. There are many advantages and disadvantages to using a tourniquet, and one prominent disadvantage is a purported increase in post-operative pain and limitations in range of motion. Objective: This study examined the literature for assessment of pain and analgesia usage in post-operative patient who have either received no tourniquet during surgery or received variations in both timing and pressure. Secondary outcomes included were functional in nature, namely range of motion and post-operative hospital stay. Methods: Three hundred and nineteen articles were searched and narrowed to 6 using the QUORUM approach. All were randomized, controlled trials with specific exclusion criteria. Results: When analyzing each trial, pain did not seem to be significantly lower in those with no tourniquet. Instead, patients who received lower pressures for only a portion of the surgery had lower pain levels. Range of motion was consistently higher in the nontourniquet groups compared to the tourniquet patients in all studies that included this measure. There was no difference in hospital stay within the groups for each trial. Conclusion: Our conclusion is that this question is not as straightforward as originally perceived. Patients who receive tourniquet compression up until cementation at lower cuff pressures using a wider cuff may be at an advantage in their post-operatively outcomes.
99. Placing a screw across the ankle syndesmosis: what are the ideal anatomical landmarks? A computed tomography evaluation Carmody Olan, Kennedy Muiris, Leong Sum, Kennedy Cian, Dolan Mark Trauma and Orthopaedic Surgery, Cappagh National Orthopaedic Hospital, Dublin and Cork University Hospital Introduction: Classical AO teaching recommends that a syndesmosis screw should be inserted at 25 to 30 degree angle to the coronal plane of the ankle. In practice accurately judging the 25/30 degree angle can be very difficult. Aims: To determine the ideal anatomical landmarks for placement of a screw across the ankle syndesmosis. Methods: The CT scans of 200 normal ankles which had been performed as part a CT angiogram were retrospectively examined. The centroid of the fibula and tibia in the axial plane 15 mm proximal to the talar dome was calculated. Since a force vector between the centroid of the fibula and the tibia in the axial plane should not displace the fibula relative to the tibia, a line connecting the two centroids was therefore postulated to be the ideal syndesmosis line. Where this ideal line passed through the lateral border of the fibula, and through the medial malleolus was then noted. Conclusion: The ideal syndesmosis line was shown to pass through the fibula with in 2.5 mm of the lateral cortical apex of the fibula, and the anterior half of the medial malleolus in 100 % of the ankles studied. The results support the concept that in the operatively reduced syndesmosis, the anterior half of the medial malleolus can be used as a reliable guide for aiming the syndesmosis drill hole, provided that the fibular entry point is at or adjacent the lateral fibular apex. The screw should also remain parallel to the tibial plafond in the coronal plane. Conflict of interest statement: In respect of the presentation titled; ‘‘Placing a Screw Across the Ankle Syndesmosis: What are the Ideal Anatomical Landmarks? A Computed Tomography Evaluation’’ the following statements are true:
100. Tranexamic acid: an audit of use in a single institution E.F. Pomeroy, G.F. McCoy Lourdes Orthopaedic Hospital, Kilcreen, Kilkenny, Ireland Total hip and total knee arthroplasty patients frequently require blood transfusion post operatively. Studies have shown that intravenous administration of tranexamic acid decreases blood loss and need for transfusion post-operatively. We performed a prospective audit of the use of tranexamic acid in a university affiliated orthopaedic unit. We also examined the effect of tranexamic acid on intra-operative blood loss as well as post-operative change in haemoglobin and blood transfusion requirements. All patients undergoing total hip arthroplasty and total knee arthroplasty at our institution between 18/08/ 2014 and 07/10/2014 were studied. Patient demographics, pre-operative haemoglobin, post-operative haemoglobin, intra-operative blood loss and postoperative transfusion requirements were recorded. We recorded 50 total hip arthroplasty and 45 total knee arthroplasty patients. In the total hip arthroplasty group, 46 % received tranexamic acid: these patients had a mean haemoglobin change of 2.8 g/dL and three patients required transfusion (six units in total). In total hip arthroplasty patients who did not receive tranexamic acid, mean haemoglobin change was 3.6 g/dL and 15 patients required
S202 transfusions (34 units). In the total knee arthroplasty group, 69 % received tranexamic acid: mean haemoglobin change was 2.5 g/dL and two patients required transfusion (three units). Total knee arthroplasty patients who did not receive tranexamic acid had a mean haemoglobin drop of 3.1 with seven patients requiring transfusion (13 units). The rate of tranexamic acid administration was lower than expected, however the benefits can be clearly seen: patients receiving the drug had significant reductions in post-operative haemoglobin change and need for transfusion.
101. Diagnostic accuracy of thessaly test for detection of meniscal tears Dr Alam Hashmi, Dr Padraig O’Loughlin, Dr Hussain, Mr Shay O’Flanagan, Mr Peter Keogh, Mr Patrick Kenny Connolly Hospital, Mill Road, Blanchardstown, Dublin Objective: To assess the accuracy of a new clinical test (Thessaly) as a means of detecting meniscal tears of the knee by comparing MRI and arthroscopic findings to a clinical examination findings. Design: Retrospective cohort study carried out from January to November, 2014 at Connolly Hospital Blanchardstown. Setting: All preoperative examinations were performed in the Department of Orthopaedics and Trauma in the presence of senior staff members. Material and methods: Eighty four patients, post knee trauma, were included in this study and underwent preoperative examination, magnetic resonance imaging (MRI) and arthroscopic surgery. No patient had an osseous or osteochondral injury. A medial and lateral joint-line tenderness test, McMurray test, Apley compression and distraction tests were performed on all patients. The additional Thessaly text involved the patient standing with support by the clinician given by holding their outstretched hands The patient then rotates their knee and body, internally and externally, three times, keeping the knee flexed first at five degrees and then 20 degrees. Patients with suspected meniscal tears typically experience joint-line discomfort. Results: Of the 84 patients with a positive Thessaly test, 83 had an arthroscopically verified meniscal tear. The Thessaly test demonstrated a sensitivity of 90.3 %, specificity of 97.7 %, positive predictive value of 98.5 %, negative predictive value of 86.0 %, likelihood ratio for a positive test of 39.3, likelihood ratio for a negative test of 0.09, and diagnostic accuracy of 88.8 %. Kappa coefficient analysis revealed a statistically significant level of agreement (P \ 0.001) for the surgical diagnosis and the Thessaly test. Conclusions: The Thessaly test is a valid and reproducible physical examination technique for predicting meniscal tears. The Thessaly test exhibits promise as an easily performed manoeuvre that may have greater diagnostic accuracy than traditional tests.
102. Radiographic and functional outcomes following knee arthrodesis using the Wichita fusion nail P.M. McQuail, J.F. Baker, P. Keogh, P. Kenny Department of Trauma and Orthopaedics, James Connolly Memorial Hospital Knee arthrodesis is a salvage procedure whose predominant indication is irretrievably failed total knee arthroplasty. Previous publications on the Wichita Fusion Nail have reported arthrodesis rates as high as 95–100 %.
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 The purpose of this study was to report both the radiographic and functional outcomes of patients undergoing knee arthrodesis with the Wichita Fusion Nail within the Republic of Ireland and compare the results to those published. Patient charts and radiographs were reviewed on all patients who had a Wichita Fusion Nail implanted in Ireland to date. Patients were invited to complete a WOMAC score (Western Ontario and McMaster Universities Osteoarthritis Index) as a functional assessment. 23 patients were identified. Patients had an average of 8 (range 0–26) knee surgeries prior to arthrodesis. Statistical analyses were conducted in R/RStudio 3.1.1/0.98. The most common indication was failed arthroplasty due to recalcitrant infection (69.5 %). Successful fusion occurred in 60.8 % of patients. The mean time to fusion was 9.21 months (range 2–24). The mean WOMAC score was 58.55 (range 30–96). We found a rate of arthrodesis in this series lower than that reported in other published series. The rate of major complications however was comparable to those published previously reflecting the often challenging patient cohort that has either undergone multiple local surgical procedures or if not fit for a greater surgical insult. Despite these findings the overall functional outcome (WOMAC) in this series was comparable to other reports on patients having had a complicated primary knee arthroplasty.
103. Novel biomimetic osteochondral defect repair scaffold demonstrates directed stem cell differentiation in each distinct layer C.J. Moran, T.J. Levingstone, F.J. O’Brien Tissue Engineering Research Group (TERG), Department of Anatomy, RCSI Osteochondral defects occur due to disease or injury. The gradient structure of osteochondral tissue, with bone, cartilage and calcified cartilage regions, poses a challenge for the design of materials for defect repair. A biomimetic tri-layered collagen-based scaffold designed to replicate the anatomical structures, comprising a collagen hydroxyapatite base layer, a type I collagen hyaluronic acid layer and a type I/type II collagen hyaluronic acid layer at the cartilage surface, has been developed. It has shown significant success as an off-the-shelf, cell free product, in the treatment of focal defects in vivo (1) by recruiting host cells and directing them to differentiate into bone and cartilage in each layer. This study aimed to elucidate the mechanism by which the extracellular matrix macromolecules in the scaffold direct stem cell differentiation. Tri-layered scaffolds were divided into constituent layers and seeded with rat bone marrow mesenchymal stem cells. Cell infiltration and proliferation, calcium production and sGAG formation were assessed. All layers allowed cellular infiltration and proliferation. The base layer was found to be osteogenic due to the constituent hydroxyapatite while the top layer demonstrated chondrogenesis in the presence of TGF-b. The biomaterial and microstructural properties within this scaffold show the value of using a biomimetic approach in attaining enhanced tissue regeneration without the need for drugs or recombinant proteins. The ability of the scaffold to appropriately direct differentiation is key to achieving the positive repair responses previously demonstrated in in vivo studies.
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104. Olecranon fractures in the elderly population. Is tension band wiring the appropriate treatment? M.M. Hennessy, S. Umar, P. Fleming, J.A. Harty Department of Trauma and Orthopaedic Surgery, Cork University Hospital Olecranon fractures are common injuries among the elderly population. The combination of poor skin condition, bone quality and comminution makes successful treatment difficult. Associated complications include infection, metal work problems and non-union with 10–60 % reported rates of complications1. Some studies recommended conservative treatment in the elderly2. In an initial literature review, no study was identified addressing complications and recommended treatment for olecranon fractures in this population. Our aim was to assess the outcomes and complications of displaced olecranon fractures in elderly patients ([70 years) treated with tension band wiring, to confirm this is an appropriate treatment for these fractures and to identify the risk factors leading to complications and provide recommendations for future practice. We completed a retrospective study. All elderly patients[70 years old with displaced olecranon fractures treated with tension band wiring over a 6 year period were included. Data was collected from admission notes, theatre notes, dictated letters from OPD attendances and radiological findings. Outcome measures included fracture type, complications, need for further surgery and range of movement obtained. 86 patients were treated at our institution in the period 2004–June 2010. Five open and 81 closed fractures were identified. 69 patients were treated with tension band wiring. 13 % suffered an infection. 18 % required removal of metal. 75 % of patients have a reduced range of movement of their elbow. The majority of fractures were comminuted or oblique and tension band wiring was not sufficient with high complication rates. Further studies comparing operative versus conservative management is warranted.
105. A radiological assessment using magnetic resonance imaging of the anterolateral ligament of the knee
S203 This study- the first of its kind in Ireland to assess the anterolateral ligament radiologically, indicates that the ALL is a discrete, visible structure on MRI. This furthers the evidence of the presence of the ALL and also provides information that may be beneficial in future studies, and assessment of knee injuries.
106. Cost–utility analysis in fracture care, what pays? A systematic review S. Coyle, J.M. Queally, B. Lenehan Department of Orthopaedic Surgery, University Hospital Limerick Background: As healthcare systems come under increasing pressure to provide more care with less resources, emphasis is being placed on value-based systems that maximise quality and minimise cost. The aim of this study was to determine which interventions in fracture care have been demonstrated to be cost efficient. Methods: A systemic review of all cost–utility studies on the management of fractures from 1976 to 2014 was carried out using a search of the Cost-Effectiveness Analysis Registry, National Health Service Economic Evaluation Database (NHS EED) and Pubmed. The data abstracted included incremental cost-effectiveness rations and utility assessment. Results: 16 studies were included. 12 (75 %) studies assessed interventions in lower limb trauma. Interventions which were shown to be cost effective were total hip arthroplasty versus hemiarthroplasty for treatment of displaced neck of femur fractures (incremental cost effective ratio of $1960 per QALY), salvage treatment for grade IIIB and IIIC open tibial fractures versus amputation, operative treatment of clavicle and scaphoid fractures. 8 (50 %) of studies included costs from a payer perspective with only 6 (38 %) studies pursuing the cost of an intervention from a societal perspective. Only 4 (25 %) met the criteria recommended by the U.S. Panel On Cost-Effectiveness in Health and Medicine. Conclusion: Certain aspects of fracture management have been shown to be cost effective. However, there is a paucity of evidence in this area and further research is required to evaluate the cost effectiveness of all aspects of fracture care so that value-based interventions are chosen by healthcare providers.
R. Hurley, C. Barry, D. Bergin, F. Shannon Department of Orthopaedics and Radiology, Galway University Hospital The anatomy of the human body has been studied for centuries. Despite this, recent articles have announced the presence of a new knee ligament—the anterolateral ligament. It has been the subject of much discussion and media commentary. Few studies assessing the ligament radiologically have been undertaken. All right knee MRIs performed on a Siemens Magnetom Espree 1.5 T scanner in Merlin Park Hospital over a 4 year period were retrospectively analysed. Patients over the age of 44 were excluded. Any MRIs with reported abnormalities were excluded. The normal MRIs were then analysed by a consultant radiologist specialising in musculoskeletal imaging. Measurements on origin, insertion, course and length were noted. All data was collected using Microsoft Excel and analysed using Minitab. 1,732 right knee MRIs were performed in the time period. 62 were classed as normal, and within the specified age range. 10 were randomly sampled. Of these the ligament was visible on all 10 MRIs, best viewed in the coronal plane. The average length (visible in 8/10) was 28.88 ± 5.14 mm. The origin (visible in all 10) was 2.25 ± 0.39 mm. The insertion (visible in 9/10) was 1.93 ± 0.424. The mid thickness was 1.87 ± 0.2 mm.
107. Agricultural and equestrian injuries in the Irish midland Ali Abdulkarim, Peter Coffey, Eoin Sheehan Orthopaedics Department, Midland Regional Hospital Tullamore Background: The agricultural and equestrian business are an important source of employment in the Midlands. This is a retrospective study examining the demographics, characteristics, and outcomes of agricultural and equestrian related injuries presenting to the Midland Regional Hospital, Tullamore, Co. Offaly. Methods: Every presentation to the Accident and Emergency Department at the Midlands Regional Hospital in 2013 was assed retrospectively to determine if an injury had been sustained in an agricultural or equestrian environment. Patient characteristics and injury details were collected for 345 patients who attended the Accident and Emergency Department. Patient demographics, month of occurrence, mechanism of injury, radiology results, management and follow up data were collected and analysed. Results: There were 196 agricultural related presentations to the Accident and Emergency Department and 149 equestrian related presentations. 23 % of the agricultural injuries and 36 % of the
S204 equestrian injuries had confirmed radiological evidence of a fracture or joint dislocation. There were significantly more males involved in agricultural injuries than females (98 vs 2 %, p \ 0.001). There were significantly more females involved in equestrian injuries than males (58 vs 42 %, p \ 0.05). 10 % of farming injuries and 15.4 % of equestrian injuries required admission. Farming machinery accidents contributed to significantly more admissions than any other cause in the agricultural category (p \ 0.01). Conclusion: Agricultural and equestrian related injuries in the Irish midland are common presentations to orthopaedic surgeon. Increased attention to occupational health hazards seems required in the equestrian environment as Prevention of adverse health outcomes.
108. A comparison of pin site infection rates between percutaneous buried and exposed K-wires in treating distal radius fractures P.M. McQuail, N. Awan Department of Trauma and Orthopaedics, Our Lady of Lourdes Hospital, Drogheda Pin site infection is a frequently reported complication of percutaneous Kirschner-wire (K-wire) fixation of fractures. In general, the literature suggests that pin site infection is more common in those treated with exposed K-wires compared with those in whom the wires are buried. The purpose of this study was to ascertain whether the pin-site infection rate differed in patients whose K-wires were buried or left exposed intra-operatively following percutaneous fixation of their distal radial fracture in our institution. We analysed all patients over 15 years of age with an acute displaced distal radius fracture who underwent closed reduction and K-wire fixation between July 1st and 31st December 2012. Patient’s pin sites were reviewed and assessed by a single Orthopaedic surgeon between 2–6 weeks post-operatively. Clinically infected pin sites were graded using the modified Oppenheim classification. 61 patients were identified. 33 patient’s K-wires were left exposed and 28 patient’s wires were buried. One patient (3 %) with exposed K-wires and three patients (10.7 %) with buried K-wires developed pin site infection. All patients had grade two infection. Three of the four patient’s infections were detected at 2-weeks post-operatively, while the fourth patient’s infection was diagnosed at the sixth week. We found a higher rate of infection in patients treated with buried K-wires compared to patients whose K-wires remained exposed following percutaneous fixation of their distal radius fracture. This is contrary to other published series reporting on K-wire fixation of distal radial fractures which document higher infection rates in those with exposed wires.
SESSION 11 CLINICAL SESSION V 109. Improving rectal cancer outcomes through the development of a regional cancer unit
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 surgery are better in high volume centres. In light of this, rectal cancer services in Ireland were centralised in eight regional centres in 2010. The aim of this study is to assess outcomes for rectal cancer patients in the South-East region following centralisation. Using a prospectively maintained database of all new rectal cancer diagnoses in the South-East from 2010–2014, we assessed overall numbers of diagnoses, stage at diagnosis, response to neoadjuvant therapy, type of surgery, number of curative resections and the morbidity and mortality of our unit to compare to best available international data. From July 2010 to August 2014 there were 257 rectal cancer diagnoses discussed at the regional multidisciplinary meeting. Of these, 42 (16 %) were metastatic at time of diagnosis. 72 % had neoadjuvant therapy (radiotherapy or chemoradiotherapy), an increase on Irish figures from 2009 and 46 % of these were downstaged radiologically prior to surgery. Of the remaining 215, 177 (82 %) had definitive surgery of which 89 % were curative (R0). 122/177 (69 %) patients underwent sphincter-preserving surgery, comparable with international data. There was one post-operative mortality, giving a 30-day mortality of 0.56 % which compares well to the international rate of 2.9 %. In conclusion, centralisation of services in a regional rectal cancer unit has resulted in quality care for a large volume of patients in the South East Region.
110. Use and abuse of the PSA test by non-urologists in the hospital setting A.S. Fawaz, E.J. Redmond, K.S. Dolbec, H.D. Flood Department of Urology, University Hospital Limerick and Graduate Entry Medical School, Limerick Introduction: Prostate-specific antigen (PSA) is used extensively as a screening tool for prostate cancer. An elevated PSA may result in unnecessary investigations if performed in an inappropriate setting or age group. The aim of this study was to assess the use of PSA testing by non-urologists in the hospital setting. Methods: PSA tests ordered by non-urologists from January–March 2014 were analysed. The indication for request and findings on digital rectal examination were recorded from patient charts. Contraindications to testing (e.g. positive urinalysis) and the outcome of patients with abnormal results were also evaluated. Results: One hundred and sixty-nine patients were included for analysis. The median age at testing was 73 (35–97). A documented discussion with the patient regarding the indication for PSA occurred in 12 % of cases. DRE findings were documented in 23 % of cases. Thirty-nine patients had elevated PSA, of which 9 had known prostatic cancer. Only 65 % of patients were within the range for screening. A total of 37 % underwent prostate biopsy resulting in the diagnosis of 15 patients with prostate cancer. Finally, 41 % of patients had contraindications to PSA testing at collection. Conclusion: The majority of patients who underwent PSA testing were outside the recommended age profile for screening. Greater education regarding the use of PSA within the hospital setting is required to reduce unnecessary investigation, cost, and the emotional burden of further investigation.
E. O’Keane, E.M. Quinn, C. O’Neill, S. Zeeshan, F. Cooke Department of Surgery, University Hospital Waterford, Ardkeen, Co. Waterford Colorectal cancer is the second most common cause of cancer death in Ireland. There is evidence that outcomes after complex cancer
111. The role of MRI in screen-detected invasive lobular carcinoma of the breast C. Nı´ Leidhin, A. Heeney, C. Quinn, A. O’Doherty, R. Prichard
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 Departments of General, Breast and Endocrine Surgery, Histopathology and Radiology, St. Vincent’s University Hospital Screening reduces breast cancer mortality but is associated with overdiagnosis . Invasive lobular carcinoma (ILC) is measured most accurately using mammography and magnetic resonance imaging (MRI) . This study aimed to investigate the use of MRI in screendetected ILC with particular regard to its accuracy in estimation of tumour size, detection of multifocality, contralaterality and impact on patient management. A retrospective analysis of all patients in the Breast Check Merrion Unit, with a histological diagnosis of ILC of the breast between 2007–2014 was carried out. Relevant data, including patient demographics, imaging, histology and management was extracted and reviewed. A total of 186 women with a mean age of 57 were diagnosed with ILC during this time. 54 % underwent breast MRI. MRI revealed multifocal and contralateral disease, which hadn’t been evident on initial imaging, in 30 and 3 % of patients respectively. There was correlation in tumour size (of within 5 mm) between initial imaging and MRI in 56 % of cases. In 62 % of patients, MRI and histology corresponded in terms of estimated tumour size. There was over- and under-estimation of disease extent on MRI in 40 and 4 % of cases respectively. Multifocality correlated between MRI and histology in 64 % of patients with over- and under-diagnosis in 17 and 19 % of patients respectively. MRI in screen-detected ILC is an important tool in assessing tumour size and in detecting multifocality but it may over and/or underestimate disease extent. It may be an important adjunct, especially in pre-operative planning, for the optimal management of breast cancer.
112. Early experience from endotherapy for dysplasia in Barrett’s oesophagus in a tertiary centre in the Republic of Ireland J. Witherspoon, D. O’Toole, N. Ravi, J.V. Reynolds National Oesophageal and Gastric Cancer Centre, St. James’s Hospital, Dublin Background: Endoscopic surgery and radiofrequency ablation (RFA) has greatly enhanced a curative approach to high-grade dysplasia (HGD) and early mucosal cancers arising in Barrett’s oesophagus (BO), compared with resectional surgery. Recent evidence shows a benefit in treating low-grade dysplasia (LGD) in addition to HGD1. We report herein the experience from the National Oesophageal and Gastric Cancer Centre in Ireland. Methods: All patients undergoing RFA, endoscopic mucosal resection (EMR) and argon plasma coagulation (APC) from 03/2009–10/ 2014 were analysed. Demographics, index Vienna grade, BO length, treatment, and outcome were collected prospectively by a database manager. The programme involves confirmation of histopathology by 2 independent pathologists, diligent lesion resection to achieve flat BO, followed by quarterly ablation therapy until specialized intestinal metaplasia (SIM) free. Results: 125 patients were treated (100 male), median age 65 years. 17.6 % patients had HALO for LGD. The majority (51 %) of patients had 1 treatment of circumferential balloon ablation (HALO 360°), 8 % had 2 treatments, 2.4 % had 3 treatments and 38.4 % had none. 24.6, 36.5, 25.4, 2.4, 1.6 and 8.7 % had 1, 2, 3, 4, 5, and 0 sessions of focal ablation (HALO 90°) treatments respectively. Six patients required dilatation for suspected endotherapy-induced strictures. 54 patients had EMR pre-RFA treatment, 28 peri-RFA and 24 patients
S205 had APC. 5 patients failed endotherapy; 4 proceeded to oesophagectomy and one underwent Nissen fundoplication and further HALO. Conclusions: Endotherapy is becoming the mainstay of therapy for dysplasia in BO. Our outcomes are comparable with international expert centres. Disclosures: The registry is supported by Dendrite Clinical Systems and funded by the Oesophageal Cancer Fund.
113. An outline of Barrett’s oesophagus in Ireland: preliminary data from a collaborative multicentre registry in Ireland J. Witherspoon, N. Ravi, J.V. Reynolds National Oesophageal and Gastric Cancer Centre, St. James’s Hospital, Dublin Background: Barrett’s oesophagus (BO) is prevalent in societies in the West, and is the sole pathological precursor of adenocarcinoma. We present preliminary data from the first national database for Barrett’s oesophagus (BO) in the Republic of Ireland. Methods: The registry was established in 2008 and includes 5 University teaching Hospitals (3 in Dublin, 1 each in Cork and Galway). Prospective clinical, pathologic and follow-up data are provided by data managers, and biopsies are bioresourced for translational studies. Results: 3,256 (2,167 males) patients with endoscopic BO and pathological specialized intestinal metaplasia (SIM) are registered. Table 1 shows the index diagnosis and the % of patients who had histopathological stability/regression/progression. 40.7 % had short segment BO, 25.6 % had 3–10 cm BO, 2.6 % had 11–15 cm BO, 0.2 % had 15–20 cm BO, and 0.2 % had [20 cm BO. 125 patients have undergone endotherapy and 70 patients have had oesophagectomies. Conclusion: Disease registries provide a valuable resource in tracking clinical and epidemiological data in a population and registries. Progression is more common in this registry from specialist centres than in population-based registries1.2. References: 1. Bhat S, Coleman HG, Yousef Y et al (2011) Risks of malignant progression in Barrett’s esophagus patients: results from a large population-based register. J Natl Cancer Inst 103:1–9 2. De Johnge PJ, van Blankenstein M, Looman CW et al (2010) Risk of malignant progression in patients with Barrett’s esophagus. A Dutch nationwide cohort study. Gut 59:1030–1036 Disclosures: The registry is supported by Dendrite Clinical Systems and funded by the Oesophageal Cancer Fund.
114. National 10-year experience with management of total anomalous pulmonary venous drainage in Ireland Tetyana Kelly, Fabrizio De Rita, Yoginee Sritharen, Jonathan McGuinness, Mark Redmond, Lars Nolke Department of Cardiothoracic Surgery, Our Lady’s Children’s Hospital Crumlin, Dublin Aim/background: Total anomalous pulmonary venous drainage (TAPVD) management has not been previously described in Ireland since 2004. The study aims to describe and compare the surgical outcomes for all TAPVD repair patients in the last 10 years.
S206 Methods: Between 2004 and 2014, 66 consecutive patients underwent TAPVD repair in the single institution. Patients were identified from theatre database logged as ‘TAPVC repair’. Data was collected retrospectively. Data was analysed using IBM SPSS Statistics for Mac Version 22.0. Results: M/F: 43/23 (65 %:35 %), median age 20.5 days (0–315), median weight 3.72 kg (2.27–7.65). TAPVD repair for supracardiac in 59 % (n = 39), cardiac 18.1 % (n = 12), infracardiac 19.7 % (n = 13) and mixed 3 % (n = 2) types. All mixed types presented with obstruction. Single ventricle physiology was present in 10.6 % (n = 7), with Heterotaxy syndrome present in 6 patients. Overall hospital mortality was 7.6 % (n = 5): there were 42.9 % (n = 3) in single ventricle physiology, 3.4 % (n = 2) in normal biventricular physiology. Significant risk factors for mortality were single ventricle physiology (p = 0.007) and young age (p = 0.001). Reintervention for cardiac cause (baffle reoperation for baffle leak, pulmonary venous stenosis repair) was required in 3 % (n = 2). New or additional diagnosis (subaortic membrane resection with left ventricular myectomy, atrial septostomy with balloon dilatation of stenosed pulmonary veins and right ventricular outflow track) was observed in 4.5 % (n = 3). Investigative cardiac catheterization was required in 3 % (n = 2). Follow up was 97 % complete and most survivors (n = 61) were asymptomatic at a median age of 4.9 years (range 0.02–9.9 years). Conclusions: Survival beyond hospital discharge offers excellent surgical outcome following an isolated TAPVD repair. Risk factors for hospital mortality were single ventricle physiology and young age.
115. FYI breast cancer: making healthcare information accessible E. Rutherford, E.A. Lehane, P. Waters, A. Ashraf, J. Finn, M.A. Corrigan Breast Cancer Research Centre, Cork University Hospital, Catherine McAuley School of Nursing and Midwifery, Brookfield, University College Cork. Supported by CUH charity Cork Background: Breast cancer is the most searched for cancer term on the internet (1). However, online medical information is often unreliable, irrelevant or in a form that makes it inaccessible to the majority of people. Aims: A study by this group found that thirty seven percent of patients attending a breast cancer clinic had inadequate health literacy. We aimed to answer the most frequently searched breast cancer questions in a way that would be accessible to individuals of all literacy levels. This information was made freely available in the form of a user-friendly app on both Apple and Android smartphones. Methods: Data mining software (2) was utilised to identify the most frequently searched for terms regarding breast cancer in a 3 month period (April–June 2014 inclusive). Terms were collated and then extrapolated into fifty questions. Spurious associations, including commercial links, were excluded. The questions were then comprehensively answered and reviewed by a literacy specialist. All content was assessed by the National Adult Literacy Agency to ensure maximum accessibility. The questions and answers were also accompanied by diagrams and recorded as audio files for patients with limited literacy. Results: FYI Breast Cancer is now freely available through both Google and Apple stores. Since its launch on Nov 12th 2014 it has been downloaded in thirty number of countries providing a breast cancer resource for patients of all literacy levels.
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116. Predictors and patterns of disease recurrence following a negative sentinel lymph node biopsy in malignant melanoma E.P. O’Connell, D.P. O’Leary, K. Fogarty, Z. Khan, H.P. Redmond Department of Surgery, Cork University Hospital Background: Sentinel lymph node (SLN) status is recognised as a prognostic indicator in melanoma. However, in the setting of a negative SLN biopsy there remains a high risk of disease recurrence. Thus, we aimed to analyse the predictors and patterns of recurrence of melanoma in patients with a negative SLN biopsy. Methods: We conducted a review of a prospectively maintained melanoma database. Melanoma patients who had a negative sentinel lymph node were identified and we performed statistical analysis on their respective demographics, tumour histology characteristics and follow-up data. Results: Of 164 patients studied, 40 (23 %) had a recurrence of melanoma at a median of 39.5 months following diagnosis (range 1–92 months). Recurrence was defined as any local recurrence, regional spread or distant metastases. Distant metastases were the most common form of disease recurrence (40 % of all recurrences). 70 % of all recurrences occurred in those with a primary tumour thickness [2.1 mm. Increasing tumour Departmenth was an independent predictor of recurrence on multivariate analysis. Median survival of 6 months was seen following disease recurrence (range 1–126 months). Conclusion: In the setting of a negative SLN biopsy there remains a risk of melanoma recurrence. Distant metastases were the most common form of recurrence. Disease recurrence occurred more frequently in those with thick primary tumours. Recurrences occurred at long intervals from diagnosis indicating the need to consider prolonged patient follow-up.
117. Clinicopathological study of atherosclerotic and inflammatory abdominal aortic aneurysms A. Elhelali, E. Kavanagh, V. Lundon, L. Morris, N. Hynes, W. Tawfick, S. Sultan Western Vascular Institute, University College Hospital Galway, Galway Clinic and Galway Mayo Institute of Technology Abdominal aortic aneurysms (AAA) can be caused by inflammation in the aortic wall or by atherosclerosis formation. We aim to evaluate inflammatory and atherosclerotic AAAs, to determine histological significance and probability of survival. Between 2001 to 2013, we examined 92 open aneurysm repairs, with available histological data. Aortic wall biopsies were examined to determine histological characteristics of inflammatory/atherosclerotic AAAs. Kaplan–Meier curves were analysed to evaluate probability of survival. Patients with inflammatory AAA were younger (70 years) compared to atherosclerotic AAA (72 years). Morbidities and length of intensive care stay was not significantly different in both groups. Inflammatory AAA was associated with a higher survival rate (82 %) compared to atherosclerotic AAA (68 %) (p = 0.008), after 10 years. Inflammatory and atherosclerotic AAA have similar complication and mortality rates. Histology illustrated a distinction between both regarding their pathology. Pathology could not be linked to specific risk factors.
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118. Does antibiotic prophylaxis prevent surgical site infection in laparoscopic cholecystectomy: a prospective observational comparative study K. Clarke, H. Mohan, E. Nugent, A. Heeney, M. Selmia, K. Mealy, K. Schmidt Department General Surgery, Wexford General Hospital Introduction: Routine use of antibiotics in laparoscopic cholecystectomy is debateable. While prophylaxis is well-established in open cholecystectomy, the risk of surgical site infection following routine uncomplicated elective laparoscopic surgery is low and the costeffectiveness of routine prophylaxis is questionable(1). Methods: A prospective observational study of standard practice among 3 consultant surgeons in a single institution was performed over a 2 year period as part of a surgical site infection surveillance program. 2 consultants routinely used antibiotic prophylaxis and one did not. Patient demographics, operative details and antibiotic prophylaxis were recorded at the time of surgery and with a follow-up phone-call 30 days later. Data was analysed retrospectively. Statistical analysis was completed using SPSS 18.0. Chi squared test was used to compare the group with and without surgical site infection. Results: 297 laparoscopic cholecystectomies were performed during the study period. Only 13 were performed in an emergent setting, 6 of which received antibiotics. The total rate of surgical site infection observed in this series was 3.6 %. There was no significant difference observed in the rate of surgical site infection among patients who received prophylactic antibiotics versus those that did not (antibiotic prophylaxis 4.7 % vs. no antibiotic prophylaxis 1.1 %, p = ns). Conclusion: In this observational study, routine antibiotic prophylaxis did not appear to reduce the incidence of surgical site infection following laparoscopic cholecystectomy. These findings are consistent with studies published in the international literature.
SESSION 12 ORTHOPAEDICS SESSION II 119. Do medical students believe the myths regarding low back pain? Improving understanding with targeted education E. McCabe, D. Abdallah, S. Munigangaiah, N. Basavaraju, J.P. McCabe School of Medicine, NUI Galway and Department of Trauma and Orthopaedic Surgery, Galway University Hospital Introduction and aims: Low back pain is a major presentation to primary care. Despite its prevalence, it is often overlooked by medical school curricula. We investigated whether general teaching throughout medical school was enough to dispel the myths surrounding low back pain and if a targeted lecture added a subsequent benefit. Methods: A cross-sectional study was carried out involving NUI Galway medical students in pre-med, first and final years who completed Deyo’s Seven Myths of Back Pain Questionnaire. Final year students completed the questionnaire before and after a lecture on back pain. The results were analysed by R version 3.1.0 for Mac and compared with a sample of the general population. Results: 219 students completed the questionnaire (65 premedical, 74 first year, 80 final year). The mean age was 21 (17–32) with 59 % female and 41 % male responders. The mean number of correct answers increased according to medical school year (premedical 3.25,
S207 first year 3.54, final year 4.66) meeting statistical significance. Previous experience of back pain and female gender were associated with a statistically significant increase in correct answers. The mean number of correct answers was 3.9 for medical students and 2.9 for the 131 members of the public. The mean number of correct responses among final years before the lecture was 4.66, increasing to 5.84 afterwards, meeting statistical significance. Conclusions: Medical students in their early education have a greater understanding of back pain than the public. This knowledge base improves throughout their general medical education and is significantly supplemented by targeted teaching.
120. The use of validated clinical outcome measures in spinal surgery: an analysis of recent annual meeting abstracts I.R. Perlus, J. Kennedy, J. Street, B. Lenehan Department of Orthopaedic Surgery, University Hospital Limerick Objective: To analyze the use of clinical outcome measures in abstracts accepted to the CSS and NASS annual meetings from 2010 to 2013 inclusively. Methods: The frequency of abstracts accepted to CSS and NASS annual meetings containing outcome measures and the frequency of validated versus non-validated outcome measures were analyzed. A literature search was performed using the NASS Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care, Cochrane Library Database, PubMed, and Google Scholar. The concepts contained in the items of the ten most commonly used outcome measures were linked to the specific ICF categories. Results: Of the abstracts accepted to CSS and NASS, 71 and 53 % contained validated outcome measures respectively. The ten most commonly used outcome measures were the ODI, VAS, SF36, NDI, SRS, SF12, EQ5D, mJOA, AIS, and RMDQ. The NASS guidelines provided limited validity recommendations covering three spinal conditions. The Cochrane Library Database published reviews for disc arthroplasty, degenerative disease, vertebral and burst fractures, spinal fusion, back pain, and cervical spondylotic myelopathy. All of the concepts for each outcome measure were linkable to the ICF. Conclusions: All of the ten most commonly used outcome measures were validated in the field of spinal surgery and were linked to the ICF. There remains a need for a universal database to determine which outcome measures would be most useful for a given spinal condition or surgical approach. This provides evidence that researchers and clinicians in spinal surgery have identified the importance of utilizing validated HRQOL outcome measures as their health predictors.
121. The benefits of an MSK clinical specialist physiotherapy (CSP) led triage service in reducing an orthopaedic/rheumatology waiting list in University Hospitals of Limerick (UHL) L. Ryan, P. Julian, F. Steed, A. Fraser, B. Lenehan University Hospital Limerick Introduction: Research shows that 70–90 % of referrals to Orthopaedic outpatients do not require surgical intervention (1). MSK CSP led triage services were established in October 2012. The primary goal was to reduce orthopaedic and rheumatology OPD waiting lists.
S208 GP referrals are triaged by consultants to MSK CSP service where appropriate. Patients are then seen in MSK CSP clinics. Aim: To examine the benefits of an MSK CSP service in reducing an Orthopaedic/Rheumatology waiting list in UHL between October 2012 and October 2014. Materials and methods: Retrospective review of all patients triaged to the MSK CSP service over a 2 year period. Results: During study period two full time MSK CSP‘s were employed in UHL.3154 patient appointments were provided. 2,774 patients attended for consultation. 13 % (381) of patients were referred onward for consultant review and 87 % of patients were discharged from the waiting list. Discussion: The results of this review show that 87 % of all referrals triaged by consultants to the MSK programme can be dealt appropriately by the CSP’s. This ultimately improves the patient pathway through reducing unnecessary Consultant appointments, leading to a reduction in waiting times for consultant appointments and ultimately improving access for those with the greatest clinical need. Conclusion: An MSK CSP triage programmes are capable of dealing successfully with 87 % of all referrals triaged by consultants to the service.
122. Inter-observer and intra-observer variability in the assessment of urgency of low back pain referrals from primary to secondary care J.E. Gilmore, B. Lenehan Department of Trauma Orthopaedics, University Hospital Limerick Lower back pain is a common cause of presentation to primary care and referral to secondary services. There is no standard of information to be included in the referral request. Canadian and Dutch studies suggest that agreed referral guidelines and a standardised referral form for primary care practitioners might be of use (Fleuren et al. 2010; Simon et al. 2009). The purpose of this study was to investigate if the quality and quantity of information provided to clinicians caused a measurable variation in their assessment of the urgency of the case. One hundred and thirty one referrals from primary care were individually reviewed by four assessors: an orthopaedic spine specialist, an orthopaedic consultant, an orthopaedic specialist registrar, and a general practitioner. The reviewers triaged the referrals as requiring urgent or routine assessment. The results were analysed using SPSS and kappa scores were formulated. Based on Landis and Koch’s definitions of strength of agreement for the kappa co-efficient, there was poor to fair inter-observer agreement regarding urgency, indicating disagreement amongst the reviewers as to what constituted an urgent referral. Meanwhile, there was moderately strong intra-observer agreement on repeated assessment of the referrals. This study suggests that there is lack of agreement among receiving clinicians as to which referrals require urgent review. We strongly recommend a standardised referral criteria and pro-forma referral document that improves triaging and care of this common condition.
123. Evolving techniques in the innominate osteotomy for developmental dysplasia of the hip O. Carmody, D.T. Cawley, M.K. Dodds, D. McCormack
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 Temple Street Children’s University Hospital, Dublin No long-term follow-up of the less invasive innominate osteotomy has been published. Introduction: In 1961, Salter described the innominate osteotomy for the treatment of dysplastic acetabuli in children with DDH. The less invasive innominate osteotomy is a modification of this original technique and allows the procedure to be performed through a limited, shortened exposure. This technique uses the oscillatory saw to perform the innominate osteotomy which is then secured with two K-wires. A plastic removable abduction brace is used post-operatively in lieu of the spica cast. Aims and methods: 36 patients remained under review following the less invasive innominate osteotomy for at least 5 years with an average of 7 years 6 months follow-up. The acetabular index was measured pre-operatively and at the most recent follow-up (mean 7.5 years). The centre-edge (CE) angle was also measured on both the affected and contra-lateral sides. Results: The mean acetabular index (AI) pre-operatively was 33.4° on the affected side and 20.9° on the contra-lateral side. At a mean of 7.25 years, the mean AI was 12.08° on the affected (post-less invasive innominate osteotomy) side and 12.0° on the contra-lateral side. Centre-edge angle at a mean of 7.5 years was 32.6° on the affected side (post-less invasive innominate osteotomy). Conclusion: At a mean of 7.5 years, results of the less invasive innominate osteotomy are very positive. We recommend that the routine use of a Gigli saw for this procedure should now cease as the use of an oscillatory saw in innominate osteotomy obviates the necessity to perform a full subperiosteal exposure. Abduction bracing post-procedure has shown decreased anaesthetic time, easier application and is also recommended.
124. Lateral trochanteric pain following total hip arthroplasty: radiographic assessment of altered biomechanics as a potential aetiology Ali Abdulkarim, Raazi Bajwa, Eoin Sheehan RCSI and Department of Trauma and Orthopaedics, Midlands Regional Hospital, Tullamore Introduction: Lateral trochanteric pain (LTP) complicates up 17 % of cases post total hip arthroplasty. Studies have refuted underlying trochanteric bursitis. Manipulation of the femoral offset and reproduction of the natural femoral centre of rotation are important in successful arthroplasty. LTP is believed to be associated with their alteration. Aim: The aim of our study was to evaluate the effect of femoral offset and centre of rotation on the incidence LTP. Methods: Retrospective analysis of all patients clinically diagnosed with LTP post primary total hip arthroplasty performed from January 2012–December 2013. A control group matched for age and sex of uncomplicated primary total hip arthroplasty performed in the same period was used for comparison. The direct lateral approach was used in all cases. Anterior-posterior pelvis radiographs before and after surgery were compared to assess the femoral, cup and global offsets and limb length discrepancies between the two groups. Statistical analyses were performed using the Mann-Whitney U test and independent samples t-test. Results: A total of 91 patients were identified; 29 diagnosed with post-operative LTP and 62 patients were asymptomatic (control group). The median ages were 72.8 (symptomatic) and 68.8 (control) and not significant (p = 0.1). The distribution of differences between the medians of femoral (p \ 0.499), cup (p = 0.398) and global
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 offset (p = 0.912) and mean of limb length discrepancy (p = 0.94) were not significant. Conclusion: No relationship was found between LTP and femoral offset or femoral centre of rotation. Disruption of the soft tissues during a lateral approach with resultant abductor tear, tendon defects and tendinitis might play a role in lateral trochanteric pain and explain apparent efficacy of corticosteroid injections.
125. Heterotopic ossification following operative treatment of acetabular fractures: the ten year experience of the tertiary national referral centre R.P. Piggott, Y. Elhassan, A. Abdelhaq, M. Leonard Department of Trauma and Orthopaedics, The Adelaide and Meath Hospital and National Children’s Hospital Tallaght Heterotopic ossification (HO) is a recognised complication in operative fixation of acetabular fractures. The incidence of HO is reported at 26 % but varies widely in the literature and many associated factors such as surgical approach, associated injuries and NSAIDs prophylaxis have been reported. Our study aimed to determine (1) the incidence of HO, (2) risk factors that influenced its development and (3) the influence of the use of NSAIDs in prophylaxis in the National Centre for the Treatment of Pelvic and Acetabular Fractures. We retrospectively reviewed 416 patients who underwent Acetabular fracture fixation over a 10 year period. Their follow up radiology was examined for the presence of HO and classified them according to the Brooker classification. An in Departmenth medical record review was performed to identify patient characteristics, admission details, surgical approach and the use of prophylaxis. Three-hundred and Seventy-two patients were included following exclusion criteria. The average age of patients was 41.6 years with a male predominance. The average Length of follow up was 23 months. The incidence of HO was 17.5 % (65 cases). Surgical approach did not influence the incidence of HO (p = 0.356). Head injury (p = 0.05), ICU admission (p = 0.021) and a longer length of stay (p = 0.001) were significantly associated with the development of HO. NSAIDs were not protective against HO formation (p = 0.085). No patients underwent radiotherapy or surgical excision of their HO. The rate of HO in the Irish population is in keeping with the published literature and not influenced by the surgical approach and NSAID use.
126. Metal on metal total hip replacement: assessing the quality of patient information on the Internet G. Crozier Shaw, D. Gibbons, J.M. Queally, J. Quinlan Department of Orthopaedic Surgery, Adelaide, Meath and the National Children’s Hospital, Tallaght Metal-on-metal total hip replacement has generated much attention in the media due to early failure of certain implant systems. To assess the quality, accuracy and readability of information on metal-on-metal total hip arthroplasty on the internet. Searches terms were ‘‘metal-on-metal hip replacement’’ and ‘‘metal hip replacement’’ on the most popular search engines: Google, Bing, Yahoo. Websites were categorised based on authorship and assessed for readability using Flesch Reading score and the Gunning Fog index. Information quality was assessed using DISCERN (1), JAMA (2) and MOM THA criteria developed for the study. Accuracy was assessed via a customized scale.
S209 69 unique websites were compiled. 76 % of websites’ target audience was patients. Media or medico-legal sources in 44 % of cases with just 28 % of websites coming from physicians or academics. Average readability scores were 35.99, 11.42 and 15.09. Average MOM specific scores 9/25. Only 9 % of websites met the HON criteria. 78 % disregarded using JAMA criteria. Average DISCERN score 3.2, with moderate shortcomings. Non-profit or governmental websites performed the best, with average MOM THA scores 15/25 and average DISCERN score 4, with very few shortcomings. This study demonstrates that online information on MOM THA was of poor quality, often inaccurate and at an inappropriately high reading level, particularly in media and medicolegal websites. This may lead to unnecessary anxiety amongst patients. Healthcare providers should counsel patients regarding the quality of information available and direct patients towards appropriate online resources.
127. Outcome of hip and knee arthroplasty in HIVinfected patients—a systematic review and metaanalysis S.C. O’Neill, J.M. Queally, A. Hickey, K.J. Mulhall Department of Orthopaedic Surgery, Cappagh National Orthopaedic Hospital, Dublin and RCSI Background: Significant advances in the treatment of Human Immunodeficiency Virus (HIV) have occurred in recent times, with life expectancy now approaching the normal population. Patients with HIV will increasingly be undergoing joint replacement in the future, however concerns remain regarding the complications and outcome in this patient cohort. Aim: To assess the outcome of total hip and knee arthroplasty in HIV-infected patients. Design: Systematic review and meta-analysis using MOOSE reporting guidelines. Methods: A systematic search of the literature was performed, assessing the outcome of hip and knee arthroplasty in HIV- infected patients. The primary outcome was infection. Secondary outcomes were all-cause revision and all-cause mortality. Results: The search yielded 433 results, of which 17 met the inclusion criteria. The overall quality of the studies was poor with significant heterogeneity between studies. Infection and revision appeared to be more likely to occur in HIV positive patients compared to HIV negative patients, with no difference in mortality. A subgroup meta-analysis of four studies revealed a risk ratio of 3.31 and 2.25 for increase in infection and revision respectively in HIV positive patients. Conclusion: This systematic review and meta-analysis demonstrates an increased risk of infection and revision in HIV infected patients undergoing total hip and knee arthroplasty. However, these findings are based on poor quality evidence in a limited number of studies and need to be interpreted with caution. Further research should concentrate on large, well-designed, prospective studies, that control for comorbidities and employ standardised outcome measures to allow for direct comparison.
128. Audit of orthopaedic operation notes C. Ni Fhoghlu, F. Coughlan, P. Ellanti, N. Hogan Department of Orthopaedic Surgery, St. James’s Hospital, Dublin
S210 The purpose of this study was to retrospectively audit 63 operation notes of procedure performed by the Orthopaedic service in St. James’s Hospital from 9/4/14 to 21/10/14 according to the Royal College of Surgeons of England Good Surgical Practice guidelines February 2008. A list of 63 operation notes were audited in terms of date and time of surgery, surgeon, procedure, elective/emergency indication, diagnosis, incision details, signature, closure details, tourniquet time, postop instructions, complications, prosthesis serial numbers. Of the 63 operation notes, 71.43 % of procedures were performed by consultants, 28.57 % by registrars. 11.1 % of operative notes were written by Consultants, 85.71 % by registrars and 3.17 % by Senior House Officers. A total of 38.1 % of notes were written by the lead surgeon, and 61.9 % by an assistant. Of those written by the lead surgeon, 11.1 % were consultants and 27 % registrars. All notes were handwritten on the St James’s Operation Sheet. Documentation was excellent for date and time of surgery, name of surgeons (100 %), procedure (100 %), and closure details (100 %). All documents were signed. Diagnosis was present in 74.6 % of notes, but rarely in the correct place. Incision details were included in 81.66 % of sheets, with incisions not applying to 3 (closed procedures). Tourniquets were applied in 23.8 % of cases but 0 % had time documented. Closure details, where applicable, were documented in 98.3 % of cases. 96.8 % had post-operative instructions; these were frequently in the incorrect space. Of the 50 cases where prosthetic equipment was used only 30 % had serial number stickers attached to the operation sheet. No operative notes documented whether it was an elective or emergency procedure. Completion and documentation of operative procedures on our operation sheets was excellent for date, time, surgeon, closure details, procedure and signatures. Improvement is needed in documenting tourniquet time, prosthesis serial numbers, filling information on the sheets in the correct places, incision details and diagnosis.
129. The quality of online orthopaedic information and its impact on contemporary clinical practice J.T. Cassidy, J.F. Baker Department of Orthopaedics, The Adelaide and Meath Hospital and Galway University Hospital Introduction: Unlike other forms of media, the internet is not regulated. Little is known about the quality or readability of online orthopaedic information. What is known, is that the information accessed online can dramatically affect patients’ opinions and expectations. Objectives: To summarise the current state of knowledge regarding online orthopaedic information and discuss how this may impact contemporary practice. Methods: We searched Pubmed, Medline and Google-Scholar using multiple localizing orthopaedic terms (e.g. ‘‘hip’’) were searched with three chosen title keywords (‘‘internet’’, ‘‘web’’ and ‘‘online’’). All
Ir J Med Sci (2015) 184 (Suppl 5):S127–S210 articles which examining online orthopaedic information from 2000 until 12th August 2014 were considered. Articles were specifically examined for how many reviewers evaluated the online material and the use of recognized quality/readability assessment tools. Results: We identified 43 articles, 29 focused on quality, seven on readability and six addressed both. The majority of authors had either addressed a single orthopaedic procedure or pathology. Eight (28 %) of the 29 studies focusing on quality used recognized quality assessment tools. To date, authors have reported the majority of the examined information to be of poor quality. All of the studies focusing on readability used a recognized readability assessment tool. Studies examining readability have focused on pages produced by professional orthopaedic societies. The proportion of material at the recommended readability level ranged from 3–29 %. Conclusions: The quality and readability of online orthopaedic information is generally poor. In order for modern practice to adapt to the internet and prevent increased confusion, the orthopaedic collective should develop high quality, readable online patient information.
130. Total joint arthroplasty: do referring doctors overestimate the risks? Carmody Olan, Nugent Mary, F. Rowan, M. Kelly, P. Kenny Trauma and Orthopaedic Surgery, National Orthopaedic Surgery, Cappagh, Dublin Introduction: The vast majority of patients undergoing Total Joint Arthroplasty are initially referred by their GP’s or Family Physicians. As such, these hold enormous influence over whether or not a patient is ultimately referred. Misjudgement of risks associated with Total Joint Arthroplasty may impact on when or if a referral is ever sent. Aims and methods: We wished to assess if Family Physicians underestimated, overestimated or estimated correctly the risks associated with Total Joint Arthroplasty. 700 General Practitioners were questioned regarding their expectations of DVT, infection, dislocation and mortality risk associated with Total Joint Arthroplasty. We also assessed when they expected the patients to fully weight-bear postoperatively and what they expected the total operative time to be. Results: 230 General Practitioners from a widely-varied demographic, of whom 75.25 % had more than 15 years experience as GP’s replied. Overall, GP’s overestimated risks associated with DVT, infection, dislocation, mortality, time to full weight-bearing and total operative time in both the total knee and the total hip group. Conclusion: GP’s will not refer certain patients if they perceive the risks associated with Total Joint Arthroplasty to be too great. Overestimation of risks may be having a significant impact on the number of patients and the characteristics of the patients being referred for joint replacements. It is very much in the interest of the Orthopaedic Surgeon to adequately inform GP’s regarding accurate risks associated with Total Joint Arthroplasty.