ROYAL ACADEMY OF MEDICINE IN IRELAND IRISH JOURNAL OF MEDICAL SCIENCE

Proceedings of the RAMI Intern Section Meeting

31st January 2015 Royal College of Physicians of Ireland

Irish Journal of Medical Science Volume 184 Supplement 7 DOI 10.1007/s11845-015-1321-6

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Disclosure Statement This supplement has received no external funding or sponsorship

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 DOI 10.1007/s11845-015-1321-6

Right Ventricular Occlusion in an Elderly Irish Woman Wong E1, Mulloy E2, Rice C3 1 Mid-West Intern Network, University of Limerick Group of Hospitals; 2Respiratory Department, St. John’s Hospital; 3 University of Limerick, Mid-West Network

Introduction: An 89-year-old woman was admitted to St. John’s Hospital last summer with worsening dyspnoea, orthopnoea, lower limb and abdominal swelling. Description: Her jugular venous pressure (JVP) was mildly elevated and she had gross lower limb oedema. There was evidence of left pleural effusion. She had no clinical evidence of superior vena cava (SVC) syndrome, no recent hospitalization or invasive medical procedure performed on her. Contrast CT scan of the thorax revealed extensive occlusion of the superior vena cava (SVC) by a huge filling defect measuring approximately 12.4 cm 9 6.9 cm which extended to the right atrium and caused almost total occlusion of the right ventricle, and left pleural effusion. There was no pulmonary embolism and no collateral vessels visible. CT of the abdomen and pelvis revealed ascites only. She was given full dose tinzaparine for 2 weeks and repeat CT scan showed virtually no change in the size of the presumed thrombus and pleural effusion but collateral vessels were visible in the axilla and anterior chest wall. However she was considerably improved clinically with less ascites, oedema and less oxygen dependency. Warfarin was commenced. On 3-month review, she was improved with little dependence on supplementary oxygen and marked improvement in ankle oedema, but was still breathless on exertion. Conclusion: This case is unusual for the size of the apparently spontaneous SVC and right heart thrombus, the lack of coexisting pulmonary embolus and superior vena cava syndrome, and her survival with anticoagulation only.

Initial CT thorax (AP view), showing large filling defect in right atrium and ventricle.

CT thorax (lateral view) post 10 days of subcutaneous anticoagulation. Note dilated intercoastal and chest wall veins.

Audit of New Oral Anticoagulant Monitoring in a General Practice: are Patients Having Their Renal Function Checked? Flynn D1, Murphy P2 1 WNW Intern Training Network; 2General Practice, Bayview Medical Centre, Bundoran, Co. Donegal

Background: New oral anticoagulants (NOACs) are becoming a popular alternative to warfarin in the prevention of thromboembolic events in non-valvular atrial fibrillation1. The most commonly reported adverse event with these drugs is bleeding2. All NOACs are really excreted to some degree and severe renal impairment is a risk factor for bleeding events2. Thus, renal function should be monitored annually in patients prescribed these medications2. Proper dosing is based on a patient’s creatinine clearance which can be calculated using the Cockgroft–Gault Equation3. Aims: • To identify all patients in a GP practice prescribed NOACs and to measure the percentage that had annual renal function monitoring since commencing treatment. • To check if a patient’s dosing is correct as per their creatinine clearance (CrCl). Methods: Patients in the practice prescribed NOACs were identified using the population analysis function on the Health one software. Each patient’s electronic chart was investigated to see if they had annual renal function checks by the GP since commencing treatment. For each patient, creatinine clearance was calculated using the Cockgroft–Gault equation and dose of NOAC was reviewed to see if it was appropriate.

This supplement has received no external funding or sponsorship

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Results and discussion: Forty-five patients in the practice were prescribed NOACs. The percentages that had annual renal function monitoring by their GP were: Dabigatran 62.5 %, Apixaban 84.6 % and Rivaroxaban 66.7 %. In total, 71 % had the annual renal function monitoring. Out of the 45 patients it was possible to calculate creatinine clearance for 37 patients (82 %). It was not possible for 8 patients as they had no weights recorded. It was noted that many of the CrCl calculated were inaccurate, as not all creatinine and weights were measured in the same year. Of the 20 patients that were deemed to have accurate calculation of CrCl, 100 % were on the correct dose. It was not possible to confirm if the remaining 25 patients were dosed correctly. Implications: Patients prescribed NOACs should have an annual renal function check and it is possible on the Health one software to flag such patients when this is due. The patient’s weight is required to calculate creatinine clearance. It is also possible to flag patients that are due an annual weight. If these changes are implemented the dose of NOAC can be properly assessed for each patient and drug dosing errors can be avoided.

investigated with a chemistry panel and serum glucose level. One (5 %) patient had urine osmolality and sodium tested and 2 (11 %) patients had serum osmolality tested. Conclusion: The 2 months period prevalence of hyponatraemia at RCH was 35.5 %. The results reveal that certain investigation of hyponatraemia are done for the majority of patients, while others such as urine and serum osmolality are not. Although there are many explanations as to why the patient population at RCH are not fully investigated, given the high prevalence and importance of this electrolyte imbalance, we should strive to better this aspect of our care.

References: 1. Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J et al (2013) EHRA practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. Eur Heart J 34(27):2094–2106 2. St. James’s Hospital (2012) Update on oral anticoagulation therapy. National Medicines Information Centre. Report number: vol 18(6) 3. Kildea–Shine P, O’Riordan M (2014) Anticoagulation in general practice/primary care—part 2: new/novel oral anticoagulants. ICGP Quality in Practice Committee. Report number 2

Antimicrobial Use in MUH Cork: a Point Prevalence Study

The Investigation of Hyponatraemia at Roscommon County Hospital: a Clinical Audit Mewa S, O’Mara O Department of Internal Medicine/Geriatrics, Roscommon County Hospital, Athlone Road, Roscommon; NUI Galway Intern Training Network Background: Hyponatraemia occurs in up to 30 % of all in-hospital patients1. Inappropriate investigation and management can lead to increased hospital stay, morbidity, and mortality2. This audit aims to determine the prevalence of hyponatraemia at RCH and evaluate the standard of care in terms of the investigation of hypotonic hyponatraemia compared to the 2014 clinical guideline set out by the European Society of Endocrinology1. Methods: All 48 inpatients on 30/08/2014 were selected. Data collected included demographic information and whether the following investigations were performed: • Severity of hyponatraemia • Symptoms at time of diagnosis • Clinical assessment of volume status • Co-morbidities • Current medications • Chemistry panel and serum glucose level • Urine osmolality and sodium level • Serum osmolality Results: Seventeen patients (35.5 %) had hyponatraemia, most of which (76 %) were mild. The majority of patients had symptoms recorded, volume status assessed, and co-morbidities noted. Seventeen (100 %) patients had an up to date list of medications and were

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References: 1. Spasovski A, Vanholder R, Allolio B et al (2014) Clinical practice guideline on diagnosis and treatment of hyponatraemia. Eur J Endocrinol 13(1020):1–47 2. Guidelines and Audit Implementation Network (2010) Hyponatraemia in adults. GAIN, Belfast

Fitzgerald GP, Jackson A Intern Network: UCC Background: The resistance of microbes to antimicrobials is an increasingly common problem faced by clinicians1. Antimicrobial stewardship is an important tool used to combat this, aiming to improve clinical outcomes and minimise the unintended consequences of antimicrobial use2. Aims: To examine the quality of antimicrobial prescribing in MUH by means of a point prevalence study of in-patient prescriptions, and to examine trends in antimicrobial use over time comparing local to national data. To use this data to target areas for improvement, and help focus antimicrobial stewardship initiatives in the future. To examine the impact of a specialist antimicrobial order form on restricted antimicrobials. Methods: A point prevalence study of antimicrobial use was conducted. Data was collected and extracted to SPSS and Excel for analysis. Antimicrobial usage data was obtained from the Mercy University Hospital pharmacy department and the Health Protection Surveillance Centre (HPSC). This was collated and analysed using SPSS, Ms Excel and Prism Graphpad. Results: Forty-four percent of patients were receiving antimicrobials at the time of the study with a mean of 1.55 agents per patient. Of the antimicrobial prescriptions surveyed, 84 % had a documented indication and 75 % were compliant with local guidelines. There was no statistically significant difference between medical and surgical patients with respect to adherence to prescribing guidelines (p = 0.26). The impact of a specialist antimicrobial order form was mixed with a reduction in the use of Linezolid and Teicoplanin but not Meropenem. Analysis of antimicrobial consumption figures demonstrated a high level of antimicrobial use in MUH. Conclusions: The point prevalence study demonstrates areas of potential improvement for antimicrobial prescribing including clear documentation of indication and proposed duration of treatment, as well as improved compliance with local antimicrobial guidelines. The results also demonstrate that the level of antimicrobial use in the hospital is higher than the national average. References: 1. Morrissey I, Hackel M, Badal R, Bouchillon S, Hawser S, Biedenbach D (2013) A review of ten years of the study for

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 monitoring antimicrobial resistance trends (SMART) from 2002 to 2011. Pharmaceuticals 6(11):1335–1346 2. Goff DA (2011) Antimicrobial stewardship: bridging the gap between quality care and cost. Curr Opin Infect Dis 24(Suppl 1):S11–S20

An Audit to Assess Methadone Prescribing Compliance with ICGP Guidelines in a General Practice Hearne E, Hanrahan C Parnell Medical Centre, Ennis, Co. Clare; UL Intern Training Network Background: The ICGP guidelines in 2008/2011 on ‘Working with Opiate users in Community…’ recommend virology screening and vaccination for all patients engaged on a methadone program and that urine must be screened at each visit for methadone, benzodiazepines, cannabis, other opiates and codeine. Aims: Audit the proportion of patients; (1) whose virology status is known through screening and (2) whose urine is tested and at what frequency, noting the results and whether the results represent other prescribed drugs or illicitly obtained substances. Design and methods: This is a retrospective study on all patients undergoing a methadone program under the practice. None were excluded. Data was collected using ‘Health One’. Results: A total of seven patients were actively involved in the methadone program at the time of audit. Virology screening was documented for one patient (positive for Hepatitis C and negative for HIV, Hep B/A. No records included documented immunisations. Urine drug screening was used at each visit for six patients, with one patient being tested sporadically. Two tested positive exclusively for methadone. Three tested positive for benzodiazepines which was always prescribed. Three test positive regularly for cannabis. Conclusions: The fact that the GP practice does not have a record of virology status represents a potential threat at patient, public health and healthcare worker levels. We recommend that methadone patients be tested yearly and vaccinated as per the guidelines described above as soon as possible. Aim to re-audit in 6 months time to complete the audit cycle. References: Working with Opiate users in Community Based Primary Care (2011) The Irish College of General Practitioners Methadone and Buprenorphine for Managing Opioid Dependence (2007) Available on: http://www.nice.org.uk/guidance/TA114

Comparison of Use of Positive Versus Neutral Oral Contrast Agent Used with CT Enterography/ Abdomen PELVIS with Crohn’s Disease Healy L, Maher M, Murphy K Department of Radiology, University College of Cork Background: Ingested oral contrast agents aid in bowel assessment during CT abdomen and can be of low (neutral) or high (positive) density. They have variable effects on patient compliance and bowel

S253 wall distension. It is assumed that positive oral contrast increases patient radiation dose and is taken into account during protocol development. Aims: To assess whether neutral oral contrast and the associated protocols decrease CT patient radiation dose and if the oral contrast agent alters image quality. Methods: Seventy-nine contemporaneously acquired conventionaldose and low-dose clinically indicated CTs were performed on Crohn’s disease patients over a 3-year period. All patients ingested oral contrast medium (35 = positive, 44 = neutral). Manufacturer recommended scanning parameters were utilised—these were identical apart from the tube voltage (positive = 120 kV; neutral = 100 kV). Patient radiation dose [ED (estimated dose)] was calculated from CT dose reports. BMIs and scan-ranges were recorded. Image quality was objectively and subjectively analysed. Data analysis was performed with graphpad Prism. Results: Significantly higher doses were seen in the conventional neutral contrast CTs when compared to positive contrast studies (6.05 ± 2.84 vs. 4.41 ± 2.77 mSv, p \ 0.05) despite excellently correlated BMIs and scan ranges. Neutral contrast CT image quality was significantly superior in objective noise, objective signal to noise ratio, subjective spatial resolution and subjective contrast resolution assessment at all levels. Diagnostic acceptability was superior at all levels but showed significance in 3 of 5 levels. Conclusion: Lowering the tube voltage, in an assumed appropriate fashion, when neutral oral contrast is utilized increases radiation dose but results in superior image quality.

An Audit on the Investigation of Elevated Ferritin Levels in an Irish General Practice Clifford C1, Breen N2 1

Department of Orthopaedic Surgery, Connolly Hospital, Dublin 15; School of Medicine and Medical Science, University College Dublin, RCSI Intern Training Network

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Introduction: Most patients with hereditary haemochromatosis are identified from investigation of elevated serum ferritin levels by their GP1. Correct investigation is important given the poor clinical expression of the disease2. Aims: Are patients investigated correctly? Materials and methods: A retrospective clinical audit was conducted over a 4 year period (January 2010–December 2013), in an urban– rural general practice using the Health One patient management system. Data was compiled on all male and female patients with elevated serum ferritin. Patients having follow-up ferritin and transferrin saturations measured and genetic tests where indicated were recorded. Re-auditing was performed, January–October 2014. We audited investigation of elevated ferritin using ICGP Guidelines3: • Serum ferritin [300 in males and[200 in females require followup fasting ferritin and transferrin saturations measured. • Genetic testing be undertaken where serum ferritin is elevated and transferrin saturations [45 %. Results: Forty-four patients had elevated serum ferritin, 61 % male (n = 27) and 39 % (n = 17) female. 34 % (n = 15) had follow-up serum ferritin and transferrin saturations measured. Four patients had transferrin saturations[45 %, where 75 % (n = 3) had a genetic test. Re-auditing, 28 patients had elevated ferritin; 68 % (n = 19) had follow-up serum ferritin and transferrin saturations measured. Three patients had transferrin saturation [45 % and 100 % (n = 3) had a genetic test.

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S254 Conclusion: Hereditary Haemochromatosis commonly presents initially with elevated iron parameters. Elevated serum ferritin is a nonspecific marker of iron overload, therefore, transferrin saturations and serum ferritin must both be measured on follow-up1. With the implementation of guidelines re-auditing demonstrated improved management of elevated ferritin. References 1. Bacon BR, Adams PC, Kowdley KV et al. (2011) Diagnosis and management of hemochromatosis: 2011 practice guideline by the american association for the study of liver diseases. Hepatology 51(1):328–343 2. van Bokhoven MA, van Deursen CTh BM, Swinkels DW (2011) Diagnosis and management of hereditary haemochromatosis. BMJ 342:c7251 3. Nicholson A (2013) Hereditary haemochromatosis-diagnosis and management from a GP perspective. ICGP Quality in Practice Committee

Management of Involved Anterior Margins After Breast Conserving Surgery; Whether or not to Re-Excise O’Connell L, Walsh S, Cheung CX, Al Hilli Z, Rothwell J, Evoy D, Geraghty J, Quinn C, O’Doherty A, McDermott EW, Prichard R Department of Breast-Endocrine-General Surgery, St Vincent’s University Hospital, Dublin 4 Background: Whilst involved radial margins after breast conserving surgery routinely undergo re-excision, the optimum approach to the involved anterior margin (IAM) remains a topic of controversy. It has been suggested that re-excision of IAM is low yield and may only be necessary in selected patient populations1,2. Aims: To examine the management of involved anterior margins after breast conserving surgery at SVUH and to provide guidance regarding this. Methods: 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. Results: Nine-hundred and thirty patients were included over the 5 year study period. The age ranged between 29 and 94 years, with an average age of 65. 121 (13 %) of the patients had an IAM. The average age of patients with a positive IAM was 64. 37 of these 121 (30.6 %) had further re-excision of margins and 16 (13.2 %) proceeded to mastectomy. Factors influencing the decision to re-excise will be presented. Out of the total 37 who underwent re-excision 7 had residual disease. Of the 16 who underwent mastectomy 7 had residual disease. Conclusions: There is currently no consensus regarding the management of IAM. This results in significant variations in management even within a single institution with MDT-based recommendations. References 1. Mullen R, Macaskill EJ, Khalil A et al (2012) Involved anterior margins after breast conserving surgery: is re-excision required? EJSO 38:302–306 2. Gurdal SO, Karanlik H, Cabioglu N et al (2012) Positive or close margins in breast-conserving surgery: is re-excision always necessary? EJSO 38:399–406

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Demographics and Mortality in Nursing Homes of North Dublin Dunlea E, Power D Department of Medicine for the Elderly, Mater Misericordiae University Hospital, University College Dublin Background: Around 20,000 people are currently resident in long term care in Ireland1. Research on this population is sparse, with little data comparing death rates in different long term care facilities. We explored the demographics and mortality rates of a sample of nursing homes in North Dublin. Methods: A postal survey was sent to 38 nursing homes in North Dublin. The crude death rate was calculated and used for comparison between nursing homes. Results: Twelve nursing homes completed the survey, representing 642 residents. About 67 % of residents were female. The average age of residents was 80. Only 52 % of the residents were classified as independently mobile. The overall prevalence of dementia among our cohort was 54.5 % of which 39 % were classified as maximum dependency. Within nursing homes, there was a wide variation in the prevalence of dementia (range 6–83 %), and prevalence of maximum dependency (range 8–83 %). A wide variance in crude death rate between nursing homes (range 8.5–25.4 %, mean 16.2 %) was seen. The crude death rate was not correlated with the rate of dementia (R2 = 0.01), maximum dependency (R2 = 0.06). Of those that passed away in the last year, 74 % died in the nursing home while 26 % died in hospital. Conclusion: This study demonstrated a wide variability in crude mortality rates among nursing home residents, which was not explained by the presence of dementia, or the degree of dependency, Further research is required to identify the factors associated with this increased mortality. References: 1. Long Stay Activity Statistics (2012). DOH

A Cyanotic Conundrum: the Blue Man McDonnell NA, Navin P, Garrahy A, O’Regan A Department of Respiratory Medicine, University College Hospital Galway A 28-year-old gentleman presented with cyanosis since birth, mistakenly diagnosed as pulmonary atresia. There was no family history of note, specifically no history of methamoglobinaemia. Examination revealed cyanosis with an oxygen saturation of 91 % on pulse oximetry. Investigations including chest X-ray, computed topography pulmonary-angiogram and pulmonary function tests were normal. Of note, bubble echocardiogram was also normal, ruling out a diagnosis of pulmonary atresia. Room air arterial blood gas revealed pO2 12 kPa with an oxygen saturation of 97 %, demonstrating a ‘‘saturation gap’’. Methaemoglobin levels were elevated at 14 %. There were no risk factors for acquired methamoglobinaemia. Genetic testing revealed a cytochrome b5 reductase deficiency, confirming the diagnosis of congenital methaemoglobinaemia. Sequencing the CYB5R3 gene and promoter revealed a heterozygous mutation of Asp240Gly, which suggests a novel mechanism for this presentation of this homozygous methaemoglobinaemia phenotype1.

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Reference: 1. Percy MJ, Lappin TR (2008) Recessive congenital methaemoglobinaemia: cytochrome b5 reductase deficiency. Br J Haematol 141:298–308

Precipitating Factors and Management of Patients with Diabetes Mellitus Type 1 Admitted with Diabetic Ketoacidosis in a Busy Regional Hospital in Ireland Loktionov D, Ismail F, Brosnan E Department of Endocrinology, Mayo General Hospital, Castlebar Background: Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus and can potentially be prevented by education of population about its precipitating factors. Methods: The list of all patients admitted with type 1 diabetes mellitus with acidosis was provided by the HIPE reporting database. Medical notes for each patient were reviewed for relevant information. The period of assessment is between August 2013 and July 2014. Results: A total of 27 admissions: 59 % were males and 41 % females. Thirty-two percent of patients were between 15 and 25 years old. Just below 30 % of admissions were due to alcohol consumptions. 25 % of admissions were newly diagnosed patients, further 25 % patients presented due to poor compliance. Presentations due to infection constituted 18 % of admissions. Alcohol was the commonest cause of presentations in the 15–25 years old age group and second commonest in the 25–35 years old age group. Mean time of hospital stay was 5.5 days. HBA1c was taken only in 30 % of patients on admissions while mean HBA1c value was 87.8 mmol/mol. Blood cultures were taken in about 40 % of patients. Conclusions: Alcohol is a major modifiable risk factor for DKA in this study compare to other studies. Young population has a higher tendency to present due to alcohol consumption. Moreover the audit shows that there are lapses in the investigation and management of DKA. Appropriate education of the population in the community can significantly reduce number of admissions with DKA in diabetic patients.

Benzodiazepine Prescribing Practices in General Medical Patients as Compared to Psychiatric Patients in a Hospital Setting: an Audit McGettigan N, Costello S, Mannion L Department of Psychiatry, University Hospital Galway; Department of Medicine, University Hospital Galway; NUI Galway Intern Teaching Network Background: Benzodiazepines are commonly prescribed, the vast majority for their anxiolytic and hypnotic effects despite being well known to cause side effects such as cognitive impairment, drowsiness, falls and development of tolerance and dependence. Aims: To investigate the practice of Benzodiazepine prescribing in medical patients as compared to psychiatric patients in the hospital setting and to compare the practice to the NICE Guidelines.

S255 Methods: A retrospective audit was conducted on two medical wards and two psychiatric wards over the period of a week in December 2014. The information was extracted from the drug kardex of the patients involved in the study. Inclusion criteria comprised of those who were prescribed a Benzodiazepine during admission and patients were aged between 18 and 90 years. Results: Eighty-eight people were eligible for inclusion in the study sample. 62.5 % (n = 55) medical patients and 37.5 % (n = 33) psychiatric patients. Eighteen percent of medical patients had been prescribed a benzodiazepine as compared to 79 % of psychiatric patients. In 100 % of medical patients there was no indication for the prescription of a benzodiazepine documented in the drug kardex compared to 94 % of psychiatric patients who did not have an indication documented. In all cases, both medical and psychiatric, there was no documented review date in the drug kardex. Furthermore, 70 % of medical patients were prescribed a short-acting Benzodiazepine increasing the risk of withdrawal. Conclusions: This study demonstrated a limited rate of compliance with NICE guidelines on both medical and psychiatric wards. This highlights the need for improved documentation when prescribing benzodiazepines to improve patient care and safety. We will be distributing hardcopies of guidelines to both the medical and psychiatric wards to increase awareness amongst NCHDs to promote improved adherence with guidelines. We plan to re-audit in 6 months time. References: National Institute for Clinical Excellence. Generalised anxiety disorder in adults: management in primary, secondary and community care. National Clinical Guidance 113. http://www.nice. org.uk. Updated Jan 2011 O’Sullivan GH et al (1994) Safety and side-effects of alprazolam. Controlled study in agoraphobia with panic disorder. Br J Psychiatry; 165:79–86

Clinical Audit on Cases of Lymphoma and Multiple Myeloma Diagnosed by Histopathology Kilmartin DM1, Kilgallen C2, Parfrey N2 1

Department of Medicine, Sligo Regional Hospital, The Mall, Sligo; Department of Pathology, Sligo Regional Hospital, The Mall, Sligo

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Background: Diagnosis of lymphoma is made primarily through tissue biopsy prompted by presentation of symptoms. Incidence of the disease is increasing steadily in Ireland1. Diagnosis of multiple myeloma should be confirmed by assessing patient bone marrow2. International comparisons of incidence rates for multiple myeloma have been recently recorded, with significantly higher levels among males in Ireland compared to the EU, Canada and UK3. Aims: Review case numbers of lymphoma and multiple myeloma diagnosed by histopathologists between January 2004 and December 2011 in Sligo Regional Hospital (SRH). Stratify cases across several categories. Compare practice to existing guidelines2,3. Methods: This audit was carried out retrospectively from CoPath patient data. 322 confirmed cases of lymphoma and multiple myeloma were stratified across 16 parameters. Results: Results of the study were outlined in seven main sections; demographics, case numbers, lymphoma analysis, turnaround time, immunohistochemistry, biopsy type and FNAs.

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S256 Of 319 biopsies performed, 16 (5 %) were needle cores, 16 (5 %) were FNAs, 152 (47.6 %) were tissue excisions, and 135 (42.3 %) were bone marrow biopsies. 235 cases (74.7 %) were lymphoma - the remaining 84 (26.3 %) were multiple myeloma. Conclusions: Over the 8-year period numbers of multiple myeloma diagnosed by histopathologists at SRH have remained stable. There has been an increase in cases of lymphoma over the 8 years by 50 %, in line with national projections over the next decade3. References: 1. Guidelines on the diagnosis and treatment of malignant lymphomas, Lymphoma Forum of Ireland (2010) 2. Guidelines on the diagnosis and management of multiple myeloma (2010) 3. National Cancer Registry of Ireland

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 References: Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA (2013) Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit. Care Med 41:580–637 HSE (2011) National early warning score patient observation chart Miller J (2014) Surviving sepsis: a review of the latest guidelines. Nursing (Lond.) 44:24–31

Emergent Transcatheter Aortic Valve Implantation: Utility or Futility?

The Vital Dynamics of Sepsis: a Case of Considering Sepsis Regardless of Source or Setting of the Patient

Martin WP, Makki H, Sharif F, Crowle J, Da Costa M, Veerasingham D, Mylotte D

White DA

Department of Cardiology, University Hospital Galway, Galway

Emergency Department, University Hospital Limerick, Limerick, UL Intern Training Network

Introduction: Transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement for patients with severe aortic stenosis at high or excessive surgical risk1. There exist, however, a cohort of elderly frail patients that are too high-risk even for TAVI. It can be difficult, however, to determine in whom TAVI will be futile, and in whom it will be lifesaving2. Case presentation: We describe a case of a 90-year-old female with critical aortic stenosis (mean gradient 65 mmHg, aortic valve area 0.33 cm2). The patient had previously undergone several aortic valve balloon valvuloplasties, rendering the valve severely incompetent. The patient presented with flash pulmonary oedema that initially responded to intravenous diuretics. Recurrent episodes of pulmonary oedema refractory to medical stabilisation necessitated emergent aortic valve intervention. Despite the patient’s critical clinical status, transfemoral TAVI was performed via the left common femoral artery as a salvage procedure. Crossing of the stenotic aortic valve resulted in haemodynamic collapse with severe mitral valve incompetence, biventricular failure, and ultimately pulseless electrical activity. A 26 mm CoreValve (Medtronic) was rapidly implanted and cardiopulmonary resuscitation initiated. Spontaneous return of circulation and a rapid improvement in haemodynamics were subsequently observed. The patient recovered well in the coronary care unit and was discharged home 5 days later. She remains well 3 months post-TAVI. Conclusion: Life expectancy in medically managed critical aortic stenosis is disappointingly poor3. TAVI offers a valid therapeutic strategy in high risk elderly aortic stenosis patients, including those at extreme risk.

Summary: A 65-year-old man presented to the accident and emergency department of a large general hospital with tonsillitis. While he waited to be seen, his condition deteriorated such that he converted into atrial fibrillation. He was subsequently treated for sepsis. Case presentation: A 65-year-old man was admitted to the emergency department of a regional hospital at 13.00 complaining of a painful sore throat, generalised aches and pains, dry mouth, fever/ chills, anorexia and insomnia. He had a 2 week history of similar symptoms and had been treated with two courses of antibiotics in the community. Initial examination showed a heart rate of 90 bpm, blood pressure of 151/91 mmHg and temperature of 38.4 C. An hour later, subsequent examination revealed a heart rate of 150 bpm with an irregular rhythm, blood pressure of 148/88 mmHg and a temperature of 39.2 C and a respiratory rate of 22 breaths per minute. Treatment: The patient was brought to resus for medical cardioversion using 2 doses of IV metoprolol. An IV bolus was commenced and IV co-amoxiclav was started empirically. At the same time all the relevant investigations for sepsis were sent (full blood count, blood cultures, chest xray, lactate). The patient was admitted for treatment of the underlying infection (glandular fever/ EBV) and for telemetry. Discussion: As junior doctors, it is incumbent upon us to recognise sepsis early and commence treatment accordingly in order to avoid severe sepsis or in the worst case scenario, septic shock. The criteria for sepsis have been made into a binary algorithm, so that an objective assessment of sepsis can be made quickly and the ‘‘Sepsis Six’’ (HSE 2011) can be carried out efficiently on the basis of this assessment. Due to surveillance on the wards, regular observation of patients’ vital signs means we hear about any worrying deviations quickly and are contacted immediately in order to react in a timely manner. In the emergency room setting however, a sick patient who may initially appear vitally well, may deteriorate in the interval between observation times or while waiting to be seen. It is important therefore to never be complacent about admitting a patient who appears unwell, even though an objective assessment of their vital signs is not alarming.

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References: 1. Smith CR, Leon MB, Mack MJ et al (2011) Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 364(23):2187–2198. 2. Vahanian A, Alfieri O, Al-Attar N et al (2008) Transcatheter aortic valve implantation for patients with aortic stenosis: a position statement from the European Association of CardioThoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 29(11):1463-1470

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 3. Vahanian A, Alfieri O, Andreotti F, et al (2012) Guidelines on the management of valvular heart disease (version 2012): the joint task force on the management of valvular heart disease of the european society of cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg 42(4):S1–S44.

Cardiac Device-Related Complications: Retrospective Analysis of One Hundred Patients Martin WP, Cuddy S, Smyth YM Department of Cardiology, University Hospital Galway, Galway Background: Cardiac devices represent an important development in the field of cardiovascular medicine and are a mainstay of contemporary practice1. However, these devices carry a significant burden of complications, rates of which vary hugely in the literature2, 3. Only with precise knowledge of local complication rates can we accurately advise our patients with regard to their use. Methods: We retrospectively analysed one hundred device-related procedures occurring in the cardiac catheterisation laboratory from January to April 2014. We determined the type of device and indication for the procedure from the cardiac technicians’ records, and gained information regarding any complications from the hospital laboratory, radiology, and echocardiogram record systems, discharge letters, and outpatient clinic letters. Results: Of the 100 procedures performed during this period, 76 were pacemakers (42 single lead pacemakers, 34 dual lead pacemakers), 7 implantable cardioverter defibrillators (ICDs) (5 single lead, 2 dual lead), 7 cardiac resynchronisation devices (CRTs) (1 CRT-P, 6 CRT-D), and 10 loop recorders. 13 (13 %) of these procedures were performed due to a device-related complication: 9 lead revisions, 3 for device-related infections (2 explants for lead endocarditis, 1 device reimplant after the original had been explanted for lead endocarditis), and 1 device required repositioning for subclavian vein occlusion. A further two device implants were complicated by pneumothoraces, one requiring chest drain insertion while the other was managed conservatively. Conclusions: Over one in ten device-related procedures were performed for device-related complications. Prospective study is necessary to accurately define local complication rates and counsel patients regarding device use. References: 1. Brignole M, Auricchio A, Baron-Esquivias G et al (2013) 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J 34(29):2281–2329 2. Udo EO, Zuithoff NP, van Hemel NM et al (2012) Incidence and predictors of short- and long-term complications in pacemaker therapy: the FOLLOWPACE study. Heart Rhythm 9:728–735 3. Kirkfeldt RE, Johansen JB, Nohr EA, Jørgensen OD, Nielsen JC (2014) Complications after cardiac implantable electronic device

S257 implantations: an analysis of a complete, nationwide cohort in Denmark. Eur Heart J 35(18):1186–1189

Vitamin A Deficiency: Prevalence and Clinical Implications for Adult Cystic Fibrosis Power BD, Harrison MJ, McCarthy M, Shortt C, Murphy DM, Plant BJ Cork Adult Cystic Fibrosis Centre, Cork University Hospital/ University College Cork, Ireland Introduction: Vitamin A deficiency (VAD) has been described in cystic fibrosis (CF)1. A Cochrane Review (2012) suggested that there was insufficient data to draw any conclusions about the benefits of vitamin A supplementation in CF2. To date, only one paediatric case report has addressed VAD in an Irish CF population3. Aims: To determine the prevalence and clinical implications of VAD in Irish adult patients with CF. Materials and method: This quantitative study was a combination of a retrospective medical record review from January 2010 to December 2012, and a cross-sectional questionnaire-based study of adult CF patients. Results: One hundred patients were included. In 2012, 8 % (n = 8) were VAD (serum retinol \0.7 lmol/L) and 17 % (n = 17) were insufficient in vitamin A (serum retinol 0.7–1.05 lmol/L). In 2011 and 2010, 8 % (n = 8) and 9 % (n = 9) were VAD respectively. There was no association between VAD and zinc deficiency, liver disease, retinol-binding protein deficiency or markers of CF clinical phenotype. Eighty-three percent (n = 83) were on multi-vitamin supplementation, including vitamin A. The questionnaire response rate was 51 % (n = 51); none of these were VAD. 23.5 % (n = 12) reported ocular symptoms; of those, three patients were insufficient in vitamin A. 5.9 % (n = 3) reported night blindness. 17.64 % (n = 9) had mild/moderate conjunctival xerosis. Discussion and conclusions: The prevalence of VAD in Irish adult CF patients is low when compared to international studies4,5 . This validates the role of multi-disciplinary teams and designated CF centres in Ireland. Three of the twelve patients reporting ocular symptoms were insufficient in vitamin A. Based on ocular questionnaire results to date, there is no clear relationship between ocular symptoms and VAD in CF. References: 1. Anderson OH (1939) Cystic fibrosis of the pancreas, vitamin A deficiency, and bronchiectasis. J Pediatr 15:763–767 2. Bonifant CM, Shevill E, Chang AB (2012) Vitamin A supplementation for cystic fibrosis. Cochrane Database Syst Rev 3. Roddy MF et al (2011) Night blindness in a teenager with Cystic Fibrosis. Nutr Clin Pract 26(6):718–721 4. Feranchak AP, Sontag MK, Wagener JS, Hammond KB, Accurso FJ, Sokol RJ (1999) Prospective, long term study of fat-soluble vitamin status in children with cystic fibrosis identified by newborn screen. J Pediatr 135(5):601–610 5. Sokol RJ, Reardon MC, Accurso FJ, Abman SH (1989) Fatsoluble-vitamin Status during the first year of life in infants with cystic fibrosis identified by screening of newborns. Am J Clin Nutr 50:1064–1071

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MRI Imaging of the Pre-pubic Aponeurosis O’Brien AC, MacMahon P, Eustace S, Kavanagh E Department of Radiology, Mater Misericordiae University Hospital, Dublin 7, Ireland Background and aims: MRI is an essential tool in the work up of groin pain, or athletica pubalgia. There are reproducible MRI findings. The differential diagnosis is broad due to variations of pathology and multiple confounders. Diagnosis can be difficult to establish due to complex interconnected anatomy. Imaging is crucial in reaching the correct diagnosis and thus allowing appropriate therapy to be instituted. Methods: Anatomy of the pre-pubic aponeurotic complex is reviewed using both diagrams and MRI images. Examples of pathology include: isolated adductor syndromes, osteitis pubis, and pre-pubic aponeurotic complex tears. These are explained and demonstrated with relevant MRI imaging findings. Results and conclusion: This poster will review the relevant anatomy, differential diagnosis, and important imaging findings encountered in the work up of athletica pubalgia, with a specific focus on the pre-pubic aponeurosis. References: MacMahon P, Hodnett P, Koulouris G, Eustace S, Kavanagh E (2010) Hip and groin pain: radiological assessment. Open Sports Med J 4:108–120 Kavanagh EC, Koulouris G, Ford S, MacMahon P, Johnson C, Eustace SJ (2006) MR Imaging of groin pain in the athlete. Musculoskelet Radiol 10:197–207 Cunningham PM, Brennan D, O’Connell M, MacMahon P, O’Neill P, Eustace S (2007) Patterns of bone and soft tissue injury at the symphysis pubis in soccer players: observations at MRI. AJR Am Roentgenol 188:W291–W296

The Embolic Implanon O’Brien AC, O’Reilly M, Sugrue G, Farrelly C, Lawler L Department of Interventional Radiology, Mater Misericordiae University Hospital, Eccles St, Dublin 7 Introduction: IMPLANON is a hormone-releasing birth control implant used to prevent pregnancy for up to 3 years. The implant is a non-biodegradable plastic rod (4 cm long 9 2 mm wide) that contains a progestin hormone called etonogestrel. Description/case presentation: A 23-year-old female presented to the Emergency Department with dyspnoea. A chest radiograph identified a left pneumothorax and a linear opacity in the left lower lung zone. CT thorax confirmed a 4 cm radiopaque foreign body within a segmental branch of the left lower lobe pulmonary artery. Endovascular retrieval was attempted via selective catheterization of the left lower pulmonary artery using a Gooseneck Loop snare. Despite several attempts, it was clear from the catheter and wire approach that the device was endothelized/fibrosed and fixed within the wall of the pulmonary artery.

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 This case suggests that unless recognized acutely, it is unlikely such devices can be removed endovascularly. Should they be secured with a snare, subsequent removal would risk tearing adjacent vasculature. This is consistent with the fact that Implanon is designed to endothelialise in tissue to stay in place. References: Patel A, Shetty D, Hollings N, Dodds N (2014) Contraceptive implant embolism into the pulmonary artery. Ann Thorac Surg 97:1452 Ismail H, Mansour D, Singh M (2006) Migration of implanon. J Fam Plann Reprod Health Care 32(3):157–159 Carroll MI, Ahanchi SS, Kim JH, Panneton JM (2013) Endovascular foreign body retrieval. J Vasc Surg 57(2):459–463

Blunt and Sharp Laryngeal Trauma Keane G, Khoo SG Department of Otolaryngology, St Vincent’s University Hospital, UCD training network Introduction: Laryngeal trauma is a rare presentation, with an incidence of only 1 in 30,000 ED patients1. Primarily, this is due to the extensive anatomical protection that the area is afforded. It can be broadly divided into blunt and sharp trauma, with blunt far more common. RTAs are the most frequent cause2. Description/case presentation: We present two recent cases of laryngeal trauma, one blunt and one sharp. Patient A, a 16-year-old male, presented with hoarseness and dysphagia following a knee to his throat in a soccer match. Patient B, a 30-year-old male, presented with multiple lacerations to his throat, chest and wrists following a suicide attempt. Patient A was stable and underwent direct visualisation of the larynx via nasal fibreoptic laryngoscopy, which revealed a haematoma of the left vocal cord. Conservative management saw him recover well in 6 weeks. Patient B was unstable and had severed his trachea, thus allowing emergency personnel to secure his airway quickly and concentrate on his other injuries. He was transferred to theatre for a formal tracheotomy and neck exploration. The patient recovered very well and is attending psychiatry. Laryngeal trauma, though rare, is life-threatening and demands immediate action. Early recognition of visceral, neural or vascular injuries is vital. If the patient is in respiratory distress and/or unstable, a cricothyroidotomy in the ED under local anaesthetic may be performed, followed by neck exploration in theatre3. Surgical intervention may be unnecessary; if the patient is stable, conservative management may be sufficient. References: 1. Jewett BS, Shockley WW, Rutledge R (1999) External laryngeal trauma analysis of 392 patients. Arch Otolaryngol Head Neck Surg 125(8):877–880 2. Verschueren et al (2006) Management of laryngo-tracheal injuries associated with craniomaxillofacial trauma. J Oral and Maxillofacial Surg 64(2):203–214 3. Bent JP III, Silver JR, Porubsky ES (1993) Acute laryngeal trauma: a review of 77 patients. Otolaryngol Head Neck Surg 109(3 Pt 1):441–449

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A Complicated Colonic Conundrum in a Set of Young ‘Irish Twins’ Fenelon C, Balasubramanian I, Mohan H, Schmidt K Department of Surgery, Wexford General Hospital, Wexford, Ireland Background: Diverticular disease is a common disease in the elderly1 but rare in those under thirty. This case report describes two young sisters diagnosed with complex diverticular disease. Case: Sister A, a 26-year-old with a BMI of 40 was referred by her GP with abdominal pain, intermittent diarrhoea and weight loss of [30 kg over 1 year. A pelvic ultrasound showed a large cystic area, and subsequent MRI and CT showed a grossly abnormal sigmoid colon with multiple localised colonic perforations with pericolic abscess formation and considerable thickening of the adjacent urinary bladder. Diagnostic aspiration of the pericolic abscess was complicated by the development of an enterocutaneous fistula. An en bloc resection of the rectosigmoid and adjacent adherent ileum and left ovary was performed, with good post-operative recovery. Two months later, Sister B, a 27-year-old, with BMI of 36 presented to the Emergency Department with a 3 days history of intermittent left iliac fossa pain associated with vomiting and diarrhoea. An abdominal and pelvic CT scan showed complicated sigmoid diverticulitis and paracolic abscess formation. Pockets of intravesical air were also identified with a possible colovesical fistula as the most probable cause as no recent catheterisation had taken place. She was managed conservatively to date. Discussion: This case series highlights the complexity of diverticular disease in young patients. Diverticular disease is not well-defined as a hereditary disease, but recent studies have shown a familial tendency, with siblings of index cases three times more likely to develop diverticular disease1,2. References: 1. Granlund J, Svensson T, Hjern F et al (2012) The genetic influence on diverticular disease: a twin study. Alim Pharmacol Ther 35:1103–1107 2. Strate L, Erichsen R, Baron JA, Mortensen et al (2013) Heritability and familial aggregation of diverticular disease: a population based study of twins and siblings. Gastroenterology 144:736–742

Central Cord Syndrome Without Boney Injury in a Gaelic Football Player with Resolving Neurology Treacy T, Jadaan M Department of Orthopaedics, Galway University Hospital Introduction: Central cord syndrome is an acute incomplete cervical spinal cord injury first described by Schneider in 19541. It is marked by a greater involvement of the motor component of upper limbs than lower limbs. It can involve sensory disturbances below the affected level with various degrees of bladder dysfunction. Incomplete spinal cord injury is perceived to be a disorder predominantly involving the elderly population as a result of hyperextension injury with resultant spinal cord compression2. However it has become apparent that it is a diverse syndrome encompassing a multitude of injuries3.

S259 Case presentation: We present the case of a 34-year-old man who developed a central cord syndrome after playing a gaelic football match. This player describes sustaining a tackle whereby he received a direct blow to his forehead from a shoulder. This resulted in a hyperextension injury to his neck and him falling forcefully onto the ground on his back. Immediately he described being unable to move bilateral arms with weakness as well as a burning pain in both arms right side worse than left. He regained power in his left upper limb after 2 h. The sensory disturbance of burning pain with paraesthesiae in C4–C7 distribution persisted over the next 5 days but slowly began to resolve. His right upper limb had persistent burning radicular pain in again C5–C7 distribution with power 4/5 (MRC grading) which resolved on the day he sought medical attention. He sought the attention of the team physiotherapist after 5 days of symptoms who promptly referred him for assessment with an MRI after consulting the local physician. Initial MRI was performed 3 days prior to orthopaedic review. Repeat imaging with plain film, CT and MRI was performed upon our assessment. An ASIA score was performed upon review and no motor deficit was elicited for the upper or lower limbs. Sensory level at C5 was elicited with a score of 106/112 for light touch and pin prick sensation in the right upper limb and 108/112 for the left upper limb. His initial MRI demonstrated congenital canal stenosis with spinal cord compression at C4,C5, C5,C6 and C6,C7. Given the continued improvement in symptoms the decision was taken to treat this patient non operatively after discussion with multiple spine consultants. He was treated conservatively with a Miami J collar and will undergo surveillance with repeat MRIs at short intervals. Discussion: Central cord syndrome (CCS) commonly occurs after a hyperextension injury in a person with long standing spondylosis. It can also occur in the setting of congenital canal stenosis as demonstrated in this case study. CCS is treated conservatively for the most part with surgery indicated only when there is gross spinal instability, progression of neurological deficits or progression of spinal cord compression. References: 1. Schneider RC, Cherry G, Pantek H (1954) The syndrome of acute central cervical spinal cord injury, with special reference to the mechanisms involved in hyperextension injuries of cervical spine. J Neurosurg 11:546–577 2. Harrop JS et al Central cord injury: pathophysiology, management, and outcomes. Spine J 6(6):S198–S206 3. Scher AT (1983) Hyperextension trauma in the elderly: an easily overlooked spinal injury. J Trauma Injury Infection Crit Care 23:1066–1068

Tuberculous Abscess of the Cervical Spine: a Rare but Important Diagnosis Berney M, Timlin M Mater Misericordiae University Hospital, Dublin 7 Cervical spinal tuberculosis is a rare presentation of extra-pulmonary TB disease1. We present the interesting case of a former meat worker from Botswana, who was admitted to a tertiary referral hospital with axial neck pain and progressive symptoms and signs of cervical myelopathy. Radiological investigations of his cervical spine demonstrated a retropharyngeal collection with subluxation of the

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S260 C1–C2 vertebrae and secondary stenosis of the upper cervical canal. Biopsy of the lesion showed caseating material with acid-fast bacilli, consistent with a diagnosis of spinal TB. Drainage of the caseous material within the spinal canal and in the retropharyngeal space was performed via a posterior approach. Due to the instability between C1 and C2 vertebral bodies, these vertebrae were fused posteriorly with instrumentation. The patient’s neurological symptoms resolved following surgical intervention and he was continued on his antituberculous medical treatment. Follow-up at 6 months revealed solid fusion of the vertebrae with no residual neurological or systemic symptoms. This is an interesting case as cervical spinal TB is a rare cause of neck pain and neurological symptoms in the developed world, however it must be included in the differential for neck pain, particularly in patients who have lived in a country where TB is endemic. This is also the first reported case of posterior decompression of a retropharyngeal tubercular abscess with subsequent instrumented stabilisation2,3. References: 1. Moon MS (1997) Tuberculosis of the spine. Controversies and a new challenge. Spine (Phila Pa 1976) 22(15):1791–1797 2. Shukla D, Mongia S, Devi BI, Chandramouli BA, Das BS (2005) Management of craniovertebral junction tuberculosis. Surg Neurol 63(2):101–106 3. Sinha S, Singh AK, Gupta V, Singh D, Takayasu M, Yoshida J (2003) Surgical Management and outcomes of tuberculous atlantoaxial dislocation: a 15-year experience. Neurosurgery 52(2):331–338

An Audit of Intra-Articular Injections Record Keeping at the North Western Rheumatology Unit Aljorfi A1, Whelan B1,2, Silke C1 1

Northwestern Rheumatology Unit, Our Lady’s Hospital, Manorhamilton, Co. Leitrim; 2National University of Ireland, Galway Objectives: The aim of this survey is to assess the compliance of clinical notes in regards to intra-articular injections with the HSE guidelines. Design/methods: Using the HSE recommendation of record keeping, a gold standard was developed within the department. In order to attain the gold standard the clinical notes should include the name, approach, technique, immediate complications of the procedure and the type of information provided to the patient. It should, also include the consent and medication details. Based on the defined gold standard a review of all intra-articular injections from January 2014 to April 2014 was conducted. Records were identified based on a prospective log of all procedures performed in the Rheumatology Day Ward in OLHM. Results: • In 72 % of procedures the type was specified. • In 32 % of procedures the approach was mentioned. • In 72 % of procedures immediate complications were mentioned. • In 32 % of procedures the technique was specified. • In 1 % of procedures the consent was mentioned. • In 87 % of procedures the medication regimen was detailed. • In 41 % of procedures the notes mentioned providing information to the patient regarding the procedure and its complications. • The maximum criteria attained were 5. Conclusions: The results demonstrate that record keeping of intraarticular injections is sub-standard in various aspects. In addition,

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 there is a huge variation in the way that clinical notes are written and recorded. This is most likely due to the lack of a unifying standard regarding clinical notes of intra-articular injections.

Does the Use of Loupe Magnification Reduce Incomplete Excision Rates of Facial Basal Cell Carcinomas? Duggan DA, Joyce KM, Dorairaj JJ, Kelly JL Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway Background: Loupe magnification is used by surgeons to improve identification of skin lesion margins. Aims: The objective of this study was to compare the use of loupe magnification with normal vision for facial basal cell carcinoma (BCC) excisions at our institution. Methods: A retrospective analysis was carried out on BCCs excised by a single surgeon under local anaesthetic over a 3-year period from November 2011 to November 2014. Facial BCC anatomical location, histological subtype, incomplete excision rate, closure method and use of loupes were noted. Results: A total of 381 facial BCCs were excised, with 89 excisions performed using loupe magnification and 292 carried out without its use. The overall incomplete excision rate was 3.1 %. Of the total excisions performed using loupes, 91 % required a local flap or skin graft compared to 19.5 % of excisions without loupes. Loupe magnification was found to be associated with a higher incomplete excision rate compared to without its use (4.5 vs 2.7 %). Conclusions: Our results highlight the low incomplete excision rate of BCCs. Positive excision margins are most likely to occur with BCCs involving the eyelids and nose or those requiring closure with local flaps or skin grafts. This study demonstrates that loupe magnification is not routinely required for facial BCC excisions.

An Audit Assessing the Number of Post-Menopausal Women with Osteoporosis on Pharmacological Therapy for Secondary Prevention of Fragility Fractures in a Rehab Unit Reynolds C1,3, Keating E1,2, Power D2 Acute Rehab Unit, Cappagh National Orthopaedic Hospital; 2Mater Misericordiae Hospital; 3St.Vincents Hospital 1

Objectives: 1. Assessing secondary preventative pharmacological therapy in post-menopausal women with osteoporosis post fracture. 2. To identify those not on pharmacological therapy and treat accordingly. 3. Assessing the appropriateness of therapy in those on bone protection and to assess the interventions made to this therapy post fracture occurrence. Design/methods: The design was a retrospective observational study. A population of 40 post-menopausal patients post fracture attending the ARU between September to November 2014 were identified and their medication reviewed. All patients were transferred from an acute

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 hospital prior to attending CNOH. Data was collected from patient charts and kardexes and stored on Excel. Results: (1) On admission only 43 % of patients were on pharmacological therapy (35 % Bisphosphonates, 8 % Denosumab) and this had only improved to 70 % at time of audit (35 % Bisphosphonates, 35 % Denosumab). (2) 57 % of patients admitted to the ARU were on no targeted bone protection treatment despite transfer from an acute hospital. At the time of audit this had only reduced to 30 %, highlighting need for further intervention. (3) Multiple deficiencies were identified in patient pharmacological therapy. For example 20 % of patients admitted to the ARU had fractured on bisphosphonates representing treatment failure however their therapy had not been adjusted. Conclusions: This audit highlights a significant discrepancy between 2014 NICE guidelines and current practice placing patients at increased risk of future fracture. This demonstrates failures in both acute hospitals and the ARU to amend patient therapy. Post audit several interventions have been made to rectify these discrepancies.

Audit of Perioperative Fasting in Elective Surgery Mac Donncha C, O’Dea J Department of Anaesthesia, University Hospital Limerick Objectives: This audit aims to evaluate the current adherence of the Department of Anaesthesia, UHL to the European Society of Anaesthesiology Guidelines on Perioperative fasting in adults and children, Eur J Anaesthesiol 2011, to identify any barriers to compliance and any actions required to improve compliance with standard. Design/methods: This will be a concurrent audit of perioperative documents where patient notes will be examined for information regarding fasting status as per routine perioperative assessment, including duration of fast and category of last oral intake, i.e. Clear fluids vs. Milk vs. Solid meal. Pre-operative BMI, Diabetes, GORD and Pregnancy Status will be surveyed where available as these patients fall into the category of delayed gastric emptying as per the ESA. Guideline document. Surgery type i.e. elective vs. emergency will be documented. This information will then be compared to the specific guidelines for each intake type e.g. Minimum fast of C2 h for clear fluids (Water, Non Pulp Juice, Black Tea and Black Coffee), C4 h breast milk, C6 h for all solids (and formula milk). Once compared, any identified barriers to compliance with the guidelines will be assessed and communication of results will be conveyed to appropriate cohort. Should significant information emerge that patients are not fasting adequately or excessive fasting is taking place, information regarding guidelines will be communicated to appropriate parties and re-audit will take place to assess for quality improvement progress following appropriate practice changes. Results: Data collection is ongoing for this audit, at present n = 32 aiming for a final cohort of n = 50+. Initial results show that of the total, 100 % are meeting the minimum fasting times as per guideline, with an average fast time of 13.5 h for all documented intake. Conclusions: Initial conclusions suggest good compliance with European Society of Anaesthesiology Guidelines, although there is an argument to be made that patients are being excessively fasted in preparation for elective surgery. References: Perioperative fasting in Adults and Children (2011) European Society of Anaesthesiology Guidelines. Eur J Anesthesiol

S261 Pre-operative Assessment and Patient Preparation (2010) The role of the anaesthetist 2’’, Appendix 1, Association of Anaesthetists of Great Britain and Ireland Guideline

Documentation of Medication Changes in Medical Discharge Summaries Gleeson M, Griffin L Mid- West Intern Training Network, UHL, Dooradoyle, Limerick Objectives: To identify current levels of compliance with the HIQA guideline; to identify barriers to compliance; to implement quality improvement as required; to re-audit to assess the impact of any quality improvements initiated. Aim: Many medical patients admitted to hospital have changes made to their regular medications during the course of their in-patient treatment. There are specific HIQA guidelines (see reference) as to how these changes should be documented in the patient’s discharge summary. The aim of this audit is to achieve 100 % compliance with these guidelines in daily practice. Design/methods: All medical discharge letters generated from patients discharged in a 2 week period in a specific ward were examined to see what medications the patient was discharged on, and if these differ from medication on admission, to see whether a reason for the change is documented. Results: Medical discharge letters were examined for twenty-four patients discharged during a 2 week period; of these three letters had no medication documented at all; nineteen of the patients had had changes made to their regular medication and of these nineteen, nine had no reason for the change in medication documented. Conclusions: There is poor compliance with the HIQA guidelines for discharge summaries in relation to documenting the reasons for changes in regular medication. Approximately half of the patients who had changes made to their regular medication had no clear explanation for this change documented on their medical discharge letter. References: 1. HIQA (2013) National Standard for Patient Discharge Summary Information

An Audit on the Time Interval from Diagnosis of Wet Age-Related Macular Degeneration (ARMD) to Treatment Initiation with Anti-VEGF Intravitreal Injections McCloskey C, Horgan N Department of Ophthalmology, St Vincent’s Hospital, UCD Intern Network Objectives: Assess interval from diagnosis to treatment of wet ARMD, with recommended standard of care. The Royal College of Ophthalmologists (RCOphth) initially recommended a time interval of 6 weeks. With increasing pressures to deliver treatment sooner, recently published guidelines recommend 2 weeks1. Method: Patients who attended for intravitreal injections during October 2013 were documented from an Attendance Record. Viewing

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S262 medical records and excluding diagnoses other than ARMD, the remaining sample size was 32. Working retrospectively from date of first injection, date of diagnosis was determined and time interval calculated. Results: In reference to the original guidelines (6 weeks), 28 (87.5 %) patients received the recommended standard of care and 4 (12.5 %) patients fell outside this advised time interval. The sample of patients on whom this audit was based, involved injections administered between 2010 and 2013. Conclusions: Twenty-eight (87.5 %) patients met the recommended standard of care according to the guidelines at the time. New guidelines published in September 2013, recommend a period of 2 weeks from diagnosis and even propose administering the first antiVEGF injection on first presentation2. Applying the data from this audit to these guidelines shows that 14 (44 %) patients received intravitreal injections within the recommended time period while 18 (56 %) patients did not.

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 (QPSD-D-006-3). The objective of this audit was to assess the implementation of this recommendation on a general surgical ward in Midlands Regional Hospital at Portlaoise. Methods: Every patient’s Drug kardex from the Surgical ward in Portlaoise hospital was gathered on 25/11/2014. Every medication prescribed was analysed to assess if it was prescribed using a Trade Name or generic name/appropriate trade name. Appropriate trade names include medicines such as anti-epileptics, lithium and long action medications. After this research, each surgical doctor was orally advised to try and prescribe generically. One week later the kardexes on the ward were re-analysed. Results: On 25/11/14 52.5 % of the medicines were prescribed in their generic form (142 of 270 prescriptions). The follow up data that was taken 1 week after verbally advising the doctors to prescribe generically showed that 48.3 % of the medications were prescribed generically (120 of 248 prescriptions). Conclusion: This audit shows low level of generic prescribing. No improvement was seen 1 week after verbal advise was given to the surgical NCHDs demonstrating a resistance to change of practice. Generic prescribing should be encouraged to improve safe prescribing and reduce costs. Despite HSE recommendations and verbal advice, there is still a reluctance to prescribe generically. Other options should be explored to promote generic prescribing and the issue re-audited.

Non-detected Primary Lung Cancers on Chest X-Ray: 3 Year Retrospective Review in University Hospital Barry C, Bergin D Recommendations: With increasing evidence showing delays in treatment can dramatically reduce visual outcomes,3 ensure all staff in the Ophthalmology Department are familiar with the new guidelines. Aim to schedule patients for their first treatment injection as soon as possible from date of diagnosis. Following this, a re-audit in 12 months to assess progress since September 2013. References: 1. Age-Related Macular Degeneration (2013) Guidelines for Management. Royal College of Ophthalmologists, London. http:// www.rcophth.ac.uk/page.asp?section=451§ionTitle=Clinical+Gu idelines. Accessed 24 Nov 2014, p 71 2. Age-Related Macular Degeneration (2013) Guidelines for Management. Royal College of Ophthalmologists, London. http:// www.rcophth.ac.uk/page.asp?section=451§ionTitle=Clinical+Gui delines. Accessed 24 Nov 2014, pp 106–108 3. Arias L (2009) Delay in treating age-related macular degeneration in Spain is associated with progressive vision loss. Eye 23:326–333

Improving Generic Prescribing Practices on a General Surgical Ward in November 2014 Daly S General Surgical Unit, Midlands Regional Hospital, Portlaoise, Co. Laois, UCD Background: The Health Service Executive has advised ‘‘where possible and appropriate only generic names are used for medication records.’’ This was recommended in the ‘‘Standards and Recommended Practices for Healthcare Records (HCR)’’ in May 2011

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Department of Radiology, Galway University Hospital, Galway Background: In a literature review the percentage of non-detected lung cancer is in the region of 10–24 % (1). This study is to investigate the percentage of lung cancer not detected on chest X-ray in the last 3 years. Methods: Data was collected from the Rapid Access Lung clinic database from January 2012 to September 2014. Patient’s date of histological diagnosis was noted and chest X-ray reports 1 year prior to that date were analyzed. All X-rays were single view studies. Only primary lung cancer was included in the study. Chest X-rays performed after CT thorax were excluded. Patients who had a chest X-ray within 1 year prior to diagnosis were divided into four categories based on the radiologists report: 1. Identified as malignant 2. Identified as indeterminate—follow up 3. Identified as indeterminate—no follow up 4. Lesion not identified All data was collated using Microsoft excel. Results: Two-hundred and sixty-six patients were histologically diagnosed with primary lung cancer, 158 (59.4 %) had a chest X-ray reported within 1 year prior to diagnosis. Of these 158, 52 (32.9 %) were identified as malignant, 74 (46.8 %) were indeterminate advising follow up, 9 (5.7 %) were indeterminate without advising follow up and in 23 (14.5 %) the lesion was not identified. Conclusions: This study showed that 14.5 % of primary lung cancer in 158 patients was not detected on chest X-ray within 1 year prior to receiving a histological diagnosis. This is in line with published literature of rates between 10 and 24 %1. Reference: 1. Stapley S, Sharp D, Hamilton W (2006) Negative chest X-rays in primary care patients with lung cancer. Br J Gen Pract 56(529):570-573. Epub 2006/08/03

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A Cross Sectional Audit of Venous Thromboembolism (VTE) Prophylaxis in Cancer Patients in the Mater Hospital ´ inle F Angelov D, Nı´ A Department of Haematology, Mater Misericordiae University Hospital, UCD Intern Training Network Introduction: Patients with cancer have a 5–6 fold increased risk of venous thromboembolism (VTE) compared to patients without cancer1,2. Aims: To audit the rate of prescribing VTE prophylaxis in a tertiary referral centre for malignant disease. Materials and methods: The medication prescription chart of 24 inpatients on the oncology/haematology ward in the Mater Hospital were audited for the prescription of thromboembolic deterrent (TED) stockings and/or low molecular weight heparin (LMWH). A risk assessment was carried out on each patient by performing a chart survey of reason for admission and current medical status as well as a bleeding risk assessment based on a chart survey along with platelet count and estimated GFR. All patients with C1 VTE risk factor in conjunction with active malignancy qualify for LMWH prophylaxis. Results: Twenty-four patients were audited on 1 day (42 % male, 58 % female). The most common cancer type was non-Hodgkin’s lymphoma (16.7 %). The median age of inpatients was 72. The median number of VTE risk factors was 3 (range 1–4). The number of patients qualifying for LMWH prophylaxis was 22 (88 %), while the number of these patients who were prescribed LMWH was 13 (59.1 %). One patient was prescribed an inappropriate dose of LMWH. Conclusion: 40.9 % Of in-patients with malignant disease who qualify for pharmacological VTE prophylaxis were not receiving LMWH. Our aim is to implement a VTE risk assessment tool and prescriber’s guide, produced by a Consultant Haematologist in conjunction with the pharmacy department, and to reassess this audit in 3 months’ time. References: 1. Geerts WH, Berggvist D, Pineo GF et al (2008) Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). American College of Chest Physicians. Chest 133(6 Suppl): 381S–453S 2. Falanga A, Russo L, Verzeroli C (2013) Mechanisms of thrombosis in cancer. Thromb Res 131(Suppl 1):S59–S62

Visualisation of the Anterolateral Ligament on MRI Barry C1, Hurley R2, Shannon F2, Bergin D1 1

Department of Radiology, Galway University Hospital, Galway; Department of Orthopaedics Galway University Hospital, Galway

2

Background: Few studies have been carried out on the assessment of the anterolateral ligament in the knee using MRI. The literature is lacking in this area. The goal of this study was to identify the ligament on MRI images. Methods: Data was collected using the PACs imaging system in Galway University Hospital. All right knee MRIs were performed on a Siemens Magnetom Espree 1.5 T scanner. Studies in the last 4 years

S263 and with a date of birth from 1970 onwards were collected. Reports were analysed and completely normal MRI’s were collated. Ten randomly selected normal images were viewed by a consultant radiologist. Measurements on origin, insertion, course and length were noted. All data was collected using Microsoft Excel and analysed using Minitab. Results: One-thousand, seven-hundred and thirty two right knee MRI’s were performed. 62 were categorized as normal. 10 were randomly selected. In all 10 images the ligament could be visualised, 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 mm. The mid thickness was 1.87 ± 0.2 mm. Conclusions: This study demonstrated the presence of the anterolateral ligament of the knee on magnetic resonance imaging. With this information, in future studies we can correlate the status of the anterolateral ligament in association with other ligamentous and soft tissue injuries.

Effective Dose Reduction for Non-contrast CT Thorax Using Adaptive Iterative Dose Reduction (AIDR) 3D and Ultra-low Milliampere Second Techniques Angelov D, Salati U, Kok T, Buckley O Department of Radiology, Tallaght Hospital, UCD Intern Training Network Introduction: The national lung screening trial (NSLT), a randomised controlled trial which recruited 53,456 participants, demonstrated a 20 % relative reduction in lung cancer mortality in patients screened annually for 3 years, with low dose CT compared with conventional chest radiography1. Aims: To audit the effective dose exposure to patients undergoing non-contrast CT thorax using fixed peak kilo-voltage (kVp) at 120 with variable milli-ampere second (mAs) and differing reconstruction algorithm including adaptive iterative dose reduction (AIDR) 3D. Materials and methods: Seventy-five patients underwent standard non-contrast CT thorax on two different CT scanners. The effective dose was calculated using a conversion factor for thoracic CT of 0.014. 28 patients underwent CT thorax with the AquilionTM CXL 64-row detector using 120 kVp with tube-current modulated mAs. 28 patients underwent CT thorax with the AquilionTM PRIME 80-row detector with AIDR 3D. Ultra-low dose non-contrast CT thorax was subsequently acquired with 120 kVp and a fixed ultra-low mAs of 3 with AIDR 3D. Results: The mean effective doses for standard CT thorax, CT thorax with AIDR 3D, and CT thorax with AIDR 3D and 3 mAs were 7.9 ± 6.10, 2.53 ± 1.84 and 0.12 ± 0.01 mSv respectively. One way ANOVA showed a significant difference between the mean effective doses of each technique (F value = 32.72, p \ 0.001). Conclusions: The utilization of AIDR 3D and ultra-low dose milliampere second with AIDR 3D allows significantly reduced effective radiation doses, by a factor of 3, for patients undergoing non-contrast CT thorax. Using a fixed ultra-low mAs of 3 with AIDR 3D the effective dose is similar to a frontal and lateral chest radiograph. The effective dose reduction with ultra-low mAs and AIDR 3D may allow safer CTbased lung cancer screening programs to be undertaken in the future. Reference: 1. Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, Gareen IF, Gatsonis C, Marcus PM, Sicks JD (2011) National lung screening trial research team. Reduced

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S264 lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365(5):395–409

Olmesartan Induced Duodenitis as a Cause of Villous Atrophy Prendergast C, Egan L UCHG Intern Network: West/Northwest Olmesartan is an angiotensin receptor blocker which has been used to manage hypertension since 2002. The link between olmesartan and a dudodenitis was first described in 2012, and should be considered as a possible cause in refractory coeliac disease. We present the case of a 62-year-old female admitted with a 6 week history of generalized abdominal pain and weight loss with severe watery diarrhoea. Background of hypertension treated with olmesartan once daily. The patient had previously been diagnosed with coeliac disease on the basis of OGD which showed villous atrophy, and had been compliant with a gluten free diet for over 1 year. Admitting CRP was 3.3. Stool cultures were negative. Initial impression was of refractory coeliac disease. Patient was commenced on budesonide 9 mg with partial improvement in diarrhoea, but abdominal pain and bloating persisted. MRI small bowel follow through performed, showed loss of small bowel folds in keeping with coeliac disease. Sigmoidoscopy performed, normal. OGD performed, D2 biopsies taken, showed blunting of villi and focal inflammation with increased eosinophils. Findings were not consistent with coeliac disease. Patient had olmesartan dose held as a possible cause of villous atrophy, and abdominal pain and bloating were partially resolved. Olmesartan is an increasingly popular choice of antihypertensive in Ireland, which has a relatively high population suffering from coeliac disease. This case illustrates a newly-described adverse effect related to this drug, and the importance of a thorough workup in patients with refractory diarrhoeal illness.

Hypoxic Ischaemic Encephalopathy and Perinatal Asphyxia: Outcomes at 24–42 Months Ring E´, Murray D Paediatric Department, Cork University Maternity Hospital; UCC Intern Training Network Introduction: Perinatal asphyxia (PA) occurs in 20 per 1,000 births, three of which go on to develop hypoxic ischaemic encephalopathy (HIE). Outcomes in HIE are well documented but not in PA. There is little consensus as to the impact of HIE and PA on long-term development and behaviour in affected babies. Aim: To assess behavioural and developmental outcomes at 24–42 months in babies with perinatal asphyxia and hypoxic ischaemic encephalopathy compared with matched controls. Methods: Prospective case–control study of babies born in Cork University Maternity Hospital recruited over 2 years. Babies with at least 1 of the following markers of HIE were included: Apgar score \6 at 5 min, pH \ 7.1, requiring intubation or CPR at birth. Controls were recruited from the BASELINE study and matched for gender, gestational age and birth weight. Parents were sent 2 validated

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 questionnaires at 24–42 months, The ages and stages questionnaire (ASQ) and the child behavioural checklist (CBCL). Results: One-hundred and seven babies initially recruited. Seven died and 69 were included. The ASQ did not detect any delayed development in those with HIE. HIE cases scored higher with regards to internalising behaviour (p = 0.039) and pervasive developmental problems (p = 0.046) on the Diagnostic Statistical Manual Scale of the CBCL compared to controls. The PA group scored higher in the Personal-Social area of the ASQ compared to controls (p = 0.040). Conclusion: The ASQ is not an adequate screening tool for those with perinatal hypoxic insults. Babies with hypoxic ischaemic encephalopathy have an increased occurrence of behavioural issues. References: Van Handel M, Swaab H, de Vries LS, Jongmans MJ (2007) Longterm cognitive and behavioral consequences of neonatal encephalopathy following perinatal asphyxia: a review. Eur J Paediatr 166(7):645–654 Robertson C, Finer N, Grace M (1989) School Performance of survivors of neonatal encephalopathy associated with brain asphyxia at term. J Paediatr 114(5):753-760

Frank Jaundice, a Rare Presentation of Ebstein Barr Virus Lillis Y, Doherty G Gastroenterology Department, St. Vincent’s University Hospital; UCD intern Network Introduction: Infectious mononucleosis (IM) caused by Epstein barr virus (EBV) usually presents in young adults and is generally a self limiting disease. Clinically, most patients with IM present with the triad of fever, sore throat and adenopathy. Whilst biochemical evidence of hepatocellular damage is often found in patients presenting with EBV, an associated hyperbilirubinaemia is a rare complication. Description: A 32-year-old gentleman was admitted from the outpatient inflammatory bowel disease clinic with 5 day history of jaundice, sore throat and fatigue. His background history was notable for Crohn’s disease, on maintenance treatment with Azathioprine. On examination the patient had scleral icterus and was clinically jaundiced. He also had palpable splenomegaly, 2 cm below the costal margin. Haemological investigation showed hyperbilirubinaemia at 83 lmol/L, and both raised transaminases (ALT 146) and a cholestatic picture, Alk phos 262 lmol/L and GGT 135 U/L. Hb was 9.4 and MCV 92 with no evidence of haemolysis. WCC 14.5 and CRP 69.1. On admission a full screen for viral, immune and metabolic markers of liver disease was sent. Liver ultrasound was performed due to the myriad of causes of jaundice, particularly in a patient with a known diagnosis of Crohn’s disease. This showed moderate splenomegaly, and of note no evidence of biliary dilatation. Haematological investigation proved conclusive with a positive Infectious Monospot test and EBV VCA IgM and IgG positive. The patient was treated symptomatically on the ward and was discharged 5 days later. His Azathioprine was on hold throughout admission and was restarted once transaminases normalised 2 weeks later. Discussion: EBV is usually a self limiting condition. This case illustrates that immunosuppression, especially thiopurines like azathioprine, can alter the way acute EBV presents as they can prevent an

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S265 Hypercholesterolaemia of the European Atherosclerosis Society. Eur Heart J 35(32):2146–2157. Epub 2014/07/24

adequate T and B cells response. Therefore, they allow a greater cumulative viral burden with greater chance of significant end-organ disease. References: Edoute Y, Baruch Y, Lachter J et al (1998) Severe cholestatic jaundice induced by Epstein-Barr virus infection in the elderly. J Gastroenterol Hepatol 13:821–824 J Infect Dev Ctries 2010; 4(10):668-673 Kofteridis DP et al (2011) Eur J Intern Med 22:73–76 Vine LJ, Shepherd K, Hunter JG, Madden R, Thornton C, Ellis V, Bendall RP, Dalton HR (2012) Characteristics of Epstein-Barr virus hepatitis among patients with jaundice or acute hepatitis. Aliment Pharmacol Ther 36(1):16–21. doi:10.1111/j.1365-2036. 2012.05122.x. Epub 2012 May 3 Ocal Sirmatel, Fatma Simatel, Fatma Nur Eris, Tekin Karsligil (2010) The cases of cholestatic hepatitis in the course of atypical Epstein-barr virus infection. Res J Med Sci 4:136–141 Murad G, Shaheen R, Farah R, Assy N (2009) Severe acute cholestatic hepatitis with encephalitis induced by Epstein-Barr virus infection

Severe Autosomal Recessive Hyperlipidaemia Due to Mutations in the ARH Gene McCarthy E, Halleran C, Dwyer C, Vaughan C Cardiology Department, Mercy University Hospital, Cork; South Intern network Introduction: Autosomal recessive hypercholesterolaemia (ARH) is a rare genetic cause of elevated low density lipoprotein cholesterol (LDL-C) typically presenting before age 30 with extremely high LDLC, xanthoma formation and premature atherosclerosis. Mutations in the ARH gene on chromosome 1p35 cause the disorder. This gene encodes the LDLRAP1 protein, which is an endocytic sorting adaptor protein that promotes normal internalisation of the LDL receptor1. Case: We present a 29-year-old lady, who was initially diagnosed in Germany at age three with multiple tuberous xanthomas and a LDL-C of 14 mmol/L. Genetic analysis of her family identified homozygosity for a nonsense mutation in codon 136 in ARH gene. She was managed initially with LDL-C apheresis that led to resolution of xanthomata and substantial reduction in LDL-C. She has been in Ireland now for 18 months. Despite maximum dose statins and ezetimibe her lipids remain alarmingly high (LDL-C of 12). In addition, she has demonstrated mixed aortic valve disease and non obstructive coronary artery disease. In December 2014 she became the first patient in Ireland to commence lomitapide, an oral inhibitor of the microsomal triglyceride transport protein. This compound interferes with assembly of apo B-containing lipoproteins. Future additional novel therapeutic options for resistant hypercholesterolaemia may include PCSK9 inhibitors. Conclusion: We present a case of severe dyslipidaemia in a young woman with a very rare molecular genetic disorder who became the first patient in Ireland to be started on a novel cholesterol lowering medication. We discuss the mechanism of lomitapide and future therapeutic options. Reference: 1. Cuchel M, Bruckert E, Ginsberg HN et al (2014) Homozygous familial hypercholesterolaemia: new insights and guidance for clinicians to improve detection and clinical management. A position paper from the Consensus Panel on Familial

Emergency Surgical Procedures Performed in the Plastic Surgery Procedures Unit at Galway University Hospital Rahmani G1, Dorairaj J1, Regan P1,2 1

Department of Plastic Surgery, University Hospital Galway; National University of Ireland, Galway

2

Introduction: The plastic surgery procedures unit (PSP) was founded in Galway University Hospital in 2012. It is a small, self-contained minor operating theatre where hundreds of minor elective procedures are performed under local anaesthetic each month. Although predominantly elective in nature, the PSP is also occasionally used as an emergency theatre for minor operations. This helps reduce the burden placed on already busy emergency operating theatres. In this study, we looked at all emergency procedures performed in the PSP over a 6-month-period. Methods: All patients who presented to the PSP for a procedure via the emergency department over a 6-month-period were included in this study. Data was collected including baseline demographics, the type of injury sustained and the type of procedure performed. The data was then analysed using SPSS 20. Results: From January 1st 2014 to June 30th 2014 inclusive, 238 emergency procedures were performed in the PSP. The majority of patients were male (72 %) and the mean age was 41 years. The most common procedure performed was repair of a finger/fingertip laceration (50.8 %). Conclusion: The PSP is a useful resource, in both an elective and emergency capacity. With an average of 1.31 emergency procedures performed there every day it has helped reduce the need for theatre time in the major emergency theatres. This is a model that carries an initial setup cost but it is one that could potentially be successfully implemented in all centres with a plastic surgery department.

A Serendipitous Case of Vomiting Rahmani G, McNicholl B Emergency Department, University Hospital Galway Background: Vomiting is a frequent presenting complaint to any emergency department (ED). This is an unusual case in which a serendipitous episode of vomiting whilst attending the ED led to the diagnosis and prompt management of a potentially life-threatening condition. Case: A 56-year-old lady presented to the ED with a left ankle inversion injury. Her history included hypertension, hypercholesterolaemia, and a 30-pack year smoking history. On arrival to the ED the patient was asymptomatic. Approximately 30 min later the emergency department intern came to examine her ankle. During the examination, the patient began to complain of severe nausea and proceeded to vomit. Her radial pulse was slow, weak and thready. The vital signs were promptly measured: blood pressure 74/45 mmHg, heart rate 45 BPM; the rest of her vitals were in the acceptable range. An electrocardiogram (ECG) was performed demonstrating ST-elevation in leads II, III and aVF with reciprocal ST-depression in V1–

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S266 V3. A diagnosis of inferior ST-elevation myocardial infarction (MI) was made and the patient was given a bolus of fluid, an antiemetic and commenced on loading doses of aspirin and ticagrelor in preparation for emergency percutaneous coronary intervention. Learning Outcomes: Inferior MI classically presents with chest pain, vomiting and hypotension due to diaphragmatic irritation and sudden right-sided heart failure. They also have a propensity for lethal arrhythmias due to frequent compromise of the sino-atrial node. In cases of sudden onset nausea and vomiting, even in the absence of chest pain, one should have a low threshold for performing an ECG.

The Use of Delayed Prescribing in Primary Care: a Questionnaire Study of General Practitioners Prendergast S1, Bradley C2 St. Vincent’s University Hospital; 2University College Cork

1

Background: The prescription of antibiotics for what is often selflimiting illness constitutes a significant public health issue in Ireland. Compared with immediate prescribing, delayed prescribing reduces antibiotic consumption amongst patients in the primary care setting, therefore reducing costs and unnecessary side effects, and combating growing bacterial resistance. Aims and methods: To investigate: (1) the frequency with which delayed prescriptions are used in General Practice (2) the reasons why Doctors either use or do not use delayed prescribing (3) to determine what other medications this method is used for. A cross-sectional study was carried out, with a self-designed questionnaire, with qualitative and quantitative elements, distributed by post to General Practitioners in Munster. Results: One-hundred and twenty-seven questionnaires were distributed, with a 61 % response rate. Seventy-eight percent of General Practitioners that responded provide a delayed prescription at least once a week, with their most common motivation being to compromise with a patient who expects an antibiotic. The most common barrier to delayed prescribing is the fact that it can place a burden of clinical decision making on the patient. Twenty-two percent indicated they seldom or never use delayed prescriptions. Twenty-two percent respondents administer delayed scripts for other medications, including steroids and anxiolytics. Conclusion: Delayed prescriptions are utilised on a regular basis by the majority of Doctors who responded in this study, although a significant proportion do not use them at all. The doctor-patient relationship is a significant influence on their usage. Although delayed prescriptions for antibiotics can be recommended in certain situations, they are being used to prescribe other classes of medications, which warrants further investigation.

A Re-audit on the Appropriate use and Documentation of Urinary Catheters in University Hospital Limerick O’Driscoll N1, Doody K2, Griffin L1 1 Mid West Intern Training Network; 2Department of Anaesthetics, University Hospital Limerick, Dooradoyle, Limerick

Background: Urinary catheters are associated with a number of potential complications and thus should only be used when necessary and removed as soon as possible. The appropriate use of urinary

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 catheter insertion and documentation in University Hospital Limerick (UHL) was audited in 2014. Forty-three percent of documented reasons for catheterisation were inappropriate and 53 % of patients had no indications documented. Objectives: Assess appropriate indications and documentation as recommended by HSE/health protection surveillance centre (HPSC)1 for urinary catheterisation for patients on all wards in UHL. Assess the correct documentation of catheter insertion as per the National intern training programme (NITP). Determine if practice has improved in the past year. Methods: All wards with male patients at University Hospital Limerick excluding the ICU/HDU/CCU were included in the audit. For every male patient with a catheter in situ the medical notes were checked to see if: 1. The indication for urinary catheter insertion was documented 2. Details of the procedure were documented as recommended by HPSC and NITP. Results: Of the 152 patients included in the audit, 17 (11 %) had urinary catheters in situ. Four (24 %) patients with urinary catheters had no documentation regarding their catheter. Nine (52 %) patients had no indication documented and 4 (24 %) had indications documented. Of those with indications documented, all catheters were appropriately inserted. Conclusions: Documentation regarding the indication for insertion of urinary catheters and also documentation of the procedure itself is grossly inadequate. In comparison with the audit of 2014, no significant improvement has been achieved. Recommendations include an emphasis on correct documentation at intern induction training. As recommended after last year’s audit a standard checklist inserted into the medical notes would standardize documentation, ensure the indication is documented and also make it easier for teams to find in the notes retrospectively. Reference: 1. HSE Health Protection Surveillance Centre (2011) Guidelines for the prevention of catheter-associated urinary tract infection [internet]; 2011 [cited 2015 Jan 3]. Available from: http://www. hpsc.ie/hpsc/A-Z/MicrobiologyAntimicrobialResistance/Infection ControlandHAI/Guidelines/File,12913,en.pdf

Streamlining Patient Discharge in Day Case Surgery Using the PADSS (Post Anaesthetic Discharge Scoring System) Sheeran R, O’Malley E, Moloney B, Collins CG Department of Surgery, Portiuncula General Hospital Background: Patient discharge following surgery is usually at the surgeon’s discretion. In an effort to reduce patient discharge times and increase patient satisfaction we looked at the impact NLD (nurse led discharge) using the PADSS would have in a day case surgery setting. This scoring system empowers nurses, encourages teamwork and allows for safe successful patient discharge. Methods: A prospective assessment of patients discharged between January 2013 and June 2014 was carried out. The patients were assessed medically by the surgical team and on three occasions by the nursing staff using the PADSS. We compared decisions to discharge and admit patients looking at PADSS scores and highest EWS (early warning score). Phone follow up was carried out 48 h post discharge. Results: A review of 128 consecutive day case procedures was performed. 85.2 % (n = 109) of patients were successfully discharged and 14.8 % (n = 19) stayed overnight. No patient was discharged with a PADSS score of less than 9. Procedures requiring admission

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 included laparoscopic cholecystectomy (13 of 45) and hernia (inguinal & 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 complications were elicited with the 48 h telephone follow up. Conclusion: In a day case surgery setting we compared the outcomes of NLD using PADSS to EWS assessment as methods of discharge suitability. When used in conjunction with medical assessment, NLD using PADSS allows nurses to confidently and safely discharge those patient meeting the criteria. EWS did not prove an accurate indicator of discharge suitability.

Dexas and Extras: Audit of Adherence to the SVUH Hip Fracture Protocol McCloskey C, O’Doherty R, Owens S, van der Kamp S, Hurson C, McKenna M Department of Orthopaedic Surgery and DXA Unit, St. Vincent’s University Hospital, Dublin Background: As part of our participation in the Irish Hip Fracture Database a Hip Fracture Bone Protection Protocol was established in July 2014. This protocol was designed to identify all patients with low trauma hip fractures, carry out relevant investigations, and institute treatment in order to prevent future fragility fractures. The aim of this audit was to assess the adherence to this new protocol. Methods: Patients who met the criteria were expected to have blood tests (calcium, phosphate, alkaline phosphatase, 25-hydroxyvitamin D and parathyroid hormone), a DXA scan requested, and to be discharged home on both calcium/vitamin D supplements and an antiosteoporosis medication. Patients fulfilling the protocol criteria were documented into a logbook post-operatively. DXA referrals were then requested on discharge for these patients. Correlating these referrals with the logbook it was possible to obtain patient demographics, fracture classification, relevant laboratory results and the medications prescribed on discharge. This data was recorded on a spreadsheet. Results: Patients were audited over a 3-month-period. The sample size was 39 (31 females, 8 males). Laboratory results were available for calcium (95 %), phosphate (95 %), alkaline phosphatase (97 %), 25 OHD (92 %), and parathyroid hormone (92 %). On discharge, calcium/vitamin D supplements were prescribed for 95 %, and bone medication for 92 % (either Alendronate or Denosumab). Conclusions: In conclusion, over the first 3 months since initiation of the protocol there was excellent overall adherence to the protocol resulting in a green risk rating across all components. Going forward we recommend that the audit be completed every quarter.

A Rapidly Progressive Subdural Empyema in a 12-Year-Old Boy Ronan V, Linnane B, O’Mahony E University Hospital Limerick, Intern Network: Mid-West Introduction: While sinusitis is a common complaint the intracranial suppurative complications are rare and challenging both diagnostically

S267 and therapeutically. We present a case of a 12-year-old boy with a subdural empyema with a delay in diagnosis and a rapid deterioration. Description/case presentation: A 12-year-old boy presented to the Emergency Department with a progressively worsening 2 weeks history of malaise and frontal headache. On admission he reported new emesis, lethargy, subjective feeling of weakness in the lower limbs and difficulty finding words. His head and neck exam showed only tenderness over frontal sinuses and dry mucus membranes. Neurological exam revealed a dysdiadochokinesia on the right, unsteady gait with right sided limp but normal tone, power and reflexes throughout. Four hours after admission his mother reported he seemed to be dazed and not understanding speech. Laboratory findings showed neutrophilic leukocytosis and elevated CRP, aciclovir and cefotaxime were commenced. Initial CT brain reported no tumor, abscess or bleed, but noted left frontal sinusitis. Eight hours after admission he began to deteriorate and displayed right buccinator weakness, right hemiparesis with up going plantar, expressive aphasia and developed partial status epilepticus. Due to the deterioration, initial scan was reviewed and signs of cerebral edema were reported. CT brain with contrast showed a left subdural empyema, left cerebral edema and queried a left sagittal sinus thrombus. He was given IV dexamethasone and transfer to Our Lady’s Children’s Hospital, Crumlin was arranged. Craniotomy was performed and the patient recovered well with deficits improving drastically. Subdural empyema is a neurosurgical emergency and although rare, presents most often in adolescents as a complication of bacterial sinusitis1. Subdural empyema can be rapidly progressive causing increased intracranial pressure, coma and death if not diagnosed and treated in a timely manner2,3. The rapid progression of subdural empyema in this case highlights the importance of a timely diagnosis and therapy. As such although not common when faced with a patient with focal neurological signs and history of sinusitis, subdural empyema should remain high on the list of differentials References: 1. David I. Bruner, Lanny Littlejohn, Amy Pritchard DO (2012) Subdural empyema presenting with seizure, confusion, and focal weakness. West J Emerg Med 13(6):509–551 2. Adame N, Hedlund G, Byington CL (2005) Sinogenic intracranial empyema in children. Pediatrics 116:e461–e467 3. Waseem M, Khan S, Bomann S (2008) Subdural empyema complicating sinusitis. J Emerg Med 35(3):277–281

One Lucky Guy: a Case of Axillary Artery Transection with Preserved Brachial Plexus Function Maguire SC, Kavanagh E, Abdulrahim EO Department of Vascular Surgery, University Hospital Limerick A large 50-year-old gentleman was brought in by ambulance following discovery by members of An Garda Sı´ocha´na. Severely intoxicated, with a Glasgow Coma Score of 14, he could indicate little more than pain and reluctance to move his right arm. There was no apparent head injury clinically or radiologically. Power varied 2–4/5 on the right with notably cool skin and a prolonged capillary refill time. He maintained full passive range of motion. There was evidence of blunt trauma to his right chest wall. Pulses distal to the right subclavian artery were absent. He was brought to theatre where he underwent an emergency repair of his ischaemic limb. 700 ml was evacuated from a chest wall/ axillary haematoma, and axillary artery transection was discovered. Proximal control was achieved through a subclavian incision and

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S268 distal embolectomy was performed. A right subclavian to axillary arterial bypass was fashioned using reversed saphenous vein. Following a short stay in ICU, he was brought back to the ward, recovered quickly, responded well to physiotherapy, and was discharged home less than 3 weeks following admission. At 2 weeks follow-up he had regained most neurological functional of his arm, though any lasting damage will not be evident for several months. Buried deep within the upper limb, transection of this major artery is rare. Avoiding injury to the brachial plexus surrounding it is even more so. Rapid intervention by an experienced vascular team fortunately resulted in minimal residual impairment or iatrogenic injury. Unfortunately his relationship with alcohol will take longer to resolve.

Paradoxical Embolism in a 29-Year-Old Patient with Tetralogy of Fallot and Multi Drug Resistant Tuberculosis Kinahan C, Hennessy T Department of Cardiology, Midwestern Regional Hospital Limerick; Intern network: Midwest We present a patient Mr DL, a 29-year-old male Haitian national with a background history of unrepaired Tetralogy of Fallot being treated for multidrug resistant tuberculosis whose hospital course was complicated by an acute onset of right-sided weakness, right facial droop, and speech difficulty. On examination he was found to have no movement of the right upper extremity, minimal movement in the right lower extremity, a visual field deficit, and unintelligible speech. CT Angiography revealed occlusion of the M1 segment of the middle cerebral artery and an aneurysm involving the right internal carotid artery. Differential diagnoses for this event include paradoxical embolic stroke, hyperviscosity secondary to polycythemia, tuberculous meningitis, miliary tuberculosis, and aneurysmal disease. DL was treated within the 3-h window for tPA therapy with no significant improvement. Further investigations revealed venous thrombosis in the left upper extremity at the site of his PICC line, suggesting a venous thromboembolic event with a right-left cardiac shunt. This case represents an insight into the high level of care required adults with complex congenital heart disease and highlights the need for appropriate thromboprophylaxis in all hospitalized patients. DL was independently mobile prior to his event but non-compliant with his prescribed low molecular-weight heparin. He had no known risk factors for venous thromboembolism and no individual or family history of clotting abnormalities. Management of this patient involved administration of tPA immediately followed by intensive management in the Neuro-ICU. Upon transfer back to the primary medical team management was focused on neurological rehabilitation, continued antituberculosis treatment, and appropriate anticoagulation.

Lack of Preparedness for Internship: What are the Difficulties Identified by Interns After Their First Week of Night Duty and What Do They Think are the Solutions? Russell S, O’Dea A, Curran C, Byrne D Intern Network: West North West Background: Interns are often the first doctors called to manage acutely unwell patients. However, there is evidence that they are ill-

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 prepared for this role1. In December 2014, The Medical Council’s ‘‘Your Training Counts’ Report showed that 3-in-10 interns felt that their previous medical education and training did not prepare them well for internship2. Methods: Semi-structured interviews were conducted with 11 interns following their first night shift rotation. An interview guide with open ended questions was used to elicit respondent’s experiences of role, task, workload, preparedness, and teamwork. Efforts were made to identify areas of difficulty and beliefs about how such difficulties could be mitigated. Interview transcripts were analysed thematically using an inductive approach3. Results: Thematic analysis of interview data identified four main areas of difficulty: teamwork, workload management, technical skills, and personal limitations awareness. Specifically, difficulties identified were: interns’ ability to manage the requests for help from other team members, their ability to ascertain critical information in order to prioritise patients, competency in performing routine technical skills, confidence in prescribing medications, and managing the effects of fatigue and stress. Conclusions: Many interns believe they are not adequately prepared for their role at the beginning of internship. They call for more on-thejob and simulation based training prior to taking an independent role in caring for acutely unwell patients. Additional training is required in the following areas: procedural tasks and prescribing as well as the ability to ascertain critical information that allows for more efficient prioritisation and management of workloads. References: 1. Tallentire VR, Smith SE, Skinner J, Cameron HS (2012) The preparedness of UK graduates in acute care: a systematic literature review. Postgrad Med J 88(1041):365-371 2. The Medical Council of Ireland. http://www.medicalcouncil.ie/N ews-and-Publications/Reports/Your-Training-Counts-.html 3. Braun V, Clarke V (2006) Using thematic analysis in psychology. Qual Res Psychol 3(2):83

Effectiveness of Direct Current Cardioversion at Maintaining Sinus Rhythm in Patients with Atrial Fibrillation or Atrial Flutter Who Have Never Been Electrically or Medically Cardioverted Previously Dunne K, Smyth Y University hospital Galway; Intern Network: West-Northwest (Saolta) Background: Electrical cardioversion is a common procedure utilised by practitioners in an attempt to return the heart to sinus rhythm and although it is a relatively safe procedure, as with all procedures it is not without risk. This risk must therefore be outweighed by the benefit of this procedure restoring and maintaining sinus rhythm. Methods: Firstly I selected 20 patients who underwent their first cardioversion in 2014 from the CCU records. Then I split them into four separate groups based on their age with: group 1 ranging from 60 to 64 years old Group 2 from 65 to 59 years old Group 3 from 70 to 74 years old Group 4 from 75 to 80 years old. Next I reviewed all of the patients follow up electrocardiograms which are done at routine outpatient appointments to see which patients maintained sinus rhythm and how many weeks they maintained it.

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Results: In all age groups direct current cardioversion (DCCV) proved very effective initially at converting the patients to sinus rhythm as 90 % (18/20) were successfully cardioverted with 85 % (17/20) of patients requiring only one shock. None of the patients were on any anti-arrhythmic medications pre procedure. Out of the 18 patients that were initially successfully cardioverted at their first follow up outpatient appointment 55 % (10/18) maintained sinus rhythm. Out of these 10 patients 5 had no further outpatient follow up at the time of writing the audit but the other 5 had all maintained sinus rhythm at their second review. Only 2 of the remaining 5 patients in sinus rhythm had a third follow up electrocardiogram and unfortunately both patients had reverted to atrial fibrillation. Conclusions: While electrical cardioversion is very successful to begin with only 55 % of patients were still in sinus rhythm at their first follow up which was on average 8 weeks post direct current cardioversion (ranging from 2 weeks post DCCV to 18 weeks and 5 days post DCCV). Although only 2 of the initial 18 successfully cardioverted had been seen for their third outpatient follow up electrocardiogram which was on average 39 weeks 6 days post DCCV neither had maintained sinus rhythm.

Stigma Towards Psychiatry and Psychiatrists Amongst the Medical Profession in a Rural Irish General Hospital McGrath T, Langan C Department of Medicine, Mayo General Hospital, Castlebar, Co. Mayo Background: The stigma attached to mental illness has been welldocumented1. Psychiatric patients encounter significant stigma not only from the general public but also members of the medical profession2. Psychiatrists themselves are also affected by this stigma, although little research exists in this field3. Aim: We aimed to investigate attitudes and perceptions held by doctors working in general hospital specialities toward psychiatry and psychiatrists. Methods: We distributed a locally-developed questionnaire to doctors attending medical, surgical and psychiatric grand rounds in the hospital. Forty-seven doctors participated, 13 of whom were psychiatrists. The survey included questions that investigated attitudes toward psychiatry and psychiatrists, satisfaction with local psychiatric services and extent of past exposure to psychiatry. Psychiatrists were asked questions that investigated any stigma they had received from peers. Results: 84.6 % Of psychiatrists reported experiencing stigma from peers, resulting in 30.7 % feeling ashamed of their speciality, while 23 % had considered changing speciality. Psychiatrists who had trained in countries outside of Europe reported experiencing higher levels of stigma. Negative attitudes towards psychiatry were expressed amongst both psychiatrists and non-psychiatrists. 15.3 % of psychiatrists reported psychiatry as less scientifically valid than other medical specialities, compared with 11.7 % of non-psychiatrists. Forty-four percent of non-psychiatrists expressed negative attitudes towards psychiatrists, compared with 7.6 % of psychiatrists who reported these attitudes. Conclusion: Preliminary findings suggest that significant levels of stigma exist towards psychiatry amongst non-psychiatric doctors, and amongst some psychiatrists themselves. Larger-scale research is

S269 required to assess the extent of stigma prior to developing strategies through which it can be addressed. References: 1. Byrne P (2001) Psychiatric stigma. BJP Sych 178:281–284 2. Gray AJ (2002) Stigma in psychiatry. JR Soc Med 95(2):72–76 3. Nasrallah HA (2011) Stigmata in psychiatry. Curr Psychiatry 10(9)

To Do Nothing at All is the Most Difficult Thing in the World: Active Surveillance vs Intervention Dunne, K, Rutherford, B University Hospital Galway, Intern Network: West–North west (Saolta) Case presentation: A 41-year-old lady was admitted to Roscommon hospital for a sleep study. A chest radiograph which was done as part of the work up showed a ‘‘round shadow projecting over upper right heart border, nature unclear’’. Apart from daytime somnolence she had no other symptoms or signs with no relevant past medical history apart from fibromyalgia. Further imaging of the mass was carried out and the CT thorax showed a ‘‘5 cm solid lesion in the retro—cardinal region. Query precise nature’’. The mass was investigated further with a bronchoscopy where the mass was aspirated and a pigmented material was obtained. Eight days after the bronchoscopy the patient was acutely admitted to hospital with a 2/7 history of general malaise, productive cough, dyspnea and right sided chest discomfort. Her initial chest radiograph showed mild right basal lung opacification and costophrenic angle blunting with elevated inflammatory markers. She was started on Intra venous antibiotics however 5 days after admission the patient acutely deteriorated and she became tachypneic (RR 48), Hypotensive (80/40) and tachycardic (HR 150). The patient was transferred to ICU where a repeat chest radiograph showed progression of the right effusion which now occupied most of the right hemithorax. A repeat CT thorax was performed which showed no change in the mediastinal mass but also identified a 1.6 cm adrenal mass. The endocrinology consult service worked the patient up for phaeochromocytoma however the plasma metanephrines were within normal ranges. Conclusion: The final diagnosis for the mass was a simple bronchogenic cyst. It is thought that during aspiration at bronchoscopy some of the fluid tracked down between the pleurae and unfortunately became infected. I think this case highlights the fact that most practitioners are much more likely to try and take some action when faced with a problem by performing a particular investigation or procedure and likewise in the modern day I think patients expect something to be done! However this case illustrates the importance of weighing up the potential risks as in this case they far outweighed any potential benefit.

Bronchial Carcinoid in a 20-Year-Old Male Carroll P, Redmond K Cardiothoracic Surgery, Mater Misericordiae University Hospital, Dublin 7; Intern Network: Dublin/Mid-Leinster Intern Training Network

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S270 Introduction: Bronchial carcinoid tumours account for approximately 1–2 % of all lung malignancies in adults and roughly 20–30 % of all carcinoid tumours. The majority of patients with a bronchial carcinoid have a centrally-located tumour and are symptomatic with coughing, haemoptysis, wheezing, or a recurrent post-obstructive pneumonia. Description/case presentation: This patient presented to casualty with similar symptoms on 2 separate occasions, 8 months apart. In both presentations, the patient had been seen by a healthcare professional prior to presentation and had been started on antibiotics for a lower respiratory tract infection (LRTI). On first presentation, in March 2014, the patient was brought in by ambulance due to haemoptysis and right sided pleuritic chest pain. He was diagnosed with an LRTI and was discharged on antibiotics and for follow-up in outpatients (OPD). At OPD, in May 2014, his X-ray showed improvement. In November 2014, he presented again with haemoptysis, right sided pleuritic chest pain and dyspnoea. CT and PET CT showed a right lower lobe mass of 5 cm suggestive of a pulmonary carcinoid without evidence of other masses or metastasis. Diagnostic bronchoscopy failed due to bleeding intraoperatively. A right thoracotomy and bi-lobectomy was performed and histology confirmed the diagnosis of a well differentiated carcinoid tumour in the right main bronchus. Although rare, bronchial carcinoid should be considered in the differential of a patient presenting with haemoptysis, pleuritic chest pain and dyspnoea. If left untreated it may cause acute airway obstruction and/or metastasise to other organs. It is advised to reconsider the diagnosis when a patient’s symptoms do not resolve and presents on multiple occasions. Although rare, an awareness of carcinoid tumours and how they can present is important as it can develop into a life threatening condition.

An Audit of Compliance with HSE Healthcare Record Standards by Surgical Doctors at University Hospital Limerick Hughes A General Surgery, University Hospital Limerick; UL Intern Training Network Introduction and aims: Medical records are essential to provide patients with consistent and continuous treatment and a fundamental means of communication among surgical teams. The aims of this audit, were firstly; to evaluate the documentation of surgical teams in UHL against specific criteria from standard three of the HSE Healthcare Record Standards and Recommended Practices for Healthcare Records Management1 and secondly; to identify shortfalls and implement change to ensure medical records comply with HSE Standards. Methods: Twenty surgical patients discharged from UHL during December 2014 were randomly selected. Their medical records were examined across the following key areas; patient identification, author identification, documenting evidence of care, legibility, medications and allergy identification. Results: This audit identified multiple sub-optimal standards across all areas. 5 % of surgical notes had patient’s name and identification number on each page. Only 65 % had a note entry every 24 h and 15 % had documented the time of entry. 75 % of handwriting was legible while 30 % of entries were signed with a clear signature,

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 printed name, title and bleep number. The name of the primary consultant clinician was clearly identifiable 60 % of times. The compliance rate for documentation of medications’ generic names was 49.7 % while patient allergy status was documented 70 % of time. Conclusion: This audit indicates that documentation standards among surgical teams at UHL are suboptimal. An electronic version of the HSE guidelines was emailed to all surgical interns to increase compliance. It is important that this audit is repeated to ensure high standards are being obtained. Reference: 1. HSE Standards & Recommended Practices for Healthcare Records Management. May 2011 Reference No: QPSD-D006-3

An Audit of Discharge Prescription in the Bon Secours Hospital Cork October 2014 Nwaezeigwe M1, Foley S2, Whelan M2, Walsh N1 1 Deptartment of Medicine; 2Deptartment of Medicine Pharmacology, Bon Secours Hospital, College Road, Cork; Intern Network: UCC Intern Training Network

Introduction: Inaccurate communication of information at vital transition points in patients’ hospital care can lead to medication errors and increases the potential for harm. Medicines reconciliation is an essential component of a sound medication management system. The aim of medicines reconciliation on hospital admission and discharge is to ensure that medicines prescribed correspond to those that the patient was taking before admission and new changes to medication on discharge. It is unknown how many, if any prescribing errors occur at the point of discharge in BSHC. Objectives: To investigate the discharge prescriptions of all medical patients discharged from the BSHC over a 2 weeks period in October 2014. To establish if the General Physician noted the medication errors. Methods: The audit was performed retrospectively. An audit tool was created with 10 types of error. The full medical notes for all patients discharged were obtained from the medical records department. Their discharge prescriptions were compared to their drug kardex and medical notes. Results: Ninety-one patients were discharged. 10 patients were excluded due to missing medical notes at the time. Of the remaining 81 patients, 58 (72 %) had inaccuracies in their discharge prescription. One-hundred and twenty medication errors were made across these 58 patients. These varied from a controlled drug prescribing error, omissions, with dosing errors occurring the most, 51/120. In many cases, the GP had realized the error, but in 3 cases the error was not realized until the GP was informed. Conclusions: The majority of discharge prescriptions for medical patients in the BSHC contain one or more prescribing errors. Further training for NCHDs is required to highlight common dosing errors. A future project to improve prescribing could look at the benefits of a ‘buddy system’ with a clinical pharmacist. I propose a re-audit to assess the impact of these measures and for completion of the audit cycle.

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Time to First Steps in the Baseline Study Nwaezeigwe M1, Murray D2 1

Department of Medicine, University College Cork Ireland; Department of Paediatrics and Child Health, Cork University Hospital, Cork, Ireland; Intern Network: UCC Intern Training Network

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Background: The acquisition of bipedal locomotion is an important aspect of gross motor development. Gross motor development is usually assessed by the age of achievement of motor milestones. The acquisitions of early developmental milestones are used to predict later cognitive outcome with some accuracy, particularly in clinical cohort. Early developmental assessment is based on the timing of gross motor, fine motor and social skills. Although there is generally an impression of faster development if the milestones are achieved at younger ages, little is known about factors affecting gross motor development in normal children. Methods: This was a prospective cohort study of 602 healthy infants born in Cork University Maternity Hospital. Age of each individual infant first steps were obtained from the Baseline study population of over 2000 babies who had already undergone their 2 years check-up. Data on numerous variables at the ante-natal and postnatal period were also obtained. Multivariate regression models were used to analyze the data collected prospectively. Results: Mean age of walking was 57 weeks (range 36–114 weeks; SD 10.246; n = 602) and mean age of walking adjusted for gestational age was 57 weeks (range 37–114 weeks; SD 10.154; n = 602). Bivariate analysis reveals the use of Vitamin D supplementation to be positively correlated (r = 0.113; P = 0.005), and Birthweight to be negatively correlated to the age of walking (r = -0.177; P = 0.000). Multiple regression analysis showed the same relationship. Conclusions: These findings indicate the role birth weight and vitamin supplementation play in the achievement of gross motor milestone in relation to the age of walking. References: Adolph KE, Vereijken B, Shrout PE (2003) What changes in infant walking and why. Child Dev 74(2):475–497 Adolph KE, Robinson SR (2012) The road to walking: what learning to walk tells us about development. In: Zelazo P (ed) Oxford handbook of developmental psychology. Oxford University Press, NY (in press)

Pathological Demand Avoidance Syndrome in the Context of a Severely Emotionally and Behaviourally Disturbed Female Adolescent: a Case Report Casey S, Byrne P Linn Dara Child and Adolescent Inpatient Unit, St. Lomans’ Hospital Grounds, Palmerstown, Dublin 20; DSE Intern Training Network Introduction: Pathological demand avoidance syndrome (PDA) is becoming increasingly recognised as a subtype of pervasive developmental disorder. The core features of PDA are high anxiety levels when faced with everyday demands, and obsessive socially-manipulative avoidance and behavioural disturbance to resist these demands. We report a case of PDA occurring in the context of a female

S271 adolescent with significant psychosocial and behavioural difficulties, in order to illustrate the complexity of this diagnosis. Description/case presentation: A 16-year-old Irish female was admitted under Section 25 of the Mental Health Act 2001. She presented with worsening emotional and behavioural difficulties, and extreme verbal and physical aggression to caregivers. These difficulties were not evident in the context of interactions with peers. She had attended CAMHS services over a number of years and had received a diagnosis of pervasive developmental disorder-not otherwise specified (PDD-NOS). She was admitted for assessment, but was unable to engage with therapeutic services within the unit due to her high levels of distress and significant behavioural disturbances. She required transfer to a specialist unit in the UK to meet her complex needs. PDA is only recently gaining recognition as a subtype of PDD, and lacks clearly-defined diagnostic guidelines at this point. As such, it represents a challenging diagnosis for clinicians to identify and treat appropriately. Evidence has shown that individuals affected by PDA have separate behavioural profiles to classic Autism and conduct disorder cases, and as such require separate therapeutic strategies. References: Newson E, Le Mare´chal K, David C (2003) Pathological demand avoidance syndrome: a necessary distinction within the pervasive developmental disorders. Arch Dis Childhood 88:595–600 O’Nions E, Viding E, U Greven C, Ronald A, Happe´ F (2014) Pathological demand avoidance: exploring the behavioural profile. Autism 18(5):538–544

Heparin-Induced Thrombocytopaenia (HIT): How to Manage Abd Rahman NA, Coffey C University Hospital Limerick, Ireland; Intern Network: Mid West Prolonged treatment of LMWH as DVT prophylaxis causing drop in platelet count warrant suspicion of heparin induce thrombocytopaenia (HIT). A 72-year-old lady had complex surgery; ileal–ileal bypass with defunctioning loop ileostomy following a finding of unresectable obstructive colon carcinoma. The surgery went well with no intra- or immediate post-operative complications. She had slow recovery progression causing her prolonged stay in the hospital due to several issues such as low albumin level, poor oral intake, refusing to participate in physiotherapy for mobility and wound infection. As part of the management, she was given prophylactic dose of enoxaparine daily. On the second week after surgery; following a routine blood monitoring, her platelet had dropped significantly over the period of 3 days from 329 to 140 to 79 (1099 per litre). She is however asymptomatic for thrombocytopaenia and was suspected of heparininduced thrombocytopaenia (HIT). Following the findings and pretest probability of 5, HIT screen was immediately sent and commenced on argotraban; a non-heparin anticoagulant instead of platelet. Her activated partial thromboplastin time (aPTT) was monitored closely to fit the target values with daily monitoring of platelet count. The HIT screen returned as negative with recovering platelet level, and alternative argotraban infusion was stopped. In conclusion, it is a common practice to prescribe thromboprophylaxis for inpatient. All patients medical or surgical; who commenced on any heparin anticoagulant should have platelet monitoring usually within day 4–14 of therapy. If patient is suspected of

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S272 HIT, immediate investigation and management could prevent thrombocytopaenic complications. Reference: Keeling D, Davidson S, Watson H, Haemostasis and Thrombosis Task Force of the British Committee for Standards in Haematology (2006) The management of heparin-induced thrombocytopenia. Br J Haematol 133:259–269. doi:10.1111/j.1365-2141.2006.06018.x

Intern Stress Levels: What are Incoming Interns Most Afraid of One Week Before Starting Internship? Russell S, Curran C, Byrne D Intern Network: West North West Intern Training Network Background: Adequate induction for any doctor into a new clinical environment is a matter of patient safety1. Moreover, it is considered critical for interns beginning their first clinical job and forms a compulsory part of intern education and training in Ireland. However, 40 % of interns in Ireland expressed dissatisfaction with their induction last year2. A recent study of 270 Irish interns showed that 48.5 % indicated a high level of stress3. Methods: Data was collected from 68 incoming interns, 1 week before commencing internship, using a mixed-methods research design. A questionnaire based on emerging themes reported from focus groups, was distributed during intern induction. The respondents ranked their fears about commencing intern life, using a Likerttype rating scale. Results: Their self reported fears that ranked highest on the scale were an inability to prescribe and cannulate, failure to manage and escalate the care of an unwell patient and concerns about working in a team. Conclusions: The themes and fears identified in this study are self identified learning needs and equate with international data identifying areas where interns feel least prepared. Ensuring these topics are covered at intern induction may help to decrease the levels of stress amongst interns as well as improve patient safety. References: 1. Health information and Quality authority. National standards for safer better Healthcare. http://www.hiqa.ie/standards/health/ safer-better-healthcare 2. Medical Council of Ireland ‘‘Your Training Counts’’ report December 2014 3. Byrne D, Buttrey S, Canberry C, O’Connor P (2014) Is there a risk profile for the stressed junior doctor?

Angiomyxoma, a Rare Tumour Abdul Aziz N, Lal A Intern Network: Midwest (Limerick) Introduction: Angiomyxoma is a soft tissue tumour that arises from pelvis. It is a benign tumour and is locally infiltrative. This tumour is

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 a rare tumour and there is fewer than 150 cases of this tumour have been reported in medical literature. Description/case presentation: A 42-year-old lady presented with 18 months history of perianal pain and feeling of swelling on the right buttock. Pain is worsened by sitting down. She denied any PR bleeding, change in bowel habit or any urinary symptoms. She had 3 LSCS surgery. There is no relevant past medical history. She’s not on any medications. She is a non-smoker and drinks alcohol rarely. On her family history, her grandmother on her maternal side has breast Ca during her 70s. – MRI scan shows lesion abutting anal sphincter, anal canal, rectum, rectovaginal septum, and lateral vaginal wall – U/S biopsy through Interventional radiology shows spindle cell neoplasm of low hypocellularity. – CT TAP for staging is negative and shows lesion only. Surgical removal by resecting the 13.5 cm right ischiorectal lesion large tumour abutting external anal sphincter, rectum, vagina, pelvic floor but not invading biopsy is taken and sent to lab Results: – Pathology specimen showed complete excision of lesion. – Histology showed that it is aggressive angiomyxoma – Will have MRI for follow up in 6 months’ time Surgical is the first line treatment for angiomyxoma. It needs to have extensive resections. This is due to the fact that it has high recurrence rate (30–70 %) but low chance of metastatic. In this tumour there is a role for adjuvant Tamoxifen therapy although the studies are limited. Reference: 1. Martı´n-Cartes, Juan Antonio, et al (2010) Aggressive angiomyxoma: an unusual female pelvic tumour. Report of three cases and review of the literature. Surg Sci 1:40

TNF-a the Culprit for TB Infection Abdul Aziz N, Casserly B Intern Network: Midwest (Limerick) Introduction: TNF-a inhibitor is being used effectively to treat diseases that are immune-mediated. But however the usage of this drug has grows concerned due to the risk of getting TB infection. In a study showed that there is increased risk by 4–20 times greater in developing TB in patient treated with this drug. Description/case presentation: A 19-year-old man manboy was transferred from St. Johns Hospital to Limerick Regional Hospital with CT thorax that raised suspicion of endobrachial lesion with right lower lobe consolidation. He’s been having unresolving lower respiratory tract infection with dry cough and swinging fevers for the past 2 weeks. He had no night sweats, some weight loss and felt generally unwell. He has had recurrent temperature spikes [39 C. He has a background history of ulcerative colitis (diagnosed 2010) and was put on Humera (TNF-a inhibitor) since February 2013 and now is on hold.

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 CT thorax—right hilar lymphadenopathy, enlarge cardinal lymph nodes, peripheral consolidation. Uniform fine nodules scattered throughout the lungs. This raised the suspicion of Miliary TB In UHL, bronchoscopy and biopsy was taken. Pathology revealed necrotising granulomatous process and culture showed positive for AFB after 16 days of growing. Mantoux test: positive 5 9 5 cm (but negative in 2011) He was seen by infectious disease and started on anti-TB TNF-a is a great agent in treating immune-mediated diseases. Therefore a precautionary approach is required in reducing the risk of exposing patient to TB infection. Such approach would be thorough assessment for clinically active TB and screening for latent TB by doing Mantoux test and CXR. There are recommendations made in Irish settings about the usage of these drugs. Reference: 1. Kavanagh P, Gilmartin JJ (2007) Tumour necrosis factor-a (TNFa) antagonists and tuberculosis

Opioid Usage and Opioid Induced Respiratory Depression in Specialist Palliative Care Inpatients McMorrow R, Sweeney C Marymount University Hospital and Hospice, UCC School of Medicine; Intern Network: Dublin Mid Leinster Background: Opioids are widely used for pain management, however opioid phobia can prevent their appropriate use in patients who would benefit. Many clinicians and families fear that opioids shorten life and hasten death1. The understanding is that if opioids kill, the mechanism by which they achieve this end is respiratory depression. In a study of US hospice and palliative medicine doctors, over 50 % reported experiencing palliative treatments being characterised as euthanasia, murder, or killing in the preceding 5 years2. Aim: To examine the usage of opioids and opioid induced respiratory depression in a specialist palliative care unit. Methods: Two hundred and twenty-two inpatient charts from Marymount specialist palliative care unit were reviewed. Basic demographics were recorded, as were the morphine equivalent daily dosage on day of admission, day three, day seven, day ten, day fourteen and on day of death or discharge. The presence of documented clinically significant respiratory depression was also recorded. Mean daily morphine doses were calculated and compared between different groups of patients. Results: No patient had documented clinically significant respiratory depression. There was no significant difference in opioid doses between patients with a known diagnosis of respiratory disease and those without respiratory disease at time of death or discharge (69.92 vs 75.72 mg p = 0.728). Conclusions: If opioids are used appropriately, healthcare professionals and the public shouldn’t fear the ending a palliative care patient’s life through opioid induced respiratory depression. References: 1. George R, Regnard C (2007) Lethal opioids or dangerous prescribers? Palliat Med 21(2):77–80 2. Goldstein NE, Cohen LM, Arnold RM et al (2012) Prevalence of formal accusations of murder and euthanasia against physicians. J Palliat Med 15(3):334–339

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A Case of Spontaneous Rupture of the Pancreaticoduodenal Artery O’Halloran N Galway University Hospital A 54-year-old woman presented to ED with a six and a half hour history of right upper quadrant pain. The pain was of sudden onset, severe, constant, ‘‘burning’’ and increasing intermittently in severity. The pain later radiated to the RIF and back. She had three episodes of vomiting: gastric contents, then blood stained and finally bilious. She also described generalised weakness. On exam there was mild abdominal distension, right sided abdominal tenderness, guarding and rigidity. Bowel sounds were present. Bloods on admission: Hb 11.7, WCC 12.2, CRP \0.6 and lactate 0.9. Two hours later the patient deteriorated becoming hypotensive 88/50, diaphoretic, Hb fell to 6.6 and lactate increased to 2. Anaesthetics inserted an arterial line and started a phenylephrine infusion. A massive infusion protocol was initiated to which the patient had an initial clinical response. An urgent CT revealed a massive intra-abdominal haemorrhage originating from the pancreaticoduodenal artery. An on the table CT angiogram was performed in theatre. A balloon was placed in the descending aorta. Surgeons then proceeded to laparotomy. A massive haemorrhage was discovered in the lesser sac. The sac was opened and the duodenum mobilised (Kocher manoeuvre). The source of intra peritoneal bleeding was a 1 cm tear in the inferior pancreaticoduodenal artery at the head of the pancreas at the junction of D1/D2. This vessel was transfixed with 5/0 prolene. She was brought to ICU post-op and had an uncomplicated recovery and was discharged home 12 days post-op.

Chest Pain in a Teenage Girl: a Difficult Diagnosis Buckley J, Shiels P Department of Cardiology, Midlands Regional Hospital, Tullamore, Offaly, Ireland Introduction: Chest pain assessment in a patient with few known cardiac risk factors can lead to a range of differential diagnoses. Is it always necessarily acute coronary syndrome? Case Presentation: An 18-year-old female presented to the emergency department in Midland’s Regional hospital with central crushing chest pain of increasing severity worsened by ambulation. Known risk factors for chest pain differentials included family history of myocardial infarction, increased body mass index and combined oral contraceptive use. Management and outcome: Focused history analysis revealed flu like symptoms in the month preceding current presentation. Initial investigations demonstrated a sinus tachycardia on electrocardiogram and a normal chest radiograph. Relevant biochemistry noted dramatically raised high sensitivity cardiac biomarkers, which remained persistently elevated. Correlating the clinical picture it was felt the current presentation was likely myocarditis secondary to a previous viral illness. A Bruce protocol exercise stress test was terminated early owing to recurrence of chest pain. Subsequently the patient was referred for cardiac magnetic resonance perfusion scan in Blackrock

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S274 clinic to assess definitively if myocarditis was the underlying issue. This revealed significant left coronary artery disease with urgent percutaneous coronary intervention and stenting to her left anterior descending artery carried out. Discussion: Acute coronary syndrome an unusual diagnosis in a teenager.

A Retrospective Study on Novel Oral Anticoagulants (NOACs) as Secondary Prevention of Thromboembolic Stroke in Patients with Nonvalvular Atrial Fibrillation Hayes E, Ng J, Moffatt U, McInerney A, Kelleher B, Hickey P

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 383(9921):955 5. Hylek EM, Held C, Alexander JH, Lopes RD, De Caterina R, Wojdyla DM, Huber K, Jansky P, Steg PG, Hanna M, Thomas L, Wallentin L, Granger CB (2014) Major bleeding in patients with atrial fibrillation receiving apixaban or warfarin: the ARISTOTLE trial (apixaban for reduction in stroke and other thromboembolic events in atrial fibrillation): predictors, characteristics, and clinical outcomes. J Am Coll Cardiol 63(20):2141 6. Piccini JP, Garg J, Patel MR, Lokhnygina Y, Goodman SG, Becker RC, Berkowitz SD, Breithardt G, Hacke W, Halperin JL, Hankey GJ, Nessel CC, Mahaffey KW, Singer DE, Califf RM, Fox KA, ROCKET AF Investigators (2014) Management of major bleeding events in patients treated with rivaroxaban vs. warfarin: results from the ROCKET AF trial. Eur Heart J 35(28):1873

Department of Medicine Sligo Regional Hospital; Intern Network: West Northwest Aims and objectives: Nonvalvular atrial fibrillation (AF) confers a fivefold increased risk of stroke1. Internationally the prevalence of AF is 5 % over 652 and in Ireland 11 % over 80 years3. Oral anticoagulation is considered the gold-standard for stroke prevention in AF. Until 2009, warfarin and other vitamin K antagonists were the only class of oral anticoagulants available. While these drugs are highly effective in prevention of thromboembolism, they have their limitations, which has led to the development of novel oral anticoagulants (NOACs). Several practical and pharmacological issues related to this class of drug have been debated. The aim of this audit was to determine the number of patients who received a NOAC rather than Vitamin K antagonist, to determine whether patients received pharmacological education prior to commencement of anticoagulation and to evaluate readmissions for adverse events. Methodology: This retrospective review was undertaken on all patients who presented to Sligo Regional Hospital with acute Stroke or TIA and Atrial Fibrillation and were subsequently anticoagulated between January 1st 2013 and September 30th 2014. Candidates were identified by the Clinical Nurse Specialist using the Stroke Register. Discharge prescriptions and case-notes were reviewed. Results: A total of 393 patients presented to the Stroke Service, of these, 269 had ischaemic stroke and 84 had TIA. One-hundred and twenty-one were found to have atrial fibrillation. Of these 82 were anti-coagulated, 40 male, 42 female. Forty were anti-coagulated with a NOAC, 20 male, 20 female. Conclusion: Early experience with NOACs has been in general satisfactory with very few adverse effects. In further work, the stroke service plans to evaluate the education received by patients and/or relatives through interview and/or questionnaire. References: 1. Pisters R, Lane DA, Marin F, Camm AJ, Lip GY (2012) Stroke and thromboembolism in atrial fibrillation. Circ J 76:2289–2304 2. Rietbrock S, Heeley E, Plumb J, van Staa T (2008) Chronic atrial fibrillation: incidence, prevalence and prediction of stroke using the congestive heart failure, hypertension, age over 75, diabetes mellitus, and prior stroke or transient ischaemic attack (CHADS2) risk stratification scheme. Am Heart J 156:57–64 3. Finucane C, Frewen J, Cronin H, Kearney P, Rice CO, Regan C, Harbison J, Kenny RA (2011) Low awareness of atrial fibrillation in a nationally representative sample of older adults. Circulation 124:A15661 4. Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD, Camm AJ, Weitz JI, Lewis BS, Parkhomenko A, Yamashita T, Antman EM (2014) Comparison of the efficacy

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Not All Metastases are Built the Same: Analysis of Changes in Rates of Reporting and Incidence of Different Metastatic Sites in Renal Cell Carcinoma (MRCC) Trials Over Two Decades Yuen Teo M, Buckley J, O’Riordan LM, Sze Yin Sui J, Gallagher J, McCaffrey J Department of Medical Oncology, Mater Misericordiae University Hospital, Dublin, Ireland; Mater Private Hospital, St James’ Hospital, Dublin Ireland Background: Different metastatic sites have recently been shown to carry variable prognostic impact in mRCC, but they are not accounted for in risk stratification, nor are they consistently reported in published data. Differences in the distribution of prognostically relevant metastatic sites in studies may influence study outcomes. We sought to investigate rates of metastatic site reporting in published studies, and changes in distribution over the last two decades. Methods: Phase two/three trials of mRCC were identified from Pubmed. Full papers were reviewed to extract mets- related data. Two comparisons of rates and distributions of mets were performed: (1) over four time periods based on publication date: 1990 s, 2000–05, 2006–10, 2011-present, and (2) between targeted (TT) and immunotherapy (IT) studies, representing separate treatment eras. Standard statistical methods were employed. Results: Between 1995 and 2014, 95 studies were identified, 25 % of which were phase 3 studies. Overall, 74 % of studies reported rates of at least 1 mets site. Rates of liver, lung, nodal and osseous mets were reported in 70, 72, 62 and 62 % of all studies respectively. No differences in rates of reporting were observed between TT and IT. However rates of reporting across the time periods decreased from 86 to 68 % (p = 0.4). Amongst studies with reported rates of mets, median rates of liver, lung, nodal and osseous mets were 19 % (range 2–52), 69 % (4–87), 41 % (3–78) and 20 % (3–57) respectively. Across the four time periods, proportion of patients with liver and lung mets has increased significantly (14 [ 22 %, p = 0.04; 38 [ 75 %, p = 0.03) but not for nodal (33 [ 46 %, p = 0.05) or osseous mets (25 [ 20 %, p = 0.42). Compared to IT trials, TT trials have higher proportion of patients with liver mets (25 vs. 14 %, p \ 0.01) and nodal mets (47 vs 34 %, p \ 0.01) but not for lung (71 vs. 64 %, p = 0.17) or osseous mets (20 vs. 19 %, p = 0.30). Conclusions: The changes in disease distribution and reporting of metastases in trials over two decades may reflect the increased

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 propensity to enroll in clinical trials or the changing nature of mRCC as a disease entity. The influence of these changes on outcomes remains to be investigated.

Audit of Oxygen Prescribing in an Irish Teaching Hospital McGoldrick DM Cork University Hospital Intern Network: UCC Intern Network Objectives: International and local guidelines recommend that all supplemental oxygen administered to patients should be prescribed as toxicity can occur. The aim of this audit was to assess compliance with these guidelines and analyse the prescribing of oxygen in Cork University Hospital. Design/methods: A random review of drug kardexes of patients on supplemental oxygen was undertaken on 1 day in December 2014. All patients over eighteen on three medical and three surgical wards in Cork University Hospital were assessed for inclusion in the study. Patients in critical care and high dependency wards were excluded. The kardexes of those on supplemental oxygen were assessed for a prescription in the first instance and then for variables such as device, flow rate or specific saturations as required on the kardex. The hospital notes of included patients were assessed to identify any preexisting chronic respiratory diseases. Results: One-hundred and fifty-seven patients were assessed for inclusion, 72 surgical and 85 medical. Of these patients, 18 (7 male, 11 female) were receiving supplemental oxygen. The average age was 59.83 years (range 21–96 years). Eight patients were surgical and 10 were medical, there was no statistical difference between oxygen usage between these groups (p = 1.00). All of the patients received oxygen via nasal prongs and no patients (0 %) were prescribed supplemental oxygen. Three patients had a history of chronic obstructive airways disease. Conclusions: This audit highlights poor compliance with oxygen prescribing guidelines. Although uncommon, risks exist with oxygen usage and interventions may be required to improve prescribing practices.

Mercy University Hospital Cork Bleep Study Ring E´, Murphy C, McCarthy J Mercy University Hospital Cork; UCC Intern Training Network Introduction: Utilization of bleeps by interns in the hospital setting is a practice used worldwide. It provides an easy method of communication between doctors and ward staff. The use of bleeps enables nursing staff to contact doctors to alert them to an issue on the ward which requires their prompt attention. There are flaws, however, with this communication method such as inappropriate bleeping of NCHDs. Aim: (1) Examine the positive and negative aspects of the current bleep system in the Mercy University Hospital (MUH). (2) Record the appropriateness of bleeps received by interns using a draft bleep policy already in existence in MUH as criteria. Methods: A survey was circulated to all interns working in MUH from 3/11/14 to 6/12/14 asking them of their opinions of the current

S275 bleep culture in MUH. Interns who took part in on-call duties the week of the 1/11/14 were asked to take note of the bleeps they received. Results: Eighteen responses were received, 9 from medical interns and 9 from surgical interns. Eighty percent of surgical interns received 20+ bleeps a day, 40–70 % of which were deemed inappropriate by the MUH criteria. Eighty percent of bleeps received by medical interns were inappropriate. All respondents received phone calls from work on their personal phone at least once a week in addition to bleeps. Seven respondents noted bleeps allowed doctors to remain in contact with the wards and that bleeps helped the doctor triage their jobs. Eight identified re-bleeping for the same job an issue and another eight reported that commonly when answering bleeps nobody answered the phone. During on call shifts, the majority of bleeps received were appropriate. 34 of the bleeps the medical intern on weekday nights received were deemed appropriate while 21 bleeps were inappropriate. The medical intern on weekend nights received 17 appropriate and 12 inappropriate bleeps. The surgical intern on weekend nights received 15 appropriate and 9 inappropriate bleeps. Conclusion: Objectively the current bleep culture appears to work well but the attitudes of interns do not reflect this. Ways to improve the current bleep system in MUH include implementing the draft MUH beep policy. Secondly implementing bleep free periods i.e. during intern teaching, grand rounds, lunchtime etc. The third method would be to introduce a jobs list, on each ward, of routine jobs so that interns would only be bleeped for urgent matters. References: Chiu T et al (2006) Frequency of calls to ‘‘on-call’’ house officer pagers at Auckland City Hospital, New Zealand. J N Z Med Assoc 119:1231 Fargen, O’Connor et al (2012) An observational study of hospital paging practices and workflow interruption among on-call junior neurosurgery residents. J Grad Med Edu 4.4:467–441. PMC Web 3 Jan 2015

Lo¨fgren’s Syndrome: a Clinical Variant of Sarcoidosis Tuohy G, Hehir D Department of General Surgery, Midlands Regional Hospital Tullamore, Tullamore, Co. Offaly; Intern Network: UCD Dublin/ Mid-Leinster Intern Training Network Introduction: Lo¨fgren’s syndrome is an acute-onset presentation of sarcoidosis characterized by erythema nodosum, polyarthralgia and bilateral hilar lymphadenopathy (BHL). A variant which is more common in Caucasians, it carries an excellent prognosis1. Description/case presentation: A 28-year-old otherwise fit and healthy male presented to the ED with erythema, warmth and pain of his left pre-tibial region with concomitant symptoms of bilateral ankle pain, fatigue, and pyrexia. Initially diagnosed as cellulitis, symptomatic improvement followed commencement of IV antibiotics and he was discharged on oral antibiotics the following day. He re-presented 5 days later with persistent erythema, a new papular rash and bilateral ankle, knee and lower back stiffness. As the erythematous nodular lesion on the left shin was consistent with possible erythema nodusum, antibiotics were ceased and a chest X-ray was ordered. It revealed BHL and paratracheal lymphadenopathy. In view of these findings, he was diagnosed with Lo¨fgren’s syndrome and referred to rheumatology for further management.

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S276 Lo¨fgrens syndrome is considered to be a variant of sarcoidosis, however the distinction between the two entities is important as it has significant bearing on the treatment and prognosis for the patient. The disease is usually self-limiting, with treatment consisting primarily of bed rest and NSAIDs with some patients requiring corticosteroids as second-line therapy2. Given its systemic nature and non-specific manifestations, the diagnosis of sarcoidosis can be challenging. However the presence of all features of Lo¨fgren’s syndrome has a 95 % diagnostic specificity for sarcoidosis, allowing a clinical diagnosis to be made without biopsy3. References: 1. Lo¨fgren S (1953) Primary Pulmonary sarcoidosis. I. Early signs and symptoms. Acta Med Scand 145:423–31 2. Zisman DA, Shorr AF, Lynch JP 3rd (2002) Sarcoidosis involving the musculoskeletal system. Semin Respir Crit Care Med 23:555–570 3. O’Regan A, Berman JS Sarcoidosis (2012) Ann Intern Med 156(9)

A Rare and Distressing Side Effect of Ipilimumab Chemotherapy Joy C, Donnellan P Department of Medical Oncology, Galway University Hospital, NUI Galway Intern Training Network Background: Ipilimumab is an immunotherapy drug used for the treatment of metastatic melanoma. It is a fully human monoclonal antibody directed against cytotoxic T lymphocyte antigen-41. Case description: We report the case of a 69-year-old gentleman with a background history of metastatic spindle cell malignant melanoma. Following the discovery of extensive hepatic and bony metastases the patient was commenced on ipilimumab. The first cycle was administered seemingly with no side effects. During administration of the second cycle the patient became cyanotic, tachycardic and hypertensive. The infusion was stopped and vital signs normalized within minutes with high flow oxygen. Thereafter the patient became confused, agitated and somewhat aggressive. Careful history and examination revealed no psychotic symptoms and no focal neurology. Review of systems was non-contributory aside from the patient’s daughter reporting increasing confusion over a 3-week-period following the first cycle. Initially it was hypothesized that opioid toxicity may have played a part in this acute episode. Despite being commenced on a weaning dose of opioids and the introduction of pregabalin as a substituting agent the patient continued to experience fluctuating levels of orientation and occasional episodes of agitation during his 18 day inpatient stay, although these episodes became fewer as time went on. Despite rigorous investigation no causative factor was discovered. Conclusions: In the absence of another cause as well as the timing in conjunction with the administration of both cycles of chemotherapy it was concluded that this was a distressing side effect of ipilimumab. Reference: 1. British Columbia Cancer Agency. British Columbia Cancer Agency Cancer Drug Manual (internet). Developed: 1 Jan 2013. Available from: http://www.bccancer.bc.ca/NR/rdonlyres/07A16

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Inadvertent Subclavian Artery Cannulation with Central Venous Catheter (CVC) ´ ’Riain S Smyth C, O Department of Anaesthesia, University Hospital Limerick, Dooradoyle, Limerick; Mid-West Training Network Introduction: Mechanical complications occur in about 5–19 % of CVC insertions1. Subclavian artery cannulation has an incidence of 0.1–1.0 %, a rare complication of CVC placement using the subclavian vein site. Pneumothorax is most common in this site. Description/case presentation: AT, a 48-year-old woman, was admitted to ICU following a road traffic accident. During her ICU stay, she required a vascath for CVVH, as well as a CVC, reducing the number of available central cannula sites. When renewing the CVC, the right subclavian vein site was chosen. The right subclavian artery was inadvertently cannulated, requiring surgical repair. Discussion: Inadvertent cannulation of the artery can be suspected on aspiration of pulsatile, bright red blood; however it may be unclear in hypotensive or hypoxic patients. Blood gas, pressure transducer tracing and CXR showing tip of CVC passing the midline will confirm malposition2. Ultrasound guidance has reduced incidence of adverse outcomes, but is less suitable for the subclavian vein due to the shadowing by the clavicle. Early recognition of arterial cannulation and prompt management will reduce further complications. References: 1. McGee DC, Gould MK (2003) Preventing complications of central venous catheterization. N Engl J Med 348(12):1123 2. Oliver WC Jr, Nuttall GA, Beynen FM et al (1997) The incidence of artery puncture with central venous cannulation using a modified technique for detection and prevention of arterial cannulation. J Cardiothorac Vasc Anesth 11(7):851

An Audit on the Use of Bone Protection Medications in Hip Fracture Patients at Risk of Osteoporosis Lee YN, Ryan J, Kao T Department of Orthopaedic Surgery, University Hospital Limerick (UHL), UL Intern Training Network Objectives: To investigate the use of bone protection medications (BPM) in hip fracture patients with risk factors for osteoporosis. Method: A retrospective study of 27 patients presenting with hip fractures to UHL between July 2014 and October 2014. Results: Only 5 of the 27 patients with risk factors were taking BPM • • • •

Previous fragility fractures: 0/9 patients were on BPM Long term oral corticosteroid use: 3/7 were on BPM Other medication that decreases bone mineral density: 0/3 patients were on BPM Rheumatoid arthritis: 1/3 patients was on BPM

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 • • • • •

Primary hyperparathyroidism: 1/1 patient was on BPM Hyperthyroidism: 0/2 patients was on BPM Alcohol intake [5 units per day: 0/2 patients was on BPM Chronic kidney disease: 0/1 patient was on BPM Coeliac disease: 0/1 patient was on BPM

Guidelines: National Osteoporosis Guideline Group (NOGG) and NICE recommends BPM treatment in: • Postmenopausal women who had a previous fragility fracture • People on long-term oral corticosteroids who are more than 70 years old NOGG recommends that postmenopausal women or men above 50 years old at risk of osteoporosis to be assessed with the FRAX calculator. Recommendations: 1. Investigate or start BPM in patients presenting with fragility fractures or on long-term corticosteroid therapy. 2. Assess patients with risk factors to osteoporosis with FRAX calculator or DEXA scan. 3. Leaflet for patients presenting with fragility fractures outlining investigations and BPM for GP to follow up. Conclusion: There was poor BPM prescribing in the cohort studied. A greater awareness for treating osteoporosis should be encouraged to prevent the morbidity associated with the disease. References: Compston J, Cooper A, Cooper C et al (2009) Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK. Maturitas 62(2):105–108 NICE (2012) Osteoporosis: assessing the risk of fragility fracture (NICE guideline). Clin Guidel 146. National Institute for Health and Care Excellence. http://www.nice.org.uk

Adenocarcinoma After Ileal Pouch Anal Anastomosis for Famial Adenomatous Polyposis McBride I, Coffey C Department of Colorectal Surgery, University Hospital Limerick, Dooradoyle, Co Limerick; Intern Network: Mid-West Intern Network Adenocarcinoma is a rare occurrence after ileal pouch anal anastomosis (IPAA) for familial adenomatous polyposis (FAP)1. This article aims to describe such a case. A 55-year-old man presented with bleeding from the anus on a background history of a total colectomy and ileal pouch formation for FAP, in 1983 and 1987 respectively. He underwent a colonoscopy and had a biopsy of the anal canal and anastomosis which revealed adenocarcinoma. Following staging investigations including an MRI and CT scan, he received short course radiotherapy and then underwent excision of the ileal pouch, the anastomosis and anus with formation of an ileostomy. Histology of the resected specimen demonstrated a 5 cm moderately to poorly differentiated adenocarcinoma at the anastomotic site between the pouch and anus. There was infiltration through the bowel wall. Resection margins were clear. 4 of 20 lymph nodes demonstrated adenocarcinoma. However the lymph nodes at the origin of the superior mesenteric artery were negative for disease. One month post operatively he was still experiencing discomfort in the perineum and CT scan revealed a large pelvic hematoma. This was treated

S277 conservatively with IV antibiotics due to his recent radiation and surgery. His symptoms have since improved significantly. He has denied adjuvant chemotherapy and is recovering well. Although the risk of malignancy with IPAA is not known this case demonstrates that IPAA does not remove the risk of metachronous intestinal neoplasia [1]. It also emphasises the importance of lifelong regular pouchoscopy and follow up in those who have undergone IPAA. Reference: 1. Campos FG, Habr-Gama A, Kiss DR et al (2005) Adenocarcinoma after ileo-anal anastomosis for familial adenomatous polyposis: review of risk factors and current surveillance apropos of a case. J Gastrointest Surg 9:695–702

Appropriate Ordering of Laboratory Tests in a Teaching Hospital, can it be Improved? Joyce D, Conlon C, Freeman K, Mahon C, McCreery C Department of Cardiology, St Vincent’s University Hospital, Dublin, Ireland; UCD Intern Training Network Background: The purpose of this study was to assess appropriateness of laboratory test ordering in a single unit of a teaching hospital based on level of physician experience. Method: A single unit study in a Dublin Teaching Hospital between October 2014 and November 2014. All laboratory tests requested by junior members of the team over a 2-week period were prospectively recorded. Consultants and registrars within the service were asked to determine retrospectively whether the laboratory tests requested were appropriate in patient management. Following a further 2 weeks of ward based education the study was repeated. Results: Part 1: FBC (n = 67) total indicated 53.3 % (n = 37) UE (n = 87) total indicated 35.7 % (n = 31) CRP (n = 52) total indicated 17.3 % (n = 9) LFT (n = 50) total indicated 48.0 % (n = 24) INR (n = 36) total indicated 66.6 % (n = 24) Part 2: FBC (n = 32) total indicated 50.0 % (n = 16) UE (n = 62) total indicated 83.9 % (n = 52) CRP (n = 22) total indicated 77.3 % (n = 17) LFT (n = 13) total indicated 61.5 % (n = 8) INR (n = 34) total indicated 68 % (n = 23) Conclusion: Laboratory usage in clinical practice is steadily increasing. They provide assistance for diagnosis, to support decision making, screening, medico-legal and for educational purposes1,2. In a hospital setting it is additionally appropriate to promote cost-effective practice. In this small study we demonstrate the value of ward-based education in directing more appropriate laboratory test requesting, resulting in a saving of approximately €480. References: 1. (1993) Med Care 31:784–794 2. (1986) Am J Med 80:865–870

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Pancoast Tumour: an Unusual Case of Unilateral Lower Limb Weakness Lee A, Quinn C Intern Network: Geriatrics, Letterkenny General Hospital; NUI Galway Intern Training Network Patient has given her consent for the purpose of this case report. Introduction: Less than 5 % of bronchogenic carcinomas are attributable to superior sulcus (Pancoast) tumours1. Physical manifestations of Pancoast’s syndrome can present late and be subtle in appearance. Case presentation: A 70-year-old lady presented with atypical chest pain radiating to the axilla, and shoulder. Background of 20 pack year smoking history. ECG normal sinus rhythm, negative serial data and normal CXR. Diagnosed with musculoskeletal pain and subsequently discharged on oral analgesia. Presented 4 weeks later with 5 day history of gradual onset right lower limb weakness and gait difficulties, without bladder or bowel symptoms. On examination—left ptosis and miosis, quadriceps muscle wasting bilaterally, power 4/5, reflexes brisk and plantars down going. Wasting of small muscles of left hand noted. Investigations—B12 deficiency 162 pg/ml, replaced parenterally. CXR—raised possibility of left apical consolidation. MRI brain normal. Urgent MRI Spine—4 cm left apical lung mass with contiguous spinal metastases between T1 and T3 level with 50 % canal stenosis. CT guided biopsy of apical lung mass confirmed small cell/pancoast’s tumour. She was commenced on dexamethasone and transferred to St Luke’s Hospital for radiotherapy. Pancoast’s syndrome typically presents as a combination of symptoms including C8–T2 radicular pain, Horner’s syndrome and wasting of the small muscles of the hand2. This is a rare presentation of primary lung cancer which can present with subtle signs, and may result in atypical sensory symptoms3. This case highlights the importance of maintaining a high index of suspicion in smokers presenting with right shoulder pain. References: 1. Foroulis CN (2013) Superior sulcus (Pancoast) tumors: current evidence on diagnosis and radical treatment. J Thoracic Dis 5:S342–S358 2. Kishan AU, S S, T J (2012) Shoulder pain and isolated brachial plexopathy. BMJ Case Rep 3. C Marangoni ML (1993) Sensory disorder of the chest as presenting symptom of lung cancer. J Neurol Neurosurg Psychiatry 56:1033–1034

Synchronous Ovarian Involvement in Colorectal Malignancies: a Single Centre Experience Duignan S, Heneghan H, Larkin J Department of colorectal surgery, St. James’s Hospital, Dublin 8; TCD Intern Training Network Introduction: Involvement of the ovaries by colorectal cancer is rare with a reported incidence of 2–3 %. Aims: The objective of this study was to analyse the experience of this phenomenon in a high-volume cancer unit.

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Materials and methods: A prospectively-compiled colorectal cancer database (2001–2010) of 1261 patients was retrospectively examined to identify cases with ovarian involvement. Results: There were 9 cases, of which 8 had complete data for analysis. One had direct invasion, one case was a colorectal lymphoma and the remaining 6 were colorectal adenocarcinomas with metastatic spread to the ovaries. This study will focus on the adenocarcinomas (n = 7). Median age was 54 (34–82), 5 were postmenopausal. In 6 cases the primary tumour was colonic. Both ovaries were involved in all cases of metastatic cancer and 83 % were lymph node positive. Four had a KRAS mutation. All were CK20 positive and 83 % were CK7 negative, giving a positive predictive value of this combination of tumour markers of 100 %. Tumour markers, where performed, were raised in all cases. All patients had other metastatic deposits (liver, lung, peritoneum). Post-operative morbidity rate was 43 %, all were Clavien-dindo grade C2. All patients received adjuvant chemotherapy. Median survival following diagnosis was 26 months (18–65). Of note, the patient with negative lymph nodes experienced the longest survival. Conclusions: Synchronous ovarian metastases from colorectal cancer are rare, occur in younger females, and confer poor prognosis despite oophorectomy. These cases should be discussed by multidisciplinary teams to question the potential benefit of extensive resection.

A National Paediatric Survey of Infection Control Measures in Cystic Fibrosis Breen C, Finn D, Greally P, O’Connell G, Elnazir B Adelaide and Meath Hospital, Dublin Incorporating National Children’s Hospital; Intern Network: DSE Intern Scheme Objectives: To compare implementation of the 2013 Guidelines for Infection Prevention and Control using a questionnaire composed from three subsections of the guidelines. These guidelines were chosen as they were all evidenced based. Guidelines were chosen which differ from previous guidelines. Method: All six established specialist paediatric centres in Ireland were included. Twenty-two evidence based recommendations were taken from within three subsections. The data was collected and recorded using a telephone questionnaire for each centre, answered by each clinical nurse manager. A standard of 90 % was chosen. Results: Two centres including Tallaght complied with 77 % of guidelines chosen. The other centres ranged from 64 to 72 % compliance. 1. Tallaght Hospital complied with 70 % of Core Recommendations. No centre complied with patients wearing masks during clinic visits. One centre complied with staff wearing aprons and gloves. 2. There was 100 % compliance regarding scheduling of clinics. 60 % of pulmonary function testing guidelines were implemented. No centre complied with an appropriate ventilated room. Two centres including Tallaght allowed 30 min between patients to compensate for this. 3. All six centres complied with 100 % of guidelines regarding inpatient settings. Conclusions: Tallaght’s implementation of the Updated 2013 Guidelines, at 73 % compliance, is below the standard set for this audit. Compliance is on par or greater than the five other National centres. The five outstanding guidelines have been presented to the Cystic Fibrosis multidisciplinary team with a view to implementing them. This audit will also be discussed at a National Cystic Fibrosis Conference to allow other centres access to these results. The audit

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 is reproducible enabling reassessment of implementation of the criteria.

Inguinal Hernia Repair Morbidity Audit Kelly C, Johnston S Department of Surgery, MRH Tullamore, Intern Network: UCD Objective: To analyse morbidity following inguinal hernia operations performed in MRH, Tullamore. Method: A total of 229 hernia repairs were performed on 224 patients between January 2008 and September 2014. Notes were available for 141 (61.6 %) of these procedures. Data was collected in the following categories: patient-related, hernia-related, and procedure-related. Results: One-hundred and forty-one procedures were reviewed, of these 11 were performed in females and 131 in males, with an age range of 15–88 years (average 55 years). Nine cases (6.38 %) were recurrences and 8 (5.67 %) were bilateral; 94 (63.08 %) were direct, 30 (20.13 %) were indirect, and 6 (4.03 %) were mixed. One-hundred and twenty-one (85.82 %) procedures were performed laparoscopically. Eighty-two cases (58.16 %) were performed as day cases. Forty patients (28.37 %) had some form of morbidity following their procedure, with a recurrence rate of 3.55 %. Overall morbidity rates were higher than those found in other similar studies, however, the incidence of individual complications was in keeping with those reported1. Post-op urinary retention (POUR) was a common complication experienced (4.96 %). Other studies greatly vary in their POUR rates, ranging from \1 to 30 %2. Given such a range, it is hard to compare the results found in this particular audit to a supposed standard. Many of the complications experienced were related to the use of general anaesthetic, as opposed to the procedure specifically; these included post-operative chest pain, pulmonary embolism and shortness of breath. Early identification of patients more likely to experience complications of anaesthesia through pre-op assessment clinics would perhaps reduce the incidence of such events3. References: 1. Awad SS, Fagan SP (2004) Current approaches to inguinal hernia repair. Am J Surg 188(6A Suppl):9S–16S 2. McClusky DA (2013) Urinary retention after laparoscopic inguinal hernia repair. SAGES Manual Hernia Repair:157–166 3. Lundstro¨m K-J, Sandblom G, Smedberg S, Nordin P (2012) Risk factors for complications in groin hernia surgery: a national register study. Ann Surg 255(4):784–788

A Case of the Blues Duignan S, O’Toole F, Abu Saadeh F, D’Arcy T Department of Gynaecological Oncology, St. James’s Hospital, Dublin 8; TCD Intern Training Network Introduction: Methylene blue (MB) is extensively used in gynaecology and is known to give falsely low SpO2 readings by interfering with light absorbance by the spectrophotometer of pulse oximeters. Case presentation: We present the case of a 37-year-old female with a stage IB1 cervical squamous cell carcinoma. The patient had no comorbidities and was a lifelong non-smoker. Following discussion at the

S279 gynaecology MDT, the patient proceeded to theatre for laparoscopic sentinel lymph node biopsy. Following port insertion, MB was injected at 4 cervical points peri-tumourally. Approximately 50 min later, the patient became cyanotic and SpO2 fell from 98 to 78 %. The pulse oximeter probe was changed, the patient examined, a transoesophageal echo was performed and yet still no cause was identified. PaO2 levels from three consecutive ABGs were above 20 and it was concluded that this was MB-induced cyanosis and the patient was not truly hypoxic. Interpretation of the dye as reduced haemoglobin by the spectrophotometer of the pulse oximeter was responsible for the decrease in SpO2. Discussion: This phenomenon should be considered in the differential for cyanosis and oxygen desaturation in order to avoid unnecessary intra-operative delays, invasive investigations, and iatrogenic toxic hyperoxaemia. It is also important to recognise that hypoxaemia may co-exist with this phenomenon and of note pulmonary oedema has been reported as a side-effect of MB1,2. References: 1. Monaca E, Trojan S, Lynch J, Dochn M, Wappler F (2005) Broken guidewire: a fault of design. Can J Anesth 52:801–804 2. Unnikrishnan KP, Sinha PK, Nalgirkar RS (2005) An alternative and simple technique of guidewire retrieval in a failed Seldinger technique. Anesth Analg 100:898–899

Synchronous Ovarian Involvement in Colorectal Malignancies: a Single Centre Experience Duignan S, Heneghan H, Larkin J Department of Colorectal Surgery, St. James’ Hospital, Dublin; Intern Network: Trinity Intern Network Objectives: Involvement of the ovaries by colorectal cancer is rare with a reported incidence of 2–3 %. The objective of this study was to analyse the experience of this phenomenon in a high-volume cancer unit. Methods: A prospectively-compiled colorectal cancer database (2001–2010) of 1261 patients was retrospectively examined to identify cases with ovarian involvement. Results: There were 9 cases, of which 8 had complete data for analysis. One had direct invasion, one case was a colorectal lymphoma and the remaining 6 were colorectal adenocarcinomas with metastatic spread to the ovaries. This study will focus on the adenocarcinomas (n = 7). Median age was 54 (34–82), 5 were post-menopausal. In 6 cases the primary tumour was colonic. Both ovaries were involved in all cases of metastatic cancer and 83 % were lymph node positive. Four had a KRAS mutation. All were CK20 positive and 83 % were CK7 negative, giving a positive predictive value of this combination of tumour markers of 100 %. Tumour markers, where performed, were raised in all cases. All patients had other metastatic deposits (liver, lung, peritoneum). Post-operative morbidity rate was 43 %, all were Clavien-dindo grade C2. All patients received adjuvant chemotherapy. Median survival following diagnosis was 26 months (18–65). Of note, the patient with negative lymph nodes experienced the longest survival. Conclusions: Synchronous ovarian metastases from colorectal cancer are rare, occur in younger females, and confer poor prognosis despite oophorectomy. These cases should be discussed by multidisciplinary teams to question the potential benefit of extensive resection. Conflict of interest: None. Disclosures: None.

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Re-Audit of Perioperative Medical Records for Patients with Neck of Femur Fractures

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344

An Unusual Cause of Appendicitis Fanning E, Sutton-Fitzpatrick U, Watson G, Veale D

McNamara I, Reid L, Butler A Mid-West Intern Training Network, University Hospital Limerick, Dooradoyle, Limerick; Intern Network: University of Limerick Intern Network Objectives: The goal of this audit is to improve patient safety. The Health Information and Quality Authority (HIQA) identified low standards of basic documentation in neck of femur fracture patients. High quality documentation supports and allows the delivery of high quality evidence based care. A multi-disciplinary team successfully collaborated to improve standards of documentation in the orthopaedic department. We present the latest iteration of the audit cycle, providing evidence of improved documentation. The aim overall was [80 % compliance with 31 criteria. Design/methods: Data Collection The data was collected retrospectively from the patient’s healthcare records, mostly contained within the admission note. The total number of patients included in this audit cycle was N = 14. Disciplines involved: Orthopaedic Teams, Clinical Nurse Specialist, Clinical Audit Officer Results: Adherence graph September 2014 vs Mar/April 2014.

Conclusions and recommendations: It is evident from this audit that the implementation of guidelines and education of junior doctors improves documentation records. Education of junior staff was achieved by introduction of posters in the wards. Every junior doctor was assigned a stamp with their initials that was used in each medical entry to manage time constraints. The findings were presented to the orthopaedic consultants during an audit presentation session. Their feedback and further improvements has been requested. Following implementation of these recommendations, a re-audit will be carried out. Standard • • •

National Standards for Safer Better Healthcare (HIQA) (June 2012) Health Service Executive Standards and Recommended Practices for Healthcare Records Management (May 2011) Guide to Professional Conduct and Ethics for Registered Medical Practitioners

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Rheumatology Department, St Vincent’s University Hospital, Dublin; Intern Network: Department of Rheumatology, St Vincent’s University Hospital, UCD Intern Training Network Introduction: Parasitic rheumatism is extremely rare and there are only isolated case reports in the literature. According to the criteria, the following should be present for parasitic rheumatism to be diagnosed: • • • • • •

Inflammatory arthropathy Residence in or travel to an area of epidemic parasitosis Absence of radiological changes Identification of parasites Inefficacy of antirheumatic drugs Efficacy of specific parasitic treatment1.

Description/case presentation: An 18-year-old lady presented with acute small joint arthritis. One week after returning from travelling in Zambia she developed early morning stiffness and swelling of the hands, wrists and ankles. She also complained of abdominal pain and fatigue. Positive findings on physical examination included pyrexia, swelling of the metacarpophalangeal joints, wrists and ankles bilaterally and difficulty straightening her fingers. Investigations were unremarkable demonstrating negative rheumatoid and malarial screens and mildly elevated CRP (5.4 mg/ L). Plain films showed no radiological change. She was diagnosed with reactive arthritis and treated with deltacortril to which she rapidly responded. However, she represented to ED 1 month later with acute onset epigastric pain radiating to the RIF. She was diagnosed with appendicitis and underwent an appendectomy. The pathology report showed an appendiceal intra-luminal parasitic organism, features consistent with Enterobius vermicularis. Enterobius vermicularis is the most common helminthic infection in Western Europe and most prevalent nematodal infection worldwide. Presentation is mostly asymptomatic. Pruritis ani is the most frequent clinical manifestation with appendicitis, eosinophilic enterocolitis and vulvovaginitis representing rare presentations. There are numerous rheumatic syndromes related to bacterial, mycobacterial, viral, and fungal infections. However, rheumatic manifestations of parasitic diseases are extremely uncommon. Therefore, diagnosis relies heavily on epidemiologic awareness and requires high degree of clinical suspicion2. References: 1. Doury P (1981) Parasitic rheumatism. Arthritis Rheum 24:638–639 2. Stanford LP (2002) Rheumatic manifestations of parasitic diseases. Semin Arthritis Rheum 31(4):228–247

An Audit of Adherence to Pre-operative Assessment Testing Protocol in the Pre-operative Assessment Clinic at University Hospital Limerick Smyth C, Donoghue L, O’Riain S Department of Anaesthesia, University Hospital Limerick, Dooradoyle, Limerick; Mid-West Training Network

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Objectives: Patients can be sent to an anaesthetic pre-operative assessment clinic, prior to elective procedures, to assess fitness for surgery. A local protocol was developed to specify pre-operative tests for patients depending on the surgery involved and their comorbidities1,2. The aim was to assess: (1) level of compliance with the protocol. (2) Only investigations required by protocol are performed. (3) Results are available before the patient presents for surgery. (4) Whether the number of echocardiograms required in preoperative assessment warranted a dedicated clinic. Design/methods: Data from 26 patients was collected from clinical notes over a 2 week period, either as they presented for surgery, or post-surgery. Results: Compliance with testing was found to be 76.9 % overall. Highest compliance was with those sent for full blood counts and chest X-rays, with 100 % of patients receiving these tests correctly. Lowest compliance was with coagulation screening at 7.6 % and liver function tests, at 69.2 %. Drug levels were not ordered when indicated for two patients. 100 % of results were available and reviewed before surgery. 49 echocardiograms were ordered and completed in 2014. Conclusions: Overall, adherence to the protocol is high. For coagulation screening, adherence is very low with all patients being tested. The protocol implies that coagulation screening is mandated only in cases of possible personal or family history of coagulopathy, liver disease or use of anticoagulant medications. Before re-audit, the reason for testing all patients should be clarified, and the protocol changed, if required. Drug level screening should be reviewed. References: 1. O’Riain S, Harmon D (2009) Preoperative assessment Guidelines 2. Pre-Operative Assessment Clinic Regional Working Group (2013) Protocol for the assessment and management of patients attending the pre-operative assessment clinic

The White Cell Count in the First Trimester of Pregnancy and Gestational Diabetes Mellitus Furey MA, O’Higgins AC, Egan A, Gaffney G, Dunne F University Hospital Galway, Newcastle Road, Galway Background: Outside of pregnancy, the development of type 2 diabetes mellitus (T2DM) is associated with a higher white cell count (WCC), which precedes the onset of diabetes. Gestational diabetes mellitus (GDM), a disease predominantly of insulin resistance, is similar in pathophysiology to T2DM. The association between WCC in early pregnancy and the development of GDM has not been described. Aims: We examined the association between the first trimester WCC and the subsequent development of T2DM. Methods: Women were recruited at their first antenatal visit. Height and weight were measured and body mass index (BMI) calculated, and a full blood count (FBC) was performed. Women were screened for GDM with a 75 g OGTT between 24 and 28 weeks gestation. Clinical details were obtained from computerized medical records. Results: There were 1225 women included in the study. The mean age was 30.4 years, mean BMI 25.8 kg/m2, 18.2 % were obese and 18.8 % were diagnosed with GDM in this cohort. Women with GDM

S281 were more likely to be older (p \ 0.001) and obese (p \ 0.001). WCC increased with increasing BMI in the total cohort (p \ 0.001). The mean WCC in women without GDM was 8.64 9 109/L compared to 9.06 9 109/L in those with GDM (p = 0.004). On multivariate analysis when controlling for BMI the WCC was not an independent predictor of GDM in non-obese women (p = 0.10) or obese women (p = 0.71). Conclusion: In this novel study, we have shown an association of increasing WCC with increasing BMI. However the WCC was not an independent predictor for the development of GDM.

Software Development of Prototype Colorectal Cancer Database Lally K, Coffey C UHL Dooradoyle Limerick; Intern Network: UL Intern Training Network Background: The number of colorectal cancer patients treated in University Hospital Limerick (UHL) has increased dramatically since the reconfiguration of surgical services. Significant opportunities now present for population-based clinical based research (e.g. for the generation and validation of outcome predictors). An integrated, electronic, prospectively maintained colorectal database with a graphical user interface (GUI) would greatly benefit such studies. This paper describes an approach to develop such a database. Methods: An appropriate dataset was developed based on an preexisting departmental dataset1. Data entry points related to demographics, pathological and radiological findings (totalling over 150). This dataset was amended to remove genuine patient data and replace it will false that to act as a placeholder. This data was then stored in a relational database management system MYSQL hosted on a Linux computer using Apache web server software. Based on the database prototype and the GUI prototype a software suite was developed using the programming language PHP and the open source web application framework CAKEPHP. Results: A GUI colorectal cancer database was produced which had 6 key functions. • Log in securely • Insert new patient data • Edit existing patient data • Delete patient data, • Search patient data • Create reports on the data set and export it to statistical analysis. The finished prototype was a web based application that was accessible through most devices capable of viewing typical WebPages, e.g. Laptops, Tablets, Mobile Phones. Security was implemented via a generic server username and password and an individual user name and password. Conclusions: This project was successful in producing a usable, working prototype of a colorectal cancer application that can be adapted for use with patient data in UHL. References: 1. Hogan J, Judge C, O’Callaghan M, Aziz A, O’Connor C, Burke J et al (2013) Introducing a novel and robust technique for determining lymph node status in colorectal cancer. Ann Surg

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Protein Tyrosine Phosphatase Receptor-Type D (PTPRD) and its Effects on Type-One Interferon Production in the TRIF Pathway of TLR-Three and TLR-Four O’Donnell L St. Vincent’s University Hospital Background: PTPRD had been previously identified as a good candidate for a tumour suppressor gene1. As the innate immune system has been proven to be involved in tumourigenesis2, much research is underway to elucidate the particular pathways by which components of the innate immune system affect tumour development. Aims: To analyse the effects of PTPRD on the innate immune system3, specifically on the TIR domain-containing adaptor inducing interferon-b (TRIF) pathway which is activated following toll-like receptor-three and four stimulation (TLR-three, TLR-four). Methods: Cell culture, cell transfection, luciferase analysis, timepoint stimulation of TLR-four on cells to assess upregulation of PTPRD which involved designing primers for PTPRD for PCR testing. Results: The results showed that PTPRD is involved in the TRIF pathway of the innate immune system and may have an effect in reducing type-one IFN expression and that PTPRD may in fact associate with a major component of the TRIF pathway, tank-binding kinase one (TBK one). Upregulation of PTPRD was also demonstrated following TLR-four stimulation of cells at different timepoints. Conclusion: The conclusion was that PTPRD is present in TLR-three and TLR-four signalling and that it may reduce type-one IFN production. However from the literature review and the known antitumour action of type-one IFN, it is unlikely that this occurs in isolation and probably extends to an effect on other inflammatory cytokines. References: 1. Beals JK (2008) PTPRD a strong candidate for new human tumour suppressor gene [internet]. Medscape. Available from: http://www.medscape.com 2. Smyth MJ (2005) Type I interferon and cancer immunoediting. Nat Immunol 6(7):646–648 3. An H, Zhao W, Hou J et al (2006) SHP-2 phosphatase negatively regulates the TRIF adaptor protein-dependent type I interferon and proinflammatory cytokine production. Immunity 25(6):919–928

Left Internal Iliac Artery Mycotic Pseudo-Aneurysm Nolan J, Dodwall J, Barry M, Sheehan S

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 antibiotics and subsequent surgical intervention. The patient underwent a repair of the internal iliac pseudo-aneurysm from an extra peritoneal approach. The internal iliac orifice was over sewn and a rifampicin soaked 8 mm Dacron jump graft was used as an anastomosis between the left common iliac artery and the left external iliac artery. The plan was to continue IV antibiotics for 10 days, followed by oral antibiotic therapy. Coined by William Osler in the 19th century, mycotic aneurysms originate from a pre-existing aneurysm that becomes secondarily infected, or conversely a bacteraemic episode can result in aneurysmal degeneration of the arterial wall. The misnomer ‘Mycotic’ leads us to believe that this is a fungal process; however common pathogens include staphylococcus spp. and salmonella spp. with treatment options being antibiotic therapy and subsequent surgical intervention with/without revascularisation.

A Suspicious Red Eye: a Case Report of Absidia Keratitis Brennan R Intern Network: Dublin Mid Leinster (UCD) Introduction: Infective keratitis is a sight threatening disease that is both avoidable and treatable. Corneal infections represent the major worldwide cause of unilateral blindness1 and place a significant burden on resources, especially in eye casualty departments. There is a global variation in causative organism based on climate and other risk factors2. Mr. MM, a 32-year-old gentleman, presented to a tertiary referral centre eye casualty department with a short history of a foreign body sensation, epiphora and decreased visual acuity (6/12, previously recorded 6/6) in his right eye. He had a history of trauma to the same eye 3 months previously. Examination showed a 0.7 9 0.7 cm ulcer in his cornea with a central defect. Corneal scrapings showed fungal hyphae and eventually grew Absidia species. He was admitted later discharged on several months of topical Amphoteracin B eye drops. Mr. MM made a good recovery, with visual acuity returning to 6/6. Fungal keratitis represents 13 % of cases of microbial keratitis in the MMUH population. Candida species compose the majority (57 %) of these. Prompt, appropriate treatment is crucial to minimize morbidity from this condition. References: 1. (2008) Risk factors and causative organisms in microbial keratitis. Cornea 27(1):22–27 2. Otri AM, Fares U, Al-Aqaba MA et al (2013) Profile of sightthreatening infectious keratitis: a prospective study. Acta Ophthalmol 91:643–651

Department of Vascular Surgery, SVUH; Intern Network: Dublin Mid-Leinster A 61-year-old male presented to the ED with a 4 days history of night sweats, rigors and chest pain. Past medical history was significant for a recent eczematous flare and dental treatment. Examination was unremarkable and blood tests revealed leukocytosis, elevated lactate and elevated CRP/ESR. Peripheral blood cultures were positive for MSSA. Investigations for a source of infection including chest X-ray, urinalysis, TTE/TOE and MRI spine were negative. CTTAP revealed a 2.43 cm mycotic pseudo-aneurysm at the origin of the left internal iliac artery. Vascular department recommendations included completion of IV

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Patient Satisfaction Survey in a Rheumatology Department Nic Shamhra´in A, Molloy E Department of Rheumatology, St. Vincent’s University Hospital, Elm Park, Merrion Road, Dublin 4, Ireland Aim: The aim of the audit was to assess the satisfaction of patients attending the rheumatology outpatient clinic at St. Vincent’s Hospital.

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Methods: For 2 weeks of Monday to Friday clinics in the Rheumatology department (15/09/14–26/09/14), questionnaires were handed out to all patients in all different clinic types as they registered at their outpatient appointment. The Questionnaire used was adapted from the Royal College of Physicians 2004 guidelines ‘‘How user friendly is your outpatient department’’1. All responses were anonymous. A total of 100 questionnaires were completed. Using Excel the data from these questionnaires was inputted and analysed. Results: (A) Patient demographic information: N = 100, 64 % female, mean age 54, range 16–87. Number of years attending the clinic, years from onset of disease to presentation to the clinic and activity of disease was measured. (B) Spectrum of illnesses (C) Frequency at which patients attended members of the multidisciplinary team (D) Information about the clinic itself: waiting times, location, accessibility (E) Communication standards Conclusions: The majority of patients felt that the Rheumatology Department met the standards of the Royal College of Physicians. The main area of weakness was poor communication between the clinic and the patients and the waiting times for urgent appointments during a disease flare. Interestingly 72 % of patients felt that waiting times were acceptable. These guidelines provide useful structures for clinics such as this one, to assess their standards, implement changes and therefore improving patient care and services. Reference: 1. 1 Royal College of Physicians (2004) How user friendly is your outpatient department? A Guide for Improving Services. Royal College of Physicians

Can Interns Teach? Establishment of a Structured Intern-Led Teaching Programme for Irish Final Year Medical Students Jenkinson A, Kelleher E, Offiah G Dublin North-East Intern Network, Royal College of Surgeons in Ireland; Intern Network: Dublin North-East Background: Near-peer teaching is a relatively new and expanding area of medical education. The benefit to medical students has been demonstrated in numerous contexts around the world1–3. We established a structured intern-led teaching programme in the context of an intern training network. We then examined the attitudes and experiences of participating students. Methods: Final year medical students were divided into groups of six over two 8-week teaching blocks and assigned a medical or surgical intern on a weekly basis to provide a one hour teaching session. At the end of each block, a feedback questionnaire was distributed to participating students to evaluate their attitudes and experiences of this new teaching modality. Results: Seventy-five students responded to the questionnaire. Tutorial topics included clinical examination, history taking, prescribing, and emergencies. The vast majority (81 %) of students considered the tutorials to be beneficial. Seventy-seven percent felt they could ask interns questions they would be reluctant to ask more senior doctors. Fifty-seven percent felt there was a more comfortable

S283 environment and information taught was considered more relevant. A significant number (55 %) of students felt less nervous about exams after the intern-led tutorials. Conclusions: The establishment of a structured intern-led teaching programme was well-received by final year medical students. This study shows that interns are a valuable teaching resource in the medical schools. In addition, because medical students can more easily relate to interns, this group is well-placed to ease anxiety about exams and the transition to being a doctor among medical students. References: 1. Ten Cate O, Durning S (2007) Peer teaching in medical education: twelve reasons to move from theory to practice. Med Teacher 29(6):591-599 2. Bulte C, Betts A, Garner K, Durning S (2007) Student teaching: views of student near-peer teachers and learners. Med Teacher 29(6):583–590 3. Lockspeiser T, O’Sullivan P, Teherani A, Muller J (2008) Understanding the experience of being taught by peers: the value of social and cognitive congruence. Adv Health Sci Educ 13(3):361–372

Incidence and Prevalence of Anaemia in a Cohort of 40 Patients Post Lung Transplantation Walsh S, Alam J, Egan J Intern Network: UCD Intern Network Background: Lung transplant recipients are predisposed to anaemia due to a combination of perioperative blood loss, the effects of immunosuppressant agents and chronic illness1. Methods: A retrospective cohort study was performed to identify the incidence and prevalence of anaemia in lung transplant recipients. Data was collected pre transplant, and at 1,6,12 and 24 months post transplant. Anaemia was defined as less than 12 g/dl in females and 13 g/dl in males. The severity of anaemia was graded as mild if haemoglobin 11–11.9 g/dl in females and 11–12.9 in males. Anaemia was categorized as moderate if between 8 and 10.9 g/dl and severe if less than 8 g/dl in either gender2. Results: The mean age at transplant was 45.9 years (SD 16.5). 22 were males and 18 females. The underlying disease process was idiopathic pulmonary fibrosis in 16, cystic fibrosis in 14, COPD in 6 (3 of which had alpha-1 antitrypsin deficiency), and other pathologies in 4. Over the 2-year-period of review only 2 patients never meet the criteria for anaemia. 30 % of patients were found to be anaemic pre transplant, 90 % at 1 month post transplant, 85 % at 6 months, 85 % at 1 year and 72 % at 2 years. 79.2 % (103/130) of anaemic blood counts were normocytic, microcytic in 3.8 % (5/130), macrocytic in 16.9 % (22/130). 56.15 % (73/130) of blood counts showing anaemia were classified as mild, 43.85 % (57/130) were classified as moderate and none showed severe anaemia. Conclusions: Anaemia is a common finding in the lung transplant population. Further study is needed to assess the impact of this on morbidity and mortality. References: 1. Yabu J, Winkalmayer W (2011) Post transplantation anaemia: mechanism and management. Clin J Am Soc Nephrol 6(7):1794–1801 2. WHO (2011) Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System: World Health Organisation

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Detection of EGFR Mutation and ALK Rearrangements in the Selection of Patients for Targeted Therapies McDonnell NA1, Scott A1, Colesky F2, Breen D1 1 Department of Respiratory Medicine; 2Department of Pathology, University College Hospital Galway

Background: Recent literature has demonstrated relationships between specific genomic alterations and response of advanced-stage lung cancer to targeted therapies. The CAP/IASLC/AMP guideline offers evidence-based recommendations for the molecular analysis of lung cancers for EGFR mutations and ALK rearrangements1. Consequently, it directs patient selection for therapy with EGFR or ALK inhibitors in patients with advanced-stage lung adenocarcinoma. This guideline prompted the lung cancer multidisciplinary team in UCHG to analyse the rate of lung adenocarcinoma cases sent for molecular analysis. Aims: The aim of this study was to establish what percentage of patients that had a histologically confirmed lung adenocarcinoma had molecular analysis for EGFR mutations and/or ALK rearrangements. Methods: Data was supplied by the Department of Pathology, UCHG. All cases of histologically confirmed lung carcinoma over a 1-year-period were identified giving an overall sample population of 165, 49 of which were confirmed as lung adenocarcinoma. Results: Of all patients with identified lung adenocarcinoma, 17 had both EGFR mutation and ALK rearrangements sent, and 7 cases had EGFR sent only. The remaining 25 cases (51 %) had not been sent for molecular analysis. Of these cases, 21 (84 %) had sufficient tissue for analysis, yet a request for molecular studies had not been sent. Conclusions: Over half of patients with identified lung adenocarcinoma did not have molecular analysis, thus preventing their consideration for targeted therapies. The authors plan to provide education for the relevant parties and propose that the topic will be reaudited in 1 year’s time. Reference: 1. Molecular Testing Guideline for the Selection of Lung Cancer Patients for EGFR and ALK Tyrosine Kinase Inhibitors (2013) College of American Pathologists (CAP), the International Association for the Study of Lung Cancers (IASLC), and the Association for Molecular Pathology (AMP). Archives of Pathology and Laboratory Medicine. J Thoracic Oncol J Mol Diagn

Massive Mediastinal Lymphadenopathy-Don’t Forget the Infectious Causes Shim R, O‘Brien A Department of Respiratory Medicine, University Hospital Limerick, Dooradoyle, Limerick; UL Intern Training Network; UL Intern training network Introduction: Tuberculosis associated mediastinal lymphadenopathy has been well described in adults of Indian subcontinent, however is rarely found in adults of European extraction1,2. Description/case presentation: A 23-year-old Indian lady presented with 2 months history of general malaise, non-productive cough, night sweats and weight loss, no haemoptysis or exposure to

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 tuberculosis cases. She had last travelled to India 14 months previously. Physical exam was normal. CXR showed consolidation in the left upper lobe with air bronchograms and peripheral modularity with a prominent mediastinum. There was no initial response to antibiotics and she required readmission 1 month later for persistent symptoms and radiological findings. CT scan demonstrated a nodular pattern of the left upper lobe, small left pleural effusion and pericardial effusion associated with extensive large volume low attenuation mediastinal lymphadenopathy. At this time sputum cultures from the initial presentation demonstrated mycobacterium tuberculosis sensitive to antituberculosis medications. She was commenced on anti-tuberculosis treatment with significant normalization in radiological abnormalities. In Ireland 2013, a total of 384 tuberculosis cases were reported, from this only 19 cases presented with intrathoracic lymphatic involvement3. Tuberculosis associated mediastinal lymphadenopathy can therefore be a diagnostic dilemma, as this is a rare presentation in adults of european decent1,2. The more common presentations include sarcoidosis, lymphoma and carcinoma. Hence it is important to consider the origin of a patient when formulating the differential diagnosis. References: 1. Bloomberg TJ, Jean Dow C (1980) Contemporary mediastinal tuberculosis. Thorax 35:392–396. http://thorax.bmj.com/content/ 35/5/392.full.pdf 2. Mehmet M, Akgun M, Kaynar H, Mirici A, Gorguner M, Saglam L et al (2004) Mediastinal lymphadenopathy due to mycobacterial infection. Jpn J Infect Dis 57:124–126 3. National TB surveillance: a report by Health protection surveillance centre. Quater 1–4 2013 TB report

Falls Presenting to the Emergency Department: the Need for Interface Geriatrics and an Emergency Frailty Unit Cronin P1, McDonough A1, Browne J1, Salter N2 1 Medicine for the Elderly; 2Emergency Medicine, St. Vincent’s University Hospital, Dublin 4

Introduction: Falls and falls-related injuries are becoming an increasingly common presentation to the Emergency Department. Falls often result in significant injury and are a leading cause of functional decline, hospitalisation and early entry into residential care1. Due to our ageing population; we can expect that falls will continue to consume a significant portion of health service demand in the future. Aims: To collect data on patients presenting with falls to the Emergency Department in St. Vincent’s University Hospital with a fall/collapse. Materials and methods: Routine data was obtained on all patients aged over 50 years presenting to the Emergency Department over a 23-week-period with a history of fall/collapse at triage. Data was then analysed to assess length of stay, presence or absence of fracture, fracture type and discharge outcome. Results: One thousand four-hundred and twelve patients presented to the Emergency Department with falls over a 23-week-period, with 36.2 % (N = 511) requiring admission. Of these, 33.9 % had sustained a fracture. Hip fractures represented the most common fracture type (49.5 %). Fractures were more prevalent in female patients across all fracture types, with the percentage of fractures increasing with age. Average length of stay in the fracture group was 18 days

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compared with 15.2 in the non-fracture group. This represents 10.2 % of total hospital bed days in St. Vincent’s University Hospital annually. In regards to discharge outcomes; 4.7 % required long-term care and the mortality rate of those admitted was 5.1 %. Conclusions: Falls make up a substantial proportion of overall emergency department presentations and hospital bed days in St. Vincent’s University Hospital. Planning an efficient falls pathway or targeted service for this patient cohort is crucial. Interface geriatrics involves implementation of rapid Comprehensive Geriatric Assessment to acute elderly admissions in hospital, with hospital and community geriatric care working in tandem. This can take the form of an Emergency Frailty Unit, a geriatrics unit, based in the Emergency Department and working alongside the emergency physicians. This model has demonstrated efficacy in other institutions2 and could be used in St. Vincent’s University Hospital to improve patient outcomes and cost effectiveness.

References: 1. Koch WM, Ridge JA, Forastiere A, Manola J (2009) Comparison of clinical and pathological staging in head and neck squamous cell carcinoma: results from Intergroup Study ECOG 4393/RTOG 9614. Arch Otolaryngol Head Neck Surg 135(9):851–858. Epub 2009/09/23 2. Agarwal V, Branstetter BF 4th, Johnson JT (2008) Indications for PET/CT in the head and neck. Otolaryngol Clin North Am 41(1):23–49

References: 1. Tinetti ME, Williams CS (1997) Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med 337:1279–1284 2. Conroy S, Ferguson C, Woodward J, Banerjee J (2010) Interface geriatrics: evidence-based care for frail older people with medical crises. Br J Hosp Med 71:98–101

Conway M

Clinical and Pathological Staging of Head and Neck Squamous Cell Carcinoma Blake A UCD Intern Training Network Background: The TNM staging system is used in the staging of head and neck tumours, and influences both management and prognosis. Clinical staging involves assessing the size and extent of tumour and nodal involvement using a combination of clinical examination, endoscopic and radiographic methods. The differences between preoperative clinical and post-resection pathological staging of head and neck squamous cell carcinoma (HNSCC) in an academic teaching hospital were compared. Methods: A retrospective review of 49 patients who underwent surgical resection of HNSCC. Differences in clinical and pathological staging were assessed according to tumour site, age of patient, smoking status, whether it was recurrent disease, tumour grade and whether the patient had received radiotherapy prior to staging. Results: Exact TNM concordance between clinical and pathological staging occurred in 57 % of patients. This is similar to larger studies on this topic1. Both T and N stages were much more likely to be clinically understaged than overstaged, with 88 % of discordance resulting in clinical understaging. T stage assessment was most likely to show disparity, being nearly twice as likely to be discordant than N stage. Tumour grade had a negligible effect on staging discordance. Conclusion: Clinical understaging was found to be much commoner than overstaging and was influenced by patient characteristics. Patients with recurrent disease and who had previously received radiotherapy treatment had a much greater risk of being understaged, whilst nonsmokers were the group most likely to show no disparity between staging. This is likely due to underlying abnormal histological changes complicating the assessment of tumour extent and nodal involvement. Increasing use of advanced imaging such as PET/CT may lead to more accurate clinical staging of HNSCC in the future2.

A Case of Levetiracetam Induced Fatigue in an Elderly Patient with a Recent Diagnosis of Partial Seizures Post CVA

University Hospital Limerick, Dooradoyle, Limerick; Mid-West Intern Network Introduction: Levetiracetam is authorised for the use in the European Union as a monotherapy for the treatment of partial seizures. It is generally well tolerated by patients but a number of rare side effects related to it can limit its use, particularly in an elderly population. Description/case presentation: A 73-year-old gentleman with a history of a CVA 6 months previously was admitted to hospital after an episode of sudden onset dysarthria, facial droop, limb jerking and disorientation to surroundings. These symptoms resolved in the ambulance before the patient arrived in the Emergency Department. Full work-up indicated no evidence of TIA or new CVA and he was discharged home. He was re-admitted 2 weeks later after two episodes of recurrence since discharge. The patient was this time reviewed by Neurology. A diagnosis of Complex Partial Seizures was made and the patient was commenced on Levetiracetam 250 mg b/d. The patient was discharged home. He re-presented to the Emergency Department 4 days post discharge with a complaint of new onset generalized progressively increasing fatigue. He was reviewed by Neurology again and it was deemed this was a side effect of his Levetiracetam. This medication was held and the patient was commenced on Sodium Valproate 300 mg o/d. The symptoms resolved and patient was discharged on same. Levetiracetam is an effective and generally well tolerated monotherapy for the treatment of partial seizures. A rare side effect of its use is fatigue which should be monitored closely for when prescribing this medication, particularly so in an elderly patient where this side effect may be under diagnosed and could be attributed to a different cause.

Acute Aortic Dissection Presenting with a Cold Blue Painful Leg Finnegan R, Chughtai Z Department of Cardiothoracic Surgery, Mater Misericordiae University Hospital, Dublin Introduction: Acute aortic dissection occurs when blood passes through a tear into the aortic media, separating the media from the intima and creating a false lumen.

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S286 Case presentation: A 44-year-old man presented with sudden onset of acute severe right hip and thigh pain. This was associated with a short episode of mild chest discomfort, which was relieved by GTN spray. There was no history of trauma. His medical history revealed multiple risk factors for vascular disease including hypertension and a significant smoking history. Examination revealed a pale cold pulseless right leg. Examination of cardiac and respiratory systems revealed no abnormalities. The main differential diagnosis at this stage was acute lower limb ischemia. However CT Aorta revealed a complex type A aortic dissection and this patient underwent emergency surgical repair involving graft to ascending aorta and stent to descending aorta. Post operatively he had a prolonged ICU stay developing multiple complications, including severe right lower limb weakness due to lumbosacral ischemia as a result of the dissection. This resulted in this patient being wheelchair bound and a hoist transfer. However, he is currently doing very well in a rehabilitation facility. Discussion: The most common presenting symptom of acute aortic dissection is severe ‘tearing’ central chest pain. However about 10 % of cases can present with isolated lower limb ischemia1. It is important to detect aortic dissections early as they are associated with a very high mortality rate, increasing by 1 %/hour without intervention. A low index of suspicion and urgent CT was life saving in this case. Reference: 1. Lee C, Chang C, Tsau Y, Wu C (2012) Isolated lower limb ischaemia as an unusual symptom of aortic dissection. Cardiovasc J Afr 23:13–14

HER 2 Positive Breast Cancer: Late Relapse or New Primary? Synnott P, Keane M Intern Network: West-North-West Introduction: This case concerns an unusual presentation of malignant breast carcinoma in a 35-year-old lady who was 7 years post mastectomy for left-sided invasive ductal carcinoma. Case presentation: A 35-year-old lady was admitted for a bilateral deep inferior epigastric perforator flap surgery. During surgery a tan nodule was found in association with her left chest wall. She underwent resection of the skin paddle and capsule of the left breast, and lymph nodes from the lateral chest wall and axilla were removed. Histology showed a mass diffusely infiltrated with invasive ductal carcinoma, with lymphovascular and perineural invasion. This was oestrogen, progesterone and HER-2 positive. Staging demonstrated no metastatic disease. Seven years previously, aged 28, the patient had a T3N1M0 Grade 3 invasive ductal carcinoma of her left breast. This was HER 2 positive and oestrogen and progesterone receptor negative. At this time she received neo-adjuvant chemotherapy (doxorubicin), a radical mastectomy and axillary clearance, and adjuvant chemo-radiotherapy (paclitaxel). She also completed 1 year of transtuzumab. She went on to have a prophylactic right mastectomy. Of note she had no family history of breast cancer. Discussion: The median interval to locoregional recurrence postmastectomy is 2–3 years and 89 % arise within 5 years1. Given the change in hormone receptor status, and the 7-year disease free

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 interval, this patient’s disease is being managed as new primary breast cancer. She is currently undergoing adjuvant treatment with paclitaxel and transtuzumab and will then be considered for letrozole with goserelin, or possible oopherectomy. Reference: 1. Willner J, Kiricuta IC, Ko¨lbl O (1997) Locoregional recurrence of breast cancer following mastectomy: always a fatal event? Results of univariate and multivariate analysis. Int J Radiat Oncol Biol Phys 37(4):853–863

Investigation of Sexual Dysfunction and Dyspareunia After Vaginal Repair Surgery? Craven S1,2, Ryan E1,3, Khalid A1, Agnew G 1

Department of Obstetrics and Gynaecology, National Maternity Hospital, Holles Street, Dublin 2; 2St. James’s Hospital, James’s Street, Dublin 8; 3St. Vincent’s University Hospital, Elm Park, Dublin 4 Dublin South East Intern Network

Background: Urinary incontinence and pelvic organ prolapse exist in 40–65 % of women1. The effect of correcting these disorders on women’s sexual function has been poorly studied, with most efforts focusing on cure of incontinence2. Many reports on sexual function after vaginal repair surgery have shown higher rates of sexual dysfunction and worsening dyspareunia3. The research objective was to assess the prevalence of dyspareunia following vaginal repair surgery. Methods: All women undergoing vaginal repair surgery from 1 January 2013 to 31 December 2013 were retrospectively enrolled. Participants completed validated sexual function questionnaires [Pelvic Organ Prolapse/Incontinence Sexual Questionnaire (PISQ), and Female Sexual Function Index (FISI)] at an interval of 6–12 months post operatively. Procedures included vaginal hysterectomy (VH), vaginal vault suspensions, sacrocolpopexy, anterior and posterior (AP) vaginal repairs and mid-urethral sling (MUS) insertions in various combinations depending on presenting complaint and examination findings. Results: One-hundred-and-forty-two questionnaires were distributed, with a response rate of 60.8 % (n = 87). Mean age was 56.8 (range 34–81). 68 % (n = 59) women were sexually active post-operatively. Mean age was 56.8 (range 34–81). 90 % of the fifty-nine sexually active women reported improved or unchanged sexual experience post operatively, 54 % (n = 32) had improved sexual experience, 36 % (n = 21) felt no change, and 3 % (n = 2) felt deterioration. Both participants with deterioration in sexual function had VH with AP repair. Conclusions: Our data suggests surgical correction of pelvic floor dysfunction results in improved sexual experience for the majority of women. The risk of deterioration in sexual experience is small and women should be counselled accordingly. References: 1. Rogers RG, Kammerer-Doak D, Darrow A et al (2006) Does sexual function change after surgery for stress urinary incontinence and/or pelvic organ prolapse? A multicenter prospective study. Am J Obstet Gynecol 195:e1–e4 2. Kelleher CJ, Cardozo LD, Khuller V (1997) A new questionnaire to assess the quality of life of urinary incontinent women. BJOG 104:1374–1379 3. Maaita M, Bhaumik J, Davies AE (2002) Sexual function after using tension-free vaginal tape for the surgical treatment of genuine stress incontinence. BJU Int 90:540–543

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Documentation of Suicide Risk in Patients Presenting for Assessment, an Audit Cycle at an Acute Psychiatric Unit

CEM guidelines recommend:

Feyzrakhmanova M, Kinahan J, Thakore J

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St. Vincent’s Hospital Fairview, Affiliated to Mater Misericoridae University Hospital; Intern Network: DML

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Introduction: St. Vincent’s Hospital Fairview is a secondary level inpatient general adult psychiatric hospital in North Dublin with an acute psychiatric assessment unit which provides a 24/7 service accepting self-presentations, primary and secondary care referrals. Aims: (1) To audit whether suicide risk is documented at each assessment in line with the HSE Risk Management policy1. (2) To audit the terms used to describe suicide risk for consistency with the Columbia Classification Algorithm of Suicide Assessment2. Materials and methods: Data were collected from retrospective chart reviews of presentations in a 62-day-period, starting 31 days before and ending 31 days after an educational intervention. The HSE Risk Management policy and C-CASA terms were used as the standards. Results: Two-hundred and twenty-seven patients presented for assessment. The percentage of assessments with no documentation of risk decreased from 14 to 11 % following intervention. The most commonly used terms were as follows, with their frequencies before and after intervention and the asterisk denoting terms defined in C-CASA: suicidal ideation* (or SI) (49, 55 %), plan (37, 32 %), intent (29, 26 %), death wish (or PDW) (16, 17 %), preparation (8, 2 %), suicidal thoughts (8, 6 %), suicide attempt* (3, 4 %), suicidality (3, 3 %) and preparatory acts* (2, 10 %). Conclusion: Suicide risk is not documented at every assessment and the terms used are not standardised. The audit cycle resulted in a modest decrease in the number of assessments with no documentation of risk and an increase in the use of standardised terms. References: 1. Health Service Executive. Risk Management in Mental Health Services (Undated) 2. Posner K, Oquendo MA, Gould M et al (2007) Columbia classification algorithm of suicide assessment (C-CASA): classification of suicidal events in the FDA’s pediatric suicidal risk analysis of antidepressants. Am J Psychiatry 164(7):1035–1043

An Audit on the Level of Compliance with the College of Emergency Medicine (CEM) Guidelines for Management of Fractured Neck of Femur (NOF) in Sligo Regional Hospital’s Emergency Department Lehane D, Hickey F, Sweeney M, Killeen M, Cunningham K Emergency Department, Sligo Regional Hospital; NUI Galway Intern Training Network Background: The significant morbidity and mortality associated with a fractured neck of femur can be reduced with good clinical practice.

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75 % of patients in moderate-severe pain should receive appropriate analgaesia within 30 min of their arrival and 100 % within 60 min 90 % of patients should have X-rays within 60 min 75 % of confirmed fractured NOF should be referred within 120 min All patients should be admitted within 4 h.

The aim of the audit was to assess compliance with CEM guidelines. It was also assessed whether notifying the emergency department (ED) of the patient before arrival would improve compliance with the guidelines. Methods: This is a retrospective study on all cases of suspected fractured NOF admitted through the ED from August to December 2014. The ED has a care pathway in place for all suspected neck of femur fractures. Data was abstracted from the last page of the care pathway which contains questions specific to the audit. This was used to formulate the data. Results: Preliminary data suggests we were unable to achieve standards compliant with CEM guidelines. Notifying ED in advance also appeared to have no improvement in time efficiency of management on arrival. Conclusion: The audit suggests need for improvement in all fields. It is also important to acknowledge some factors outside of the control of ED staff i.e. admission to a bed requires input from Orthopaedic speciality as well as bed management. A follow-up audit will be conducted to assess improvement in compliance with CEM guidelines. References: Hip fracture clinical guidelines (2012) NICE. CG124 Brown J, Klein C, Lewis B et al (2003) Emergency Department analgesia for fracture pain management. Ann Emerg Med 42(2):197–205 Stahmer SA, Shofer FS, Marino A et al (2008) Do quantitative changes in pain intensity correlate with pain relief and satisfaction? Acad Emerg Med 5(9):851–857

‘Honest Lying’: Anton-Babinski Syndrome McNulty M, Harbison J Department of Medicine for the Elderly and Stroke, St James’s Hospital, Dublin 8; TCD Intern Training Network Introduction: Anton-Babinski Syndrome, or visual anosognosia, is a rare condition associated with cortical blindness. Despite obvious visual loss on examination, patients will firmly deny any visual impairment and will confabulate to compensate for the lack of sensory input. It occurs following insult to the occipital cortex, in addition to damage of the visual association cortex and related pathways. Case presentation: An 82-year-old previously independent woman presented to the ED following a collapse. On arrival, she was confused and agitated. The pertinent feature of her neurological examination was a marked loss of visual acuity, with preserved pupillary reflexes and ocular movements, consistent with cortical blindness. Despite this, the patient affirmed adamantly that she was

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S288 capable of seeing and demonstrated confabulation when asked to describe her surroundings. Anton-Babinski Syndrome was suspected at this point. MRI brain showed extensive foci of acute infarction in occipital regions bilaterally, confirming the diagnosis. Discussion: Stroke is the most common aetiology of this condition, as is seen in our patient. However, any cause of cortical blindness may lead to Anton-Babinski syndrome. It is important to consider the diagnosis in a patient presenting with atypical visual loss and confirmed occipital lobe trauma. Diagnosis of the condition is commonly missed in the few days following the event. It is then recognised when the patient continues to walk into walls and describe inaccurate accounts of their surroundings. Prognosis and recovery of vision is highly variable and depends on the underlying cause, with cases due to stroke generally having a poorer prognosis. References: Maddula M, Lutton S, Keegan B (2009) Anton’s syndrome due to cerebrovascular disease: a case report. J Med Case Rep 3:9028 Carvajal JJR, Ca´rdenas AAA, Pazmin˜o GZ, Herrera PA (2012) Visual anosognosia (Anton-Babinski Syndrome): report of two cases associated with ischemic cerebrovascular disease. J Behav Brain Sci 2:394–398

Management of Splenic Artery Aneurysms Fee N, Barry M Department of Vascular Surgery SVUH Dublin 4 Introduction: Splenic artery aneurysms are the most common type of visceral artery aneuryms with 94 % comprising of incidental findings discovered on imaging for other indications1. Case presentation: A 47-year-old gentleman presented to Wexford General Hospital with a 3 days history of right flank pain and four episodes of vomiting. Patient underwent a CT KUB with a positive finding of a 0.45 cm calculus at right vesicoureteric junction. CT KUB incidental query of a splenic artery aneurysm and a CT angiogram was recommended which confirmed a 2.4 cm splenic artery aneurysm. It was decided that this gentleman should undergo intervention and as a day case procedure had a stent inserted in interventional radiology. Current data available on splenic artery aneurysms cite a lifetime risk of rupture at a rate of 4.6 % and with this a mortality of 25–70 %1. There is a disproportionate increase in mortality if rupture occurs during pregnancy 70 % for the mother and 90–95 % fetal mortality1. The most recent systematic review from the Journal of Vascular Surgery compared the three management options; conservative monitoring, endovascular repair and open repair2. They concluded that open repair had fewer late complications with a higher peri-operative morbidity and mortality. Endovascular had better short term results with conservative management having a higher late mortality. It was recommended that these aneurysms should be managed when symptomatic and ruptured, asymptomatic SAA [2 cm, women of childbearing age with aneurysm \2 cm in anticipation of future pregnancy2. References: 1. Abbas MA, William MS, Richard JF et al (2002) Splenic artery aneurysms: two decades experience at Mayo Clinic. Ann Vasc Surg 16:4 2. Hogendoorn W, Lavida A, Hunink MM et al (2014) Open repair, endovascular repair, and conservative management of true splenic artery aneurysms. J Vasc Surg 60(6):1667–1676

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Appropriate Ordering of Exercise Stress Tests in a Teaching Hospital, can it be Improved? Conlon C, Joyce D, Freeman C, Mahon C, Ibrahim M, McCreery C St. Vincent’s University Hospital; Intern Network: University College Dublin Objective: To determine the appropriateness of exercise stress test (EST) ordering. Standard: 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. Method: All ESTs requested over a 2-week-period were prospectively recorded in a single Dublin Teaching Hospital between October and November 2014. Indications and results of ESTs performed were reviewed. The appropriate ordering of this test was determined. After the completion of cycle 1, a guide form to improve ordering was attached to EST requests and the cycle was repeated. Results: Cycle 1: Total EST requested = 64. 68 % (n = 44) tests were inappropriately ordered. Cycle 2: Total EST requested = 67. 64 % (n = 43) tests were inappropriately ordered. A guide form was completed correctly in 25 % (n = 16) cases. There was a numerical improvement in appropriate requesting, albeit not statistically significant. Conclusion: Because of its simplicity EST remains a useful investigation in patients with suspected coronary artery disease and a pretest probability of 15–65 %. Inappropriate testing leads to difficulty in result interpretation and possible further investigations. In a hospital setting it is important to promote cost-effectiveness. This audit demonstrated a small, albeit non-statistically significant improvement in appropriate EST requesting. Importantly the additional guide form was only completed in 25 % on cycle 2. Further audit would make completion of the guide form mandatory.

Descriptive Study and Review of Inpatient Echocardiography Request Forms in University Hospital Limerick Zulkifli MD1, Griffin L2, Kiernan T3 Department of Cardiology, University Hospital Limerick, Limerick, Ireland; Intern Network Mid-West Network Introduction: Rapid understanding and development in echocardiography has seen the test as one of the most requested cardiology diagnostic modalities nowadays1. The clinical details provided in the request form are vitals in clinical judgment to justify the selection and priority of the test for the patient. Objectives: The aims of the study are to analyse the demographic pattern of inpatient transthoracic echocardiography request in University Hospital Limerick and review on the current echocardiography request form. We aim to improve on the quality of the request form in helping the Cardiology Diagnostic Department to prioritise and be more selective on performing the echocardiography. Design/methods: Inpatient request made from 29th September 2014 to 3rd October 2014 were included in this study. Outpatient request and request made prior to the study date were excluded from the study. The Horizon Cardiology Web (web application used in University Hospital Limerick to access cardiovascular database) was used to review patient’s previous echocardiography date and result.

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Results: Fifty-five patients were included in this study. In terms of the demographic study, 33 are males and 22 are females. Patient age group between 55 and 74 years old record the highest request with 26 requests. Stroke or Transient Ischaemic Attack (TIA) work up group is the highest clinical indication with 11 requests. For the analysis of the request form, 30 out of 55 (54.5 %) requests have no patient’s relevant past medical history, 49 from 55 (89.1 %) requests have no relevant physical examination, 29 from 55 (52.7 %) have no date of request, 42 out of 55 (76.3 %) have no list of medication written and 8 from the 55 samples (14.5 %) have no patient’s location written on the form. Forty-seven from 55 (85.4 %) have no previous echocardiography date and 51 from 55 (92.7 %) have no previous echocardiography result written on the request form. Conclusions: There are sections in the request form that were poorly filled in, particularly the previous echocardiography date and result section and the clinical diagnosis and specific question section. Education and improvement on current request form is recommended for Cardiology Diagnostic Department to have more relevant patient’s clinical details written on the form. We suggest the request form should be closed answer form like a tick box that is more convenient for fill in and more specific and relevant clinical details can be gathered. Future studies or re-audit with the data collection from the newly redesign form can help to produce a quality guideline on echocardiography request which may help to reduce the number of request in the hospital. References: 1. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E et al (2005) Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography. Am Soc Echocardiogr 18 2. Clinical Indications Echocardiography. British Society of Echocardiography [cited Oct 6 2014]. Available from: http:// www.bsecho.org/indications-for-echocardiography/

First Episode Psychosis Following Post Traumatic Stress Disorder Blake A Intern Network: UCD Intern Training Network Introduction: Patient A is a 44-year-old gentleman with a 4 years history of posttraumatic stress disorder (PTSD) who subsequently developed new onset complex psychotic symptoms. Description of case: Patient A was working in construction and suffered significant facial injuries when a cutting blade shattered and struck him in the face. These injuries required a lengthy period of hospitalisation and surgical repair. During this time he developed symptoms of hypervigilance, intrusive flashbacks, emotional blunting, anhedonia, detachment and avoidance behaviours and was diagnosed with PTSD. There was no psychiatric history prior to this accident. Seven months after this accident he presented to a psychiatric unit with a recent onset, acute psychotic episode requiring voluntary inpatient admission. He presented with complex bizarre delusions of persecution, reference and passivity. He also developed negative symptoms of apathy, avolition, affective flattening and inattention,

S289 which subsequently required 3 further voluntary inpatient admissions, each of several weeks duration. These symptoms have proven refractory to multiple biopsychosocial interventions including CBT, day hospital attendance, and a range of antipsychotics and antidepressants. He is currently on clozapine, ariprazole, amitryptiline, flurazepam and promethazine, and reports minimal change in his symptoms with persistent persecutory delusions, depressed mood, hypervigilance and severe insomnia. Discussion: Although positive psychotic symptoms commonly cooccur alongside PTSD, to our knowledge there have been no case reports of schizophrenia spectrum psychosis following non-combat related PTSD1. PTSD with psychotic symptoms is not currently recognised as a distinct nosological entity, and there is a paucity of data concerning the longitudinal course and optimum treatment of such psychotic symptoms. Consequently, it is not clear whether this case represents a distinct sub-type of PTSD with secondary psychotic symptoms, or separate co-existing disorders representing distinct psychopathological processes. Reference: 1. Sareen J, Cox BJ, Goodwin RD, Asmundson GJG (2005) Cooccurrence of posttraumatic stress disorder with positive psychotic symptoms in a nationally representative sample. J Trauma Stress 18:313–322

Human Papilloma Virus Associated Oropharyngeal Cancer: a Case Report Waters D, O’Duffy F, Kinsella J Department of Surgery, Trinity Centre for Health Sciences, St James’s Hospital, James’s St, Dublin 8; Intern Network: DSE Network Introduction: The incidence of HPV associated oropharyngeal cancer (HPVAOC) increased by 225 % in US from 1988 to 2004. We describe a case of recurrence of HPV-positive base of tongue tumour. Description/case presentation: A 51-year-old male was referred to St James’s Hospital (SJH) for management of recurrence of a p16 positive base of tongue tumour. He previously had chemo-radiotherapy, right-sided neck dissection and prophylactic tonsillectomy for a right-sided level 2a neck lump and left base of tongue tumour. The tumour was strongly p16 positive, a surrogate for HPV infection. Unfortunately the tumour recurred months later. He was referred to SJH where the decision was made for surgery. He underwent Total Glossectomy, left-sided radical neck dissection and anterior lateral thigh free-flap reconstruction. Postoperatively the patient made a fast, uncomplicated recovery. He was discharged and is for regular follow-up. The incidence of HPVAOC increased by 225 % in US from 1988 to 20041. HPVAOC patients are approximately 10 years younger than HPV-negative patients. This difference in patient age has major implications in terms of performance status, comorbidities, and ultimately, prognosis. HPVAOC tend to present with an early stage primary tumour (T1/2) but advanced nodal disease in the neck (N1/2). Despite this aggressive behaviour they are associated with a better prognosis than HPV-negative cancers with a 3-year survival of 82 vs 57 %2.

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S290 HPVAOCs respond better to chemo/radiotherapy than HPV-negative cancers and it is often possible to avoid major surgery. There are a number of vaccines available against HPV. Vaccination is most effective if administered before the onset of sexual activity. References: 1. Chaturvedi A, Engels E, Pfeiffer R, Hernandez B, Xiao W (2011) Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol 29(32):4294–4301 2. Gillison ML, Harris J, Westra W, Chung C, Jordan R, Rosenthal D, Nguyen-Tan P, Spanos WJ, Redmond KP, Ang K (2009) Survival outcomes by tumor human papillomavirus (HPV) status in stage III–IV oropharyngeal cancer (OPC) in RTOG 0129. J Clin Oncol 27

Pyogenic Liver Abscess in a 9-Year-Old Boy Ten Days Post-appendectomy Mc Donnell K, Stallard L, Moylett E Paediatric Department, University Hospital Galway; West North West Intern Network Introduction: Liver abscess in paediatrics is a rare and serious infectious disease; mortality ranges from 2 to 12 % in developed countries1. Description: A previously healthy 9-year-old boy presented to the ED with a 3 days history of fever, anorexia and feeling unwell, 10 days post uncomplicated open appendectomy. Physical examination revealed pyrexia, tachycardia, and non-localised abdominal tenderness without guarding. Blood results revealed a raised CRP, WCC and thrombocytosis. Ultrasound abdomen revealed two discrete lesions of mixed echogenicity in the right hepatic lobe; delineated further by CT which revealed a large liver abscess (6 cm 9 6 cm 9 4.5 cm) in the right hepatic lobe. Piperacillin/tazobactam and metronidazole were started followed by percutaneous incision and drainage, drain left in situ. Aspirate cultured Streptococcus anginosus group with Aggregatibacter species isolated, sensitive to piperacillin/tazobactam, co-amoxiclav and ceftriaxone. Immune work-up including assessment of neutrophil function was normal. The patient improved and was discharged on piperacillin/tazobactam via outpatient parenteral antimicrobial therapy and reviewed weekly. He received 4 weeks of IV piperacillin/tazobactam and 2 weeks of oral co-amoxiclav. Follow-up ultrasound at 8 weeks revealed a resolving liver abscess. Discussion: This is a case of a liver abscess in a previously well child. In healthy children S. anginosus infections are uncommon however complications post purulent appendicitis in the presence of S. anginosus group are well described3. In this case appendicitis was not identified on post-operative histology, immune work-up was entirely normal. Leakage of pathogens via the portal circulation remains the likely pathogenesis. References: 1. Rahimian J, Wilson T, Oram V, Holzman RS (2004) Pyogenic liver abscess: recent trends in etiology and mortality. Clin Infect Dis 39:1654 2. Mishra K, Basu S, Roychoudhurmar P (2010) Liver abscess in children: an overview. World J Pediatr 6(3):210–216 3. Corredoira J, Casariego E, Moreno C et al (1998) Prospective study of Streptococcus milleri hepatic abscess. Eur J Clin Microbiol Infect Dis 17:556–560

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A Clinical Audit to Assess the Adherence to Guidelines for Antibiotic Prescribing in Acute Otitis Media Chambers E, Breen N Greystones Harbour General Practice, Trafalgar Road, Greystones, Co. Wicklow; UCD Intern Training Network Introduction: The inappropriate prescription of antibiotics is a major contributing factor to high rates of antibiotic resistance. Aims: This audit aims to assess adherence to NICE and AAFP guidelines when prescribing antibiotics for acute otitis media (AOM) in a general practice setting. Materials and methods: A database analysis of HealthOne was used to identify patients with a diagnosis of AOM over a 1 year period from 1st September 2013. Patients were excluded if the duration of their symptoms or the antibiotic prescribed were undocumented. Following intervention a re-audit was performed over the subsequent 3-month-period. Results: After exclusions, 103 patients diagnosed with AOM were included in the first audit. 98 % were prescribed antibiotics. Of these, 52 % of antibiotic prescriptions were in accordance with NICE guidelines and 71 % were in accordance with AAFP guidelines. Percentages were somewhat lower for compliance with recommendations for documentation of analgesia 47 %, and documentation of clinical review, 36 %. After exclusions, 10 patients were included in the re-audit. 100 % were prescribed antibiotics, 80 % of these were in line with both NICE and AAFP guidelines. Conclusion: Over-prescription of antibiotics and/or not prescribing the currently recommended first line antibiotics were the main issues. Following the original audit and resulting staff education, a re-audit demonstrated improved compliance in respect of both guidelines. A further audit is planned to review compliance after 1 year. The results show that intervention improved adherence to guidelines. Further progress is required in order to bring antibiotic prescription practice into line with the current guidelines. References: Respiratory Tract Infections (2008) Antibiotic prescribing: prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. National Institute for Health and Clinical Excellence: Guidance. London Lieberthal AS, Carroll AE, Chonmaitree T et al (2013) The diagnosis and management of acute otitis media. Pediatrics 131(3):e964–e999

Inpatient Evaluation of Vitamin D Levels in Roscommon County Hospital Donaghy C, O’Mara G Roscommon County Hospital; NUI Galway Intern Training Network Introduction: Vitamin D deficiency leads to osteomalica in adults and rickets in children. Sub optimal levels can contribute to secondary hyperparathyroidism, bone loss, muscle fatigue, falls and fragility fractures in the elderly. Vitamin D deficiency is prevalent in Ireland in most part due to its northernly latitude; the sun contributes to the most potent form of Vitamin D1. Aims: To evaluate vitamin D levels in current inpatients in Roscommon County hospital.

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Design/methods: Twenty inpatients were randomly selected for assessment of their vitamin D levels. The patients were selected irrespective of their diagnosis, age, or length of hospital stay. Serum 25OHD of less than 30 nmol/l were categorized as deficient. Serum 25OHD of 30–50 nmol/l were categorized as being inadequate in some people. Serum 25OHD of more than 50 nmol/l were categorized as sufficient1. Results: Of the 20 patients surveyed (ages ranged from 67 to 90), with respect to vitamin D levels 30 % were found to be deficient, 45 % were found to be inadequate and 25 % were found to be sufficient. Among those classified as being deficient (Serum 25OHD\50 nmol/l) less than 40 % were receiving treatment. The majority of patients categorized as deficient were female, with greater than 60 % found to be deficient. Of the patients with levels deemed sufficient, greater than 60 % were receiving some form of Vitamin D therapy. Conclusions: Testing of vitamin D levels may need to be expanded beyond those patients with symptoms of vitamin D deficiency or where low vitamin D levels could affect treatment for osteoporosis. Patients who need rapid correction of vitamin D deficiency should be treated with fixed loading doses, followed by regular maintenance therapy. As more is learned about Vitamin D’s role in diseases and health new targets may be established for treatment and therapy of Vitamin D deficiency. Reference: 1. Irish Osteoporosis guidelines. Irish Osteoporosis Society. www.irishosteoporosis.ie/images/uploads/OsteoporosisGuidelines.pdf

First Presentation of Myasthenia Gravis in an 84Year-Old Lady Troddyn L, Peters C University Hospital Limerick; UL Intern Training Network Introduction: Myasthenia gravis in the elderly population is increasingly being diagnosed more often but is often a difficult diagnosis to make. Important clinical signs of myasthenia gravis may be present in the elderly population but may be attributed to ageing or to other medical conditions. Case presentation: An 84-year-old lady presented with increasing shortness of breath, a cough, particularly while taking liquids, and fatigue. Respiratory exam revealed reduced air entry in both bases with crackles in the right base. She was treated with antibiotics and bloods were monitored for signs of infection. This lady also complained of blurred vision, and bilateral ptosis was noted on exam. Ophthalmology determined bilateral age related macular degeneration, with a history of cataracts. Swallow difficulties were flagged early on in the admission and a thorough SALT assessment revealed a dysfunction that was neuromuscular in origin. A neurology consult confirmed a neuromuscular disorder with myasthenia gravis the most likely diagnosis. This was confirmed in time with positive acetylcholine receptor antibodies. She was treated with pyridostigmine and IV immunoglobulin. Her symptoms improved slightly but she then deteriorated dramatically and was treated with IVIg and plasmapheresis. She improved somewhat, but again deteriorated, and passed away. Discussion: Myasthenia gravis is traditionally associated with young adults particularly females, but is thought to be on the increase in the elderly population1. The initial presentation in this case was not immediately associated with myasthenia gravis, but certain signs and

S291 symptoms should be flagged early on and a diagnosis of myasthenia gravis considered in the elderly population. This case also highlights the importance of the multi-disciplinary team approach to treating patients. Inputs from other specialties can prove invaluable to confirming a diagnosis and with the development of the subsequent management plan. Reference: 1. Aarli JA (2008) Myasthenia gravis in the elderly. Ann N Y Acad Sci 1132(1):238–243

An Audit of the Footwear Worn by Elderly Patients in General Medical Wards Troddyn L, Byrne C University Hospital Limerick; UL Intern Training Network Introduction: Falls are the leading cause of injuries (75 %) in older people aged over 65, with 30 % of people [65, and 50 % of people [80, falling on one or more occasions each year. Proper footwear plays an important role in the prevention of falls in the elderly population, and the use of unsupportive, worn, and inappropriate footwear may increase the risk of a fall in this group. Aim: This audit evaluated the type of footwear worn by inpatients on the general medical wards. Materials and methods: The footwear of 30 patients on four of the main medical wards was evaluated using a standardized footwear assessment tool. Patients were included if they were aged[65 years old, mobile, and either receiving physiotherapy or were an active falls risk. Results: Slippers were the most common type of footwear worn on the wards (22/30). The majority of footwear was poorly supportive (21/30), with only 8/30 pairs consisting of proper athletic type shoes, providing proper support and proper fixation. The sole type on the majority of the footwear was flat rubber 25/30, with 12/30 having a worn or poor tread pattern. Conclusions: The majority of older patients on general medical wards who are at risk of a fall wear inappropriate footwear with poor support. Considering falls are a leading cause of injuries in this population, any contributing factor, i.e. poor footwear, should be evaluated and modified accordingly. References: Gannon B, O’Shea E, Hudson E (2008) Economic consequences of falls and fractures among older people. Ir Med J 101(6): 170–173 HSE Strategic Health Planning (2008) Strategy to prevent falls and fractures in Irelands Ageing population. 2008 June ISBN 978-1906218-13-3

A Case Study of Three Abscesses of Iliopsoas: Variety in Etiology, Presentation and Organisms Crozier-Shaw G, Magill P Department of Orthopaedic Surgery, AMNCH (Tallaght Hospital), Dublin 24 Introduction: Iliopsoas abscesses present with an inconsistent variety of clinical signs and symptoms and as such, can present a diagnostic

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S292 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. Aims: (1) We aim to illustrate the variety in etiology, presentation and causative organisms involved in iliopsoas abscesses. Methods and Materials: This is a retrospective report of cases. Clinical information was gathered at time of presentation. Imaging was reviewed and microbiology reports were used for confirmation of organisms. Results: We present three clinical 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 post-partum. She had signs of systemic sepsis and was diagnosed with an iliopsoas abscess. Organisms isolated were streptococcus pneumonia. She was treated with intravenous antibiotics only. Conclusions: These cases highlight the variability of iliopsoas abscesses in terms of presentation, microbiology, severity and treatment. Our knowledge of their etiology is lacking. References: 1. Wong OF, Ho PL, Lam SK (2013) Retrospective review of clinical presentations, microbiology, and outcomes of patients with psoas abscess. Hong Kong Med J 19(5):416–423 2. Rao PK, Sharpe H, Sherlock R, Muralikrishnan V (2013) Uncommon presentation of a common condition: an easily missed cause of hip pain. BMJ Case Rep

Influenza and Pneumococcal Vaccination Uptake in Diabetic Patients Hussey T, Fingleton CG St James’s Hospital, Dublin 8; TCD DSE Intern Training Network Introduction: The National Immunisation Guidelines for Ireland states that diabetic patients are at increased risk of influenza and pneumococcal related complications1. Objectives: The aim of the audit is to reduce morbidity and mortality related to influenza and streptococcus pneumoniae by increasing vaccination uptake. The standard was set at ninety percent vaccination uptake rate, with criteria to be measured based on the immunisation guidelines. Methods: The objectives were discussed with the practice team. Helix Practice Manager was used to search for ICPC2-coded diabetic conditions. Retrospective data of the influenza vaccination (2013) and pneumococcal polysaccharide vaccine (2003–2013 inclusive; exclusions as per guidelines) were collected in insulin and non-insulin dependent diabetic patients only. Results were interpreted in a practice meeting.

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Results: Fifty-nine percent and ten percent of patients had been given the influenza and pneumococcal vaccinations respectively. When the rate was divided by age and status, it was found the uptake was much greater in those aged 50 years or older and/or public patients. Conclusion: The audit was done to provide baseline figures for influenza and pneumococcal vaccination uptake in a target practice group. The results showed that the vaccination uptake was well below the standard and that a practice protocol is necessary to improve the rate. Attention should be given to PPV administration, influenza vaccination in those under 50 years old and the private sector. A second data collection should be carried out to complete the audit. If uptake is increased, the strategy may be applied to other high risk groups. Reference: 1. National Immunisation Advisory Committee of the Royal College of Physicians of Ireland (2013) Immunisation Guidelines for Ireland 2013 Edition. Dublin: National Immunisation Office

An Audit of Clinical Photography and Consent By Interns at University Hospital Limerick in 2014 Hiu J, Griffin L Department of Surgery, University Hospital Limerick, Co. Limerick; UL Intern Training Network Introduction: With the evolution of digital technology, clinical photography has become an integral component in medicine and surgery. However, these advances bring with them new ethical and legal issues, of which clinicians must be aware1. Aim: To audit compliance of interns from the Mid West Intern Training Network (MWITN) with the local guidelines regarding clinical photography2. Method: Interns were asked to complete an anonymous questionnaire related to use of photography during routine clinical practice. 84 % of the interns responded (37/44). Results: In the last 6 months, 65 % of interns have taken photographs of patients and 81 % have taken photographs of a patient’s data (e.g. scan results, ECG strips). Only 30 % were aware of a UHL guideline for clinical photography. When asked which piece of digital equipment would be used, 92 % reported use of personal smart phones with the remaining 8 % using hospital cameras. Only 22 % of interns reported deleting the data immediately, while 30 % reported leaving it on their personal smart phone for more then a month. 84 % were motivated to properly consent patients due to the perceived risk of medico-legal action. Levels of knowledge varied especially with regards to difficult areas such as taking a photograph of an unconscious patient. Conclusion: The majority of interns use clinical photography but poor awareness and compliance with guidelines is demonstrated. Recommendations of this audit include dissemination of the results of this audit, education for NCHDs of existing policies, use of verified written consent forms, introduction of an official hospital photographer and finally re-auditing. References: Van der Rijt R, Hoffman S (2014) Ethical considerations of clinical photography in an area of emerging technology and smartphones. J Med Ethics 40: 211–212 HSE Mid-West Area Acute Hospitals (2009) Guidelines for consent to clinical examination and/or Treatment. Report number: 26.0 Clinical photography and other recordings

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An Audit of the Roll Out of the Health Service Executive’s National Bone Anchored Hearing Aid Programme in the South Infirmary Victoria University Hospital O’Leary J, O’Sullivan P Department of Otolaryngology, Head and Neck Surgery, South Infirmary Victoria University Hospital, Cork Introduction: Bone anchored hearing aids (BAHA), are a hearing aid device based on the principle of osseointegration of titanium implants into bone. The HSE National Audiology Review (NARG) recommended roll out of the National BAHA Programme to begin October 20121. This study of the BAHA Programme in the South Infirmary Victoria University Hospital (SIVUH) occurred concurrently with the first year of service, 2013, as one of six specialised sites offering this service. Aims: To describe and measure the clinical activities and functional outcomes of the new BAHA service at SIVUH, with a view to aid future service planning. Methods: Case review conducted via chart audit. Data collected was analysed and compiled using Microsoft Excel and descriptive statistics were used to illustrate the findings. Results: Fourteen patients, 11 adult and 3 paediatric, underwent BAHA surgery in the first year of service. The age range of the patients was 7–71 years old, with a median age of 40.8 years. Indication for surgery met BAHA criteria. Implants were fixed unilaterally under general anaesthesia using the FAST Dermatome surgical technique. There was 1 peri-operative complication (7 %), and 4 minor postoperative complications (28.6 %). Sound processors were fitted on average 6 weeks post surgery. Using the Client Orientated Scale of Improvement (COSI) Questionnaire the mean degree of change in hearing abilty rated on a five point scale was 23.3, (SD 2). The mean final benefit was 22, (SD 1.3). Expressed as a percentage, the mean final benefit aided with the BAHA was 84 %, (SD 6). 90 % of patients expressed a satisfactory response to the hearing aid. Conclusion: This study found the results of the National BAHA Programme in SIVUH conformed to international standards. There was a high surgical success rate with minimal post-operative complications. BAHAs were shown to be reliable form of auditory rehabilitation, with a gain in final hearing ability and a positive degree of situational hearing change in all patients. Reference: 1. HSE National Audiology Newsletter, 1(3), Oct 2012

VTE Prophylaxis for Stroke Patients in University Hospital Limerick Quane M, Byrne C Intern Network: Mid-West Intern Network Objectives: We examined if University Hospital Limerick (UHL) is adhering to Scottish Intercollegiate Guidelines Network (SIGN) guidelines1 for prevention and management of Venous ThromboEmbolism (VTE) in acute stroke patients. Anti-Embolism Stockings (AES) should not be routinely used in stroke patients. Intermittent

S293 Pneumatic Compression (IPC) should be considered and in patients with ischaemic stroke at high risk of VTE, Low Molecular Weight Heparin (LMWH) can be used in addition to IPC. Methods: Data was collected from all patients on the acute stroke unit in UHL. Prescribing of AES, LMWH and Heparin was noted. The wearing of AES was also recorded. An email was subsequently circulated to all interns in the hospital reiterating the SIGN VTE guidelines in stroke patients and a re-audit performed. Results: IPC is not available to acute stroke patients in UHL. 100 % of patients were complying with not wearing AES despite 17 % being charted for them. 55 % of ischaemic stroke patients were considered high risk of VTE and therefore should be considered for LMWH. However, only 33 % of these high-risk patients were prescribed LMWH. 50 % of non high-risk patients were prescribed LMWH. After the email intervention 100 % of patients were compliant with the AES guideline, 33 % of high-risk patients of ischaemic stroke were not on LMWH, while 16 % were charted LMWH unnecessarily. Conclusions: UHL is compliant with AES in acute stroke patients, however there should be increased consideration of the use of IPC devices and LMWH where appropriate. Publicising VTE prophylaxis would help increase appropriate use. References: 1. http://www.sign.ac.uk/pdf/sign122.pdf

Return of an Old Enemy: a Case Report of Syphilis Presenting to a Dublin Ophthalmology Service Barrett M1, Connolly S1, Treacy M1, Smyth S2, Sheehan G3, Fulcher T1 Department of Ophthalmology; 2Department of Neurology; Department of Infectious Diseases, Mater Misericordiae University Hospital, Eccles St, Dublin 7 1

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Background: Syphilis has re-emerged as a common infection in STI clinics around Ireland, with reported cases doubling in Dublin over the past 6 years1. Aim: This case study illustrates an unusual ophthalmic presentation of syphilis, and the value of a high index of suspicion for infectious causes of disc swelling. Methods: The medical records and investigations were analysed, along with a review of the relevant literature. Results: A 63-year-old man was referred to the Mater Hospital ophthalmology service from his optometrist following routine annual check-up which revealed bilateral optic disc swelling. The patient was asymptomatic—visual acuity 6/6 unaided bilaterally and colour vision was preserved. Pupillary responses were normal, but disc examination revealed oedema with nerve fibre layer haemorrhages in the left and blurred nasal disc margins in the right eye. Work-up included extensive serology tests, Goldman visual fields, CT brain, MR venogram, lumbar puncture and chest radiograph. The left blindspot was enlarged, and serum inflammatory markers were elevated. CSF analysis revealed a leucocytosis (95 % mononuclear) and elevated protein. Serology tests revealed a diagnosis consistent with recent/active syphilis infection. HIV, Lyme serology and TB were negative. With input from neurology and infectious diseases consultants, a complete sexual health workup was undertaken and the patient began treatment for neurosyphilis. Discussion: Syphilis cases are rising in Ireland. It follows that an increasing number of atypical presentations will be diagnosed in

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S294 services other than infectious diseases2. This case illustrates that neurosyphilis, though rare, is an important cause of disc swelling. References: 1. Health Protection Surveillance Centre (2012) Summary of Syphilis Cases in Ireland in Quarter 1, 2012. Dublin: Health Service Executive 2. Porto L, Capelo J, Carragoso A. Unilateral swollen optic disc: do not forget neurosyphilis. BMJ Case Rep [Internet]. 2013 July 9 [cited 2014 Nov 11]. Available from: http://www.ncbi.nlm.nih.g ov/pubmed/23843402

Capnocytophaga Canimorsus: an Unusual Etiology for Septicaemia McGlacken-Byrne A, O’Callaghan D Department Respiratory Medicine, Mater Misericordiae University Hospital, Dublin 7; Intern Network: MMUH Mater Misericordiae University Hospital Introduction: A 62-year-old previously well male presented with a 24-h history of malaise, rigors and vomiting. Within hours, lifethreatening septicemia resulted in purpura fulminans, widespread micro-embolic necrosis and multi-organ failure. A slow-growing, fastidious, facultative anaerobe was isolated by PCR: capnocytophaga Canimorsus (C. canimorsus). This gram-negative rod is commonly found in the gingival and oropharngeal flora of dogs. The mortality rate in the published cases is 25–30 %. Description/case presentation: On admission to the emergency department the patient was hypotensive, tachycardic, tachypnoeic and febrile. He was in respiratory distress and speaking in short sentences. Investigations on admission confirmed septic shock, metabolic acidosis, rhabdomyolysis, acute renal injury and disseminated intravascular coagulation with thrombocytopenia. The focus of sepsis was unclear. The patient was intubated and ventilated, received broadspectrum antibiotics, inotropic support, dialysis and blood products. Recovery over the following months required debridement procedures of the fingers and toes. Auto-amputation of his nose and perioral tissues resulted in contracture microstomia requiring release surgery. Typically the bacilli C. canimorsus is acquired by a traumatic dog bite, however in this case the patient recollected merely a lick to the face. A careful history regarding animal contact should be elicited when there is no apparent source of sepsis. This should include specific questioning regarding seemingly insignificant events the patient may omit—minor scratches or even a traumatic licking. A high degree of suspicion allowing for early recognition and aggressive empirical treatment is paramount.

Pomegranate Sign: the Characteristic Radiological Appearance of a Submental Epidermoid Cyst Keane M, O’Dwyer TP Department of Otorhinolaryngology, Mater Misericordiae University Hospital, Dublin; Intern Network: UCD Introduction: Epidermoid cysts are ectoderm derived inclusion cysts lined by squamous epithelium. Unlike dermoid cysts they do not contain skin appendages. Epidermoid cysts of the head and neck are

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 rare but when they do occur they are most commonly found in the submental region1. The contents of these cysts are often homogeneous fluid but may contain multiple nodules of fat giving them a characteristic radiological appearance2. Case description: We present the case of a 32-year-old gentleman who was referred to the ENT department of the Mater hospital with a 5 years history of submental swelling. He had no associated B-symptoms. Examination showed a 4 9 5 cm soft, regular swelling to the left of the midline. It did not move on tongue protrusion and there was no associated lymphadenopathy. MRI scan showed that the mass contained within it an array of hyperintense foci giving it an appearance similar to that of a pomegranate. The cyst was excised to reveal that the cavity was filled with mucoid and numerous soft cream coloured pellets. Discussion: Epidermoid cysts of the head and neck are rare and, as such, may be unfamiliar to many radiographers. We hope that this notable radiological appearance will help in their diagnosis. References: 1. Koeller KK, Alamo L, Adair CF, Smirniotopoulos JG (1999) Radiographics 19(1):121–146; quiz 152–153 2. TB Hunter, SH Paplanus, MM Chernin, SW Coulthard (1983) Am J Roentgenol 141:1239–1240

The Standard of Medical Notes Keeping Oikeh M, McCarthy E, Shanahan E Cork University Hospital, Department Of Geriatric Medicine; Intern Network: South Intern Network Background: The importance of good medical record keeping is usually underrated. Good notes’ keeping is an essential part of a patient’s care, for communication between members of a team and for medico-legal purposes. Methods: Using the Royal College of Physician’s ‘Generic Medical Recording Standards’ as guidelines, we set 10 standards for note keeping as set out below. We looked at all record entries of an admission period of fifty patients, which included medical and surgical admissions. Results: • 100 % of notes did not have patient’s names and MRN on EVERY page • 98 % of notes did not have patients’ location • 92 % of notes had a standardized structure • 96 % of notes reflected a continuum of care • 100 % of notes had admission/discharge recorded using a standardized proforma • 18 % of notes were dated, legible and signed. 76 % were dated and legible. 6 % were illegible and not signed. • Only 6 % of notes had a deleted entry and these deletion were not countersigned/dated/timed • 50 % of the notes did not indicate the most senior Health Care Professional. • 98 % of notes had discharge summary commenced at the time of admission • Only 2 % of the notes had a DNR patient and it was clearly recorded Conclusion: Medical record keeping did not meet the standards set out by the RCP which could have serious patient safety and medicolegal implications. We recommend that Interns and SHOs should have a quick talk on medical records keeping at their induction.

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Reference: Health informatics unit. Standards for the clinical structure and content of patient records. www.rcplondon.ac.uk. Accessed 15 Dec 2014

A Curious Case of Otorrhea Connolly C, O’Malley G Department of Medicine, Sligo regional Hospital; NUI Galway Intern Training Network Case report: Bacterial menigitis is a severe, life threatening infection associated with high morbidity and mortality rates of up to 20–25 %1. Up to 6 % of patients presenting with bacterial meningitis will develop a recurrence2. Thus, rapid diagnosis of any predisposing pathology is crucial in prevention of further episodes. While rare, recurrent bacterial meningitis infection represents a significant challenge to the clinician A 64-year-old lady presented to SRH with acute onset headache, vomiting and photophoba. She was subsequently diagnosed with pnuemococcal meningitis which was treated effectively wth appropriate antibiotic therapy. Three out of 52 following discharge the patient re-presented with similar symptomatology. She was duly diagnosed with a recurrence of pnuemococcal meningitis. On further perusal of the patient’s history, it was revealed that she had experienced intermittent watery discharge from her right ear for many years. This was confirmed as CSF leakage following B2 transferrin testing. Secondary radiological investigation revealed the presence of a fistula extending from right lateral ventricle to the right mastoid air cells. The patient was transferred to the neurosurgical department in Beaumont, where she underwent stealth guided right temporal craniotomy and intradural subtemporal repair using temporalis fascial graft. She was transferred back to SRH, and discharged home 4 days later. Prompt recognition and diagnosis combined with emergent treatment enabled this patient to be managed effectively, preventing the potential sequelae associated with future episodes. This case highlights the infrequently encountered cause of recurrent bacterial meningitis, and also reveals the manner in which timely and appropriate referrals to a tertiary hospital centre ensure the highest standards in patient care. References: 1. Sigurdardottir B, Bjornsson OM, Jonsdottir KE, Erlensdottir H, Gudmundsson S (1997) Acute bacterial meningitis in adults. A 20 year review. Arch Intern Med 157:425–430 2. Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS, Caviness VS Jr, Swartz MN (1993) Acute bacterial meningitis in adults. A review of 493 episodes. N Engl J Med 328:21–28

Health and Safety Audit of a General Practice Daly C, Sayegh M Mater Misercordiae Hospital; Intern network: Dublin Mid Leinster/ University College Dublin Intern network The objectives of this audit were to ensure that the general practice was working within standards/framework for health and safety in the

S295 workplace; to implement measures to amend shortcomings that were identified and to re-audit 1 month later with a view to achieving 90 % compliance with health and safety standards. The standards in the practice were compared with those set out by the Health Information Quality Authority and the Irish College of General Practitioners. The documents consulted to form a template for this audit included ‘‘National Standards for Better Safer Healthcare’’— HIQA 2010 and ‘‘Managing Health and Safety in General Practice’’— ICGP. These prompted the design of a hazard checklist allowing assessment of different areas of the workplace to identify physical, biological, chemical and psychosocial hazards. The data was collected over 3 weeks, identifying the type of risk and who was at risk. After developing a checklist of 57 potential hazards, the practice was found to be compliant with standards set out in 86 % of cases. The main areas where deficiencies were identified included physical hazards and chemical hazards. One example of a hazard included the medications kept in the practice. There was no list available to monitor what medications were present and the expiry date of same. This audit highlighted the importance of regular review of health and safety practices in all healthcare services. The hazards identified were rectified and the audit was repeated 1 month later with a resulting compliance of 99 % with the health and safety standards devised.

The Two Halves of the Harlequin Syndrome: a Primary and Secondary Case of a Facial Dysautonomic Syndrome McGurgan I, Lonergan R, Farrell C, Killeen R, Connolly S, Tubridy N Department of Neurology, St. Vincent’s University Hospital, Elm Park, Dublin 4; Intern Network: UCD Intern Training Network Introduction: The Harlequin syndrome is a rare disorder of the sympathetic nervous system characterised by unilateral reduced facial sweating and flushing in response to exercise, heat or embarrassment. It was first described by Lance et al. in 1988, who coined the term from the red and black masked servant character from the Italian Commedia dell’arte1. Description of cases: Patient 1 is a 31-year-old left-handed woman who was referred with a 10 years history of headaches and intermittent facial sensory symptoms. Since childhood she has experienced unilateral (right-sided) facial flushing and excess sweating triggered by heat, exertion, eating and embarrassment. On examination there was a left-sided Horner’s syndrome, confirmed with apraclonidine pupillary testing. Nerve conduction, autonomic and radiological studies (MRI Brain, MRA neck) were all within normal limits. Patient 2 is a 30-year-old right-handed man referred with presyncopal symptoms following intense exertion. Since the age of 16 he has experienced sweating and flushing limited to the left side of his face. On examination, there was a right-sided Horner’s syndrome. MR imaging of the neck and thorax demonstrated a large well-circumscribed mass in the right lung apex extending into the neural foramina T2–3 on the right, consistent with a schwannoma of the sympathetic chain. Discussion: The cases described are classic examples of an exceedingly rare syndrome. It is frequently associated with other autonomic features, particularly Horner’s syndrome2. The first case likely displays a primary Harlequin syndrome; a manifestation of an idiopathic

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S296 sympathetic chain lesion that follows a benign natural course. The second represents a secondary form of the syndrome, illustrating the importance of having an awareness of this condition and investigating appropriately given the potential to unmask an underlying lesion. References: 1. Lance JW, Drummond PD, Gandevia S, Morris JG (1988) Harlequin syndrome: the sudden onset of unilateral flushing and sweating. J Neurol Neurosurg Psychiatry 51:635–642 2. Willaert WIM, Scheltinga MRM, Steenhuisen SF, Hiel (2009) JAP Harlequin syndrome: two new cases and a management proposal. Acta Neurol Belg 109(3):214–220

A Rare Cause of Life-Threatening Cervical Myelopathy McGurgan I, Lonergan R, McEvoy S, Brennan P, Thornton J, McGuigan C Department of Neurology, St. Vincent’s University Hospital, Elm Park, Dublin 4 Intern Network: UCD Intern Training Network Introduction: Spinal vascular malformations represent a rare but important and treatable cause of myelopathy and frequently provide a diagnostic challenge. The spinal dural AVF (DAVF) is the most commonly detected malformation, accounting for 70 %1. DAVF’s originate predominantly in the thoracolumbar spine and typically affect middle-aged men. Reported is a rare case of a DAVF involving the cervical cord diagnosed in a patient with progressive myelopathy. Case description: A 55-year-old left-handed man presented with a 3 months history of progressive bilateral lower limb weakness and unsteadiness. Clinical examination demonstrated a spastic paraparesis and multiple cutaneous telangiectasias. Subsequent development of upper limb weakness, acute urinary retention and eventually respiratory compromise resulted in his transfer to a tertiary centre and ICU admission. MR imaging of the spine revealed diffuse T2 signal hyperintensity in the cervical cord with cord expansion. Empiric immunosuppressive therapy for a presumed diagnosis of transverse myelitis yielded no response. A vascular aetiology was suspected and spinal angiography demonstrated a DAVF involving the upper cervical cord just inferior to the foramen magnum. Endovascular embolisation was successfully performed and the patient continues to improve clinically. Discussion: Cervical DAVF’s have been reported to present with progressive myelopathy, radiculopathy, brainstem dysfunction and subarachnoid haemorrhage, the latter of which is almost never associated with a thoracolumbar DAVF2. Management typically comprises either endovascular embolisation or surgical interruption. A clinical diagnosis of hereditary haemorrhagic telangiectasia (OslerWeber-Rendu syndrome) was made in this case (classified as definite disease according to the Curac¸ao diagnostic criteria), and to our knowledge this represents only the second such reported case in the international literature. References: 1. Gilbertson JR, Miller GM, Goldman MS, Marsh WR (1995) Spinal dural arteriovenous fistulas: MR and myelographic findings. Am J Neuroradiol 16: 2049–2057 2. Fassett DR, Rammos SR, Patel P, Parikh H, Couldwell WT (2006) Intracranial subarachnoid hemorrhage resulting from cervical spine dural arteriovenous fistulas: literature review and case presentation. Neurosurg Focus (1):E4

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An Audit of Medical Admissions in Sligo Regional Hospital Connolly, C, O’Malley, G Department of Medicine, Sligo regional Hospital; NUI Galway Intern Training Network Medical admission notes are integral to effective patient care. Clarity of medical admissions is paramount for effective communication, and have been shown to have positive impacts upon both patient care and clinician’s performance1,2. Healthcare is an environment constantly striving to improve quality of patient care and efficiency of practice. Thus, the importance of structured clinicial recording is increasing. Aims and objectives: Assess the standard of medical admission in Sligo Regional Hospital against the gold standard outlined by Royal College of Physicians. Methodology: We completed a cross-sectional study incorporating thirty medical charts chosen at random from SRH medical wards. Each admission record was anlaysed employing the 49 item area record keeping audit tool devised by the Royal College of Physicians. Results: Item areas that were completed to a very high standard included those pertaining to primary medical presentation, medication history and the completion of a thorough management plan. Interestingly, item areas relating to the person completing the admission were often either poorly documented or illegible. Conclusion: This audit has revealed that there is great variability in the performance of practitioners when admitting patients. Although there is much evidence to show that admission notes are fundamental to adequate patient care, documentation is often given quite a low priority. We propose the introduction of a medical admission proforma, to ensure that the standards current guidelines outline are being fulfilled. References: 1. Rogers, Harding (1979) The impact of a computerized medical record summary system on incidence and length of hospitalization. Med Care 17:618–630 2. Humphreys et al (1992) Preformatted charts improve documentation in the emergency department. Ann Emerg Med 21:534–540

Removed from Isolation: a Case of Suspected Pulmonary Tuberculosis in a Patient with Anorexia Nervosa McGurgan I, Hanley M, Mikulich O, Maher C, McDonnell T Respiratory Department, St. Vincent’s University Hospital, Elm Park, Dublin 4; Intern Network: UCD Intern Training Network Introduction: Protein-energy malnutrition, as occurs in anorexia nervosa, is a well-documented cause of immunodeficiency. Despite the much lower prevalence of infections in anorexia nervosa patients than one would expect, those patients with a long history of severe malnutrition are increasingly recognised as susceptible to opportunistic infections1. Case description: A 39-year-old woman was electively admitted on the basis of an incidental chest X-ray detection of a cavitating lesion in the right upper lobe, occurring on a background of severe anorexia nervosa diagnosed at age 13. The patient remained completely

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 asymptomatic, was HIV negative and had no recent foreign travel or tuberculosis contacts. Her weight at the time of admission was 24.5 kg. Bronchoscopy was performed and microscopy of obtained aspiration samples demonstrated acid-fast bacilli on Ziehl-Neelsen staining. After appropriate patient isolation, anti-tuberculosis medications were started dosed according to body weight and oral intake was significantly improved with input from psychiatry and dietetics. Interval deterioration was demonstrated on subsequent chest imaging. Cultures from the bronchoscopy specimens returned and demonstrated a growth of Mycobacterium malmoense. The patient was removed from isolation and began a long-term course of rifampicin, ethambutol and clarithromycin. Discussion: This report describes to our knowledge the first documented case of M. malmoense (a non-tuberculous mycobacterium) infection in a patient with anorexia nervosa. Mycobacterial infections, including both pulmonary tuberculosis and nontuberculous mycobacterial lung disease, have been described in patients with eating disorders and some authors have suggested that this population should be considered an at-risk group2. This case also highlights the importance of improving nutritional status in the context of both mycobacterial infection acquisition and management. References: 1. Hotta M, Nagashima E, Takagi S et al (2004) Two young female patients with anorexia nervosa complicated by Mycobacterium tuberculosis infection. Internal Med 43(440–4) 2. Portillo K, Morera J (2012) Nutritional status and eating disorders: neglected risks factor for nontuberculous mycobacterial lung disease? Med Hypotheses 78(39–41)

Giant Desmoid Tumour of the Thorax Following Latissimus Dorsi and Implant Breast Reconstruction: Case Report and Review of the Literature Granahan A1, Collins AM2, Healy DG, Lawlor CA, O’Neill SP Department of General Surgery; 2Department of Plastic and Reconstructive Surgery, St.James’s Hospital, Dubilin 8; 3 Department of Thoracic and Transplant Surgery, Plastic and Reconstruction Surgery, St. Vincents Hospital Dublin 4

S297 extraabdominal desmoid tumour; fully excised. The post-operative course was uncomplicated. There was no evidence of recurrence at 2 months follow-up. There are fewer than 30 cases of desmoid tumours associated with breast implants cited in the literature. The maximum diameter of this tumour was measured at 23.6 cm. This represents the largest documented implant associated desmoid tumour to date. The exact aetiology remains unknown. A multidisciplinary approach is essential, particularly in the management of large complex tumours necessitating chest and abdominal wall resection and reconstruction, as was required in this case. Clinical follow-up is paramount due to the inherent risk of recurrence. References: Sakorafas GH, Nissotakis C, Peros G (2007) Abdominal desmoid tumors. Surg Oncol 16:131–142 Chummun S, McLean NR, Abraham S, Youseff M (2010) Desmoid tumour of the breast. J Plast Reconstr Aesthet Surg 63:339–345 Godwin Y, McCulloch TA, Sully L (2001) Extra-abdominal desmoid tumour of the breast: review of the primary management and the implications for breast reconstruction. Br J Plast Surg 54:268–271.# 7 Gandolfo L, Guglielmino S, Lorenzetti P, Fiducia G, Scenna GBV (2006) Chest wall fibromatosis after mammary prosthesis implantation. A case report and review of the literature. Chir Ital 58:655–660 Neuman HB, Brogi E, Ebrahim A, Brennan MF VZK (2008) Desmoid tumors (fibromatoses) of the breast: a 25-year experience. Ann Surg Oncol 15:274–280

Giant Necrotic Gastrointestinal Stromal Tumour Granahan A, Witherspoon J, Heneghan H, Ravi N, Reynolds JV Department of Upper GI Surgery, St James University Hospital Dublin

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The case of a giant thoracic desmoid tumour in a 44-year-old woman, with a background history of a delayed right breast reconstruction with a pedicled latissimus dorsi (LD) myocutaneous flap and implant, is reported. Initial breast cancer management included neo-adjuvant chemotherapy, a right mastectomy and axillary clearance, in addition to adjuvant radiotherapy and tamoxifen. Four years after the cancer diagnosis and 2 years after reconstruction, the patient presented with a rapidly growing, painless mass in the right anterolateral thorax. Pre-operative imaging with CT suggested both skin and intercostal soft tissue invasion. After establishing a tissue diagnosis, the tumour was subsequently resected with an overlying skin ellipse, the LD muscle, the inferior portion of the implant capsule and six underlying rib segments. The resultant thoracic and abdominal wall defects were reconstructed with Dualmesh and polypropylene meshes respectively. Pathological analysis confirmed the diagnosis of an

We report the case of a 59-year-old man with a 3-month history of an enlarging left upper quadrant mass, vomiting and weight loss. Computed tomography of abdomen identified a 24 9 20 cm mass in the retroperitoneal space displacing the left kidney and spleen inferolaterally, and the stomach and pancreas anteriorly. Endoscopic ultrasound-guided biopsies of the lesion yielded indeterminate pathology. Given his significant symptoms he underwent exploratory laparotomy, however resection was not feasible due to proximity of the lesion to critical mesenteric vessels and inseparability from the entire pancreas. Further biopsies confirmed a gastrointestinal stromal tumour (GIST). Postoperatively he commenced Imatinib therapy, to which he had an excellent response with the tumour decreasing in size by 50 % over an 8-month-period. Unfortunately, after 8 months of imatinib treatment he presented acutely with sepsis secondary to central necrosis and abscess formation within the GIST. Signs of sepsis persisted for 48 h despite broad spectrum antimicrobial therapy so another attempt at surgical resection was planned. The tumour was successfully resected enbloc, with a subtotal gastrectomy, distal pancreatectomy and splenectomy.

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 6. Have you ever been told that you are lacking in certain vitamins, such as vitamin K? 7. Are you aware of any large blood loss during a previous operation? 8. Have you ever had a blood transfusion?

Box 2 Clinical conditions that increase bleeding risk during surgery

CT Images Pre and post neoadjuvant Imatinib therapy Gastrointestinal stromal tumours (GISTs), most commonly located in the stomach and small bowel have the potential to invade locally. Imatinib, a tyrosine kinase inhibitor, is commonly used in the neoadjuvant or adjuvant setting for the treatment of GIST, but surgical excision remains first line treatment. To our knowledge, this case represents one of the largest resected GISTs to date. Furthermore, it highlights the advancements in molecular biology in the management of such tumours.

The Pre-operative Coagulation Screen: How Often is it Indicated? Lyons C, Clarkson K Department of Anaesthesia and Critical Care, University Hospital Galway Background: An abnormal coagulation screen has a poor positive predictive value for bleeding in unselected populations1. The European Committee for Standards in Haematology (ECSH) recommends that a structured bleeding history is undertaken in the pre-operative period for surgical patients, followed by coagulation screening only in selected cases2. Aim: To assess the extent of evidence-based coagulation screening in a sample of patients attending a pre-operative assessment clinic. Methods: The indication for coagulation screening was assessed for a sample of 100 patients attending the Pre-Operative Assessment Clinic at Merlin Park University Hospital prior to undergoing orthopaedic surgery. Assessment was undertaken via a specially created patient questionnaire (Box 1) and a review of medical records for relevant comorbidities (Box 2). All patients attending this clinic receive a coagulation screen.

Box 1 Questions for a bleeding history 1. 2. 3. 4.

Have you ever had a bleed that was unexpected? Have you ever had a bleed that was prolonged or difficult to stop? Do you have any condition that affects the liver? Do you have any relative with a condition that makes them more likely to bleed? 5. Are you taking any medications that thin the blood?

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• • • • • • •

Known bleeding disorders Nutritional deficiencies (vitamin K) Liver disease Pre-eclampsia Cholestasis Sepsis Disseminated Intravascular Coagulation

Results: Eighty-six out of 100 patients had a negative response to all questions in the bleeding history, and had no past medical history of concern for bleeding. Fourteen out of a 100 patients gave a positive response to one or more questions above: Eight patients were taking warfarin, three patients were taking rivaroxaban, one patient had a previous blood transfusion, one patient had haemochromatosis, and one patient had liver cirrhosis. Coagulation screening is not used to monitor rivaroxaban use, and so was not beneficial in those three instances. Hence, only 11/100 patients had an indication for a coagulation screen. Conclusion: Only patients with heightened bleeding risk should receive a coagulation screen. In other patients (who currently account for the majority being tested), this investigation is not predictive of bleeding risk, is a cost burden without benefit, and could lead to unnecessary additional investigation and delays in undergoing surgery, potentially increasing patient morbidity. References: 1. Van Veen JJ, Spahn DR, Makris M (2011) Routine preoperative coagulation tests: an outdated practice? Br J Anaesth 106(1):1–3 2. Chee YL, Crawford JC, Watson HG (2008) Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures, British Committee for Standards in Haematology. Br J Haematol 140(1):496–504

Intern’s Experiences of Information Handover at the University Hospital Limerick Roche D, Griffin L, O’Connor M Mid-West Intern training Network, University Hospital Limerick; Intern Network: Mid-West Intern training network Background: Handover is a system by which the responsibility for a patient’s care is transferred between healthcare professionals. The Royal College of physicians describe failure in handover as a major preventable cause of patient harm1. With implementation of the European working time directive, Interns at UHL are increasingly involved in both receiving and giving handover of patient information when engaged in on-call shifts.

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Aims: This study aims to assess the experiences of Interns at UHL in relation to patient handover. Methods: Interns at UHL were asked to fill out a questionnaire on information handover. The questionnaire was divided into three parts in order to assess the three types of handover that interns at UHL engage in. Results: Interns experiences showed a variation in the type of information and method of communication of patient information, particularly when the handover took place between a primary team and an intern on call. Use of the hospital bleep system was low, and personal text messages were ranked as the 2nd most common method of handover, after face to face communication. Regardless of the type of handover, experience of using a structured handover format was less than 10 %. Eighty-two percent of respondents felt an electronic handover system would be beneficial to their practice. Conclusion: There is variation in Intern’s experiences of handover of patient information, particularly when communicating with the patient’s primary team. Implementation of a structured handover system could reduce these variances and reduce the risk of handover failure. Reference: 1. Royal College of Physicians (2011) Acute Care Toolkit 1: Handover, May 2011

An Audit of Diabetic Patient Attendance, Knowledge and Satisfaction with Services Fanning A, Sharma J Department of Medicine, Midlands Regional Hospital Portlaoise, Co. Laois; Intern Network: UCD Network Objectives: To assess diabetic patient engagement with resources, knowledge and attitude towards diabetes, and satisfaction with services. Design/methods: A randomized anonymous patient survey was given by healthcare staff over 3 weeks. Both outpatient and inpatient type 1 and type 2 diabetics were selected. Results: Forty-three completed surveys were included, with ages ranging from 18 to 95. 88 % attended diabetic clinic annually or more frequently, as with their diabetic doctor (77 %), diabetic nurse (70 %), and GP (72 %). Up to 26 % did not answer whether they were seeing an eye specialist, 49 % for chiropody, and 39 % a dietician. Most patients checked blood sugars daily or 2–3 times/ week. 46 % used insulin, and the majority self-injected. Only 55 % were comfortable adjusting insulin while sick, and 45 % while exercising. 74 % knew what a hypoglycaemic attack was, and 86 % understood what diabetes was. Type 2 diabetics reported medication adherence of 95 %. Eighty-seven percent admitted diabetes affected eating patterns either a lot, or somewhat, and 58 % said it affected their quality of life and mood. Nobody was dissatisfied with their clinic experience, and waiting times were not a concern. Conclusions: Guided by NICE guidelines1, there is good attendance for annual review with doctors and nurses, but room for improvement with linking patients in with other HCPs. Only 40 % have been on a structured education programme, which is an area to focus on. There is a psychosocial element highlighted here, which could be further targeted with psychological resources and support groups. A followup audit to assess improvement is proposed. Reference: 1. NICE Guidelines (2015) Diabetes in adults quality standard. http://www.nice.org.uk/guidance/QS6. Accessed 3 Jan 2015

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Are the Methods Used to Measure Ejection Fraction Interchangeable? Murphy R St. Vincent’s University Hospital Introduction: Left ventricular ejection fraction (LVEF) represents the volume of blood pumped out of the ventricle with each heartbeat. It is a powerful prognostic indicator in cardiac patients1. There are different methods of measuring the ejection fraction, but it remains unclear how interchangeable and accurate these measurements are. Aims: To retrospectively compare LVEF measurements by echocardiography, angiography, and cardiovascular magnetic resonance imaging (cardiac MRI), in patients who have undergone all three investigations within a short time frame. Cardiac MRI was considered the gold standard measure2–3. Methods: Medical record numbers of all patients who underwent a cardiac MRI in Cork University Hospital over the past 4 years were collected. Electronic databases were used to determine which patients also underwent angiographic and echocardiographic evaluation. A total of 63 patients underwent the 3 investigations within a 4 week time frame. Of these, 38 had full reports with no missing data. The data was analysed using SPSS v.17 and MedCalc v.12. Results: The mean LVEF determined by angiography was not significantly different to that of cardiac MRI (p = 0.11). Conversely, there was a significant difference between cardiac MRI and echocardiography LVEF measurements. The Simpson’s method overestimated the LVEF by 3.9 % on average (p = 0.02) while the Teicholz M mode method overestimated by 8.7 % on average (p = 0.0002). Bland– Altman plots showed wide limits of agreement for all groups. Conclusions: The Bland–Altman plots suggest that none of the three methods could be considered interchangeable. However, when compared to echocardiography, angiography appears to be a more accurate means of assessing the LVEF. Therefore, in patients who have undergone both investigations, this measurement should be used to guide clinical decision making. References: 1. Solomon SD, Anavekar N, Skali H et al (2005) Influence of ejection fraction on cardiovascular outcomes in a broad spectrum of heart failure patients. Circulation 112(24):3738–44 2. Longmore DB, Klipstein RH, Underwood SR et al (1985) Dimensional accuracy of magnetic resonance in studies of the heart. Lancet 1:1360–1362 3. Mogelvang J, Stockholm KH, Saunamaki K et al (1992) Assessment of left ventricular volumes by magnetic resonance in comparison with radionuclide angiography, contrast angiography and echocardiography. Eur Heart J 13:1677–1683

A 39-Year-Old Man with a New Diagnosis of Acute Promyelocytic Leukemia McCool S Haematology Department University Hospital Galway Introduction: A 39-year-old man with a new diagnosis of acute promyelocytic leukemia, starting Induction therapy as per the PETHEMA LPA 2005 Protocol.

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S300 Case presentation: The patient presented to his GP complaining of bruising after minor trauma and bleeding gums, ongoing for the past 2 weeks. On examination, he exhibited extensive Ecchymosis confined to his left and right flanks. Routine bloods were carried out showing a high white cell count of 23.2 9 109/L and a low platelet count of 9 9 109/L. His peripheral blood smear showed 90 % blasts, and morphological findings were suggestive of Hypogranular APML and the diagnosis was confirmed by a bone marrow aspirate and biopsy. He was admitted to hospital and was commenced on all-trans retinoic acid (ATRA), and Idarubicin, as per the PETHEMA LPA 2005 Protocol, and Dexamethasone, Fibrinogen, Platelets and Octaplex. Discussion: Presence of Auer rods on a peripheral blood smear is highly suggestive of a diagnosis of Acute Promyelocytic Leukemia, but is definitively diagnosed by testing for the PML/RARA fusion gene by cytogenetics on bone marrow or peripheral blood. This gene results from a mutation involving a translocation of the long arms of chromosomes 15 and 171. APML is responsive to all-trans retinoic acid (ATRA), distinguishing it from other forms of Myeloid Leukemia. The PETHEMA LPA 2005 Protocol consists of ATRA, idarubicin along with dexamethasone as Induction therapy, ATRA, mitoxantrone, cytarabine, idarubicin as consolidation therapy and ATRA, 6-mercaptopurine and methotrexate as maintenance therapy2. References: 1. Kotiah SD, Besa EC (2013). In: Sarkodee-Adoo C, Talavera F, Sacher RA, McKenna R, Besa EC (eds) Acute Promyelocytic Leukemia. Medscape Reference. WebMD. Retrieved 14 January 2014 2. Sanz MA, Martin G, Gonzalez M et al (2004) Risk-adapted treatment of acute promyelocytic leukemia with all-trans-retinoic acid and anthracycline monochemotherapy: a multicenter study by the PETHEMA group. Blood 103(4):1237–1243

HER2 Positive Metastatic Adenocarcinoma of Skin: a Case Report Baxter C1,2, Donnellan P1 1 Department of Oncology, Galway University Hospitals, Newcastle Road, Galway, Ireland; 2NUI Galway Intern Training Network

Introduction: HER2 is a transmembrane receptor over-expressed in 25 % of primary breast carcinomas, associated with aggressive disease. Trastuzumab (Herceptin) a humanised monoclonal antibody is used as a therapeutic agent to improve survival in these patients. Over-expression of HER2 is also associated with poorer outcomes in gastric, oesophageal and endometrial cancers and rarely, is demonstrated oropharyngeal, lung and bladder malignancies1. Case description: A 69-year-old woman presented to the Emergency Department with a left buttock mass and associated sudden onset loss of lower limb power. Examination revealed a polypoid lesion with surrounding florid erythema extending across the natal cleft and inferiorly to the perineum and genitalia. Investigations showed metastases to lymph nodes, liver, lung and bone. Lesion biopsy demonstrated moderately differentiated adenocarcinoma of probable sweat gland origin. Tumour staining was positive for CK7, AE 1/3, GATA3, EMA, PR, HER2(3+) and negative for CK20, CDX2, BerEP4, CK5/6, S100 and TTF1. Three cycles of Taxol/Herceptin were undertaken, complicated by Taxol pneumonitis with subsequent continuation on Herceptin alone. Onset of confusion 6 months post diagnosis prompted readmission. CT TAP demonstrated response to treatment, however MRI brain revealed leptomeningeal disease for

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 which whole brain radiotherapy was commenced. Herceptin treatment continued post discharge. Discussion: HER2 amplified breast cancers have biologic characteristics that distinguish them from other breast cancer subtypes including an increased propensity for brain metastases [1]. This case demonstrates an unusual metastatic primary skin malignancy with over-expression of HER2, with a behaviour and therapy response similar to HER2 positive breast cancer. Reference: 1. Moasser MM (2007) The oncogene HER2: its signalling and transforming functions and its role in human cancer pathogenesis Oncogene 26:6469–6487

Case Report: Small Cell Lung Cancer Presenting as SIADH De Freitas SP, O’Callaghan D Department of Respiratory Medicine, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland Small cell lung cancer can present with a multiplicity of clinical pictures and is the most frequent cause of paraneoplastic syndromes. SIADH is the most common paraneoplastic syndrome and it occurs in approximately 11 % of patients1. A 64-year-old gentleman presented with new-onset confusion on a background of a 60 pack-year smoking history. His past medical history is otherwise unremarkable. On examination he had tender, craggy hepatomegaly extending into the RIF. There were no focal neurological signs. Biochemistry studies showed a hyponatraemia of 121 mmol/L with serum and urine osmolar patterns in keeping with SIADH. Liver US identified multiple rounded and well-defined hypoechoic nodules with near-complete replacement of the liver parenchyma. Preliminary histology on liver biopsy suggested undifferentiated carcinoma with neuroendocrine features and subsequent chest imaging was suspicious for primary lung malignancy. Immunohistochemistry confirmed the diagnosis of SCLC. Mental status returned to baseline with normalisation of serum sodium. The patient returned home with community palliative care services and was reunited with relatives from abroad. Serum sodium levels remained in check with fluid restriction. The development of SIADH depends on the functional properties of the neoplastic cells and does not reflect tumor burden, metastases or histologic subtype. In the clinically euvolaemic patient, a urinary sodium greater than 40 mmol/L or a urinary osmolality greater than 100 mOsm/kg is suggestive of SIADH. In addition serum osmolality should be measured to rule out pseudohyponatremia2. Should fluid restriction fail to manage hyponatremia, the clinician may consider the use of demeclocycline or a vaptan3. All patients with otherwise unexplained SIADH should be investigated thoroughly for a possible lung tumor. References: 1. Chute JP, Taylor E, Williams J, Kaye F, Venzon D, Johnson BE (2006) A metabolic study of patients with lung cancer and hyponatremia of malignancy. Clin Cancer Res 12:888–96 2. Ellison DH, Berl T (2007) The syndrome of inappropriate antidiuresis. N Engl J Med 356:2064–72 3. Elhassan EA, Schrier RW (2011) Hyponatremia: diagnosis, complications, and management including V2 receptor antagonists. Curr Opin Nephrol Hypertens 20(2):161–68

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A Monu-Omental Discovery: Idiopathic Omental Infarction (Associated with Early Simple Appendicitis) McCafferty B, Elzamzami O Letterkenny General Hospital Introduction: Omental infarction is a rare cause of acute abdomen1,2,3. Case presentation: A 45-year-old gentleman was admitted via the emergency department with a 2 days history of sudden onset severe right iliac fossa (RIF) pain. The pain was constant in nature, nonradiating and aggravated by movement with no alleviating factors. It was associated with three episodes of non-bloody diarrhoea during the 2 days prior to admission and no other symptoms. On examination he was afebrile and haemodynamically stable. Abdomen was soft and positive for rebound tenderness in the RIF; Rosving’s sign also positive. CRP was elevated at 87.32, WCC normal (9.41). Urinalysis and chest radiograph did not demonstrate abnormalities. He was taken to theatre for laparoscopy, impression being acute appendicitis. Extensive necrosis of the omentum was visualised, as well as a thickened tip of appendix. A small amount of serosanguinous fluid was aspirated from the RIF and appendectomy and omentectomy were performed laparoscopically. Post-operative course was uncomplicated; discharged on second post-operative day. Histology has since demonstrated a small amount of neutrophils in the superficial mucosa suggesting early simple appendicitis. In the omentum, there was significant focal haemorrhage with inflammatory infiltrate and fat necrosis. Discussion: There is no clear established consensus for optimal management of omental infarction in the literature. A trend towards imaging first (CT or US) to establish the diagnosis with subsequent conservative management with anti-inflammatories is emerging and has provided good outcomes. However, laparoscopy is required when imaging findings are inconclusive or conservative management fails1,2,3. References: 1. Park TU, Oh JH, Chang IT, Lee SJ, Kim SE, Kim CW et al (2012) Omental infarction: case series and review of the literature. J Emerg Med 42(2):149–54 2. Itenberg E, Mariadason J, Khersonsky J, Wallack M (2010) Modern management of omental torsion and omental infarction: a surgeon’s perspective. J Surg Educ 67(1):44–7 3. Abdulaziz A, El Zalabany T, Al Sayed AR, Al Ansari A (2013) Idiopathic omental infarction, diagnosed and managed laparoscopically: a case report. Case Rep Surg 2013:193546

Haemophagocytic Lymphohistiocytosis: a Sinister Cause Behind a Common Presentation Quiros M, Mulpeter, K Letterkenny General Hospital, Donegal, Ireland; WNW Intern Training Network Introduction: Haemophagocytic lymphohistiocytosis is a rare life-threatening syndrome occurring as hereditary or acquired form. Acquired HLH results from immune dysregulation with associated pancytopenia and elevated inflammatory markers. The triggers are systemic infection, immunodeficiency and underlying malignancy. Description: An 82-year-old gentleman presented with a 6 week history of dry cough. He was a healthy man with a history of hypertension. Initial bloods showed pancytopenia with elevated ESR, CRP, LDH, ferritin of 2686, deranged liver and renal profile. Blood cultures grew Oerskovia spp. which was treated with meropenem and vancomycin. A CT TAP showed mediastinal lymphadenopathy, paraaortic lymphadenopathy and splenomegaly. His bone marrow biopsy was diagnostic for diffuse large B cell lymphoma. Bone marrow aspirate showed evidence of hamophagocytosis. His condition deteriorated with worsening pancytopenia and decreasing GCS. He was urgently transferred to a Tertiary Haematology Centre. Discussion: HLH has a highly aggressive clinical course with a high mortality rate hence early diagnosis is crucial. However this is often difficult due to a varied clinical presentation of this condition. The aim of treatment is to suppress the hyperinflammatory and hyper cytokine response, control underlying conditions such as infection, malignancy or autoimmune disease and eliminate macrophage overactivity. Chemotherapy, immunotherapy and corticosteroid are the mainstay of treatment with antibiotics for infection, and blood and platelet transfusion. Allogeneic bone marrow transplant is potentially curative in hereditary HLH and refractory or relapsed acquired HLH. Reference: 1. Jordan MB, Allen CE, Weitzman S, Filipovich A, McClain KL (2011) How I treat hemophagocytic lymphohistiocytosis. Blood 118(15):4041–4052

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Audit of Waiting Time for Imaging Investigations Ordered from Rheumatology Out Patient Department McCafferty R, Clifford S, Sebastien A, McCarthy C Rheumatology Department, Mater Misericordiae University Hospital (MUH), Eccles Street, D7, Ireland Objectives: This audit aims to examine wait times for imaging investigations requested by the Rheumatology Outpatient Department over a 3 year period. Methods: PatientCentre, the hospital electronic system, was used to create a dataset of 1230 scans. The mean waiting times for MRI, CT, X-ray, DEXA and US were calculated and compared using a paired student’s t test. A standard target maximum wait time of 60 days for MRI, CT and DEXA, and 30 days for X-Ray and US was decided upon following literature review1,2. Results: Wait times were longest for MRI scans (= 306 days). Mean waits for DEXA, CT, US and X-Ray were 155, 89, 66 and 7 days, respectively. The differences between the wait times for each modality were statistically significant, with the exception of CT vs US. 10 % of MRIs, 46 % of CTs and 9 % of DEXAs were done within the target period of 60 days. 98 % of DEXAs and 33 % of Ultrasounds were done within the target period of 30 days. Conclusion: Imaging studies play a crucial role in the diagnosis of Rheumatic disease. For the majority of patients in our service, the wait for radiological investigation is in excess of recommended targets. There is a need for agreed upon target wait periods and guidelines for appropriate referral, which may result in improved access to these services.

Audit of Letters to General Practitioners from Psychiatry Out-Patient Department McCafferty R, Sheehan J Psychiatry Department, Mater Misericordiae University Hospital (MUH), Eccles Objectives: Effective communication between Psychiatrists and GPs is necessary for high quality patient care. This audit examines the quality of letters sent to GPs regarding new patients attending the MUH Psychiatry Department. Methods: The standard for information to be included in letters was decided following literature review and discussion: 1. Patient details, date 2. ICD10 diagnosis 3. Co-morbidities 4. Update on symptoms 5. Mental state examination 6. Opinion/summary 7. Recommendations 8. Medications 9. Follow-up arrangements The dataset consists of 60 letters sent between 2012 and 2013. PatientCentre, the hospital electronic system, was used for data collection. Results: All letters contained patient details and the appointment date. 67 % stated an ICD10 diagnosis, 42 % mentioned co-morbidities and 96 % provided an update on symptoms. Mental state examination was detailed in 42 % of letters, while 87 % gave an opinion/summary. Recommendations were given in 98 % of letters, psychiatric medications detailed in 65 %, but a full medication list was provided in only 7 %. 76 % of letters mentioned follow-up.

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Conclusions: Letters from the department are providing a satisfactory level of information for most, but not all categories. Medications and doses should be mentioned in every letter to provide a record of treatment; however in 45 % of letters the medications used were not mentioned. That the majority of letters (58 %) lacked a mental state exam is pertinent. Letters could be improved by the use of a standard letter format, including sections for each of the headings highlighted in this report. There is potential for re-audit following the introduction of the letter template. National Maximum Wait Time Access Targets For Medical Imaging (MRI AND CT). The Canadian Association of Radiologists (CAR) Jan 2013. http://www.car.ca/uploads/standards %20guidelines/car_national_maximum_waittime_targets_mri_and_ct _2013_en.pdf: recommend within 60 days NHS: http://www.england.nhs.uk/statistics/statistical-work-areas/ diagnostics-waiting-times-and-activity/: recommend within 6 weeks

An Audit of Antimicrobial Prescribing in an Acute Medical Inpatient Setting Lillis Y, Beary E, Chadwick G Department of General Medicine, St. Columcilles Hospital, Loughlinstown; UCD Intern Network Background: There is evidence to indicate that inaccurate and inappropriate prescription of antimicrobial drugs is associated with significant mortality and morbidity. Objectives: To evaluate antimicrobial prescribing practices in medical inpatients. To promote antimicrobial stewardship. To provide feedback on prescribing practices. Methodology: A point prevalence survey to analyze antimicrobial prescribing was carried out on medical inpatients on 1 day, 25/11/ 2014. Each patient’s (n = 69) drug kardex was examined to assess: 1. Documentation of allergy status 2. Inpatients who were on antimicrobial treatment—the date the antibiotic was commenced, duration of antimicrobial cover and whether there was documented reason for prescribing the antibiotic. 3. Prescriber identification (initials, bleep number and medical council registration number). Results: 66/69 patients (96 %) had documentation of known allergy status. 22/69 patients (32 %) were on antibiotic treatment at time of audit. 18/22 patients (82 %) who were prescribed an antibiotic had a documented indication. 17/22 patients (77 %) on antibiotics had a legible, appropriately written personal identifier.

Indication

Number

Antibiotic

LRTI

9

Co-amoxiclav 5, Piptazobactam 3, Clarithromycin 3, Levofloxacin 1

UTI

8

Nitrofurantoin 4, Trimethoprim 1, Co-amoxiclav 1, Piptazobactam 1

Skin

1

Benzylpenicillin/Flucloxicillin

C. Diff

1

Metronidazole

Candida Patient total

1 18

Fluconazole 22

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Conclusions: Prudent documentation surrounding antimicrobial prescribing aids communication between health care workers and also decreases morbidity to inpatients. Our audit illustrates that antibiotic documentation within the hospital is acceptable with 96 % of patients having allergy documented, 77 % accurate personal identifier and 82 % documented indication for antimicrobial therapy. The results of the audit have been presented at hospital grand rounds to provide feedback and to reinforce principles of antimicrobial prescribing. Regular audit should be undertaken to monitor and maintain compliance.

An Audit Assessing the Uptake of Flu Vaccines Amongst SVUH Interns for the 2014–2015 Influenza Season Fanning E, Reynolds C Department Of Respiratory Medicine, St Vincent’s University Hospital, UCD Intern Training Network Objectives: (1) Audit rates of Influenza vaccine uptake amongst SVUH Interns. (2) Identify motivational factors/barriers to vaccine uptake. (3) Consider strategies to improve vaccine uptake. Design/methods: A questionnaire was designed assessing current vaccination status of SVUH Interns, motivations/barriers to vaccination and measures to improve future uptake. This questionnaire was anonymous and circulated to Interns over 2-weeks. Results: Twenty-eight Interns participated in the audit (12 males, 16 females). Uptake of vaccine this year was 57 %. Of those vaccinated, nine were female, seven male. The vaccinated group were more likely to have been vaccinated previously; 56 %. Protection against the flu was the most important motivational factor, followed by protection of patients. The unvaccinated group consisted of seven females, five males. Barriers to vaccination included: time constraints followed by the fear of side effects. Prior vaccination history did not seem to impact on current flu vaccine status in this group (50 % previously vaccinated). Amongst both groups, the majority were aware that the vaccine was available in SVUH (84 % in unvaccinated, 88 % vaccinated). Awareness was predominantly achieved via posters and leaflets. Conclusions: Each year the HSE recommends that all healthcare staff get the Influenza vaccine. In SVUH, the majority of Interns were vaccinated. The most important motivational factor in this group was to protect themselves from the flu. Conversely, the main barrier to uptake was that they were too busy to attend. In the future, ward-based provision of vaccines is an important intervention to improve vaccine uptake amongst a busy cohort of healthcare workers.

An Audit on Ward Rounds in a Munster Training Hospital Casey A, Dr Griffin UL intern network Introduction: Ward rounds are ubiquitous and defined as different scenarios involving communication between healthcare professionals and the service user, to develop an integrated care plan.

S303 Local hospital policies exist and are in line with those internationally, the ward round is focused to increase efficiency and communication between patients and their multi-disciplinary care team. Aims: To take a snapshot of the working life of interns in one centre, examining participation in ward rounds and how this compares to the local ward round policy. Materials and method: An anonymous survey of interns in which the questions put to them were based on key aspects of the local hospital policy. Results: All interns surveyed—70 % responded. Ward rounds were part of everyone’s day. 82 %—clear on their roles and responsibilities during a ward round. 46 %—team members and patients were never introduced on ward rounds, time constraints being cited as the major barrier. 75 %—felt patients do not understand the purpose of a ward round. 82 %—documentation and IT policies delayed ward round which for the vast majority took over an hour a day. Conclusion: Notable deficits in the policy were involving introduction to patients and their perceived understanding of the purpose of a ward round. This could be addressed by an information leaflet and pictures of their MDT briefly outlining roles and responsibilities in the patients care. Also continued improvements in documentation and IT systems could reduce the ward rounds length. When the above is implemented we will re-audit. References: Process for conducting ward rounds within the Mid West Regional Hospital Group 2012 Multidisciplinary Ward Rounds, a Resource, NSW Health 2011 O’Hare, James A Anatomy of the ward round. Eur J Internal Med 19(5):309–313

Assessment of Glycaemic Control of Patients Attending the Diabetes Service at the National Children’s Hospital, Tallaght, 2013 Stephens CM, McDonald DR, McDonnell CM, Roche EF Paediatric Department, Adelaide and Meath National Children’s Hospital, Dublin Objectives: Optimisation of glycaemic control in diabetes can decrease complications in later life. The International Society for Paediatric and Adolescent Diabetes (ISPAD) has developed HbA1c targets and recommends three to four consultant led clinics per year1. The aims of this audit were to: 1. Assess level of glycaemic control of patients attending the NCH in 2013; 2. Quantify average number of consultant led clinics; 3. Quantify proportion of patients on CSII; 4. Assess level of glycaemic control amongst patients on CSII and compare with ISPAD targets and the recent National Diabetes Audit2. Design/methods: Patients attending services were categorised by age. HbA1c for each visit documented and average calculated for each patient and age group. Hba1c was compared for those on CSII

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S304 versus those on injections. Average number of clinics attended determined. Results: Level of glycaemic control was within national ranges. On average 11.8 % achieved ISPAD targets comparing favourably with NHS National Diabetes Paediatric Audit 2010– 20113. Average number of clinics was 3.2, below our target of four but within ISPAD recommendations. However 16–17.99 age group only attended 2.8 clinics. Forty-three percent were on CSII exceeding national average2 and glycaemic control was subsequently better controlled. Conclusions: Glycaemic control was within national ranges but not reaching ISPAD targets in majority of patients Poor attendance in 16–17.99 age group must be investigated. CSII therapy must be considered in more patients considering the tighter glycaemic control achieved under this regime. References: 1. Rewers M, Pihoker C, Donaghue K, Hanas R, Swift P, Klingensmith GJ (2009) Assessment of monitoring of glycaemic control in children and adolescents with diabetes. ISPAD Clin Prac Consensus Guideline 2009 Competition 2. Hawks CP, Murphy N (2012) Paediatric diabets in Ireland— results of the First National Audit. Irish Med J 107(4) 3. NHS National Diabetes Paediatric Audit 2010–2011

Pancreas Divisium: an Anomaly of Pancreatic Ductal Anatomy Cromwell P, McEntee, G Hepatobiliary Surgery, Mater Misericordiae University Hospital Introduction: Etiology should be investigated in all cases of pancreatitis. Congenital abnormalities and varieties of the pancreas are seen in approximately 10 % of the general population and are a significant cause of pancreatitis. Description/case presentation: A 20-year-old female presented to ED with a 1 day history of severe epigastric pain radiating to her back associated with nausea and vomiting. She was 1 month post partum but had no medical or surgical history of significance and was on no medications. She only drank alcohol occasionally but not since prior to her pregnancy. On examination she had a tender epigastrium. Her urinary amylase was raised (3722) as were her inflammatory markers and she was diagnosed with acute pancreatitis. An abdominal ultrasound showed no evidence of gallstones and all other relevant investigations were normal. A subsequent MRCP showed pancreas divisium. In all cases of pancreatitis the etiology should be investigated and guidelines suggest that no more than 20 % should be diagnosed as idiopathic. Pancreas divisium is the most common congenital abnormality occurring in 7 % of the population and is more common in those diagnosed with idiopathic pancreatitis. It is a result of failure of fusion of the ventral and dorsal duct system resulting in the presence of a secondary ‘‘minor’’ papilla. It is thought that the minor papilla’s orifice is so small that excessively high intrapancreatic ductal pressure occurs during active secretion which may lead to inadequate drainage, ductal distension, pain and in some cases pancreatitis. Diagnosis is made either with ERCP or MRCP. Generally, minor papilla therapy is performed if there has been two or more bouts of pancreatitis or one event of severe pancreatitis.

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Lupus - Atypically Textbook Calpin P, Cormican S, Lappin D, Reddan D Department of Nephrology, University Hospital Galway Introduction: A previously healthy 66-year-old female was admitted from Dermatology OPD with a 4 week history of chest and neck rash and 5 week history of arthralgias and myalgias. Case description: On admission the rash had spread to her back, arms and hands with associated vulvar lesions and lip desquamation. She complained of a non-productive cough but had no malar rash, fever, dyspnoea, chest pain, urinary or gastrointestinal symptoms. Vital signs and clinical examination was normal. Urine dipstick showed 3 + haematuria and proteinuria. Laboratory investigations showed a normal full blood count and electrolyte profile. The blood urea was 7.3 mmol/L and creatinine 94 lmol/L. Estimated glomerular-filtration-rate was 52. Her ESR was 38 mm/h and C-reactive protein was 40.4 mg/L. Her antinuclear-antibody was strongly positive with homogenous pattern and anti-double-stranded DNA was 656 with low C3 and C4 complementprotein levels. Urine protein-creatinine ratio was 142 mg/mmol. The patient subsequently became acutely hypoxic and hypocapnic requiring 100% oxygen therapy and developed fast atrial-fibrillation. She was treated empirically with therapeutic heparin, intravenous methylprednisolone 500 mg x 3 and transferred to HDU for non-invasive ventilation. Chest X-ray was normal and CT-pulmonary angiography showed no embolus or obvious parenchymal lung disease. Skin biopsy revealed C3, IgG and IgM granular staining along the dermoepidermal junction and renal biopsy showed class 4 diffuse proliferative lupus nephritis. She was treated with intravenous cyclophosphamide and high dose oral prednisolone. She rapidly weaned from oxygen therapy and her dermatological symptoms significantly improved. Conclusion: This case illustrates how there may be extensive renal involvement with preserved renal function and highlights the value of a simple urine dipstick in detecting urinary abnormalities when routine lab investigations and imaging are normal. The abrupt unexplained hypoxia and hypocapnia with good response to high-dose corticosteroid therapy but without obvious parenchymal lung disease is most likely to represent the rare, ‘‘Acute reversible hypoxemia in systemic lupus erythematosus’’1,2. It is believed to be caused by complement activation leading to leukoaggregation within pulmonary capillaries and has only ever been reported a handful of times. References: 1. Abramson SB, Dobro J, Eberle MA, Benton M, Reibman J, Epstein H, et al (1991) Acute reversible hypoxemia in systemic lupus erythematosus. Ann Intern Med 114(11):941–7 2. Martinez-Taboada VM, Blanco R, Armona J, Fernandez-Sueiro JL, Rodriguez-Valverde V (1995) Acute reversible hypoxemia in systemic lupus erythematosus: a new syndrome or an index of disease activity? Lupus; 4(4):259–62

Review of Screening for Metabolic Syndrome in Patients Being Treated with Atypical Antipsychotics in the Roscommon County Hospital Psychiatric Unit Shiel C, O’ Loughlin A Roscommon County Hospital Background: Metabolic syndrome is a combination of medical disorders affecting up to 25 % of the population that increase the risk of

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 developing atherosclerotic disease and type 2 diabetes1. According to the CATIE trial the prevalence of MS using the ATP-IIIa was found to be 36 % in male patients and 51.6 % in females. Atypical antipsychotics are associated with weight gain, dyslipidemia and the development of T2DM2. ATP III: Components of MS3 1. Abdominal obesity Men [102 cm Women [88 cm 2. Atherogenic dyslipidaemia TGs [1.7 mmol/L HDL Cholesterol \1.03 mmol/L (M) or 1.29 mmol/L 3. Raised blood pressure 4. Insulin resistance ± glucose intolerance Fasting glucose [6.2 mmol/L 5. Pro-inflammatory state 6. Pro-thrombotic state Aims: To assess screening for MS in patients receiving atypical antipsychotics. Methods: • A pro forma was created. • A review of the medical charts of the 22 inpatients in RCH psychiatric unit was carried out and their blood tests for the past year recorded. Limitations of the audit: • • •

CRP and fibrinogen not recorded. Bloods potentially done by GPs not included. Blood pressure readings not included

Results: • 16 inpatients currently on atypical antipsychotic medication. • 0 % had waist circumference recorded, 37 % had weight and height recorded and therefore a calculable body mass index. • 25 % had a lipid profile • 0 % had a fasting glucose recorded. 25 % had a HbA1c • 1 patient with a known diagnosis of T2DM • 25 % currently on antihypertensive therapy Conclusion: Monitoring for MS in the psychiatric unit, RCH is suboptimal. Recommendations: • • •

Admission biochemical and anthropometric data to screen for metabolic syndrome. Analysis of information gathered over 2 months to assess burden of disease in this cohort. Pilot a liaison endocrinology service.

References 1. Semple D, Smyth R (2009) Oxford handbook of psychiatry. Oxford: Oxford University Press 2. McEvoy J, Meyer J, Goff D et al (2005) Prevalence of the metabolic syndrome in patients with schizophrenia: baseline results from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial and comparison with national estimates from NHANES III. Schizophr Res 80(1):19–32 3. Expert panel on detection, evaluation, and treatment of high blood cholesterol in adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA 285(19):2486–2497

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Teenage Radiotherapy and its Lifelong Shadow Gorman, I St. James Hospital, Dublin 8 Introduction: A 49-year-old man presented to his GP with a new growth behind his left ear, increasing in size over several months. Biopsy of this exophytic lesion showed squamous cell carcinoma. Presentation of Case: This gentleman had a background of nasopharyngeal cancer aged 16, treated with right neck dissection and radio/chemotherapy. He suffered late complications of his treatment. Damage to his carotid arteries by radiotherapy contributed to a cerebrovascular accident at age 32. Now this second primary SCC, behind his left ear, is also within his previous radiotherapy field. Referral to ENT services and MDT discussion led to surgical resection via Wide Local Excision of the lesion and Lateral Temporal Bone Resection, Parotidectomy, Radical Neck Dissection and Rotational Pectoralis Major Myocutanous Flap. This patient has had a complicated post-op recovery. Poor wound healing, dehiscence and infection have led to two urgent returns to theatre. First, day 9 Post-Op an urgent exploration of neck flap was needed for control of bleeding from the Internal Jugular vein. Following this, by day 12 Post-Op, his Neck Flap was deemed no longer viable, needing to be replaced by Latissimus Dorsi pedicle flap and Lateral Thigh skin graft. Discussion and conclusions: This case is notable for highlighting and opening discussion of the late secondary complications of radiotherapy, in this instance his CVA and second primary SCC, occurring here up to 30 years post treatment. Another key aspect of this case was the technical challenges posed to the surgical team. A combination of the patient’s elevated BMI, the limitation to rotational pedicle flaps due to bilateral carotid disease and the irradiated tissue present in the surgical field, added increased complexity to his surgical management.

Prevalence of Ursodeoxycholic Acid Use in a Paediatric Cystic Fibrosis Clinic: a Re-audit Clarke R, Linnane B Cystic Fibrosis Department, Paediatrics Department, University Hospital Limerick Objectives: 1. What percentage of patients in the paediatric CF unit in UHL are now on URSO 2. Establish current liver status and prevalence of CFALD (Cystic fibrosis associated liver disease) amongst this cohort 3. Review the effects of dis-continuing URSO Design/methods: The list of patients attending the CF paediatric unit in UHL were reviewed. Original audit results were revised and the audit cycle was completed. A CFALD screening tool as suggested by Debray et al. in (2011) using physical exam, LFTs and ultrasound was implemented. Medical records were reviewed to establish if a patient was on URSO, and the data were analysed. Results: Twenty-one percent of CF paediatrics patients are currently on URSO in UHL, 34 have been discontinue. Four patients in the paediatric CF unit in UHL have CFALD, representing 6 % of the

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S306 patient group. There was no significant change in liver status amongst patients who had been discontinued on URSO. Conclusions: The prevelance of CFALD is 6 % in this patient group. With 21 % of patients on URSO, UHL’s statistics are now much closer to the national figures estimated by CFRI in 2011 to be 18.2 %. References: 1. Debray D, Kelly D, Houwen R, Strandvik B, Colombo C (2011) Best practice guidance for the diagnosis and management of cystic fibrosis-associated liver disease. J Cyst Fibros 10(2):29–36 2. Cystic Fibrosis Registry Ireland (2012) Annual Report

An Interesting Case of Sitophobia (SiToPhoBiA [Si00 To-Fo0 Be-Ah] N: an Abnormal Aversion to Food) Haire G, MacMathuna P Department of Gastroenterology, Mater Misericordiae University Hospital, Dublin 7, Ireland Introduction: The differential diagnosis of food aversion and weight loss is broad with both organic and psychosocial aetiologies1. Description/case presentation: A 66-year-old lady was admitted from a general gastroenterology clinic following a 1 year history of food aversion, significant weight loss and abdominal pain on a background of coeliac disease diagnosed around time of onset of symptomatology in addition to presence of profound psychosocial stressors. Past medical history was also significant for intermittent claudication which was medically managed and osteoporosis. A CT Thorax-Abdomen-Pelvis performed primarily as part of malignancy work up revealed incidental findings of high grade calcification and stenoses of the Coeliac Axis and Superior Mesenteric Artery. Subsequent Mesenteric Angiography confirmed presence of significant disease in the splanchnic arterial system. A diagnosis of Chronic Mesenteric Ischaemia was made and subsequent percutaneous transluminal angioplasty and stenting of the above named vessels provided excellent, near immediate, symptomatic relief. The diagnosis of chronic mesenteric ischaemia requires a high degree of suspicion but should be considered in cases of significant unexplained weight loss and food aversion in particular in the presence of vascular risk factors or personal history of vascular disease1. Definitive management takes the form of open surgical endarterectomy or bypass2 versus minimally invasive techniques as employed here. The choice of approach is dictated by the presence of skilled personnel required to complete the latter form of intervention as there is a scarcity of randomised controlled trails comparing treatment approaches3. References: 1. American Gastroenterological Association (2000) Medical position statement: guidelines on intestinal ischemia. Gastroenterology 118:951 2. Davenport DL, Shivazad A, Endean ED (2012) Short-term outcomes for open revascularization of chronic mesenteric ischemia. Ann Vasc Surg 26:447 3. Davies RS, Wall ML, Silverman SH et al (2008) Surgical versus endovascular reconstruction for chronic mesenteric ischemia: a contemporary UK series. Vasc Endovasc Surg 43:157–64

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Vancomycin-Induced DRESS Syndrome Haire G, Mahon DN, McCann H, Blake G Department of Cardiology, Mater Misericordiae University Hospital, Dublin 7, Ireland Introduction: DRESS syndrome, or drug reaction with eosinophilia and systemic symptoms, is a rare but potentially life threatening disorder characterised by the development of a severe eruption with associated fever, eosinophilia and internal organ involvement in relation to the administration of a certain drug1. Description/case presentation: A 44-year-old gentleman was transferred from an outside hospital for management of sub-acute infective endocarditis secondary to an infected pacemaker lead. Following successful lead explantation and 3 weeks of vancomycin therapy, he developed a diffuse erythematous pruritic maculopapular rash on the torso and proximal limbs in addition to development of significant facial oedema, deranged liver function tests and eosinophilia. A skin biopsy was also performed and was significant for eosinophilia. Vancomycin therapy was stopped and the gentleman was started on intravenous hydrocortisone which resulted in rash improvement and normalisation of liver function. Following commencement of an oral prednisolone taper, symptomatology returned and as a result of this, the speed of taper was dramatically reduced. The gentleman was subsequently discharged home following completion of alternative antibiotic course and full resolution of rash and related symptoms. Whilst most commonly associated with the administration of carbamazepine and allopurinol, up to 50 different medications2 have been described as causing DRESS syndrome with vancomycin listed in at least 20 case reports3. Early recognition of this drug complication is of utmost importance as mortality can reach 10 %. The cornerstone of treatment includes cessation of the offending drug in addition to commencement of corticosteroid therapy1. References: 1. Bocquet H, Bagot M, Roujeau JC (1996 ) Drug-induced pseudolymphoma and drug hypersensitivity syndrome (drug rash with eosinophilia and systemic symptoms: DRESS). Semin Cutan Med Surg 15(4):250–7 2. Cacoub P1, Musette P, Descamps V, Meyer O, Speirs C, Finzi L et al (2011) The DRESS syndrome: a literature review. Am J Med 124(7):588–97 3. Young S, Ojaimi S, Dunckley H, Douglas MW, Kok J, Fulcher DA et al (2014) Vancomycin-associated drug reaction with eosinophilia and systemic symptoms syndrome. Intern Med J 44(7):694–6

An Incidental Finding of IVC Occlusion Wherity R Intern Network: NUIG Introduction: Thrombosis of the IVC is an underidentified diagnosis that has varying clinical presentations. Virchow originally described

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 the triad of vessel injury, stasis and hypercoagulability which predisposes a patient to venous thrombosis. Case presentation: A 25-year-old male presented to the ED with haematuria and RUQ pain, 19 h post blunt trauma to his abdomen following a fall on a night out. On examination his abdomen was soft with mild tenderness and a palpable central mass. A CT abdomen was performed and showed an ‘‘absent IVC below the intrahepatic portion. Multiple prominent retroperitoneal venous collaterals, with draining of the renal veins into these collaterals, an atrophic left kidney and compensatory hypertrophy of the right kidney and a low density soft tissue attenuation which represented the haematoma, and a cluster of midline prominent retroperitoneal venous collaterals’’. The significance of these findings were uncertain, but were thought to be in keeping with chronic thrombosis of the IVC with extensive and prominent retroperitoneal venous collateralization. A thorough history was taken to try and establish a cause for this in the patient’s past. Discussion: The incidental finding of the IVC occlusion in the context of a fit and healthy young man is significant in the setting of intervention, as to whether or not recanalisation of the chronically thrombosed IVC is appropriate, and the patient was referred to the interventional radiology department for further assessment of same.

S307 2. Szold A, Katz LB, Lewis BS (1992) Surgical approach to occult gastrointestinal bleeding. Am J Surg 163(1):90

Appropriate Prescribing of Dabigatran Within the Primary Care Setting McNeill D, Hayes R Intern Network: Mid Western (UHL) The Objective of the project was to use the NICE guidelines on the appropriate prescribing of Dabigatran to determine if: • •

The following analysis was completed: •

To Bleed or Not to Bleed…: Where is the Question

•

Geraghty L, Lavelle A, Stewart S Department of Gastroenterology and Hepatology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland

All the appropriate patients within the practice had been transferred from using Warfarin to using Dabigatran. The appropriate dose of Dabigatran had been prescribed to these patients.

•

Analysis of all 782 patients within the practice to determine who had a history of atrial fibrillation. Analysis of these patients with atrial fibrillation to determine their current coagulation therapy and if they meet the criteria set out under the NICE guidelines for Dabigatran therapy. Analysis of the current dosage of Dabigatran prescribed to each patient within practice and compared against Nice Guidelines.

Results: Introduction: Obscure gastrointestinal (GI) bleeding is defined as occult or overt bleeding from the gastrointestinal tract that persists or recurs without an obvious aetiology after upper tract endoscopy, ileocolonoscopy and radiologic evaluation of the small bowel1 and accounts for approximately 5 % of GI bleeds2. Case: We present the case of an 80-year-old lady admitted with a 3-day history of melaena on a background of rheumatic valvular heart disease with metallic aortic and mitral valve replacements. Previous similar presentations had not identified a source at neither oesophagogastroduodenoscopy (OGD), colonoscopy nor mesenteric angiography. The patient was haemodynamically unstable on admission with a haemoglobin of 4.7 g/dl and an INR of 6.1 (target 2.5–3.5). Following stabilisation and consultation with the patient, haematology and cardiology services, warfarin therapy was reversed using a combination of Octaplex and parenteral vitamin K. Anticoagulation was subsequently maintained with unfractionated heparin. While no source was identified at push enteroscopy, capsule endoscopy demonstrated small bowel angiodysplasia that was treated with argon diathermy at double balloon enteroscopy. Subsequent medical management included thalidomide and somatostatin analogue therapy with good clinical result. This patient was recommenced on warfarin therapy with a lower target INR as the only licensed thromboprophylaxis for metallic valves. Discussion: This case demonstrates the complexities of diagnosing and treating occult GI bleeding in tandem with the dilemma faced by clinicians in managing bleeding in the setting of anticoagulation. Paramount is the immediate stabilisation of the patient, with close multidisciplinary collaboration and continual patient involvement in the decision making process. References: 1. Raju GS, Gerson L, Das A, Lewis B (1694) American Gastroenterological Association Institute medical position statement on obscure gastrointestinal bleeding. Gastroenterology 133(5)

Patient status

Coagulation Quantity therapy

History of atrial fibrillation and currently not None on any Coagulation

2

History of atrial fibrillation and currently Warfarin using Warfarin but eligible for Dabigatran

17

Using Dabigatran without a History of Arial Dabigatran fibrillation

0

Conclusions: This study showed that the primary care facility is largely compliant with the NICE guidelines with respect to Dabigatron. We found the following discrepancies: • •

2 people have atrial fibrillation but have not been prescribed any coagulation therapy. 17 people currently on warfarin are eligible to switch over to Diabagatron.

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S308 •

8 people were not on the correct dose of Diabagtron as recommended in the NICE guidelines. Costs are not taken into account in this analysis. The dosing issues were as a result of either recent deterioration in renal function or patient ageing. These have been resolved and they are currently investigating if any of the other patients outlined in the study are suitable to switch to Diabagtron. A re Audit is recommended in the future. References: 1. Pradaxa (2011) Summary of product characteristics, Europe. 2. http://www.medicines.ie/medicine/15122/SPC/ Pradaxa+150+mg+hard+capsules/. April 2013 3. Pradaxa Full Prescribing Information. Boehringer Ingelheim. Retrieved October 2010. 4. NICE Guidelines: dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation (TA249)

A Case of Severe Diabetic Ketoacidosis (DKA)

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An Acutely Irreducible Ankle Fracture: the Bosworth Fracture Kelly GA, Morrissey DI, O’Sullivan ME, Kearns SR 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 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.

Geraghty L, Davenport C, Byrne M Department of Endocrinology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland; Intern Network: University College Dublin (UCD) Intern Network Introduction: Diabetic Ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus (T1DM), and one that frequently presents to the emergency department. This case was particularly notable due to the severity of the presentation and multiple management challenges. Description/case presentation: A 51-year-old man with T1DM presented to the emergency department. He had initially been discovered on the floor and was unresponsive with evidence of faecal incontinence. On arrival he had a Glasgow Coma Scale (GCS) of 10/15, was hypothermic (31.6 C), hypotensive (74/40 mmHg), and had severe metabolic acidosis (pH 6.69). His serum blood glucose level was 66 mmol/l, blood ketones were 5.5 mmol/l and bicarbonate was 6.6 mmol/l. He also had biochemical evidence of an acute-onchronic kidney injury. He was treated according to DKA protocol including vigorous warmed intravenous (IV) fluid replacement, an Actrapid insulin infusion, empiric antibiotics and IV sodium bicarbonate. His initial Apache II Score was 13, and he was admitted to the ICU for inotropic support. His DKA slowly resolved with a return to baseline function. The precipitant appeared to be insulin omission. This case highlights a number of challenges associated with managing severe DKA. Specific to this case were hypothermia, deceased GCS, initial glucose levels [44 mmol/l, which is atypical for DKA and increases the risk of cerebral injury due to osmolar shift1, as well as the severity of the acidosis. The indications for bicarbonate therapy in DKA are controversial and evidence of benefit is lacking2,3 with further research required. References: 1. Kitabchi AE, Umpierrez GE, Fisher JN et al (2008) Thirty years of personal experience in hyperglycemic crises: diabetic ketoacidosis and hyperglycemic hyperosmolar state. J Clin Endocrinol Metab 93(5):1541 2. Adrogue´ HJ, Eknoyan G, Suki WK (1984) Diabetic ketoacidosis: role of the kidney in the acid–base homeostasis re-evaluated. Kidney Int 25(4):591 3. Latif KA, Freire AX, Kitabchi AE et al (2005) The use of alkali therapy in severe diabetic ketoacidosis. Diabetes Care 25(11):2113

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A Lipoma of the Transverse Colon Causing Intermittent Abdominal Pain Sheeran R, Orefuwa F, Collins, CG Department of Gastroenterology and Hepatology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland The occurrence of intussusception, the telescoping of bowel wall segments, in the adult population is uncommon, accounting for 5 % of all intussusceptions1. Its presentation in adults differs from the classic triad found in the paediatric population and the vague nature of its symptoms such as intermittent pain, nausea and vomiting and occasional change in bowel habit can lead to difficulty in its diagnosis2. Intussuception secondary to an organic lead point lesion such as a colonic lipoma is exceedingly rare and occurs predominantly in those lipomas over 4 cm in diameter3. Lipomas are benign non epithelial fatty tumours that can be found throughout digestive tract. Most often found incidentally during a colonoscopy, surgery, computed tomography or autopsy. The reported incidence of colonic lipomas ranges from 0.2 to 4.4 %. There is predilection towards right colon in women and left colon in men. Lipomas that grow to be greater than 4 cm in size can lead to obstruction and intussusception requiring surgical intervention. We will report the case of a 64-year-old female with a transverse colon lipoma causing intermittent abdominal pain, belching and reflux like symptoms. Colonoscopy revealed a broad based mid transverse colonic lipoma which we believe resulted in the development of intusseception. We will take a detailed look at the presentation, diagnosis and management options available for this unusual abdominal pathology. References: 1. Intussusception of the bowel in adults: a review. World J Gastroenterol 2009 5(4):407–11 2. Marinis A1, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, Theodosopoulos T (2005) Adult intussusception: case reports and review of literature. Postgrad Med J 81(953):174–7

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3. Yalamarthi S1, Smith RC (2010) Education and imaging. Gastrointestinal: lipoma induced intusscuception of the transverse colon. J Gastroenterol Hepatol 25:1177

Vitamin D and IBD

Multivitamin 45 % Smoker 30 % Sun exposure (hours per 48.2 week) Physical activity 8.4 Nutritional status 80 % nourished)

15 % 35 % 16.38 5.1 (well 100 % (well-nourished)

Geraghty, L, Haire, G, Boyle, M, Leyden, J Department of Gastroenterology and Hepatology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland Objectives: To analyse the performance of vitamin D measurement in IBD patients and ascertain if vitamin D deficiency is an issue in our population. Design/methods: Retrospective data collection from 164 IBD patients from 2 IBD centres (MMUH and SVUH) between January 2009 and September 2014. Prospective analysis of vitamin D levels of 20 IBD patients and 20 healthy controls. Results:

Institute 1 (n = 82)

Institute 2 (n = 82)

Age

41.2

46.5

Sex

45 % female

48 % female

55 % male

52 % male

93 % Irish

95 % Irish

Ethnicity Disease phenotype

7 % Non-Irish

5 % Non-Irish

48 % UC 52 % CD

49 % UC 50 % CD

Conclusions: Recent research suggests that vitamin D supplementation may lower disease activity and improve quality of life and rates of remission in people with Crohn’s Disease1,2. Furthermore IBD patients with low levels of vitamin D may be more likely to need inhospital treatment3. This study demonstrates that we are not actively measuring vitamin D. However looking prospectively, vitamin D levels were higher in our 20 IBD patients vs. 20 healthy controls. This may reflect increased sun exposure and more robust nutritional supplementation in a sicker population. Based on this small preliminary pilot study this may not be as serious an issue as the literature would suggest. A large national study is needed to better assess the role for screening in Ireland where our Northerly latitude means that we are at risk of having one of the highest rates of vitamin D deficiency in the industrialized world. References: 1. Ananthakrishnan AN, Cagan A, Gainer VS et al (2013) Normalization of plasma 25-hydroxy vitamin D is associated with reduced risk of surgery in Crohn’s Disease. Inflamm Bowel Dis 19:1921–27 2. Yang L, Weaver V, Smith JP et al (2013) Therapeutic effect of vitamin D supplementation in a pilot study of Crohn’s patients. Clin Transl Gastroenterol 4:1–8 3. Jorgensen SP, Agnholt J, Glerup H et al (2010) Clinical trial: vitamin D3 treatment in Crohn’s Disease—a randomized double-blind placebo-controlled study. Aliment Pharmacol Ther 32:377–383

1 % IDC Ileal involvement

43 %

31 %

Previous surgery

30 %

44 %

Dexa scan in last 3 years

14 %

2.4 %

Vitamin D level (last 5 years)

10 % (n = 8)

6 % (n = 6)

Mean vitamin D level

57 mmol/l

54.24 mmol/l

Overall level of vitamin D deficiency (\50 mmol/l)

38 %

1

Surgery, 2Medicine, South Tipperary General Hospital, Clonmel; RediCare Ballincollig Cork

IBD group (60 % in Control remission, 30 % ileal group involvement)

Sex

BMI

English J1, Colwell N2, Egan S3, Dr Sheppard A4

3,4

Prospective cohort

Age

Real-Time Monitoring of Patients Diet, Exercise and Weight Has a Substantial Positive Effect on Weight Loss

39.15

48.2

35 % female 65 % male

55 % female

23.8

45 % male 27

Mean vitamin D level

82.5 mmol/l

64 mmol/l

Suboptimal vitamin D levels (\50 mmol/l)

10 %

25 %

Aims: The purpose of this study was to evaluate the efficacy of the RediCare weight loss intervention. The intervention is an intensive behavioural change program which uses remote monitoring technology to track participant’s daily calorie intake, exercise and weight change. Methods: Twenty-eight participants who were over weight or obese (BMI [25 and \40) were enrolled. Participant’s baseline resting metabolic rate (RMR) and BMI was calculated. A target weight loss per week was assigned to each participant which was driven by reduced calorie intake of c. 300–500 calories below their RMR and increased daily exercise (10,000–12,500 steps) daily. Phone app training allowed a convenient way to accurately track calorie intake for each meal, snack or drink consumed, a wireless connected scale and a pedometer enabled exercise and weight tracking. Daily adherence to each participants plan was monitored remotely. Non-adherents were emailed, sent an SMS or called to motivate them to comply. Participants were met weekly, either face to face or via a Skype video conference call.

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S310 Results: Significant weight loss was achieved by week 4 and week 8, with an average reduction of body weight of 5.6 %, (±1 %) P = 0.01 and 9.0 % (±1.6 %) P = 0.01, respectively. Conclusion: Results indicate that intense lifestyle and behavioural intervention coupled with daily remote monitoring of patients diet, exercise and weight has a substantial positive effect on weight loss success.

Review of Outcomes Following the Introduction of Nurse-Led Discharge (NLD) Following Day Case Surgery Sheeran R, O’ Malley E, Moloney B, Collins CG Department of Surgery, Portiuncula General Hospital, Ballinasloe, Galway Background: Identifying patient suitability for discharge has been the responsibility of the attending surgeon. NLD using Post Anaesthetic Discharge Scoring System (PADSS) empowers nurses and provides easy to use criteria for safe successful discharge. We compared discharge outcomes of NLD with both doctor assessment and with the Early Warning Score (EWS). Methods: Discharges between January 2013 and June 2014 were prospectively assessed. Patients were scored three times using the PADSS. Patients were assessed medically by a member of the surgical team pre discharge. Discharge and admission decisions were compared. PADSS scores were also compared to the highest EWS. Patients successfully discharged were followed up by telephone after 48 h. Results: A review of 128 consecutive day case procedures was performed. 85.2 % (n = 109) of patients were successfully discharged and 14.8 % (n = 19) stayed overnight. No patient was discharged with a PADSS score of less than 9. 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 complications were elicited by telephone follow up. Conclusion: NLD using PADSS identifies patients suitable for same day discharge in agreement with medical assessment. EWS is not a reliable indicator of requirement to stay. NLD allows nurses to confidently and safely discharge patients who meet the criteria, improving patient flow in day case surgery.

An Audit of Medication Prescribing at the Preoperative Assessment Clinic: are We Compliant with the Regional Protocol? Donoghue L, Smyth C, O’Dea J Department of Anaesthesia, University Hospital Limerick (UHL), Dooradoyle, Limerick; UHL Intern Training Network Background: The preoperative assessment (POA) clinic at UHL evaluates an individual’s readiness for surgery. It optimises individual patient health and provides an opportunity to discuss essential medication changes prior to surgery. Such modifications can reduce

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 morbidity and post-operative length of stay so it is therefore vital that they are standardised. Aims: (1) To audit current preoperative prescribing practices at UHL’s POA clinic. (2) To explore the possible barriers to compliance and actions required to improve compliance with the regional protocol. Methods: A retrospective chart review was carried out at the POA clinic. Data collected included surgery type, anaesthetic technique, regular medications and medications prescribed on the morning of surgery. This was then analysed and compared to the regional protocol. Results: In total, 26 charts were reviewed. Patient age ranged from 32 to 83 years with a male: female ratio of 1:1.4. Overall compliance with the regional protocol was 81 %. One hundred percent compliance was noted with anticoagulation, endocrine, rheumatologic and analgesic medications. Less than standard set compliance (\85 %) was noted for Cardiovascular (75 %), Psychotropic (64 %), Pulmonary (75 %) and Gastrointestinal (75 %) medications. Conclusion: The preoperative prescribing practices at UHL’s POA clinic are marginally below the standard set before auditing. Below standard compliance with the protocol could potentially lead to postoperative morbidity and increased length of stay for patients. A number of barriers to compliance were identified which included inadequate documentation of preoperative instructions and unavailability of the protocol on the hospital database ‘‘QPulse’’. Future educational interventions will focus on circulating the protocol to the perioperative team in addition to uploading the protocol on QPulse. A re-audit will be undertaken in 3 months time. Reference: Bourke A, Mahdy S (2013) Protocol for the assessment and management of patients attending the preoperative assessment clinic—Appendix IV. University of Limerick Hospital Group, Limerick

Audit on the Use of High-Flow Nasal Oxygen in Bronchiolitis in the Paediatric Unit at University Hospital Galway (UHG) McDonnell K, Stallard L, Moylett E Paediatric Department, National University of Ireland Galway; West North West Intern Network Background: High Flow Nasal Oxygen (HFNO) therapy was introduced in the Paediatric unit at UHG in September 2013. The aim of this study was to determine whether HFNO decreases rates of intubation or transfer to a Paediatric ICU (PICU). Methods: Retrospective chart review of infants \24-months old with a diagnosis of bronchiolitis who were commenced on HFNO between September 2013 and September 2014. Admission rates, coded as bronchiolitis on the HIPE system, over a 3 year period, 2011–2014 were also reviewed. Results: A total of 115 infants were admitted with bronchiolitis from September 1st, 2013 to September 30th 2014, 9 (7.8 %) were commenced on HFNO. Those requiring HFNO were younger (mean age 102 vs. 246 days old), had a higher RSV incidence (78 vs. 30 %) and were more likely to receive antibiotics, bronchodilators and nebulised saline. During the study period 11 infants (9.6 %) were admitted to ICU, 6 had (54.5 %) received HFNO prior to ICU admission. One infant (9 %) required invasive ventilation. Three infants (27.3 %) required transfer to a tertiary PICU. During the 24-month-period prior

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 to the use of HFNO; the ICU admission rate for bronchiolitis was 4.3 %, with 22.2 % (2/9) requiring invasive ventilation and 44.4 % (4/9) requiring transfer to a tertiary PICU. Conclusion: Despite a higher than average ICU admission rate during the study period (9.6 vs. 4.3 %), there were fewer transfers to tertiary centers (27.3 vs. 44.4 %) and decreased need for invasive ventilation (9 vs. 22.2 %). Guidelines for commencing HFNO need further development along with ongoing auditing of our management practices for bronchiolitis.

Personality Traits and Self-Management in Patients with Type 2 Diabetes Miller R South; Cork University Hospital Background: Once a patient is diagnosed with type 2 diabetes, continual medical care is required. The goal of treatment is the prevention of acute and long-term complications. It is essential that individual patients play a central role in their own care. Sub-optimal self-management is a major cause of treatment inefficacy. This research project sought to establish the degree to which personality affects the self-management of type 2 diabetes. By having a deeper understanding of how personality affects self-management, clinicians may be better able to tailor treatment regimens to individual needs. Methods: Study participants were recruited from a general practice in north Cork. All patients from the practice with type 2 diabetes, with certain exclusion criteria, were sent a questionnaire by post. The questionnaire comprised personality and self-management components. The medical records of patients who returned the questionnaire were reviewed to obtain objective metrics of self-management and relevant biomarkers. Results: There was a response rate of 37 % yielding a sample size of 57. A statistically significant correlation was found between the following personality traits and self-management scores: agreeableness (+0.41), conscientiousness (+0.34) and neuroticism (-0.32). The degree to which the variation in self-management score can be explained by these traits was as follows: agreeableness (17 %), conscientiousness (12 %), and neuroticism (10 %). Conclusions: The results of this study indicate that self-management behaviour is partly explained by personality traits. These results point to the potential of personality assessment as a predictor of selfmanagement behaviour. A Further study with a larger sample size is warranted.

S311 Corpuscular Volume of [100 fL1. Megalobastic anaemias are due to Vitamin B12 deficiency, folate deficiency or can be drug-induced1. Case presentation: A 30-year-old male presented with a history of loss of consciousness, feeling ‘clammy’ before falling to the floor. He had a 2 week history of exertional dyspnoea and lightheadedness. He consumed ninety units alcohol per week and had a reasonable diet of green vegetables. Examination revealed pallor, nil else. Bloods included: haemoglobin 6.3 (13–18); haematocrit 0.17 (0.4–0.54); MCV 123.9 (78–98); platelets 135 (145–450); lymphocytes 0.79 (1–3); monocytes 0.07 (0.2–0.8); folate \1 (3.3–17.1); iron 52.6 (10.6–28.3); iron saturation [99 % (15–50), ferritin 769.1 (21.8–274.7); haptoglobin \0.2 (0.3–2) and LDH 2617 (240–480). B12 was normal. On admission, two units Red Cell Concentrate (RCC) were transfused. Blood film demonstrated hypersegmented neutrophils. Gastroscopy showed mild gastritis. Lansoprazole and folate 5 mg/day were commenced. No further RCC transfusions were advised. Discussion: This is a case of megaloblastic anaemia due to folate deficiency. Folate is found in green veg, nuts. Symptoms include weakness, palpitations, irritability, glossitis. Causes include poor diet, malabsorption, alcohol, antiepileptics1. Patients have macroovalocytic anaemia, elevated iron, indirect bilirubin and LDH, low haptoglobin and reticulocytes, and the presence of hypersegmented neutrophils1. Treatment is with folate 5 mg/day [1]. B12 is supplemented if level is low (folate replacement alone with low B12 can precipitate subacute degeneration of cord)2. Transfusion is not recommended, posing risk for congestive failure due to expanded plasma volume from chronic anaemia and the association between heart failure and elevated levels of homocysteine3. References: 1. Van Der Weyden MB, Campbell L (1988) Clinching the diagnosis: macrocytic anemia. Pathology (4):353–357 2. Lever EG, Elwes RD, Williams A, Reynolds EH (1986) Subacute combined degeneration of the cord due to folate deficiency: response to methyl folate treatment. J Neurol Neurosurg Psychiatry 49(10):1203–7 3. Chanarin I (1990) Investigation, management and treatment in megaloblastic anaemia. The megaloblastic anaemias (3rd ed). Blackwell Scientific Publications, Oxford, pp 78–79

Did You Document That? Rates of Compliance with the Hse Recommended Practices for Healthcare Record Management at the University Hospital Limerick Griseto L, Reid L, Kennedy J

Loss of Consciousness, Exertional Dyspnoea, Lightheadedness and Pancytopaenia in a 30-YearOld Gentleman Ryan S, Quinn C Letterkenny General Hospital I have obtained consent from the patient involved to construct this case presentation. Introduction: Anaemia is defined as a haemoglobin of \13.5 g/dl in men and \12 g/dL in women1. Macrocytic anaemias have Mean

University Hospital Limerick Objectives: The Healthcare Record (HCR) is the primary source of patient information used by all healthcare providers to maintain a quality service. We note that vital pieces of information are often missing from these records and legibility is poor. Aims: 1. Conduct an audit against specific criteria in Standard 3 of the HSE Recommended Practices for HCR Management. 2. Make suggestions for simple practices to improve the quality of the HCR. Design/methods: As part of a large scale, multidisciplinary HCR audit ongoing at UHL, we randomly selected twenty charts of patients

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S312 in a short stay medical ward between 5th and 15th December, 2015 and retrospectively audited them against the following criteria: I. Service user’s name on both sides of the page. II. Signature, printed name, title and bleep number of author. III. Legibility. IV. Entries dated and timed. V. Lab results signed. VI. Consultant name identifiable. VII. Referral letters dated and stamped. VIII. Referral letters filed correctly. We examined the medical notes, the emergency record and admission proformas for 5 consecutive HCR entries. The HCR was ‘‘compliant’’ if all 5 entries had the criteria necessary and ‘‘non compliant’’ if some or none of the HCR entries met specific criteria. Results: Of the entries, 5 % always had patient’s name on both sides of the page. Compliance rates for the above author ID criteria were 100, 15, 22 and 65 %, respectively. 20 % of entries were consistently clear and legible, 100 % were dated and 2.5 % had a time. The compliance rate for signed lab results was 2.5 %. The primary consultant’s name was identifiable 60 % of the time. Referral letters were dated and stamped in 20 % of the records and they were filed correctly in 40 % of charts. Conclusions: Shortcomings are present throughout most criteria evaluated here. We are tailoring an education session for medical students and NCHDs to be held at the lunchtime Department of Medicine conference in January 2015. We aim to implement consultant and NCHD stamps with adjustable date and time for each HCR entry. Lab results software should include a checkbox for results to avoid time-costly signing of each lab result. Where legibility is poor, we suggest writing in block capitals. We aim to re-audit in February 2015. Reference: HSE Standards and Recommended Practices for Healthcare Records Management, QPSD-D-006-3 V3.0

An Unusual Presentation of Restless Legs Syndrome Kit Ting Yuen, T, Mcmanus, J Department of Acute Medical Unit, University Hospital Of Limerick, Dooradoyle, Ireland Introduction: Restless legs syndrome (RLS), also known as WillisEkbom disease (NED), is a sensorimotor disorder characterised by an irresistible urge to move the legs. The syndrome is usually accompanied by sensory disturbances ranging from discomfort to pain in the affected area. We report a case of variant of RLS in a 75-year-old man and demonstrate a treatment approach in this case. Case presentation: A 75-year-old man referred by GP with a 3-month history of widespread burning peripheral neuropathy. Patient described that as a constant, burning sensation inside him. Symptom developed bilaterally gradually from his feet, ascending to his hands and trunk, but never exceeded beyond his neck. The neuropathy was worse on lying and resting, but improved on moving all limbs Neurological examination was grossly normal, with no clinical evidences of sensory or motor abnormalities. Discussion: Further investigation on the cause were carried out and showed gross picture of iron deficiency anaemia. Based on the characteristic of neuropathy, which was exacerbated with resting and improved with moving, a final diagnosis of restless legs syndrome variant secondary to iron deficiency anaemia was made. RLS mimics peripheral neuropathy, it is important to rule out the common causes for widespread neuropathy before making the final

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 diagnosis. Follow-up is required to assess the response to treatment and to look into the underlying cause for the disease. References: Allen Rp, Walters As et al (2005) Restless legs syndrome prevalence and impact: REST general population study. Arch Intern Med 165(11):1286–92 Allen Rp, Picchietti D, Hening WA et al (2003) Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology. Sleep Med 4(2):101–119

Endovascular Stent Explanation with Associated Morbidities Lynch M, Madhavan P St James Hospital, Dublin Introduction: Endovascular repair of Abdominal Aortic Aneurysm has far surpassed traditional open repair in recent years, however endoleaks are an important complication associated with EVAR, particularly in healthy patients with a long life expectancy post procedure. Case presentation: A now 74-year-old gentleman, underwent EVAR for a 5.6 cm asymptomatic AAA in 2006. After 2 years of subsequent good health, he began to develop distal emboli in the lower limb, of unknown cause along with an expanding aneurysm sac. Along with this, he developed a blockage of the right endograft limb and experienced severe symptoms of intermittent claudication. A type one endoleak with an aneurysm sac of 8 cm was diagnosed and the patient was admitted for EVAR explantation along with open repair. Subsequently, a graft infection developed, which was first treated with a failed course of prolonged antibiotics. This was then treated with explantation of the aortic graft and a bilateral axillary to femoral artery graft. The patient has now been discharged from ICU and is continuing to recover on a surgical ward. Discussion: Endovascular repair of AAA is associated with endoleaks in later life, and there is a high morbidity for patients undergoing EVAR explantation. In considering the risk: benefit ratio of EVAR versus open AAA repair, it is important to consider the patients anticipated life expectancy post procedure.

High-Intensity Exercise in a Young Man Resulting in Rhabdomyolysis with Acute Kidney Injury McKenna MC, Lavin P Department of Nephrology, Tallaght Hospital, Dublin 24 Introduction: Rhabdomyolysis, a state of skeletal muscle necrosis resulting in leakage of intracellular muscle content such as myoglobin and creatinine kinase (CK), clinically presents as a triad of muscles aches, weakness and tea-coloured urine. It may result in acute kidney injury (AKI) via direct renal tubular toxicity of myoglobin, tubular obstruction and intrarenal vasoconstriction1. Aims: To report a case of exercise-induced severe rhabdomyolysis, complicated by AKI that was managed conservatively. Materials and method: A 33-year-old man presented with a 3-day history of generalised severe myalgia after attending a 45-mi spinning class for the first time. This was associated with extreme nausea, multiple episodes of vomiting, and low volume of dark-coloured urine.

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Laboratory investigations showed severe rhabdomyolysis (CK [22,000 units/L) with AKI (creatinine = 576 lmol/L). In addition, he had hypocalcaemia (corrected calcium = 2.06 mmol/L) and hyperphosphatemia (phosphate = 1.91 mmol/L). Urinary catheter was inserted in order to closely monitor urine output and fluid balance. Results: He was managed conservatively with intravenous administration of normal saline, isotonic crystalloid containing sodium bicarbonate, and diuretics. Serum creatinine peaked at 1172 lmol/L on day 7. Fortunately, he avoided dialysis as he maintained urinary output. At the time of discharge on day 12, creatinine was 394 lmol/ L and CK was 998 units/L. On outpatient review 3 weeks later, renal function had returned to normal. Conclusion: We report an unusual case of severe rhabdomyolysis in a healthy young man after short duration of intensive exercise. A combination of proactive fluid resuscitation, diuresis, and urinary alkalinisation averted the need for RRT.

or minor manifestations need be present for diagnosis of APECED and so predicting severity or extent of disease is impossible. The most vital conclusion I have drawn from this case is the importance of balancing the risks of non-treatment with the risks of treatment which can be seen in this case, with recurrent hypoglycaemic episodes occurring with lifelong insulin administration

Reference 1. Al-Ismaili Z, Piccioni M, Zappitelli M (2011) Rhabdomyolysis: pathogenesis of renal injury and management. Pediatr Nephrol 26:1781–1788

Objectives: This project aimed to assess the effectiveness of Mouth Cancer Awareness Day in raising public awareness of oral cancer, using Google search activity as the indicator for public interest in Ireland. A further aim of this work was to compare the level of internet search traffic on the subject of oral cancer between Ireland and other largely English speaking countries worldwide. Methods: Google Trends was utilised to investigate search trends for the terms ‘‘oral cancer’’ and ‘‘mouth cancer’’ via Google Search between May 2010 and December 2014. Search trends for Ireland and worldwide were investigated. Results: Each September, when Mouth Cancer Awareness Day takes place, greatly increased levels of online activity related to oral cancer were seen in Ireland. This interest has become less dramatically increased in the years since 2011, with Google searches in September 2014 standing at 25 % of the September 2011 volume. There was a similar background level of search interest in oral cancer seen in Ireland, UK, USA, Canada and Australia, however only Ireland showed an annual period of greatly heightened interest corresponding to a public awareness campaign. Conclusion: The yearly Mouth Cancer Awareness Day has stimulated online interest in oral cancer in Ireland, which compares favourably to that in UK, USA, Canada and Australia. This impact has lessened as Mouth Cancer Awareness Day has become an annual event.

Recurrent Hypoglycaemia in Polyglandular Autoimmune Syndrome Type 1 Johnson K, Healy ML Department of Endocrinology, St. James’ Hospital, Dublin 8 Introduction: Polyglandular autoimmune syndrome type 1, otherwise known as the APECED (autoimmune polyendocrinopathycandidiasis-ectodermal dystrophy) syndrome, is a rare autosomal recessive condition affecting as little as 30–40 people in Ireland. Case presentation: A 23-year-old male well known to the endocrine services presented with recurrent hypoglycaemic episodes resulting in seizures and loss of consciousness on a background of APECED. Examination was unremarkable. On admission blood glucose was 4.5 with HbA1C 61. FBC, U&E, LFT and CRP were non-contributory. Corrected calcium was low and phosphate elevated consistent with primary hypoparathyroidism. Magnesium levels were also low. Cortisol levels were stable on long term steroid therapy. The management of APECED is complex representing the complexity of the syndrome itself and is targeted towards the affected organs. In this case the priority was optimization of glycaemic control with multiple alterations in insulin dosing and regimes in order to achieve normoglycemia. In addition to this, management of adrenal insufficiency with hydrocortisone and fludrocortisone was optimized and calcium and magnesium supplementation was required. Follow up of this patient involved endocrinology with regular visits to the diabetic service to assess glycaemic control and re-educate re. hypo-awareness, regular lab tests, particularly electrolyte monitoring, yearly OGD to assess for candidiasis. Discussion: This case highlights the complexity of APECED as a medical condition and poses an important lesson in the management of conditions which are defined by multi-organ involvement. Each manifestation of APECED tends to present at different stages of life, and although the major manifestations usually follow chronological order, prudent follow up is necessary so that early detection of clinical manifestations are made. The variability in presentation of the condition also contributes to its difficulty in management as not all major

Mouth Cancer Awareness Day and Google Search Trends for Oral Cancer O’Connell RM Department of Surgery, Saint James’s Hospital, Dublin 8

Lithium Monitoring in a Primary Care Setting McHugh H, Halloran R HSE West Galway University Hospital Background: Lithium is a drug with a narrow therapeutic index and is associated with a high number of adverse effects, in particular decline in renal function and hypothyroidism1,2. The Irish Medication safety network (IMSN) in accordance with NICE recommend monitoring Lithium levels 3 month, as well as Thyroid function tests and Urea and Electrolytes 6 month3. Aims: The aim of this audit was to assess whether the IMSN recommendations relating to lithium therapy are being adhered to in a single primary care setting. Methods: A total of twenty patients currently taking lithium were identified. Using the ‘‘Socrates’’ tool, each patient’s file was examined for relevant haematological investigations over the past 12 months. In some instances haematological monitoring was being carried out by the Psychiatry Department. The lab system in GUH was checked for all patients to account for this.

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S314 Results: A total of six patients were monitored regularly in the last 12 months. A further three were being monitored exclusively by the psychiatry outpatient service. Sixteen patients were attending Psychiatry outpatients on a regular basis. Just two patients did not undergo any haematological monitoring in the previous year. Conclusions: This audit showed that while haematological monitoring was taking place, there is still much scope for improvement. Not meeting best practice guidelines puts patients at risk of receiving a subtherapeutic or toxic dose, and also may mask adverse effects. Putting reminders in place on the practice computer system, and attaching reminders to patients’ scripts to attend could help improve current rates of monitoring. References: 1. Bocchetta A, Loviselli A (2006) Lithium treatment and thyroid abnormalities. Clin Pract Epidemiol Ment Health 2(23) 2. Tredget J, Kirov A, Kirov G (2010) Effects of chronic lithium treatment on renal function. J Affect Disord 126(3):436–440 3. Irish Medication Safety Network (2012) Best Practice guidelines for prescribing and monitoring of lithium therapy, p 7

Recurrent Seizures Secondary to Complicated Manifestations of Cowden Syndrome Steen J, Daly T Department of Medicine for the Elderly, Mater Misericordiae University Hospital, Dublin, Ireland Cowden syndrome (CS) is a are autosomal dominant genetic syndrome characterised by multiple hamartomatous polyps predominantly affecting the skin, mucous membranes, breast, thyroid, endometrium, gastrointestinal tract and brain. It represents a cancerous predisposition in numerous tissues but most commonly in breast, thyroid and endometrium1. We present the case of a 44-year-old lady with CS who presented with a 3 h history of partial focal seizure of the right-upper limb, requiring a loading dose of IV phenytoin to settle the activity. Her complex medical history includes: meningioma resection, epilepsy, right cerebellar stroke, panproctocolectomy with end-ileostomy for colorectal carcinoma, laryngeal papilloma, thyroid nodule excision, and ALL-treated with chemo-radiotherapy. She had further seizure activity on the ward, with one episode of continuous focal seizure lasting over 1 h necessitating further IV phenytoin. After noting a recent increased output from her end-ileostomy, the thought of reduced absorption of her anti-epileptic medication from this was proposed, and appeared appropriate given the positive response she showed to their IV counterparts. She was also subsequently found to be extremely deficient in magnesium (\0.25) a further complication of her end-ileostomy, which was replaced intravenously followed by magnesium oxide (which also helped with the increased output). She was discharged home with no further seizures and close follow up to monitor electrolytes. This case highlights the extensive spectrum of disease potential associated with cowden syndrome and importantly reminds us of the value of assessing the patient as a whole, and not simply focusing on their presenting symptom. Reference: 1. Scheper MA, Nikitatis NG, Sarlani E et al (2006) Cowden syndrome: report of a case with immunohistochemical analysis and review of the literature. Oral Med Oral Pathol Oral Radiol Endod 101:625–631

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Audit of the Implementation of National Consent Policy in University Hospital Limerick Surgical Patients Finegan, P, Baban, C, Merrigan, A University Hospital Limerick Objectives: (1) Assess and improve compliance with national guidelines on consent, (2) Correlate subjective patient experience with compliance. Design/methods: Consent is an important moral, ethical and legal requirement to be completed by doctors prior to carrying out a procedure. Professional guidelines are available on how this process should be carried out1,2. In this audit patients who had been consented were asked to complete a questionnaire recording their satisfaction with how they had been consented as measured against the national standard aspired to. Additionally consent forms were examined for presence of professional identifiers such as MCRN number, Bleep number and discernible signature. The study was conducted in University Hospital Limerick using an adaption of a previously validated audit tool3 and the sample population was a representative cross section of patients across the various surgical disciplines in the hospital. Results: A high degree of subjective satisfaction with the consent process was found in the patient study group. Objectively the traceability of the consent form via professional identifiers to a particular doctor was variable in quality. Conclusions: Whilst high patient satisfaction is reassuring variability between doctors in completing this important legal document should be addressed. A brief intervention reinforcing awareness of guidelines for completing official documentation might be beneficial for consenting and beyond. Additionally consent forms should prompt doctors to provide a MCRN number to ensure this important identifier is recorded. A future re-audit would of course then be required. References: 1. National Consent Policy QPSD-D-026-1. V.1, Health Service Executive, Quality and Patient Safety Directorate 2. (2009) Guide to professional conduct and ethics for registered medical practitioners, 7 ed. Irish Medical Council 3. Wall D, Alani A, Sadlier M et al. An augmented audit of consent for dermatological surgery; correlating performance with patient experience. Department of dermatology, University Hospital Limerick, Ireland.

Steroid-Resistant Sarcoidosis: an Emerging Role for Biologic Therapy Maraj A, Mulloy E Department of Respiratory Medicine, St. John’s Hospital Limerick Background: Sarcoidosis is a multisystem, chronic inflammatory condition characterized by the formation of non-caseating epithelioid granulomata at various sites across the body. There is no cure at present; while systemic corticosteroid treatment aims to alter the granulomatous process and improve clinical outcomes, there is little evidence to support their long-term effect. Given the risk of chronic corticosteroid treatment, and with growing awareness of steroid-resistant disease, alternative steroid-sparing immunosuppressive therapies are increasingly being explored.

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Case: AX, a 64-year-old white Irish gentleman with a 12 year history of sarcoidosis, was admitted with relapsed, severe stage IV disease complicated by respiratory infection and significant weight loss. Failing prolonged intravenous steroid therapy, the TNFa antagonist Infliximab is trialled and subsequently changed to Adalimumab maintenance therapy, evoking dramatic and sustained clinical and radiological improvement in AX’s pulmonary sarcoidosis and return of his weight and performance status to baseline. Conclusion: With more clinical trials needed to fully evaluate the use of TNFa inhibitors, this case report hopes to highlight their growing role as an effective alternative to corticosteroids in chronic, resistant sarcoidosis. As demonstrated in our patient, careful use of biologic agents can precipitate remission, offering hope to patients with severe disease failing conventional medical therapy.

Beauty Parlour Syndrome Fitzpatrick O University Hospitals Galway Beauty parlour syndrome or VertebroBasilar Insufficiency refers to a temporary set of symptoms due to decreased blood flow in the posterior circulation of the brain. These symptoms may be preempted by full extension of the neck as is the common position for washing hair in a beauty parlour. Symptoms include vertigo, syncope, diplopia and focal limb weakness. Less commonly reported symptoms include headaches and drop attacks. Our case is that of a 52-year-old lady who presented with severe neck pain, headaches, syncope and a sensation of pressure in the posterior aspect of her neck. She also described a ‘‘whooshing’’ feeling on neck flexion associated with severe right arm pain. She did not report any previous trauma to her neck and her history was significant only for rheumatoid arthritis. A series of radiological investigations revealed no abnormality with the exception of an MRI of cervical spine which demonstrated a central canal stenosis with forminal stenosis on the left side at C5/C6 and C6/C7. Medical physicians, Neurology, Cardiology and ENT departments were consulted in relation to this case and involved in this lady’s care. An Anterior Cervical Decompression and Fusion (ACDF) was undertaken to relieve the patients severe arm and neck pain. The symptoms experienced by this patient were resolved post operatively including her syncope and sensation of pressure following the ACDF. This variation has not previously been documented in current literature. We believe this constellation of symptoms may have been provoked by forward neck flexion coexisting with cervical disc prolapse.

Ovarian Cancer and the Colon: an Unusual Presentation and Mechanism of Metastatic Spread Fegan J, Nally D, Malone C Department of Surgery, Galway University Hospital, Newcastle, Galway Background: Mortality from ovarian cancer is greater than that of all other gynaecological cancers combined. Ovarian cancer was the fourth most common cancer diagnosed in Irish women between 1994

S315 and 20101. Ovarian cancer usually spreads transcoelomically, and, bowel obstruction, where it occurs, is due to extrinsic compression2. We unveil a case of haematological or lymphatic spread of a previously undiagnosed ovarian cancer, which invaded through the colonic wall in three separate areas and presented with bowel obstruction. Case presentation and methods: A previously well, 72-year-old lady was admitted to a University Teaching Hospital with symptoms of an acute bowel obstruction. CT scan showed a large, heterogeneous mass in the transverse colon and soft tissue thickening of the mid sigmoid colon, worrisome for a sigmoid mass. An emergency subtotal colectomy and end ileostomy were performed. Results: Findings at laparotomy demonstrated three large colonic masses which had invaded the bowel wall and resulted in perforation. Histology revealed that the masses were metastatic cancer of an ovarian origin. There was no nodal metastasis. She had an uncomplicated post operative course. She was staged, underwent six cycles of chemotherapy and is due ovarian de-bulking surgery. Conclusion: In addition to highlighting the occult nature of ovarian cancer, this case demonstrates an unusual presentation of metastatic disease. Furthermore, the mechanism of metastasis, which is haematological or lymphatic, is poorly described, particularly in a patient who had no previous diagnosis of ovarian cancer especially as metastasis of this nature is more characteristic of late stage disease3. References: 1. www.ncri.ie [National cancer registry in Ireland]. www.ncri.ie/s ites/ncri/files/atlas/2007/Ovarian%20cancer.pdf 2. Randal T, Rubin S (2010) Management of Intestinal Obstruction in the Patient With Ovarian Cancer. Am J Pathol 177(3):1053–1064 3. Ghesani M, Patel A, Sara G (2011) Spread of ovarian carcinoma via lymphatic dissemination. HemOnc Today

Clinical Audit on Operation Notes Documented Doyle, D, Adeyanju, T, Healy, D Sligo Regional Hospital Background: This is an original, retrospective audit examining the accuracy and completeness of general surgeon’s operative notes. The topic was chosen because this documentation represents an activity that is high volume, high risk and high cost. The Royal College of Surgeons England template1 was used to compare operative notes with. Methods: A patient list was generated for all four of Sligo Regional Hospital’s general surgeons. Patients undergoing any theatre procedure other than endoscopy were eligible. The most recent patients from August 31st backwards were selected to have their notes scrutinised. This process involved ticking a checklist that itemized the RCS England requirements. 52 charts were sampled during my working timeframe at SRH. The extracted data was compiled and analyzed. Results: The time of the operation, and whether the operation is elective or emergency, are inadequately recorded (2 and 4 %, respectively). Other deficient areas include the consultant name, type of incision and operative diagnosis. Conclusions: Omitting details such as the time of an operation has conceivable implications, such as delayed administration of antibiotics. Medicolegal issues are another consideration. We recommend improving documentation with respect to the areas outlined in the results section. This begins with an educational intervention to highlight the deficits. The RCS England template should be circulated among the surgical staff. We can achieve our goals by implementing a proforma containing headings for all necessary details. Alternatively

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computer software could be used by surgeons to ensure no information is missing. We recommend repeating this audit in order to appraise our successes or failures.

The Irish Contribution to Paediatrics: a Decade of Publications

Reference: 1. The Royal College of Surgeons England (2008) Good Surgical Practice, England

Byrne K1, Rahmani G2, Ryan E

Slipped Upper Femoral Epiphysis; a Rare Clinical Manifestation Of MEN2: a Case Report Slattery L, Crowley R Department of Endocrinology, St. Vincent’s University Hospital, Dublin Introduction: Multiple endocrine neoplasia type 2 (MEN2) comprise a group of heritable disorders that result from mutations in the RET proto-oncogene on chromosome 10. MEN2 is subclassified into MEN2A and MEN2B; these syndromes are characterised by the development of tumours at multiple sites. MEN2A is characterised by medullary thyroid cancer, pheochromocytoma, and primary parathyroid hyperplasia. Aim: To examine the potential link between SUFE and MEN2A Case presentation: The index case is a 49-year-old female with a recent diagnosis of right pheochromocytoma on MIBG on a background of MEN2A. Her mother had a parathyroidectomy in 1976, a partial thyroidectomy in 1976 and bilateral pheochromocytomas in 1976 and 1983. The index case had a total thyroidectomy in 1980 at which time C cell hyperplasia was noted. Diagnosis was confirmed by RET oncogene mutation analysis. She has two sons and one daughter who are MEN2A positive. Her daughter was diagnosed with a pheochromocytoma in 2006 with a subsequent unilateral adrenalectomy. There is a family history of slipped upper femoral epiphysis; she had a unilateral SUFE in her teens prior to her diagnosis of MEN2A; this diagnosis was initially missed. Her daughter underwent surgery for bilateral SUFE aged 11 and 12. Both the index case and her daughter did not fit the typical profile for a SUFE, and there was no history of trauma Discussion: Primary hyperparathyroidism and deranged thyroid function are recognised component of MEN2A. Prophylactic thyroidectomies are performed in children with RET germline mutations increasing their risk of hypothyroidism. It has been reported in the literature that endocrine disorders may contribute to abnormal growth plate development and mineralisation of cartilage and represent a significant risk factor for SUFE. Complications of a SUFE include osteonecrosis, chondrolysis and osteoarthritis; prognosis is related to the severity of the slip and early recognition. Conclusion: Alterations of parathyroid hormone function in MEN2A may play a significant role in the development of SUFE in the susceptible adolescent population. A holistic approach to diagnosis may aid earlier patient identification. References: Machens A, Dralle H (2006) Multiple endocrine neoplasia type 2 and the RET protooncogene: from bedside to bench to bedside. Mol Cell Endocrinol 247 (1–2):34–40 Brandi ML, Gagel RF, Angeli A (2001). Guidelines for diagnosis and therapy of MEN type 1 and type 2. J Clin Endocrinol Metab 86:5658–5671

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Departments of Rheumatology1, Emergency Medicine2, Paediatrics3, University Hospital Galway, Galway Introduction: Ireland has contributed greatly to the field of paediatrics although this has never been formally quantified. The aim of this study was to analyse the academic contribution of Irish institutions to the field of paediatric, perinatal and developmental medicine in the last decade. Methods: The top 20 international paediatric, perinatal and development journals, according to the Thomson Reuters Journal Citation Report were selected. These were the journals with the highest impact factors in 2013. The journals were then analysed using Scopus, the largest abstract and citation database of peer-reviewed literature. All articles from 2005 to 2014 in which the first author was affiliated with an Irish institution were included. Papers were examined for articletype, level of evidence, and institution of origin. Results: A total of 195 articles were published in 17 of the 20 selected journals. ‘Archives of Disease in Childhood’ was the journal with the most Irish publications (49 articles) and the institution with largest contribution to these high impact journals was The National Maternity Hospital, Holles Street, Dublin (41 publications). The year with most publications was 2008 with 25 articles published. Conclusion: Ireland has made a significant contribution to the paediatric literature over the past decade with a total of 195 articles published. Despite being a relatively small paediatric community, the academic output is impressive, and clinical and scientific research should continue to be encouraged across all units.

Complete Urethral Rupture in a Young Male Following a Road Traffic Accident in the Absence of Pelvic Ring Fracture Tansey D1,2, O’Kelly F1, Sheehan E2, O’Malley K1 Mater Misericordiae University Hospital1, Eccles Street, Dublin 7; Midland Regional Hospital Tullamore (MRHT)2, Co. Offaly Urethral injury is a common complication of pelvic trauma, occurring in 24 % of adults with pelvic fractures1. This can lead to long-term morbidity for the patient2. Urethral strictures occur in 31–69 % of patients after complete disruption of the bulbar urethra3. Although Computerized Tomography (CT) is used as the initial imaging modality in the assessment of polytrauma patients, urethrography remains the gold standard for urethral assessment. A 24-year-old driver involved in a road traffic incident was admitted with a stable L1-vertebral body compression fracture with minimal retropulsion, as well as an isolated non-displaced fracture of the left iliac crest. The patient was fitted with a TLSO brace, and discharged with a follow-up appointment. The patient subsequently represented, with vomiting and acute urinary retention 9 16-h. Examination revealed a non-palpable prostate, with a suspected urethral injury. Retrograde urethrography demonstrated complete urethral rupture. A supra-pubic catheter was inserted, and the patient referred to a supra-regional center for further urethral management.

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This rare case demonstrates the importance of a high index of suspicion in any polytrauma patient even in the absence of significant pelvic injury. Pelvic fracture patterns alone do not predict the presence of an injury. When it occurs, it appears to be related to the fracture mechanism, and the pattern of injury to the soft tissue envelope and supporting ligaments of the lower urinary tract4. Prompt and effective diagnosis of these injuries is essential to successful outcomes, which is potentially complicated by poor communication and coordination among the many specialists involved5.

References: 1. Sanjay M et al (2012) Contemporary reviews: updates in cardiac amyloidosis: a review. J Am Heart Assoc 2. Rodney H et al (2014) Contemporary reviews in cardiovascular medicine: diagnosis and management of the cardiac amyloidoses 3. Kyle RA, Gertz MA (1995) Primary systemic amyloidosis: clinical and laboratory features in 474 cases. Semin Hematol 32:45–5

References: 1. Koraitim MM (1996) Pelvic fracture urethral injuries: evaluation of various methods of management. J Urol 156:1288–1291 2. Eaton J, Richenberg J (2005) Imaging of the urethra: current status. Imaging 17:139–149 3. Ku JH, Kim ME, Jeon YS, Lee NK, Park YH (2002) Management of bulbous urethral disruption by blunt external trauma: the sooner, the better? Urology 60:579–583 4. Andrich DE, Day AC, Mundy AR (2007) Proposed mechanisms of lower urinary tract injury in fractures of the pelvic ring. BJU Int 100(3):567–573 5. Figler BD, Hoffler CE, Reisman W, Carney KJ, Moore T, Feliciano D, Master V Multi-disciplinaery update on pelvic fracture associated bladder and urethral injuries. Injury 43(8):1242–1249

A Case that Breaks the Mould

The Great Masquerader of the 21st Century: a Case Report on a Atypical Presentation of Cardiac Amyloidosis Tansey D1, MacRae C2, Keane D3 Mater Misericordiae University Hospital1, Eccles Street, Dublin 7; St. Vincent’s University Hospital2, Elm Park, Dublin 4; Brigham and Women’s Hospital3, 75 Francis Street, Boston, USA Amyloidosis is the deposition of mis-folded and insoluble fibrous proteins in normal organs and tissues1. It is a multisystem disease that can occur anywhere in the body. Amyloidosis is rare with an incidence of 6–8 people per million people2. This case details a 73-year-old lady who presented to the Emergency Department with a 2 month history of progressively worsening chest pain and dyspnea. This was on the background of coronary artery disease and multiple cardiac risk factors. On examination, the patient was bradycardic, hypertensive and tachypneic. She had an elevated Jugular Venous Pulse and trace pedal oedema. Her Echocardiogram showed an ejection fraction of 65 % and an angiogram showed no change to her prior study in 2011. Importantly, Her ECG was abnormal and showed sinus bradycardia with new 2:1 s degree conduction block. She had a dual chamber pacemaker fitted as further investigations continued to determine the aetiology of her symptoms. The real breakthrough in the diagnosis came with a serum gamma M spike of 1.22 g/dl on serum protein electrophoresis, suggesting AL amyloidosis. Diagnosis of AL amyloid was then made based on anterior fat pad aspirate and she was referred to Oncology. This patient’s overall atypical presentation of amyloidosis resulted in the diagnosis of amyloidosis being initially overlooked which delayed the initiation of treatment. It is well recognized that delayed diagnosis is a major factor in the poor outcome and prognosis of amyloidosis. Therefore, it is important that clinicians have a high index of suspicion to detect amyloidosis.

O’Reilly E, Brennan S, Timon C Department of Otolaryngology, Head and Neck Surgery, St James Hospital, Dublin, Ireland Background: Hypothyroidism post neck radiotherapy has been well documented, with a 27 % risk and a median time to diagnosis of 1.8 years1. A patient presented to St James Hospital for a total laryngectomy with a recurrence of laryngeal cancer; initially treated with radiotherapy 6 months previously. Post-operative recovery was complicated with refractory infections, cardiorespiratory decline, hyponatremia and extreme fatigue. Two weeks post operatively the patient was diagnosed with profound hypothyroidism. An ICU admission was required and liothyronine sodium was administered to correct inordinately low thyroid hormone levels. Discussion: Radiotherapy can induce hypothyroidism in several ways: direct cellular damage, vascular damage or can even trigger an autoimmune reaction. Consequently patients receiving radiotherapy to the neck can lose function of the thyroid gland to a variable degree and at a variable rate. Thyroid function tests (TFTs) are usually carried out over a year post treatment. This case however, highlights the need to increase surveillance. Profound hypothyroidism develops over time therefore it is possible that this patient was subclinically hypothyroid prior to the initial treatment. This would suggest a role for baseline TFTs in addition to post therapy surveillance at 6 month intervals. Conclusion: Hypothyroidism post radiotherapy for head and neck cancer is common. This case highlights the need to alter protocol in Ireland to increase surveillance TFTs in this cohort of high-risk patients. Reference: 1. Tell R1, Lundell G, Nilsson B, Sjo¨din H, Lewin F, Lewensohn R (2004) Long-term incidence of hypothyroidism after radiotherapy in patients with head-and-neck cancer. Int J Radiat Oncol Biol Phys 60(2):395–400 Conflict of interest: No conflict of interest, no funding. Disclosures: No disclosures.

A Clinical Audit of the Decision to Delivery Interval (DDI) in the Management of Umbilical Cord Prolapse at the Rotunda Maternity Hospital in 2014 Tansey D1, Eogan M2, Coulter Smith S2 Mater Misericordiae University Hospital1, Eccles Street, Dublin 7; Rotunda Maternity Hospital2, Parnell Square, Dublin Background: Prolapse of the umbilical cord is a rare obstetric emergency that in the viable fetus necessitates an expeditious delivery1. The

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S318 overall incidence of Cord Prolapse is 0.1–0.6 %2. Cord prolapse is defined as the descent of the umbilical cord through the cervix alongside or past the presenting part in the presence of ruptured membranes3. Methods: All Category 1 Lower Segment Caesarian Sections (LSCS) in 2014 were examined and the Cord Prolapse cases were identified. There were 9 cases of Umbilical Cord Prolapse at the Rotunda in 2014. Of these 9, 1 of these patient’s charts was off-site and so was excluded from the Audit, which gave a cohort size of 8 patients. Results: The average DDI was 10.625 min ranging from the shortest at 8 min to the longest at 14 min. Three of the mothers were multigravida while five were primiparous. Only two of the patients were at full term at the time of the Cord Prolapse; one of which was artificially induced while the other was spontaneous rupture of membranes. Six cases presented with Preterm premature rupture of membranes (PPROM). Seven of the babies were live-births, six of whom required admission to the Neonatal ICU, while one baby was stillborn. Conclusions: The incidence of Cord Prolapse at the Rotunda is comparable to that in other maternity hospitals in Ireland and the UK. The Rotunda Maternity Hospital is achieving excellent DDI times that are on average more than half that of the RCOG recommended 30 min. References: 1. Lin MG (2006) Umbilical cord prolapse. Obstetric Gynecol Surv 2. (2008) RCOG Green Top Guideline No. 50 3. (2004) NICE CG13 Caesarean Section Clinical Guideline

An Unusual Cause of Gastrointestinal Bleeding During Pregnancy Kelly GA, Kearney CG, Collins C Department Of Surgery, University College Hospital Galway Gastrointestinal Stromal Tumours (GISTs) are rare tumours of mesenchymal origin arising anywhere along the GI tract. There occurrence during pregnancy is extremely rare with fewer than 10 cases previously reported upon. We present a case of a 29-year-old para 0 + 1 who presented complaining of hyperemesis associated with fresh hematemesis and melena at week 8 of gestation. An esophagogastroduodenoscopy was performed which detected a large tumour below the oesophagogastric junction. A GIST tumour was suspected clinically. Laparoscopic Subtotal Gastrectomy was performed and Immunohistochemistry confirmed this to be a gastrointestinal stromal tumour (GIST) which arised from the stomach. Postoperative Transvaginal Ultrasound showed fetal heart activity was present. This case highlights that surgical management can be undertaken in a patient at an early gestational stage with excellent postoperative outcomes from both a surgical and obstetric point of view.

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 laminectomy as the definitive treatment of the pathology. This report discusses the two broad surgical options for treating a T10 intramedullary SOL, and illustrates why the surgical option selected was more appropriate for this case. Case presentation: A.C. is an 18-year-old female who presented to A&E with a 1 week history of lower back pain and progressively worsening bilateral lower limb weakness and sensory loss. Following spinal radiological investigations, A.C. was diagnosed with a T10 intramedullary SOL. Three days following her initial presentation, she received a T10 laminectomy and excision of the spinal SOL. No immediate complications followed surgery and A.C. was initially confined to bed-rest. Ten days after the operation, an ASIA Assessment was performed which illustrated that A.C. remained in a state of significant lower limb motor and sensory deficit. In the weeks that followed the operation, A.C. underwent intensive daily physical therapy but did not progress at the rate expected of the orthopaedic specialists or physiotherapists. Discussion: It is almost universally accepted that the definitive treatment for any symptomatic spinal SOL is immediate surgical intervention. The two broad surgical options are laminectomy and laminoplasty. When considering the entire spine, oppose to the individual vertebral column segments, the incidence of spinal instability and/or deformity post-surgery is lower in laminoplasty than laminectomy1. In light of A.C.’s slow recovery of peripheral senses and slow progression to mobilize, a laminoplasty would initially appear to have been a better option considering the aforementioned benefits over laminectomy. However, studies show that the incidence of deformity following a laminectomy at the thoracic spine is low as long as more than 50 % of the facet joints are not disrupted2. Furthermore, there is no evidence that laminoplasty is more beneficial than laminectomy for improving neurological function3. Conclusion: This case illustrates the importance of considering the individual vertebral segments when debating which operative course is more appropriate. Laminoplasty is indeed less invasive and results in a lower incidence of deformity when considering all spinal SOLs. However, for thoracic spine SOLs, laminectomy is arguably more appropriate as it produces similar clinical outcomes while having the added benefit of being a faster and more economical procedure. References: 1. Atiba et al (2007) Laminoplasty versus Laminectomy is associated with a decreased incidence of spinal cord deformity after resection of intramedullary spinal cord tumors in children. Am Assoc Neuro Surg 2. Schalto et al (2014) Laminoplasty. emedicine.medscape.com 3. McGirt MJ et al (2010) Short-term progressive spinal deformity following laminoplasty vs. laminectomy for resection of intradural spinal tumor: analysis of 238 patients. Neurosurgery 66(5): 1005–12

Kikuchi Disease: a Case Report Laminectomy vs. Laminoplasty: the Operative Choice in the Definitive Management of a T10 Intramedullary Space-Occupying Lesion

O’Grady C, Gon KJ, McGrath E Acute Medical Unit, St. Vincent’s University Hospital, Elm Park, Dublin 4

Sheehan K Department of Trauma and Orthopaedic Surgery, University Hospital Limerick, Dooradoyle, Co. Limerick Introduction: A.C. was diagnosed with a symptomatic T10 intramedullary space-occupying lesion (SOL). The patient received a T10

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Introduction: Kikuchi disease is a histiocytic necrotizing lymphadenitis. It is a rare condition characterised by fever and benign cervical lymphadenopathy, first described in Japan in 1972. Case description: A 29-year-old gentleman presented to the Emergency Department with a 6 week history of fever, night sweats, malaise and recent weight loss. His past medical history was

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 unremarkable and he was on no medications. On examination, he was noted to have multiple palpable lymph nodes in the cervical region. A CT scan of his neck, abdomen, thorax and pelvis revealed bilateral cervical and supraclavicular lymphadenopathy. He was also noted to have mild right sided iliac lymphadenopathy. The patient went on to have an excisional node biopsy of a left cervical lymph node. Biopsy results were consistent with a diagnosis of Kikuchi disease. The patient was treated supportively with non steroidal anti-inflammatory drugs. Towards the end of his 2 week admission, he was noted to have no further temperatures or night sweats. He was clinically well on discharge. Discussion: Kikuchi disease is typically a self-limiting condition. Treatment is supportive, generally with analgesia, antipyretics and non steroidal anti-inflammatory drugs. In more severe cases, corticosteroid treatment may be required to achieve remission. Although rare, it is important to differentiate Kikuchi disease from other causes of lymphadenopathy and fever, such as Lymphoma, SLE and Tuberculosis, in order to avoid inappropriate therapy and investigations. Kikuchi Disease has a very good prognosis, typically resolving within 1–4 months, although a recurrence rate of 3–4 % has been described1. Reference: 1. Bosch X, Guilabert A, Mquel R, Campo E (2004) Enigmatic Kikuchi-Fujimoto disease: a comprehensive review. Am J Clin Pathol 122:141–152

Prevalence of Benzodiazepine Usage Amongst Inpatients at Mayo General Hospital McGrath T, Keane M, Lee T Department of Medicine, Mayo General Hospital, Castlebar, Co. Mayo Background: Benzodiazepines (BZDs) are indicated by the BNF as short-term hypnotics and anxiolytics recommended for no longer than 2–4 weeks’ use1. They have significant addictive potential and may precipitate a withdrawal syndrome if treatment is suddenly discontinued2. Aim: To investigate the prevalence of BZD use in Mayo General Hospital with an aim to develop a stop-start prescribing protocol for BZDs. Methods: We analyzed the charts of 100 randomly-chosen inpatients on medical wards, taking note of BZDs prescribed prior to admission and those commenced since admission. Psychiatric diagnoses and coprescribed psychiatric medications were also noted. Results: Nineteen patients were currently receiving BZD therapy at time of audit. Of these, 12 patients had been commenced on BZDs since admission. Alprazolam was the most common BZD in current use, prescribed in 8 patients. Eleven patients had been prescribed BZDs prior to admission; 4 of these had BZD therapy stopped since admission. Temazepam was the most commonly prescribed benzodiazepine prior to admission, prescribed in five patients. At no point had an indication nor a duration for BZD therapy been noted in the drug kardex or chart. Conclusions: BZD prescribing is highly prevalent in MGH with no clear guidance for prescribers in relation to indication or duration of therapy. This audit highlights the need for a stop-start protocol for these highly addictive medications. Along with this we would recommend the need for education of both medical and nursing staff at

S319 the risks of over-prescribing of benzodiazepines and encourage regular review of these medications once prescribed. References: 1. British Medical Association and the Royal Pharmaceutical Society of Great Britain (2014) British National Formulary, 67th ed. BMJ Publishing Group, London, pp 219, 224. 2. Longo, LP, Johnson, B (2000) Addiction: Part I. Benzodiazepines—side effects, abuse risk and alternatives. Am Fam Physician 61(7):2121–2128

CT Guided Thrombin Injection of a Left Internal Mammary Artery Pseudoaneurysm Secondary to Lung Empyema McNamara Y, Lawlor L Radiology Department, Mater Misericordiae Hospital, Dublin 7 Introduction: This case report discusses a patient who underwent a CT guided thrombin injection of a mycotic left internal mammary pseudoaneurysm secondary to lung empyema; an unusual entity. It discusses CT/US or fluoroscopic approaches and reviews therapeutic options for the management of pseudoaneurysms. Case presentation: A 75-year-old woman was admitted with a 10-month history of lower respiratory tract infections, haemoptysis, anorexia and weight loss. A CT scan confirmed a left lung empyema with secondary left internal mammary artery mycotic pseudoaneurysm. A CT guided thrombin injection the pseudoaneurysm was performed. Follow up non-contrast CT showed successful therapy. In a literature review mycotic pseudo-aneurysm of the internal mammary artery secondary to lung empyema is unreported. Furthermore CT guided therapy is unreported to our knowledge. This presentation discusses this unusual entity, the options for therapy and the ultimately successful approach we took though minimally invasive image guidance.

Therapeutic Hypothermia IN Patients Admitted to ICU in University Hospital Limerick Post Cardiac Arrest in 2014 Quick L, O’Dea J Intensive Care Unit, University Hospital Limerick, Midwestern Regional Training Network Introduction Therapeutic hypothermia has been a commonly used method to improve neurologic outcomes and reduce mortality rates in patients post cardiac arrest. The International Liaison Committee on Resuscitation (ILCOR) recommend cooling should be started as soon as possible and continued for at least 12–24 h, maintaining a temperature of 32–34 C. Aims: Audit the rates and outcomes of active cooling in ICU patients admitted post cardiac arrest according to the ILCOR guidelines. Materials and method: This is a retrospective study of all patients admitted to the ICU post cardiac arrest in University Hospital Limerick (UHL) in 2014. The rhythm causing the arrest, location of arrest, time to ICU admission and relevant data regarding cooling were extracted from patient records.

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S320 Results: A total of 45 patients were admitted to ICU post-cardiac arrest in 2014 in UHL. Forty-five percent of these arrests occurred out of hospital. Forty-four percent of patients were treated using Therapeutic Hypothermia. Of the OHCA patients cooled, 75 % had a shockable rhythm causing the arrest (Vfib/VT). All patients were cooled used the Blanketrol system of which 4 % were cooled to a target temperature of \32 C, 38 % to between 32 and 34 C, and 33 % to [34 C; the remainder were unspecified. Average time from Arrest to ICU admission was 4.5 h. Noted delays included transfer via the cardiac cath lab, and a lack of available beds. Discussion: Adherence to the Resuscitation Guidelines in UHL may reflect the recent controversy surrounding target temperature. Recent evidence indicates that mild hypothermia, or avoidance of pyrexia2 post cardiac arrest may have similar outcomes without added risk such as re-warming cardiac arrhythmias. Following publication of updated resuscitation guidelines, re-audit is recommended. References 1. Nolan JP et al (2003) Therapeutic hypothermia after cardiac arrest. An advisory statement by the Advancement Life Support Task Force of the International Liaison Committee on Resuscitation. Resuscitation 57:231–235 2. Nielsen N, J et al (2013) Targeted Temperature Management at 33 versus 36 C after Cardiac Arrest. N Engl J Med 369(23):2197–2206 3. Schneider A, Bottiger BW, Popp E (2009) Cerebral resuscitation after cardiocirculatory arrest. Anesth Analg 108:971–9

Is Anti-tTG Alone Sufficient for Diagnosis of Celiac Disease? Sheahan K, Wallace E, Cullen G Intern Network: UCD Intern Network, Department of Immunology and Histopahtology, St. Vincent’s University Hospital, Dublin Background: The aim of the audit was to look at whether anti-tissue transglutaminase (tTG) levels alone were sufficient or not for the diagnosis of coeliac disease (CD). Anti-endomysial antibody (EMA) tests are ordered if there are positive or borderline anti-tTG results. However, patients usually have duodenal biopsies, regardless of the EMA result, particularly if clinical suspicion is high. This audit looked at the possibility of removing the EMA test as futile and expensive considering the high sensitivity of the anti-tTG test and histology. Methods: Anti-tTG test results performed in SVUH in 2012 and 2013 were examined. Positive anti-tTG results were collected and collated with the EMA result and histology. The standard cut off value for antibody used were anti-tTG \7 IU/mL and EMA \10 (titre). Results: In 2012 and 2013, anti-tTG was positive in 107 samples, 68 of which were EMA positive, and 39 were EMA negative. Eighty three percent of samples (57/68) that were anti-tTG Positive/EMA Positive were CD+ on biopsy. While 82 % (32/39) of samples antitTG Positive/EMA negative were CD+ on biopsy. Where clinical suspicion is high, there is no significant difference in the diagnosis of CD by biopsy whether EMA is positive or negative. Eighteen percent of these anti-tTG positive samples (n = 107) had normal biopsies. Conclusions: Where clinical suspicion of celiac disease is high, a positive anti-tTG should lead directly to biopsy. EMA is not required at diagnosis or for monitoring of Gluten Free Diet which will result in significant savings (cost of EMA for 2 years = €6038).

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Can ‘Hotspotting’ Prove to be a Useful Tool to Reduce ED Attendance in the General Hospital Setting? McGovern EJ1, Bolger J1, Coyle P1, Courtney D1, Jackson A2, Barry K1, Waldron R1 Departments of Surgery1, Emergency Medicine2, Mayo General Hospital, Castlebar, Co Mayo Background: There is increasing strain put on existing emergency services as acute hospital services are rationalized. Previous work identifies 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. Thus allowing focused allocation of community resources, leading to significant cost savings and ease of burden on acute services. Hotspotting to date has focused on large urban centres. This research aims to determine if hotspotting may be of use to identify disproportionate ED use in the rural 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). Conclusions: A number of geographically distinct hotspots exist for frequent users of ED services for the rural general hospital. 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.

A Case of Cardiac Carcinoid Smyth Y, Ridge P Intern Network: WNW This is the case of a 54-year-old postman who is a patient of the cardiology services in UHCG. This patient has a significant background of prostate adenocarcinoma, metastatic neuroendocrine carcinoma (carcinoid subtype) and bladder carcinoma (TCC). The patient had multiple mediastinal, pulmonary and hepatic neuroendocrine metastatic lesions that were under active surveillance. He developed carcinoid syndrome in 2013 and subsequent echocardiogram revealed cardiac carcinoid causing severe tricuspid regurgitation. Monthly injections of somatostatin analogue and oral furosemide were commenced. The patient presented to ED in November 2014 with a 3 day history of palpitations, dyspnoea and a 3 week cough. Examination was consistent with heart failure and a 7 kg weight gain was noted from his last clinic. An echocardiogram was performed and showed an EF of 45 % and a worsened tricuspid regurgitation due to a thickened, open and immobile tricuspid valve. Chest radiography and CTPA identified left lower lobe pulmonary emboli and the patient was commenced on innohep, furosemide,

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 bisoprolol, eplerenone and discharged. He represented the next month with worsening shortness of breath. Chest radiography, coronary angiogram and right heart catheterisation revealed a left sided pleural effusion, moderate CAD and a wide open tricuspid valve, respectively. The patient is now being assessed for tricuspid valve replacement. Cardiac carcinoid usually affects the right heart as the left side is thought to be relatively protected by filtering of blood through the pulmonary vasculature. There is considerable debate regarding valvular surgery as previous case series have shown a high peri-operative mortality, but marked reduction in morbidity in those who survive.

An Aortocaval Fistula, an Unusual Complication of Ruptured Abdominal Aortic Aneurysms: a Case Report Sheahan K, Ramesh N Intern Network: UCD Intern Network (DML), Surgical Department, Radiology Department, Midlands Regional Hospital, Portlaoise Introduction: Rupture of an abdominal aortic aneurysm (AAA) into the inferior vena cava (IVC) is an uncommon and often devastating condition, involving less than 3–6 % of all ruptured aortic aneurysms1. This diagnosis can be missed if meticulous examination is not performed, particularly for a pulsatile mass and a bruit which is associated with ACF. Case description: A 61-year-old gentleman presented with worsening, severe back pain followed by collapse in the Emergency Department (ED). His medical history was significant for epilepsy, taking lamotrigine 100 mg BD. CT abdominal aorta with contrast was performed which showed a large infra-renal AAA measuring 10.5 cm 9 8.8 cm in width, length of 14.6 cm with leak along the right postero-lateral margin with aorto-caval fistula (ACF). No haematoma. There was a 4.5 cm 9 4.5 cm right internal iliac artery aneurysm, 3.0 cm 9 3.2 cm left internal iliac aneurysm. Initial resuscitation and stabilization in ED in peripheral hospital before transfer to tertiary hospital for admission under the Vascular Team for emergency repair of ruptured abdominal aortic aneurysm. He was brought immediately to theatre where a large inflammatory AAA with an aortocaval fistula was found and repaired. The patient recovered well post operatively, spending 3 days in ICU and was discharged to the ward. Discussion: Over 80 % of reported ACF are related with ruptured AAA. Other causes refer to penetrating trauma, mycotic aneurysms and connective tissue diseases2. The mortality rate of ACF patients is high 10–36 %3. Endovascular techniques have good early results, open surgery remains the cornerstone of treatment. References: 1. Schmidt R, Bruns C, Walter M, Erasmi H (1994) 2Aorto-caval fistula-an uncommon complication of infrarenal aortic aneurysms, 2. Thorac Cardiovasc Surg 42(4) 208–211 2. Davis PM, Gloviczki P, Cherry Jr KJ et al (1998) Aorto-caval and ilio-iliac arteriovenous fistulae. Am J Surg 176(2):115–118 3. Gilling-Smith GL, Mansfield AO (1991) Spontaneous abdominal arteriovenous fistulae: report of eight cases and review of the literature. Br J Surg 78:4

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Diagnosing Pleural Tuberculosis (TB) in a 28-YearOld Vietnamese Prisoner Mc Donnell K, Fleming C Department of Infectious Disease, University Hospital Galway; West North West Intern Network Introduction: Pleural TB is a form of extrapulmonary TB. Obtaining TB isolates for drug-susceptibility testing often presents a diagnostic challenge. Delays in diagnosis and therapy initiation are associated with increased mortality. Description: A 28-year-old Vietnamese male prisoner presented to the ED with a 1-week history of vomiting and right upper quadrant (RUQ) pain, 2-week history of weight loss and a 4-week history of malaise, night sweats and productive cough. Physical examination revealed pyrexia, reduced air entry and stony dullness to percussion in the right lower lung zone and RUQ abdominal tenderness. Blood tests revealed a raised CRP. Chest X-ray revealed a right pleural effusion. Sputum testing was negative for acid fast bacilli. Antibiotics were commenced and a chest drain inserted; an exudative pleural aspirate was obtained with lymphocytosis (96 % mononuclear cells) and negative PCR analysis. A pleural biopsy was performed via video assisted thoracoscopic surgery. Gene-expert testing on pleural biopsy revealed a very low level of MTB complex DNA with no rifampicin resistance. Histology revealed granulomatous pleuritis consistent with TB. 6-months of anti-TB treatment were commenced. Discussion Pleural fluid seldom confirms a diagnosis of pleural TB. The diagnosis is based on microbiology and pathology. Pleural biopsy is indicated when a lymphocyte-dominant exudative effusion is identified. In this clinical setting, experience with gene-expert, as a diagnostic tool, is still being acquired; however the sensitivity is at least 25 %1. The combination of AFB culture and histology from pleural biopsy is most sensitive in diagnosing pleural TB2,3. References 1. Friedrich SO, von Groote-Bidlingmaier F, Diacon AH (2011) Xpert MTB/RIF assay for diagnosis of pleural tuberculosis. J Clin Microbiol 49(12):4341–4342 2. Kim HJ, Lee Hj, Kwon SY et al (2006) The prevalence of pulmonary parenchymal tuberculosis in patients with tuberculous pleuritis. Chest 129:1253–1258 3. Siebert AF, Haynes J JR, Middleton R et al (1991) Tuberculous pleural effusion: 20-year experience. Chest 99:883–886

Don’t Be Misled by a Negative ANCA: a Case of Limited Granulomatosis with Polyangiitis Ridge P, Garrahy A, O’Regan A Department of Respiratory Medicine, Galway University Hospital This is the case of a 48-year-old lady who presented to University College Hospital Galway with a severe presentation of tracheal stenosis illustrated by her pulmonary function tests and stridor. This patient presented with a 3 week history of exertional dyspnoea and nocturnal cough. Examination revealed stridor. CT Scan

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S322 demonstrated upper tracheal narrowing and pulmonary function tests were consistent with extrathoracic upper-airway obstruction. Renal function was normal and ANCA negative. A tracheal biopsy showed fibrosis with minimal inflammation. The diagnosis was felt consistent with idiopathic tracheal stenosis, although limited granulomatosis with polyangiitis can also occur with a negative ANCA. She was therefore commenced on glucocorticoids and methotrexate as well as proton pump inhibition due to the association of idiopathic tracheal stenosis with GORD. She remains well 24 months later. Tracheal stenosis has numerous possible aetiologies. In this case we felt it was either caused by limited Granulomatosis Polyangiitis or idiopathic in nature. We feel this case highlights that a negative ANCA and negative histopathology does not out rule GPA, neither does it diagnose Idiopathic Tracheal stenosis.

Bayesian Analysis of a Patient with Either Recurrent Metastatic Melanoma or Ipilimumab-Induced Sarcoidosis McNamara Y, Kelleher F Department of Oncology, Beacon Hospital, Dublin 18 Background: In 2007, a 46-year-old male patient had excision of a nodular melanoma with a Breslow’s thickness of 1.3 mm. A wide local re-excision and sentinel lymph node biopsy were negative. In 2013, a left axillary nodal recurrence was detected. The tumour was BRAF V600E positive. In 2014, he developed a solitary metastasis in the left triceps. Ipilimumab was commenced in a pseudo-adjuvant context. A pre-surgery MRI brain and (18F FDG) PET CT revealed no other sites of disease. A subsequent (18F FDG) PET CT 6 weeks post completion of 4 cycles of Ipilimumab described FDG avid hilar and mediastinal adenopathy and bilateral FDG avid lung nodules. There was lowgrade bilateral uptake in the lower limbs. In view of the distribution of the likely recurrent melanoma we considered the possibility of this radiology representing sarcoidosis as an immune related adverse reaction secondary to Ipilimumab. Prior to initiation of anti-PD1 we assessed the merit of undertaking a biopsy to confirm a second relapse of metastatic melanoma. Method: Quantitative appraisal of the clinical dilemma arising in this case was approached using Bayes’ theorem. Results: Endobronchial biopsy station 4R lymph node, found abundant histiocytic aggregates focally forming granuloma and no melanoma cells in either nodes. The diagnosis was Ipilimumab-induced sarcoidosis. Conclusions: Positive finding on PET imaging in patients with melanoma treated with Ipilimumab can represent other entities including iatrogenic sequelae from immunotherapy.

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Hospital (SJH) over a 6 month-period. Various steps along the thrombolysis pathway were measured in order to identify delays and examine how thrombolysis management can be improved. Design/methods: All strokes presenting to or occurring in SJH are inputted into the National Stroke Register, available online via the HSE’s HIPE data portal. This was combined with information from SJH’s own Electronic Patient Records to create a data-set which included: symptom onset time, hospital Admission time, door to CT Brain time, door to thrombolysis time, length of hospital stay. The data was collected from 01/01/2014 to 30/06/2014. Results: In total, 11 out of 105 ischaemic strokes were thrombolysed (10.48 %). Of these thrombolysed strokes, mean symptom onset time to hospital admission was 62.3 min (with a range from 12 to 130 min). Door to CT Brain time had a mean of 38.1 min (range 24–66 min). Door to thrombolysis time had a mean of 83.8 min (range 49–140 min). The average length of hospital stay for these patients was 18.1 days (range 5–76 days). Conclusions: The overall thrombolysis rate at SJH meet the Stroke Council of Irish Heart Foundation targets of 5–10 %. Door to needle time is not yet in line with international best practice guidelines (\60 min). Notably, a delay between CT Brain and thrombolysis was identified. A number of suggestions were put forward to address some of these delays, including the idea of initiating thrombolysis in the radiology department.

Gastrojejunal Intussusception a Rare Cause of Obstruction Mc Donald D1, Neary P1, Eguare E22 Department of Surgery1, AMNCH, Dubin 24; Department of Surgery2, NGH, Naas

Department of Stroke Medicine, St James’s Hospital, Dublin 8

A 69-year-old female was brought in by ambulance with collapse following a 5 h history of sever epigastric pain followed by 6–10 episodes of haematemesis. Her history was significant for a vagotomy and gastrojejunostomy for a duodenal ulcer 40 years previously. On examination the patient was haemodynamically stable, she had marked tenderness, guarding and rigidity in the epigastric region. There were no palpable masses. A CT scan revealed a retrograde jejunal intussusception through the gastrojejunostomy which was located along the posterior aspect of the stomach. She underwent an emergent laparoscopy where the 30 cm intussusception was reduced. There was enteric ecchymosis but it was deemed viable. Follow up endoscopy was unremarkable and the patient was discharged well 9 days later. Gastrojejunal intussusception is a rare complication of gastric surgery which was first identified in 1914 by Bozzi. As of 2006 only 200 cases have been reported including only one in Ireland. Potential complications include bowel ischaemia, perforation and death therefore; a high index of suspicion is required to make a prompt diagnosis. Contrast enhanced CT is the most reliable diagnostic test with an accuracy up to 80 %, however many cases are still diagnosed at surgery1. Treatment options include simple reduction, reduction with plication or surgical resection with revision of the anastomosis. This will be determined by the findings at surgery however, the latter two have been shown to have decreased risk of reoccurrence2. In summary intussusception should be considered in patients with gastroenterostomy presenting with abdominal pain or haematemesis.

Objectives: Examining the use of thrombolysis in the management of acute ischaemic strokes presenting to or occurring in St James’s

References: 1. Majeski J, Fried D (2004) Retrograde intussusception after Rouxen-Y gastric bypass surgery. J Am Coll Surg 199(6):988–9

Thrombolysis Management of Acute Ischaemic Strokes Presenting to St James’s Hospital Over a 6Month-Period McLoughlin F, McShane C, Harbison J

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 2. Simper SC, Erzinger JM, Mc Kinlay RD, Smith SC (2008) Retrograde (reverse) jejunal intussusception might not be such a rare problem: a single group’s experience of 23 cases. Surg Obes Relat Dis 4(2):77–83

A Case of Pesudomyxoma Peritonei Sabirin S, O’Mara G Roscommon County Hospital, Roscommon, Ireland Pseudomyxoma peritonei is a clinical syndrome of diffuse intraperitoneal collections of gelatinous material, commonly attributed to ruptured mucinous adenocarcinoma (most often appendiceal origin). The overall incidence is *1.2 per million per year. The natural history is still not fully understood and remains elusive to treat. A 69-year-old male patient was referred to outpatient department with 5-months history of increasing abdominal girth associated with bilateral pedal oedema and anorexia. Of note, he is a non-smoker, with average alcohol intake of 6-units per week. Past medical history was unremarkable. On examination, patient was of cachectic appearance with large ascites, tense non-tender on palpation. CRP: 233, ESR: 118, albumin: 27.6, ALP: 126, the rest of LFT normal, WCC: 13.4, neutrophils: 12 (H), hepatitis screen negative. CT-TAP confirmed massive ascites. A paracentesis was performed, draining 1 L of thick gelatinous green viscous fluid. The sample was unsuitable for analysis due to viscosity with scanty white cell differentials and negative culture reported. A CT-guided peritoneal biopsy was carried out and confirmed the diagnosis of disseminated peritoneal mucinous adenocarcinoma. The patient was subsequently referred to Mater Misericordiae University Hospital where an exploratory laparotomy was carried out and 10 L of gelatinous fluid was drained. However due to the extent of the disease, attempt of hyperthermic intraperitoneal chemotherapy (HIPEC) was aborted. The drainage slightly alleviated the symptoms and patient was discharged to the palliative care in community for palliative measures.

An Audit of GI Endoscopic Surveillance in Sligo Regional Hospital Kilmartin DM, Khan T, Walsh K Department of Gastroenterology, Sligo Regional Hospital; NUI Galway Intern Training Network Background: Upper and lower GI endoscopy allow early detection and intervention of many diseases, most notably malignancies. An audit of GI endoscopy surveillance was carried out according to Joint Advisory Group recommendations1. Aims: (a) To determine if surveillance patients are receiving follow up procedures within the recommended JAG timeframe. (b) To determine if the recall surveillance is appropriate according to the national surveillance guidance.

S323 Methods: Inclusion criteria included (a) patients scheduled for upper or lower GI endoscopy surveillance in 2015 at Sligo Regional Hospital or (b) patients who have had a surveillance GI endoscopy carried out in 2014 at Sligo Regional Hospital. The surveillance time requested by the clinician was recorded. We also recorded if these requests were in accordance with GI endoscopy surveillance guidelines and reasons for non-adherence. Results: Of the 57 cases we analysed, we found that 29 (51 %) were requested as per surveillance guidelines. Furthermore, 43 (75 %) were scheduled and carried out within 6 weeks of the requested time, with 46 (81 %) being carried out within 13 weeks of the requested time. Of note, of the 20 patients who had endoscopy carried out by the medical clinician, 19 (95 %) were carried out within 6 weeks of the requested time, with all 20 (100 %) carried out within 13 weeks of the requested time. This was found this to be in line with national levels1–3. Conclusions: We recommend repeating this audit next year to ensure that the department is adhering to national guidelines1–3. References: 1. Joint Advisory Group on GI Endoscopy (2011) Users guide to achieving a JAG compliant endoscopy environment 2. QA Guidelines for GI Endoscopy (2011) National Quality Assurance Programme in GI Endoscopy, Conjoint Board in Ireland of the Royal College of Physicians and Royal College of Surgeons 3. National Cancer Screening Service for Adenoma Surveillance (2013)

Recurrent Hypoglycaemia: Highly Suspicious for Insulinoma McDonnell NA, Bell M Department of Endocrinology, University College Hospital Galway A 60-year-old lady who was brought in by ambulance with an acute episode of confusion, disorientation and amnesia. A blood glucose was 3.1 mmol/L. Clinical examination was normal. The patient had no known history of diabetes and denied taking exogenous insulin or hypoglycaemic agents. Her medications included an SSRI and she was not taking anything known to cause hypoglycaemia. She was employed as a healthcare worker. The patient reported daily episodes of dizziness for the previous 18 to 24 months, which were relieved by eating. She had 2 recent hospital admissions for orthopaedic procedures, and was noted to have low blood glucose levels during these admissions. Initial investigations revealed hyponatraemia with a sodium ranging from 126 to 134 mmol/L. In light of this and the hypoglycaemia it was necessary to out-rule adrenal insufficiency. A Synacthen test was normal with a cortisol level of 370 nmol/L at 0 min, 855 nmol/L at 30 min, and 1095 nmol/L at 1 h. The patient was commenced on a 72 h fast, and became hypoglycaemic after 38 h with a confirmed plasma glucose level of 2.2 mmol/L. Blood tests revealed a low insulin level at 45.6 pmol/L (17.8–173), a normal c-peptide level at 569 pmol/L (370–1470) and a beta-hydroxybutyrate level of 340 umol/L (\ 600 umol/L). Proinsulin and sulphonylurea levels are pending.

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S324 CT pancreatic protocol revealed no pancreatic lesion. However, hyperplasia of the left adrenal gland was identified. Plasma metanephrines were normal. Dexamethasone suppression test was normal. Renin-aldosterone ratio was sent and results are pending. Albeit no pancreatic lesion was visualised on CT, the patient’s clinical condition and laboratory results are suggestive of an insulinoma.

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Images

Vertebroplasty: State of the Art Method for the Palliative Treatment of Spinal Cancer Metastases McNamara I, Munk PL, Mallinson PI University Hospital Limerick, Dooradoyle, Limerick Introduction: A 58-year-old female presented with back pain for 8 weeks, diagnosed with breast carcinoma 8 years prior. Description/case presentation: The patient had no history of metastatic disease prior to the presentation. A CT spine of T1-L3 showed marked right anterolateral L1 compression, moderate anterior T12 vertebral wedging and mild T10 vertebral compression with extensive patchy sclerotic density through all vertebral bodies, partially sparing the left lateral L1 body (Figs 1, 2). The appearance reflected metastatic disease. In view of the patient’s marked pain symptoms, the patient was treated with vertebroplasty at all three levels. Discussion: Vertebroplasty is a safe, inexpensive, and effective interventional vertebral augmentation technique that provides pain relief and stabilisation in carefully selected patients with severe back pain due to vertebral compression1. Osteoporotic vertebral fractures, as with hip fractures carry a very high rate of morbidity and mortality. Wedge compression fractures (as seen in this case) are the most frequently observed particularly in the thoraco-lumbar region2. The procedure can typically be carried out under local anaesthetic with conscious sedation. Needles are placed under fluoroscopic guidance taking care to avoid puncturing the medial wall of the pedicle and entering the spinal canal. Published data shows the complication rates with malignant fractures are below 10 %3. In recent years the life expectancy of cancer patients has increased. With increased survivorship, there is a greater risk of development of spinal metastases. The overall aim is to ensure adequate pain relief. Regarding malignant fractures treated with vertebroplasty, this can be achieved in 60–85 % of cases4. References: 1. Young C, Munk PL, Heran MK, Lane MD, Le HB, Lee S, Badii M (2011) Clarkson PW and Ouellette HA. Treatment of severe vertebral body compression fractures with percutaneous vertebroplasty. Skeletal Radiology 40(12):1531–6 2. Waterloo S, Ahmed LA, Center JR, Eisman JA, Morseth B, Nguyen ND, Nguyen T, Sogaard AJ, Emaus N (2012) Prevalence of vertebral fractures in women and men in the population-based Trosmo study. BMC Musculoskelet Disord 13:3 3. McGraw K, Cardella J, Barr JD (2003) Society of Interventional Radiology Quality Improvement Guidelines for percutaneous vertebroplasty. J Vasc Interv Radiol 14:827–831 4. Shimony JS, Gilula LA, Zelle AJ et al (2004) Percutaneous vertebroplasty for malignant compression fractures with epidural involvement. Radiology 232:846–853

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Fig 1. 25 MM Coronal CH ABD. This image shows sclerotic changes through vertebral bodies T10, T12 and L1.

Fig 2. Spine CT in the saggital plane. A slight thoracolumbar kyphosis may be seen with compression fractures of T10, T12 and L1.

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Fig 5. This CT spine image post procedure shows the placement of the cement in the vertebral bodies.

The Prevalence of Laxatives Prescribing in the Elderly Population on a Medical Ward in Roscommon County Hospital Fig 3. This CT spine image shows the insertion of the needles through the pedicle of each vertebra.

Sabirin S, O’Mara G Department of Geriatrics, Roscommon County Hospital, Roscommon, Ireland; WNW Intern Training Network

Fig 4. CT spine image monitoring the cement as it is released into the body of the vertebras.

Background: Constipation is a common problem encountered in elderly population. It was estimated that 50 % of institutionalized elderly population suffer from constipation. While laxatives have its therapeutic values, lack of evidence hamper its use. This audit aims to discover prevalence of laxatives prescribing in the elderly population and its appropriateness. Methods: This is an observational cross-sectional study where data were collected from 33 elderly patients ([65 years old) in St Coman’s ward on a single day; noting gender, type of laxatives, durations and strength, use of opioids and the availability of stool chart. A quick review of medical file to determine if the cause of constipation was fully explored based on World Gastroenterology Organisation (WGO) Guidelines carried out. Results: 21 of 33 (64 %) elderly patients are prescribed one laxative or more. Of these patients, review of medical file showed no full exploration of the causes of constipation (0 %) and indications were unrecorded in the majority of them. No stool charts are recorded unless patient had diarrhoea (0 % of patients). Osmotic laxatives are recognised as the choice of laxatives prescribed (86 %) followed by stimulant laxatives. Conclusions: The majority of the institutionalized elderly patients (64 %) are on laxative prescription; with no clear indications and stool chart recorded. In order to ensure appropriateness of laxatives prescribing, it is recommended that (1) causes of constipation are fully explored and noted in patient’s chart as per WGO Guidelines, (2) stool chart recorded for every patient, (3) a survey on patients’ satisfaction of symptoms alleviation is carried out.

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S326 Reference: 1. Lindberg G, Hamid S, Malfertheiner P, Thomsen O et al (2010) World Gastroenterology Organisation Global Guidelines. Constip Glob Persp:1–13

Bilateral Lumbar Pedicle Fractures in the Absence of a Neurological Deficit or Concomitant Osseous Injury Neary C, Hurley R, Baker J, Jadaan M

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 patients were only affected from 50+, with most patients between 80 and 89 years. Those patients with multiple diagnoses (=64) were significantly older than patients with only one diagnosis (=55). Conclusions: This study shows there are age-based differences in the diagnostic profiles of Rheumatology outpatients. Older age is associated an increased likelihood of having multiple Rheumatologic diagnoses and also with diagnoses of RA, PMR and OA. These differences from younger patients would support the idea of having a separate clinic for elderly patients. Abbreviations: PSA, psoriatic arthritis; AS, ankylosing spondylitis; FMS, fibromyalgia syndrome; IA, inflammatory arthritis; OA, osteoarthritis; PMR, polymyalgia rheumatica; RA, rheumatoid arthritis; SLE, systemic lupus erythematosus

West-North West Region Isolated fractures of the lumbar spine pedicles are very rare in the context of simple trauma (Guo et al.). Elsewhere in the spine they are wellreported, occurring iatrogenically or as stress fractures. (Awad et al.; Kim et al.). In one reported case the zone of injury was wider with the immediately caudad vertebral body also being fractured (Singh et al.). A 61-year-old male with recurrent syncopal episodes presented 4 months after a low-energy fall in which he sustained a lower back injury. He has a past medical history of COAD. No investigations were performed, and he improved symptomatically. Unfortunately he suffered a second fall and was attended the orthopaedic service due to new-onset lower back pain, right L3 radiculopathy and weakness of knee extension. Computed tomography lumbar spine revealed healing fractures of the L3 pedicles. Magnetic resonance imaging showed a large disc prolapse at L3/4 with cephalad migration. The STIR sequence on magnetic resonance imaging revealed low signal at the fracture sites suggesting healed fractures. Our impression is that he sustained the pedicle fractures at the initial injury with a possible subclinical injury to the L3/4 disc. Only at the time of a second fall did the disc prolapse and neurological signs developed. Right sided decompression, L3/4 discectomy with instrumentation at L2 and L4 was performed, avoiding violating the healing fractures. The patient’s neurological symptoms resolved subsequently.

Age Profiles of Patients Attending Rheumatology Department and Relationship to Diagnosis McCafferty R, Ibrahim F, McCarthy CJ Intern Network: Dublin/Mid-Leinster (UCD) Background: This cross-sectional study illustrates the age profiles of patients seen in the Rheumatology Department, and examines the relationship between patient age and diagnosis. Methods: A dataset was created of patients seen in the Rheumatology Outpatient Department over a 2-month-period (n = 402). From this data patient records were broken into age groups (\20, 20–29, etc.). The 9 largest diagnostic groupings (Gout, PSA, AS, FMS, IA, OA, PMR, RA, SLE1) were chosen for study. ANOVA was used to determine statistical significance. Results: Overall, there is a bell-shaped curve in the age profile of outpatients, 60–69 years is the largest group, (= 57 years). AS and SLE patients were significantly younger than other patient groups (mean ages 39; 42). PSA, IA and Gout had the largest number of patients in the 60–69 age groups. There was no significant difference between the ages of patients with these diagnoses and those without. Patients with RA, OA and PMR (=61; 64; 73) were all significantly older groups. With PMR,

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Neuromyelitis Optica with Optic Chiasm Involvement Associated with MOG Antibody Welaratne I1, Lynch T2, O’Rourke K2 Departments of Neurology1, Dublin Neurological Institute2, Mater Misericordiae University Hospital, UCD, Dublin 7 Neuromyelitis Optica (NMO) is an autoimmune, demyelinating disease of the CNS affecting the spinal cord and optic nerves but sparing the optic chiasm. 90 % of patients are serum aquaporin-4 antibody positive. Of the remaining 10 %, some are Myelin Oligodendrocyte Glycoprotein (MOG) antibody positive. We present a patient with marked optic chiasm involvement that improved with aggressive immunosuppression but resulted in severe complications. A 21-year-old Moldovan male presented with acute, painless, bilateral vision loss. MRI revealed an enhancing lesion in the optic chiasm. Initial serum NMO antibodies were negative but he was positive for MOG antibody. IV methylprednisolone showed little improvement. He subsequently had 5 cycles of plasma-exchange with marked return in vision. He developed line sepsis during plasmaexchange. He was discharged on prednisolone 60 mg and azathioprine 25 mg BD. He later presented to a different hospital with left lower limb weakness and was presumed to have new transverse myelitis secondary to NMO. Due to delayed access to imaging, IV methylprednisolone was commenced. Subsequent MRI excluded transverse myelitis but showed a psoas abscess. He later developed avascular necrosis of both hip joints. NMO can affect the optic chiasm causing visual loss. Plasmapheresis can be effective in steroid-resistant NMO but can result in significant complications, including MSSA sepsis from an infected vascath, seeding the psoas muscle, leading to leg weakness that understandably was thought to be NMO-related. This highlights the importance of redoing a full history and examination in patients with complex disease to avoid misdiagnosis and iatrogenic disease.

Hypoperfusion Brain Injury Nolan F, Watts M, Ryan D Department of Medicine, University Hospital Limerick Introduction: Acute brain injury secondary to hypoperfusion is a rare phenomenon and involvement of deep brain structures in a stroke syndrome is unusual.1 While polypharmacy is an accepted means of blood pressure control, the risk of end-organ hypoperfusion is not

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 insignificant. We describe a case whereby a patient on multiple antihypertensive medications presents with acute multifocal cerebral ischemia. Case presentation: A 72-year-old male presented acutely confused. Collateral history indicated pre-syncopal symptoms, headache and collapse. Heart rate was 30 bpm. ECG recorded sinus rhythm with first degree heart-block. BP was 90/30 mmHg. The patient was afebrile, disoriented in time, person and place with coherent but contextually inappropriate verbalisations. The presentation evolved to include an episode of transient bilateral visual loss. Differential diagnosis included stroke and encephalitis. CT brain was normal. The beta-blocker, alpha-blocker, calcium-channel blocker, angiotensin-receptor blocker and pregabalin were held to prevent further low output events. Acyclovir and Tazocin were started prior to LP/ MRI. Cognition improved but remained impaired. Diffusion-weighted MRI-brain illustrated acute multifocal ischemia in temporal, occipital and thalamic regions, extending through perfusion territories of perforating arteries of the posterior cerebral artery and lateral lenticulostriate branches of the middle cerebral artery. Discussion: MRI is consistent with hypoperfusion-related brain injury potentiated by chronic intra-cranial small-vessel disease1,2,3. Global cerebral ischemia may result from aggressive anti-hypertensive combinations. There is increased vulnerability of deep brain structures, vascularised by long non-anastomosing end-vessels that respond poorly to hypoperfusion-ischaemia and autonomic influences. The elderly are at increased risk due to ineffectual cerebral autoregulation.

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Figure 2 b100 DWI image demonstrating acute infarction in the posterior cerebral artery distribution bilaterally. References: 1. Strandgaard S, Andersen GS, Ahlgreen P, Nielsen PE. (1984) Visual disturbances and occipital brain infarct following acute, transient hypotension in hypertensive patients. Acta Med Scand 216(4):417–22 2. Cove OH, Seddon M, Fletcher RF, Dukes DC (1979) Blindness after treatment for malignant hypertension, II. Br Med J 245–6 3. Pitlik S, Manor RS, Lipshitz I, Perry G, Rosenfeld J (1983) Transient retinal ischaemia induced by nifedipine. Br Med J 287:1845–6

Intestinal Obstruction in a Pregnant Lady Moloney C, Moran K Department of Surgery, Letterkenny General Hospital, Co. Donegal; NUI Galway Intern Training Network

Figure 1 ADC map

Introduction: Intestinal obstruction is a rare emergency complication of pregnancy affecting 1:1500–1:66431 pregnancies most commonly in the second trimester1. Case description: A 38-year-old lady, para 1, presented at 32 + 4 weeks gestation with severe colicky central abdominal pain and nausea. The abdomen was tender but soft with breech presentation without engagement. Vital signs and CTG findings were normal. There was no transvaginal bleeding. The initial working diagnosis was threatened preterm labour and the patient was initiated on

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S328 Betamethasone and an Atosiban infusion. On day 2 an Ultrasound abdomen after the patient began to vomit bilious fluid was normal. An MRI Abdomen on day 4 when the patient was vomiting feculent material confirmed proximal small bowel dilatation with a transition point and distal ileum collapse. The patient underwent urgent transfer to Galway University Hospital where she delivered a baby by Caesarean section and underwent laparotomy the next day. At laparotomy a necrotic Richter’s Hernia was discovered. 165 cm of necrotic bowel was removed and a primary anastomosis established without complication. Discussion/Conclusion: Although a high index of suspicion is required to diagnose intestinal obstruction in pregnancy, this case highlights the importance of keeping an open mind in your differential in pregnancy. A delay in diagnosis often occurs due to nonspecific symptoms, reluctance to expose the foetus to radiation and difficulty in abdominal examination. Reference: 1. Stukan MI et al (2013) Intestinal obstruction during pregnancy. Ginekol Pol 84(2):137–41

Secondary Amyloidosis: an Unusual Cause of Renal Failure in the Lung Transplant Setting Purcell AJ1, Hudson AA2, Al-Alawi MM1, O’Meara YM2, Egan JJ1 National Heart and Lung Transplant Unit1, Department of Nephrology2, Mater Misericordiae University Hospital/University College Dublin Intern Network: UCD Introduction: Secondary (AA) amyloidosis complicates chronic diseases associated with a sustained inflammatory response such as rheumatoid arthritis, inflammatory bowel disease and rarely, cystic fibrosis (CF). Chronic kidney disease is common post lung transplantation and is most frequently attributed to calcineurin inhibitor use with up to 15 % ultimately reaching ESRD. We describe a case post lung transplantation for cystic fibrosis where AA amyloidosis was a significant contributor to the development of ESRD. Description/case presentation: A 31-year-old female with a history of double lung transplant for CF (2006), redo right single lung transplant (2012), bronchiectasis and diabetes was first reviewed by the nephrology service in 2012 and diagnosed with CKD3a secondary to CNI toxicity (Creatinine 95 mol/L). 24 h protein excretion was normal as was renal imaging. Over the following year there was an upward trend in serum creatinine to 150 mol/L, with recurrent episodes of respiratory sepsis. In August 2014, she presented with progressive dyspnoea, anorexia and vomiting. Creatinine was 490 mol/L, albumin 18 g/L, and proteinuria was 3.2 g/24 h. Renal biopsy revealed severe interstitial fibrosis (up to 70 %) with features of secondary amyloidosis. Intermittent haemodialysis was commenced for control of uremia and volume overload and there was no recovery of renal function. While CNI toxicity is the most common cause of CKD posttransplant, other causes of ESRD should be considered particularly if atypical features such as nephrotic range proteinuria are present. Secondary amyloidosis in this case is presumably related to a chronic inflammatory state from recurrent suppurative lung infections seen with bronchiectasis.

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The Effect of IV Zoledronic Acid on Renal Function and Serum Calcium in an Elderly Osteoporotic Population McNulty M, Rice A, Roche S, Fallon N, Mahon J, Devaney N, Casey M MedEl Directorate, St James’s Hospital, Dublin 8 Background: IV zoledronic acid is frequently used to treat severe osteoporosis in elderly patients attending our bone health clinic. The frequency of administration is either once or twice yearly dependant on the patient’s renal function, which is checked before and 2 weeks after treatment. Calcium levels are also measured due to the known effect of zoledronic acid on calcium. Method: In this retrospective study we used the electronic patient record system and our bone health database to collect pre- and posttreatment blood results. We analysed the results of 192 patients chosen at random from the database, of which 51 had both pre- and posttreatment values available. Renal function was assessed by examining creatinine, urea and eGFR, which is calculated by the system using 4vMDRD formula. We also analysed corrected calcium levels. Results: 51 patients, mean age 75.54 years (SD10.94). 88.2 % female. Mean pre-dose creatinine 70 micromol/l (SD 17.7); mean post-dose creatinine micromol/l 66.96 (SD 17.5). Mean pre-dose eGFR 76 ml/min (SD 16.25); mean post-dose eGFR 78.55 ml/min (SD 16.56). Mean pre-dose serum corrected calcium mmol/l 2.33 (SD 0.133); mean post-dose serum corrected calcium 2.26 mmol/l (SD 0.129). Conclusion: IV zoledronic acid did not adversely affect the renal function of our patients. Nor was there significant hypocalcaemia following infusions. This re-affirms the safety of this valuable therapy.

Phaeochromocytoma: a Rare Cause of Hypertension Gormley S Department of Medicine, University Hospital Waterford-RCSI Training Network Introduction: Phaeochromocytomas are rare catecholamine secreting tumours that arise from the chromaffin cells of the adrenal medulla. These rare endocrine neoplasms are found in less than 0.1–0.2 % of patients with hypertension. Case presentation: A 33-year-old gentleman re-presented to the Emergency Department with a 1 week history of right sided abdominal pain, nausea, vomiting and palpitations. He also reported paroxysmal episodes of diaphoresis, palpitations, dizziness, anxiety and erectile dysfunction along with a 2 year history of headaches. Blood pressure on admission was 180/114 mmHg. He presented 2 weeks prior to this admission as a GP referral for headaches and hypertension (BP = 246/180 mmHg). On physical examination he was tender in the right iliac fossa but no mass was detected on palpation. CT—KUB reported a large heterogenous supra- renal mass measuring 6.2 9 7.4 cm which was suggestive of a pheochromocytoma. Renal ultrasound scan confirmed a 6.6 9 6 9 7.8 cm solid mass on the right adrenal gland. For blood pressure management his

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 valsartan was held and he was given a trial of phenoxybenzamine as a result. Within 24 h of commencing the alpha blocker his blood pressure dropped to 80–110 mmHg systolic and 40–60 mmHg diastolic. During the admission it was difficult to control the patient’s blood pressure. He experienced recurrent episodes of paroxysmal hypertension with blood pressure readings as high as 240/180 mmHg. After 7 days phenoxybenzamine was stopped and he was commenced on doxazosin. He continued to complain of intermittent episodes of chest pain and right sided flank pain that would radiate to his lower back along with palpitations and diaphoresis. Numerous electrocardiograms and repeated troponin measurements were negative for an ischaemic event. A transthoracic echocardiogram reported no abnormalities and an ejection fraction of 55–65 %. In order to localise the mass he subsequently underwent an MRI of both adrenal glands which reported a 6 9 7 9 7.5 cm solid slightly heterogenous mass lesion involving the right adrenal gland. In addition a CT—TAP reported a 8.1 9 7.5 cm heterogenous mass in the right adrenal gland with areas of high density suggesting adrenal haemorrhage into the mass. A 24 h collection of urinary catecholamines and metanephrines was sent to King’s College London for analysis. Plasma metanephrines were also measured. The results of these biochemical investigations were consistent with a neuroendocrine tumour such as a pheochromocytoma. The patient was subsequently transferred to the Cork University Hospital for further confirmation that the adrenal mass was a pheochromocytoma by a MIBG scan. He then underwent a laparoscopic right adrenalectomy. The diagnosis of a pheochromocytoma poses an immense clinical challenge. Their presentation is highly variable from the classic triad of episodic headache, sweating and tachycardia to a spectrum of non specific signs and symptoms. As a result there is often a delay in the initial detection of this rare insidious endocrine tumour.

Octreotide Treatment for Chemotherapy Induced Carcinoid Crisis Cox F

S329 hypertension (192/142) and confusion on day 2 of treatment, refractory to conventional management. An octreotide infusion was commenced, which restored blood pressure and cognition within 24 h. Conclusion: This case demonstrates a chemotherapy-induced carcinoid crisis and highlights the possible need for co-administration of octreotide infusion with chemotherapy, particularly in patients with a high burden of disease.

A Case Report of Intussusception of a Meckels Diverticulum in a 28-Year-Old Creavin B, Sheahan K, Siddiqui A Intern Network: UCD (DML) Introduction: Meckels Diverticulum is one of the most common congenital abnormalities of the Gastrointestinal Tract with a prevalence of 2 %. Known as a true diverticulum, Meckels arise due to incomplete obliteration of the vitelline duct between the fifth and seventh weeks of gestation. Meckels Diverticulum are usually asymptomatic and are commonly an incidental finding however can present with abdominal pain, obstruction or GI bleeding. Symptoms usually arise due to complications, commonly haemorrhage, diverticulitis, chronic ulceration, obstruction and rarely intussusceptions. Description: A 28-year-old female presented to the emergency department with lower abdominal pain and vomiting. On exam she was tender in her RIF and LIF with no guarding or rigidity. A CT scan was performed which demonstrated ileo-ileal intussusception with moderately dilated proximal small bowel loops. A laparotomy was perfromed where an 11 cm length of small bowel was excised from the mid ileum, with a side to side anastomosis formed. Histopathology reporting showed a congested and oedematous small intestinal mucosa within the centre of which was a Meckel’s diverticulum with gastric metaplasia. Discussion: The aim of this case report is to raise greater awareness of this condition and the complications that can arise from it along with the management of these.

Department of Oncology, SVUH, Elm Park, Dublin 4 A 63-year-old gentleman was admitted to the oncology service for management of metastatic neuroendocrine tumour and worsening carcinoid syndrome refractory to Transcatheter Arterial Chemoembolisation (TACE). Initially diagnosed with a low grade carcinoid tumour in 2011 the patient underwent a right hemi-colectomy and duodenal cuff excision. Progression of disease was first noted on routine octreotide scan in October 2013, which demonstrated pleural, bone, and multifocal liver up-take; consistent with disseminated disease. MR imaging confirmed metastatic deposits, involving up to 50 % of the liver parenchyma. The patient was commenced on somatostatin and features of carcinoid syndrome (flushing, diarrhoea, hypertension) were treated symptomatically. The patient underwent four TACE procedures, over a 6-month-period, accompanied by octreotide infusions. There was minimal reduction in liver lesions on MRI, which failed to meet criteria for partial response as per Response Evaluation Criteria in Solid Tumors. Recent CT imaging confirmed progression of extra-hepatic disease, showing splenic deposits and new pulmonary nodules. The patient required a VATS pleurodesis, for management of a symptomatic malignant pleural effusion. Subsequently he was admitted with symptomatic progression of disease and commenced on carboplatin-etoposide chemotherapy. This was complicated by severe

A Case Report of Two Anterior Abdominal Wall Collections Following Perforation of a Diverticulum Creavin B, Sheahan K, Siddiqui A Intern Network: UCD (DML) Introduction: Diverticulitis is a common disease in the general public, with an increase in prevalence with age. Complications arise frequently with diverticulitis, reports reaching as high as 25 %. The most common complications of diverticulitis include perforation, obstruction, peritonitis and abscess formation. Abscesses usually arise in the pelvis with rarer collections arising in the abdominal wall. Management of these complications have progressed over the past couple of years with conservative approaches coming to the fore. Case: A 54-year-old male presented to the emergency department with left sided abdominal pain, nausea, diarrhoea and blood PR. On exam he was extremely tender in the LIF, was guarding and had a palpable mass in this region. A CT scan was performed which showed acute diverticulitis with two collection situated in the anterior abdominal wall musculature, one in the internal layer of the musculature and one in the outer musculature layer extending down to the left inguinal region/

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S330 symphysis pubis. A Hartmanns procedure was performed on the patient with drainage of the abdominal collections at the time of surgery. Discussion: Here we discuss the complications of diverticular disease especially with regards to the rare formation of abdominal wall abscess and the management options available to deal with these.

Chronic Renal Disease: Infective Endocarditis, Sepsis and then Calciphylaxis: the Final Stepping Stone in Chronic Renal Disease? Loughlin E, Bergin E Department of Nephrology, Midlands Regional Hospital Tullamore; St. Vincent’s University Hospital, UCD Training Network Background: A 73-year-old male with a background history of endstage kidney disease on haemodialysis following a failed renal transplant was being managed with 6 weeks of vancomycin for mitral valve endocarditis following sepsis of his haemodialysis catheter. He also had a history of left stroke syndrome secondary to septic emboli, hypertension and atrial fibrillation, The patient was deemed unsuitable for surgical intervention of his endocarditis. He subsequently developed two areas of necrotic tissue secondary to distal emboli and was confirmed as being VRE and C. difficile positive. Once 6 weeks of therapy was completed, vancomycin was stopped. The patient subsequently suffered several episodes of deterioration following cessation of antibiotic therapy. At this time he also developed an area of painful necrosis on the dorsal aspect of the lower leg. A clinical diagnosis of calciphylaxis was made. The patient was managed supportively. Considering infection represents the primary cause of the high mortality associated with calciphylaxis1, with a 1 year survival of 45.8 %2 the development of this condition gave important direction in terms of the likely prognosis of our patient with already very significant and life threatening co-morbidities. It also correlated well with the clinical pathway of calciphylaxis, with our patient already presenting with recurrent infections. Conclusions: Complex chronic diseases such as renal disease present many clinical challenges. Occasionally the development of some complications yield important guidance on the likely prognosis and thus appropriate management of these patients. References: 1. Adrogue´ HJ, Frazier MR, Zeluff B, Suki WN (1981) Systemic calciphylaxis revisited. Am J Nephrol 1(3–4):177 2. Weenig RH, Sewell LD, Davis MD, McCarthy JT, Pittelkow MR (2007) Calciphylaxis: natural history, risk factor analysis, and outcome. J Am Acad Dermatol 56(4):569

Presentation and Surgical Management of Ectopic Parathyroid Adenoma Herlihy N, Redmond K Intern Network: DML Introduction: Primary hyperparathyroidism involves excess secretion of parathyroid hormone (PTH) due to overactivity of the parathyroid glands, most commonly caused by parathyroid adenoma or hyperplasia. PTH hypersecretion results in a concomitant rise in

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 extracellular calcium. Clinically, this may present with abdominal discomfort, recurrent nephrolithiasis, osteoporosis and fractures, fatigue, polydipsia, polyuria, and depression. Case: A 72-year-old lady was admitted with a 1 week history ofi ntermittent central abdominal pain and fatigue. A routine health screening 2 months previously had revealed hypercalcaemia. On admission, laboratory investigations showed raised corrected calcium (3.17), raised parathyroid hormone (PTH) (18.0) and hypophosphatemia (0.7), suggesting hypercalcaemia secondary to primary hyperparathyroidism. Sestamibi scan revealed abnormal accumulation of radiotracer in a retrosternal soft tissue nodule, consistent with ectopic parathyroid adenoma. Thymectomy was completed by video assisted thorascopic surgery (VATS) with identification and excision of the parathyroid lesion. Discussion: The proportion of ectopic parathyroid adenomas accounting for primary hyperparathyroidism may be as high as 20 %. Abnormal location of parathyroid glands appears to originate from aberrant migration during embryogenesis. Conventional scintigraphy is currently considered the gold standard for preoperative identification of ectopic parathyroid tissue causing primary hyperparathyroidism, which is important to avoid failed parathyroid exploration and morbidity related to reoperation in recurrent hyperparathyroidism. Approximately 2 % of ectopic glands are inaccessible by standard cervical incision and traditionally were removed using more invasive approaches, such as sternotomy. VATS is a refined procedure with advantages including reduced tissue dissection and decreased morbidity, and smaller incisions, resulting in improved cosmesis.

A Completed Audit Cycle on the Rejection of NCHD Radiological Imaging Requests in a Tertiary Referral Hospital from August 2014 to February 2015 Courtney W1, Kelly P2, Griffin L3, Crotty J4 Radiology Department, Limerick University Hospital, Dooradoyle, Co. Limerick; Mid- West Intern training Network Introduction: A proportion of radiological investigation request forms, ordered by Non- Consultant-Hospital-Doctors (NCHDs), are rejected by radiological departments in hospitals throughout Ireland even though there are clear guidelines on the indications for performing such radiological investigations on patients. Rejection rates of three commonly ordered scans were examined in an attempt to identify any common errors or barriers. Aims: 1. To quantify the rejection of radiological request forms for ultrasound of abdomen (US-abdomen), US of pelvis (US-pelvis) and computed tomography of the abdomen and pelvis (CT-abdomen/ pelvis). 2. To establish which level of NCHD is most commonly denied radiological requests. 3. To perform an intervention and attempt to decrease the proportion of rejected radiological investigation requests. Materials and methods: Radiological request forms for US-abdomen, US-pelvis, and CT- abdomen/pelvis were searched for on an electronic database over an initial 10 week period. The data was analysed and feedback was gathered, via questionnaire, from a sample of service users (interns), and informal interviews were held with a consultant radiologist. An educational intervention comprising of a leaflet, with commonly made mistakes, and advice, was created and distributed to interns. This was further reinforced by semi- formal tutorial sessions over a 2 weeks period. We then commenced a reaudit of scan requests.

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Results: In total, 1315 radiological request forms were reviewed in the first cycle. CT- abdomen/pelvis was the most commonly rejected radiological investigation (12.39 % rejection rate) and interns were the most commonly denied NCHD (42.40 % of all rejections). Data from the re-audit shows that intern rejection rates, for all three scans, were reduced. The greatest reduction was seen in the rejection of CTabdomen/pelvis where intern rejections fell from 42.40 to 25.90 %. Interestingly, the overall NCHD rejection rate for CT-abdomen/pelvis remained the same. Conclusions: Our study shows a focused educational intervention can decrease the proportion of radiological request forms from interns being rejected. This can reduce the number of rejected requests and allow interns to work more efficiently, Improve communication between Interns and the radiology department, and possibly shorten inpatient stays. We would recommend building on our educational intervention- at intern education at induction and throughout the year. The concept of extending this intervention to other NCHD groups is possible. Our educational leaflet will be incorporated into the published intern handbook for following years. Reference: 1. The American College of Radiology. http://www.acr.org

Cerebellar Ataxia due to Vitamin E Deficiency in Refractory Coeliac Disease Hazel K, Keohane J Department of Gastroenterology, Our Lady of Lourdes Hospital, Drogheda, Co Louth Our patient, a 64-year-old lady presented to Our Lady of Lourdes Hospital, Drogheda in July 2014 with a recent history of worsening ataxia, limb paraesthesia and weakness. The patient had a long-standing history of coeliac disease and was non-compliant with a gluten-free diet. On examination, she exhibited profound sensory ataxia secondary to a complex polyneuropathy. She was profoundly cachectic and unable to mobilise alone. OGD and biopsy were characteristic for refractory coeliac disease. Capsule endoscopy showed proximal jejunal enteropathy. Due to the non-traditional presentation of coeliac disease, the patient underwent a full autoimmune screen, HIV testing, syphilis serology, lymphoma screen and paraneoplastic antibody testing; all of which were negative. Coeliac serology was significant for highly-active disease. Radiological investigations, including PET-CT yielded insignificant results. Nerve conduction studies showed significant deficits bilaterally in the upper and lower limbs. The patient’s serum vitamin E levels were zero and vitamin A levels were half of normal levels, a direct result of her significant malnutrition. Vitamin E deficiency has been shown in studies to produce a cerebellar ataxia and peripheral neuropathy resembling that of Friedrich’s Ataxia1. Over a course of 16 weeks, in-patient treatment included highdose steroid, vitamin E supplementation and replacement, total parenteral nutrition and extensive physiotherapy. She showed significant improvement and is currently mobilising using a stick, a successful result in this interesting case of refractory coeliac disease and cerebellar ataxia due to vitamin E deficiency. Reference: 1. Jayaram S, Soman A, Tarvade S et al (2005) Cerebellar ataxia due to isolated vitamin E deficiency. Indian J Med Sci 59(1):20–3

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The Use of Adjuvant Carboplatin in the Setting of Stage One Testicular Seminoma in Terms of Effectiveness and Safety Kelly D, Buckley J, McCaffrey J Department of Medical Oncology, Mater Misericordiae University Hospital, Dublin, Ireland; Mater Private Hospital, Dublin, Ireland; Cavan General Hospital, Cavan Ireland Purpose: Stage 1 testicular seminomatous germ cell tumors occur in young men. They have a cure rate of 99 % and as such, long term toxicities of treatment are a concern. The standard of care is orchidectomy followed by radiotherapy or chemotherapy or surveillance. The purpose of our audit was to review patients with stage 1 seminomas who were treated with carboplatin. The aim was to ascertain the extent of relapse, dosage regimen, along with immediate and long-term sequelae associated with its use. Patients and methods: Data was collated from all patients treated with carboplatin for stage one seminomas. Age, carboplatin dosing, long and short term toxicities, recurrence and comorbidities were reviewed. Results: Twenty one patients treated over 7 years were included. 100 % of patients had no recurrent disease. Immediate common adverse effects included nausea/dyspepsia in 2 (9.5 %) patients, fatigue in 1 (4.7 %) patient and constipation in 1 (4.7 %) patients. Documented long term sequelae included epididymo-orchidits in 1 (4.7 %), recurrent diarrhoea in 1 (4.7 %) and persistent fatigue in 1 (4.5 %) patients. 1 patient had a second malignancy (4.7 %). Conclusions: Our audit demonstrated that carboplatin is a safe, effective, well tolerated treatment option for stage 1 seminomatous germ cell tumors.

Day Case Laparoscopic Cholecystectomy: a Retrospective Review of 208 Consecutive Patients O’Malley E, Moloney B, Hag Elfadl M, Orefewa F, Collins CG Department of Surgery, Portiuncula General Hospital Background: The drive for economy and efficiency has led to an increase in day case procedures: introduction of day-case (DC). Laparoscopic Cholecystectomy (LC) is a major target of healthcare providers. Acceptability amongst surgeons is variable. Aim: Following introduction of day case laparoscopic cholecystectomy (DCLC) to our institution in November 2011, we assessed the safety of the procedure with relation to successful discharge, complication and readmission rates. Method: All patients admitted for DCLC were reviewed by retrospective chart analysis. Demographic data, preoperative fitness, duration of surgery, complications and failure to discharge and rates of readmission were assessed. Successfully discharged DCLC patients were followed up with a telephone call at 48 h. Results: Since November 2011, 208 of 337 (60.8 %) LC performed in this institution were deemed suitable for DC surgery. 148 of the suitable patients (71.1 %) 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). Median ASA was 1 (1–2). Median operation time was 66 min (27–160). Median stay was 9 h (5–12). Of patients discharged as DCLC, 6 (2.9 %) were readmitted.

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S332 Conclusion: With careful patient selection protocols DCLC can be performed safely and effectively with few complications and a low readmission rates. Our results compare favourably with international standards1. Reference: 1. Gurusamy K, Junnarkar S, Farouk M et al (2008) Meta-analysis of randomized controlled trials on the safety and effectiveness of day-case laparoscopic cholecystectomy. Br J Surg 95(2):161–8

Compliance with ECT Treatment Pack Standards Owens S, O’Donnell L, Walsh C Intern Network: St Vincent’s University Hospital, Dublin 4; UCD Intern Training Network Objectives: An Electro Convulsive Therapy (ECT) treatment pack was developed by the College of Psychiatrists of Ireland to ensure a number of procedural checks are carried out. This audit aims to assess compliance with the treatment pack. Design/methods: Charts containing the treatment pack for any patient that underwent ECT August–October 2014 were pulled from medical records. Data was counted in a basic ‘‘yes/no’’ format in a proforma designed by the Sphinx system, which was also used to scan the results. The results were then hand checked and tabulated in Microsoft Excel. Results: A total of 9 patients underwent 70 distinct ECT procedures. Compliance with documentation of allergies (96 %), ASA grade (83 %), ECG (93 %), preprocedure vital signs (93 %) and orientation (99 %), involuntary consent (100 %), voluntary consent (85 %), postprocedure symptoms (96 %), airway requirements (86 %), time-out (96 %), documentation in the clinical notes (94 %) and subsequent discharge (96 %) was high. Blood test results were not fully documented 40 % of the time, however these patients had blood results documented offsite. The Clinical Global Impression (CGI) score was not documented 64 % of the time. A baseline CGI score with follow up scores post ECT is designed to guide further treatment. Conclusions: There was excellent compliance with treatment pack, however the main element undocumented was the CGI score. The clinical significance of this is not clear but warrants further investigation. Its place in the treatment pack is to be discussed with ECT team in January 2015 and a re-audit within 12 months time has been recommended.

A Rare Case of Metastatic Small Cell Carcinoma of the Bladder Hanley BM, Keane MP, Butler MW, Salib Q, McDermott R St. Vincent’s University Hospital; UCD Intern Training Network Introduction: Small cell carcinoma of the bladder accounts for less than one percent of all bladder tumours1. It is highly aggressive and is usually in its advanced stages when diagnosed. Presentation: This is the case of a 44-year-old male with a background of spina bifida and small cell bladder cancer who presented to the Emergency Department with a 5-month history of pain in the left

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 side of the neck radiating to the left arm with progressive left arm weakness. A hard mass had been noticed in the left posterior neck 2 weeks prior to presentation and the patient began to develop confusion and speech difficulties. He was admitted for investigation. CT Neck showed a large left-sided neck mass with invasion of the spinal canal and moderate-to-severe compression of the spinal cord from C4 to C6 while CT Brain showed multiple brain metastases with associated cerebral oedema causing 0.8 cm of midline shift. He was immediately started on intravenous dexamethasone. Histopathology from the subsequent biopsy of the neck mass confirmed metastatic small cell carcinoma and he has commenced palliative radiotherapy prior to consideration of palliative chemotherapy. Discussion: Palliative radiotherapy is rarely used in metastatic small cell carcinoma as chemotherapy is usually highly effective. However, it is still reserved for cases like this where the patient has symptomatic brain metastases or cord compression2. References: 1. Sved P, Gomez P, Manoharan M et al (2004) Small cell carcinoma of the bladder. BJU Int 94:12 2. Ismaili N (2011) A rare bladder cancer—small cell carcinoma: review and update. Orph J Rare Dis 6:75. doi: 10.1186/1750-1172-6-75

A Stercoral Perforation Sheahan K, Creavin B, Siddiqui A Intern Network: UCD Intern Network (DML) Introduction: Stercoral ulcer perforation (SUP), (first diagnosed by Berry in 1894), is caused by prolonged faecal impaction resulting in pressure-induced necrosis of the colorectal wall. SUP is a rare entity with fewer than 100 cases reported in the literature. Case description: A 62-year-old female, with a history of Crohn’s disease was admitted from the emergency department with sudden onset left sided abdominal pain, nausea and abdominal distension. On exam she was tender on her left side with guarding and rigidity. There was nothing of note on PR exam. Her inflammatory markers were elevated. She has had multiple surgeries (right hemi colectomy, small bowel resection, anastomotic resection and formation of a defunctioning ileostomy with reversal at a later date). A CT abdomen and pelvis was performed which showed the proximal descending colon dominated by a 13 9 9 9 4.5 cm central luminal mixed gas and lamellated soft tissue filling defect which resembled a bezoar or ‘stercolith’/stool concretion. This patient proceeded to laparotomy where a large indentable mass was noted in the mid descending colon with necrotic patches of bowel (impending perforation) 2 cm proximal to the mass with adhesions. An emergency Hartmann’s procedure was performed and the section of bowel resected and sent for histopathology. Examination of the tissues revealed complete transmural necrosis with active inflammation consistent with impending perforation and multiple foci of necrosis with underlying transmural active inflammation in keeping with stercoral ulceration. Discussion: Surgery is the only acceptable approach because conservatively treated cases present a mortality rate of 47 %1. Reference: 1. Brombacher GD, Murray WR (1998) Emergency subtotal colectomy for chronic constipation. Scot Med J 43(1):21–22

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Review of Outcomes of Admissions after Laparoscopic Cholecystectomy Following the Introduction of Day Case Laparoscopic Cholecystectomy Surgery O’ Malley E, Moloney B, Hag ElFadl M, Orefewa F, Myers EM, Collins CG Department of Surgery, Portiuncula General Hospital Background: Laparoscopic Cholecystectomy (LC) is a common minimally invasive elective procedure performed in Ireland. Patients who fulfil strict criteria are offered day case laparoscopic cholecystectomy (DCLC). Introduction of DCLC may also have an effect on non-day case laparoscopic cholecystectomy outcomes. Aim: To audit outcomes for non DCLC performed in Portiuncula Hospital, Ballinasloe before and after the introduction of DCLC in November 2011. Method: Retrospective analysis of all LC was performed and DCLC were excluded. Two groups were identified, Group A included all cases prior to the introduction of DCL (November-2011) and Group B represented all non-DCLC performed after. Both groups had rates of conversion to open, readmission rates, operation times and ASA classification determined. Results: A total of 507 non day case LC were performed. Group A included 318 patients (82.4 % female), and group B 189 patients (76.3 % female). Median ASA in both groups was 1 (1–3).

Group A (n = 318)

Group B (n = 189)

P value

Age (years) Median (range)

44.6 (15.4–86.6) 48.9 (16.3–82.8) 0.130

Weight (kg) Median (range)

79 (43–141)

78 (49–130)

0.759

Median (range)

3 (1–31)

1 (1–19)

0.000

1–4 (%)

74.5

84.7

0.007

5+ (%) 25.5 Readmission rate (%) 6.5

15.3 5

0.007 0.830

1

0.667

Length of stay (nights)

Readmission duration (nights) Median (range)

3 (1–5)

Tumefactive MS: Uncertainties in Diagnosis and Treatment Lucey R1, Lynch T2 Mater Misericordiae University Hospital1, UCD; Dublin Neurological Institute2, Mater Misericordiae University Hospital, UCD-Intern Network: UCD Introduction: Multiple Sclerosis (MS) affects approximately 8000 people in Ireland. Tumefactive MS is an uncommon variant of MS. It is characterised by demyelinating lesions, which are larger than typically seen in MS, and clinical features can often mimic spaceoccupying lesions. Due to its rarity and lack of randomised controlled trials, it poses diagnostic and treatment challenges for the clinician. Description/case presentation: A 29-year-old woman, presented with subacute onset of unsteadiness, fatigue, right upper and lower limb weakness and urinary incontinence. Examination showed speech apraxia, right facial weakness, hemiparesis and no lymphadenopathy. Family history was notable for Hodgkin’s Lymphoma. MRI Brain showed multiple partial ring-enhancing lesions suggestive of tumour, abscess or Tumefactive MS. CSF findings showed raised protein, 11 mononuclear cells, positive oligoclonal bands but no malignant cells. CT-Thorax Abdomen and Pelvis excluded malignancy. Patient responded minimally to steroids and plasma exchange. Repeat MRI brain showed progression of disease with increasing oedema and midline shift. MRI spectroscopy favoured an inflammatory process. Dexamethasone was started with clinical improvement. Brain biopsy was done because of ongoing concern of a tumour and was non-diagnostic. Subsequently Rituximab was commenced with clinical benefit. Ring-enhancing brain lesions pose diagnostic challenges especially in immunocompetent individuals. Like in our case, MS can present like a tumour and brain biopsy has a role, even if negative, in helping to rule out malignancy. The use of Rituximab in MS has a limited evidence base but has a valuable role in cases refractory to other agents1. Reference: 1. Hardy TA, Chataway J (2013) Tumefactive demyelination: an approach to diagnosis and management: J Neurol Neurosurg Psychiatry 84:1047–1053

Early EEG and Clinical Findings for the Prediction of 2-Year Outcome in Pre-terms Ogbo S1, Boylan G1, Korochikova I1, Cronin AM2, Murphy K11

No statistical difference in complications emerged between both groups. There was no mortality. Conclusions: Following DCLC introduction, LOS has decreased in non day case LC (P = 0.000). DCLC may also improve outcomes and encourage efficiency in non day case LC. Results compare favourably with international standards1. Reference: 1. Vaughan J, Gurusamy K, Davidson B (2013) Day-surgery versus overnight stay surgery for laparoscopic cholecystectomy (review). Cochrane Library:7

Department of Paediatrics and Child Health1, Department of Physiotherapy2 Background: Pre term new-born infants are at risk of a number of complications an early (EEG) might be a reliable predictor of later outcome. An EEG is used as a predictor in neonatal encephalopathy. A role of the EEG as a predictor of neurodevelopment outcome in preterm newborns should be properly investigated. Aim: The purpose of this study was to associate neurodevelopmental outcome at 24 months of corrected age with early EEG, clinical

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S334 findings and scores in a sample of preterm low birth weight infants born admitted to an Irish tertiary centre between 2009 and 2010. Method: Forty Babies only 22 of them were analyzed for their Bayleys score. Of the 22 infants three are deceased, with a birth weight \2500 g (gestational age, range 24–32 weeks) were followed at 24 months of corrected age with a Bayley’s score. An analysis was conducted in order to look for associations between clinical variables and neuropsychomotor outcome at 24 months. EEG reports and certain clinical variants such as the (Clinical Risk Index score for babies) CRIB 11; Apgar score were calculated on the babies; any clinical diagnosis during their stay and the severity of the illness and their cranial ultrasound (CRUS) was retrieved and qualitatively analysed. I collected and recorded all of this information i.e. CRIBS, EEG, clinical diagnosis and Bayley’s score then transferred the information into SPSS for analysis, using Spearman rho correlation and descriptive Statistics. Continuous, multi-channel, video EEG was recorded for the infants by expert EEG personnel, from \6 to 72 h after delivery. Features of EEG section 10 min long and the burst and interburst periods were analysed visually by an expert. Result: Twenty-two infants weighing \2500 g were admitted to the Cork University Hospital NICU; 19 of these infants (86 %) survived, while 3 (14 %) died during their initial hospital course; of the 3 infants who died 2 had an abnormal CRUS. There is an association between CRIBs II score and outcome, and also a negative correlation with language and Motor composite score (p value = respectively) of the BSID-III, which is consistent with previous research. Therefore a high CRIBs score predicted a poor outcome and a low CRIBs score predicted a good outcome at 2 years of age. The range of preterm CRIB-II scores in this study was from 2 to 16 points with the infants who died having the highest scores of 15, 16. The BSID-III of the 19 infants who survived is between 55 and 110 for Cognitive score, 59 and 141 for Language and 46 and 124 for Motor scores which are on the 25th–98th percentile rank this is within normal range seen in full term infants. There is a negative correlation between the amplitude height (HT) in the EEG and survival (p value 0.025). The lower the amplitude the higher the risk of death, seen in infants who are deceased. Conclusion: a normal BSID-II score is seen in preterm neonates. Clinical Risk index Score in babies is associated to outcome at 2 years corrected age and low amplitude height on EEG correlates to poor outcome. References: Measurement science review, Volume 2, Section 2, 2002 fundamentals of EEG measurement M. Teplan Institute of Measurement Science, Slovak Academy of Sciences, Du´bravska´ cesta 9, 841 04 Bratislava, Slovakia Baley N Bayley (1993) The Psychological Corporation. Bayley scales of infant development 2nd edn. San Antonio Parry G, Tucker J, Tarnow-Mordi W, Collabo UKNSS (2003) CRIB II: an update of the clinical risk index for babies score. Lancet 361(9371):1789–91

Interruption of the Inferior Vena Cava: a Rare Cause of Deep Venous Thrombosis McInerney J1, Canning C1, Farrelly C2, O’Donohoe M1 Departments of Vascular Surgery1, Radiology2, Mater Misericordiae University Hospital, Dublin Introduction: Interruption of the inferior vena cava (IVC) is an uncommon vascular anomaly. Patients are usually asymptomatic and

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 it rarely results in deep venous thrombosis (DVT), as the azygous and hemi-azygous veins develop as a collateral system for venous return. Here we present a case of suprarenal interruption of the IVC which presented with symptoms of a DVT. Case report: A 31-year-old man presented with acute onset right lower limb swelling and pain. Duplex scan confirmed an ileofemoral DVT extending to the IVC and involving both ileo-femoral systems. IV heparin infusion was commenced. The patient had no known risk factors for DVT and past history was non-contributory apart from varicose vein surgery in the same limb 1 year previously. Interruption of the IVC was subsequently identified on abdominal contrast CT scan, which showed chronic suprarenal IVC occlusion with collateral formation. The patient subsequently had catheter directed thrombolysis and mechanical thrombectomy followed by venoplasty of the IVC and right common iliac vein. He was discharged 1 week later on lifelong warfarin and grade 2 compression stockings. Conclusion: This case illustrates that in the event of a DVT, especially in younger patients, thorough investigation is warranted and interruption of the IVC should be considered.

An Audit to Determine the Need for the Introduction of a Post-Fall Medical Proforma to Improve Standards of Assessment Amongst Medical Staff in the Immediate Post-Fall Period Murphy R, Brophy A, Clifford AG, Shea D St. Vincent’s University Hospital; UCD Intern Training Network Introduction: Falls amongst inpatients are common and contribute considerably to rates of patient morbidity, mortality, reduced functional capacity, and prolonged inpatient stay. The aim of this audit is to determine the level of patient assessment in the immediate post fall period and the subsequent paths of investigation, management and strategies to help prevent further falls. It will also act to evaluate medical staff’s attitude towards falls and falls management. Methods: Twenty NCHDs in SVUH participated in an analysis of falls management by medical staff by the use of a written survey questionnaire. Question types included a mixture of polar, likertscale, and open-ended questions. Attitudes and behaviors were assessed with categories including; General perceptions; History taking; CT red flags; Physical examination; Investigations considered; Falls Preven4tion; High risk medications-knowledge and rationalization. Results: Average likert score was 9/10 in those strongly agreeing that a post falls checklist would aid assessment. Fifty percent only sometimes examined for joint tenderness, 40 % of participants never reviewed medications, with 55 % never modifying high falls risk meds; the most common reason being lack of knowledge of alternatives (90 %). No participants had ever contacted the ward pharmacist for advice. Sixty percent of participants moved on to other jobs without consideration of prevention strategies. This increased to 90 % if the fall was deemed harmless. Conclusion: Inconsistencies and inadequacies in patient assessment, management and prevention strategies in the immediate post fall period were demonstrated. Participants attitudes and behaviors suggested that an ‘aide memoire’ such as a ‘Post-Fall Medical Proforma’ would be welcomed and warranted and may increase the quality and standardization of patient reviews, indeed acting to help fatigued, pressurized and often inexperienced medical staff in their initial patient assessment.

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344

Cerebral Cavernous Malformations in the Setting of a Multi-Factorial Coagulopathy: a Therapeutic Challenge Kennedy C, James K, O’Meara Y Intern Network: Dublin/Mid-Leinster Intern Training Network Introduction: Cerebral Cavernous Malformations are a rare cause of intracranial hemorrhage and stroke. The risk of hemorrhage in cavernous malformations (CMs) depends on lesion, host, and environmental factors. This case highlights the interaction of an underlying coagulopathy secondary to alcohol and hepatitis induced cirrhosis and the presence of CCMs. It also highlights the clinical boundaries in the prompt correction of a multi-factorial coagulopathy in the bleeding patient. Description/case presentation: Cerebral Cavernous malformations are vascular malformations that form from closely clustered enlarged capillary channels (caverns) with a single layer of endothelium without mature vessel wall elements or normal intervening brain parenchyma. We present the case of a 49-year-old male who presented with a 2 week history of diplopia on right lateral gaze, failure of upward and downward gaze bilaterally and failure of convergence on a background of thrombocytopenia and multiple clotting factor deficiencies secondary to alcoholic liver disease. An MR Image obtained in presentation revealed multiple cerebral cavernous malformations with haemorrhage within left mid brain extending to the left thalamus. The CMs exist in two forms, familial and sporadic, each with a different hemorrhagic potential: the familial form represents a variable percentage ranging from 24 to 56 % of cases. Familial CMs are linked to mutations of the Krit1 gene at the CCM1 locus and to mutations at two other loci, CCM2 and CCM3.Our patient and his family underwent genetic testing for the familial variant. Our patient presented a clinical dilemma regarding the ongoing need to replace coagulation factors given dual diagnosis of CCMs and a multi-factorial coagulopathy.

When Drug Reactions Become a Pain (in the Abdomen) Heffernan L, Hennessey M Department of Pharmacotherapeutics, St James’ Hospital, Dublin 8; Intern Network: DSE Network Introduction: An unusual case of abdominal pain, haematuria and renal failure. Description/case presentation: I present a 44-year-old man (exIVDU, Hep C positive) with undiagnosed IgA nephropathy who was treated for abdominal pain in the community with Vimovo (esomeprazole and naproxen). He subsequently went on to develop worsening abdominal pain and renal impairment and a vasculitic rash as a result. Initial presentation with abdominal pain and microscopic haematuria led to the patient being investigated for nephrolithiasis, however a CT urogram was negative for renal calculi. The patient complained of a mild rash on his chest hence his Vimovo was stopped as a presumed drug reaction. Over the course of a week, the patients’ clinical situation deteriorated with worsening renal function and

S335 appearance of a widespread rash. His abdominal pain also became more distressing and he mounted a severe inflammatory response, renal failure and liver impairment with the patient becoming markedly oedematous. An extensive petechial rash emerged, affecting the patient’s limbs in particular and exhibiting necrotic areas. Prednisolone was initiated and subsequently resulted in improvement of the rash, abdominal pain and renal function. Extensive vasculitic, porphyric and viral screens were largely non-conclusive but revealed a high IgA count. A renal biopsy showed a dual pathology of severe eosinophilic interstitial nephritis and mesangial glomerulonephritis. This case reminds us of the link between drugs and vasculitis and the life-saving potential of steroids when used in the right situation.

Conversion Disorder in Severe Refractory Epilepsy McShane C, Cooney J Liaison Psychiatry, St. James’s Hospital, Dublin 8 Introduction: The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition defines Conversion Disorder as having a symptom of altered voluntary motor/sensory function which is incompatible with a medical condition and causes significant psychosocial impairment. Subtypes include both psychogenic nonepileptic seizures (PNES) and paralysis1. PNES are common at epilepsy centers, where they are seen in 20–30 % of patients referred for refractory seizures2. Case description: A 17-year-old girl presented to clinic for assessment of non-epileptic seizures. She gives a long history of epilepsy diagnosed aged 9 years. Good seizure control was maintained until 12 years whereupon she was hospitalised with a cluster of seizures. Here she admitted feigning seizures. It was noted that this coincided with considerable social changes. From 13 years seizure frequency steadily increased. Video telemetry showed frontal lobe epilepsy but also non-epileptic seizures. At 15 years she developed paralysis of the lower limbs, requiring prolonged wheelchair use and subsequent gait disturbance. Currently despite full compliance with optimal antiepileptic therapy she has 10 events/day including seizures, drop attacks, gagging and blindness. A record kept by her mother shows clustering at times of heightened stress. These symptoms have resulted in lengthy hospital admissions and significant social dysfunction including lack of school attendance. The current treatment strategy is to provide information about the diagnosis with an emphasis on return to normal social functioning. Discussion: This case demonstrates the complexity in diagnosing and treating Conversion Disorder, particularly when compounded by an intricately linked medical illness. References: 1. Uptodate Article—Conversion disorder in adults: Terminology, diagnosis, and differential diagnosis 2. Selim R Benbadis, Helmi L Lutsep Medscape—Psychogenic Nonepileptic Seizures

Heterotopic Pregnancy: a Hidden Complication McDonnell S, DeTavernier MC Department of Obstetrics and Gynaecology, Portiuncula Hospital, Ballinasloe; WNW Intern Training Network

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S336 Introduction: Heterotopic pregnancy by definition involves the implantation of two or more simultaneous pregnancies at different sites, most frequently intra- and extra-uterine. A tubal pregnancy accompanied by an intrauterine pregnancy is the most common manifestation by virtue of the fact that the fallopian tube is the most common implantation site of an ectopic pregnancy1,2. Case presentation: A 27-year-old para 1 + 0 self-referred to the emergency department at 5 weeks gestation complaining of intermittent lower abdominal cramping. Examination revealed a mildly tender left iliac fossa, no vaginal blood loss and a normal speculum examination. She was hemodynamically stable and serum b-hCG was 3553. An appointment was arranged for the Early Pregnancy Unit (EPU) the following day. Two subsequent transvaginal scans a week apart revealed a viable intrauterine pregnancy. At 7 weeks gestation, the woman represented to the emergency department with severe diffuse abdominal pain accompanied by vomiting and signs of hemodynamic collapse. Two hours following admission the pain localised to the right hypochondrium and shoulder tip. Transvaginal and transabdominal ultrasound scan were challenging due to the severity of the pain. A laparoscopy performed due to the high index of clinical suspicion revealed a ruptured ectopic pregnancy in the cornua of the right fallopian tube and moderate haemorrhage into the pelvic cavity. A salpingotomy was performed and she was transfused with two units of red blood cells. The intrauterine pregnancy remained viable and a healthy female infant was delivered at term with no complications. Discussion: Although a rare obstetric complication, the incidence of heterotopic pregnancy is increasing due to the rising ectopic pregnancy rate. The diagnostic challenge presented by heterotopic pregnancy results from the fact that the index of suspicion for an ectopic pregnancy is low once a viable intrauterine pregnancy has been confirmed on ultrasound scan. Heterotopic pregnancy provides an additional therapeutic challenge for obstetricians as the maintenance of the intrauterine pregnancy is also a consideration. Laparotomy or laparoscopic removal of the ectopic pregnancy remains the most favourable therapeutic choice with good outcomes reported for the continuation of the intrauterine pregnancy1-3. Conclusion: Despite the rarity of heterotopic pregnancies, obstetricians should remain vigilant and consider it as a differential especially patients who are symptomatic. References 1. Dharmarajah K, Rudra T (2012) Spontaneous heterotopic pregnancy. BMJ Case Rep. doi:10.1111/j.1471-0528.2012.03382.x 2. Luckas MJM et al (1997) Survival of intrauterine twins and an interstitial singleton fetus from a heterotopic in vitro fertilisationembryo transfer pregnancy. BJOG 104:751–752 3. Seow KM et al (2002) Transvaginal colour Doppler diagnosis and assessment of a heterotopic cervical pregnancy terminated by forceps evacuation following in vitro fertilisation and embryo transfer. BJOG 109:1072–1073

Removed from Isolation: a Case of Suspected Pulmonary Tuberculosis in a Patient with Anorexia Nervosa McGurgan I, Hanley M, Mikulich O, Maher C, McDonnell T Respiratory Department, St. Vincent’s University Hospital, Elm Park, Dublin 4; Intern Network: UCD Intern Training Network

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Introduction: Protein-energy malnutrition, as occurs in anorexia nervosa, is a documented cause of immunodeficiency. Patients with a long history of severe malnutrition are increasingly recognised as susceptible to opportunistic infections1. Case description: A 39-year-old woman was electively admitted for evaluation of a cavitating lesion in the right upper lobe on chest X-ray. This occured on a background of severe anorexia nervosa diagnosed at age 13. The patient was completely asymptomatic but was isolated on admission. She had no cough, sputum production or fevers but her weight at the time of admission was 24.5 kg. She was HIV negative and had no recent foreign travel or tuberculosis contacts. Bronchoscopy was performed and microscopy of aspirated samples demonstrated acid-fast bacilli on Ziehl-Neelsen staining. Anti-tuberculous medications were commenced according to body weight but deterioration was noted on subsequent chest imaging. Cultures subsequently confirmed a growth of Mycobacterium malmoense. The patient was removed from isolation and began a longterm course of rifampicin, ethambutol and clarithromycin. Subsequent improvement was noted once oral intake improved. Discussion: This report describes to our knowledge the first documented case of M. malmoense (a non-tuberculous mycobacterium) infection in a patient with anorexia nervosa. Mycobacterial infections, including both pulmonary tuberculosis and nontuberculous mycobacterial lung disease, have been described in patients with eating disorders and some authors have suggested that this population should be considered an at-risk group2. This case also highlights the importance of improving nutritional status in the context of both mycobacterial infection acquisition and management. References: 1. Hotta M, Nagashima E, Takagi S et al (2004) Two young female patients with anorexia nervosa complicated by Mycobacterium tuberculosis infection Internal Med 43(440–4) 2. Portillo K, Morera J (2012) Nutritional status and eating disorders: Neglected risks factor for nontuberculous mycobacterial lung disease? Med Hypotheses 78(39–41)

Richter’s Hernia in Congenital Mesenteric Diverticulum During Pregnancy Gilmore JE, Malone C Department of Surgery, Galway University Hospital, Galway; Intern Network: WNW Introduction: This case explores the unusual presentation of a mechanical small bowel obstruction, later shown to be a Richter’s hernia, in a pregnant woman. Description: A 38-year-old female presented to a peripheral hospital at 30 + 6 weeks gestation with a singleton pregnancy, complaining of new-onset central abdominal pain and feculent vomiting. Her CTG was abnormal, and the baby breech presentation. The impression was of small bowel obstruction. An NG tube was passed that aspirated feculent fluid. MRI showed mechanical small bowel obstruction, with a possible transition point at the paramedian left mid abdomen. She was transferred to GUH for joint care under general surgeons and obstetrics. Following discussion with the patient, a midline laparotomy was performed. Dilated loops of bowel were noted to be adherent to a fixed structure in the sigmoid mesentery, posterior to the gravid uterus. Following operative delivery of a live male infant, a necrotic segment of small bowel that had been stuck in a mesenteric diverticulum was resected and anastomosed, and the mesenteric defect was closed.

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Discussion: A Richter’s hernia is a subset of abdominal wall hernias, in which only part of the circumference of the bowel is incarcerated. This patient presented with the symptoms of a mechanical bowel obstruction and did not respond to conservative management, requiring further intervention. This was complicated by her gravid state, since options for radiological investigations were limited.

Assessment of Drug Tapering in a Methadone Maintenance Programme Based in General Practice

S337 antagonist treatment: state of the art and new perspectives. Curr Drug Abuse Rev 5(1):52–63 3. Bart G (2012) Maintenance medication for opiate addiction: the foundation of recovery. J Addict Dis 31(3):207–25

Waldenstrom’s Macroglobulinaemia: a Rare Clinical Entity Nestor S, Mulkerrin E

Murphy J, Doyle M, Breen N Kilmainham Medical Centre, Dublin 8

Department of Geriatrics, Galway University Hospital; Intern Network: West/Northwest Intern Training Network

Introduction: Methadone is the first choice of treatment for opioid dependence in a primary care setting. Anecdotally primary care physicians report that it is very difficult for patients to completely taper off methadone. Given that methadone treatment has been shown to have a link between long QT syndrome1, the rate of methadone tapering was assessed in general practice. Aims: To see how effective the methadone tapering process is in this particular practice and to possibly discuss alternatives based on the results. Materials and method: The inclusion criteria were all patients on the methadone maintenance program for at least 1 year in a GP practice in south Dublin City. Data was retrospectively recorded and analysed from the practice’s Socrates computer system. Each individual’s daily methadone dose was recorded from their first visits to the practice and then compared to their daily dose 12 months later. Results: Twenty-five percent of patients were on the same dose of methadone as they were exactly 12 months previously. Coincidentally these patients also had the highest maintenance dose ([95 mls/day). Of the remaining patients the tapering level varied greatly, from 2.25 to 78.50 %. Overall the initial average maintenance dose was 87 mls/day. The final average maintenance dose 12 months later was 74.25 mls/day. This represents an average tapering decrease of 1.06 mls/month. Conclusion: Methadone is an extremely addictive drug. Higher doses of methadone are more difficult to taper off. Patients on similar doses have variable abilities to taper off the drug. Overall the tapering process is slow in this practice (ca. 1 ml/month) but is moving in the right direction. It should be noted that Methadone has been shown to have a link with long QT syndrome1. Buprenorphine-naltrexone switch showed greater rate of tapering off than methadone2. Regardless, behavioural interventions alone are of little benefit3.

Introduction: Waldenstro¨m’s macroglobulinemia is characterised by an IgM paraproteinaemia, hyperviscosity, renal impairment, cryoglobulinaemia and anaemia. Description/case presentation: A 73-year-old previously-healthy gentleman presented to ED with erythema, pain and swelling of his left lower limb. He also reported recent weight loss and altered bowel habit. Preliminary laboratory investigations yielded an elevated D-Dimer (1781), macrocytic anaemia with combined B12 and Iron deficiency and a raised CRP (57). Leukocyte count, hepatic and renal function tests were normal at presentation. Ultrasound Doppler excluded a deep vein thrombosis and Flucloxacillin was commenced to treat cellulitis. The patient remained in hospital to complete his antibiotic therapy. OGD and colonoscopy excluded a gastrointestinal malignancy and he received three units of blood. Gradually, the patient’s renal function began to decline. Without any aetiology, a Nephrology opinion was sought and the overall impression was that of a post-strep Glomerulonephritis but an underlying haematological malignancy had to be excluded. Anti-streptolysin titres were negative but complement levels (C3 and C4) were low. CT imaging of neck, thorax, abdomen and pelvis revealed mediastinal lymphadenopathy and widespread subcentimetre lymph nodes. Further laboratory testing revealed an IgM spike on immunofixation, Cryoglobulinemia, elevated free kappa light chains, raised LDH (465), persistent anaemia, thrombocytosis, GGT 302 and urinary Albumin: Creatinine ratio of 82. Bone marrow analysis to date has been inconclusive and the patient remains under active surveillance. The clinical picture is highly suggestive of Waldenstrom’s Macroglobulinaemia although the differential also includes Multiple Myeloma, Lymphoma, MGUS, Chronic Lymphocytic Leukaemia and Mixed Cryoglobulinaemia Syndrome.

References 1. Mayet S, Gossop M, Lintzeris N, Markides V, Strang J (2011) Methadone maintenance, QTc and torsade de pointes: who needs an electrocardiogram and what is the prevalence of QTc prolongation? Drug Alcohol Rev 30(4):388–96 2. Mannelli P, Peindl KS, Lee T, Bhatia KS, Wu LT (2012) Buprenorphine-mediated transition from opioid agonist to

References: Fonseca R, Hayman S. Waldenstrom (2007) Macroglobulinaemia. Br J Haematol 138:700 Kyle RA, Treon SP, Alexanian R et al (2003) Prognostic markers and criteria to initiate therapy in Waldenstrom’s macroglobulinaemia: consensus panel recommendations from the Second

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S338 International Workshop on Waldenstrom’s macroglobulinaemia. Semin Oncol 30:116 Sant M, Allemani C, Tereanu C et al (2010) Incidence of hematologic malignancies in Europe by morphologic subtype: results of the HAEMACARE project. Blood 116:3724

Vancomycin and Opiods Fathil I, Garrahy A, O’Regan A Respiratory Medicine, University College Hospital, Galway; Intern Network: WNW 338 Introduction: Vancomycin is an antibiotic used in the case of B-lactamase resistant staphylococcus or severe allergic reaction to penicillin based antibiotic1. However, vancomycin can cause plenty of adverse reaction that include mast cell degranulation and histamine release. Opiods also cause mast cell degranulation2. Description/case presentation: A 96-year-old man admitted to hospital with bilateral obstructive uropathy and acute kidney injury. He had background history of hyperparakeratosis and MRSA carrier. During admission, patient developed MRSA bacteremia post anterograde insertion hence was given 2 weeks course of vancomycin with adjustment to renal dose. On day 11, patient complaint of pain of arms and feet and was prescribed with oramorph 2.5 mg. He then eventually developed anaphylactoid reaction on the next morning; he is hypotensive at 72/50, normocardic at 72 bpm and had angioedema (swollen lip, hands and feet). His blood markers were vancomycin level = 24.9, CRP = 72, urea = 10.1 and creatinine = 153. He was managed with regular hydrocortisone, antihistamine and fluid resuscitation. Vancomycin was switched to daptomycin, after consultation with microbiology. Patient improved subsequently. Vancomycin and opioids can cause mast cell degranulation and histamine release. Together it can cause anaphylactoid reactions. References: 1. Wong JT, Ripple RE, MacLean JA, Marks DR, Bloch KJ (1994) Vancomycin hypersensitivity: synergism with narcotics and ‘‘desensitization’’ by a rapid continuous intravenous protocol. J Allergy Clin Immunol 94(2 Pt 1):189–94 2. Levy JH, Mart AT (1993) Vancomycin and adverse drug reactions. Crit Care Med 21(8):1107–8

Heart-Block Smoothie Calpin P, Daniels F Department of Nephrology, University Hospital Galway Introduction: A healthy 22-year-old male presented to ED complaining of drowsiness, abdominal cramps, nausea and vomiting, light-headedness and associated visual light-flickering and yellow/ blue hyperactivity. Case description: Of note, the patient had ingested a smoothie the previous day which he had made himself with home-grown apples, cucumber, lettuce and 2 large foxglove leaves. On admission heart rate was 38 and blood pressure was 117/56. Other vital signs and clinical examination was normal. An electrocardiogram confirmed the patient to be in sinus bradycardia but with no other abnormal features. Routine laboratory investigations including a digoxin level were

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 ordered and he was placed on continuous cardiac monitoring. The patient was initially treated with activated charcoal and atropine 1.2 mg on the advice of the National Poisons Information Centre. Treatment with digoxin antigen-binding fragments (Digibind) was not advised at that time. Initial digoxin levels were 0.6 lg/L. The patient subsequently progressed to first-degree heart-block, to second-degree type I (Wenckebach) and type II (Mobitz) to complete heart-block (CHB). He was treated with Digibind 228 mg and forced diuresis. He remained in CHB with associated weakness and postural syncope episodes for 6 days before returning to second-degree heart-block. He alternated between Wenckeback and Mobitz rhythms for 7 days. He was discharged 16 days post-admission in first-degree heartblock with episodes of sinus rhythm. He failed to attend for possible investigation of a queried congenital cardiac abnormality at cardiology OPD 2 weeks later as well as numerous rescheduled appointments. Conclusion: This case illustrates the value of obtaining a thorough history, including what one may have consumed. The patient was aware that he had ingested the foxglove plant but was unaware of its pharmacological properties. It is also interesting to note that digoxin assays and Digibind are not specific or sensitive for digitalis, and while his digoxin level returned to zero the patient may well have had large concentrations of undetected and unbound digitalis. It is also interesting to hypothesize about an underlying congenital cardiac abnormality given that it was one of the longest and more persistent reported cases of heart-block secondary to digitalis toxicity.

An Unusual Presentation of Splenic Injury in the Trauma Patient Hollywood A, Boyle T Department of General Surgery, St James’s Hospital, Dublin 8; TCD Intern Training Network Introduction: The spleen is the most commonly injured intra-abdominal organ following blunt abdominal trauma. The classical presentation of splenic injury is a hemodynamically unstable patient with left upper quadrant pain and signs of peritonitis following a history of trauma. Description/case presentation: We present the case of a 20-year-old female, known background of hepatitis C, end-stage liver cirrhosis, portal hypertension, and intravenous drug abuse, who attended the ED with a history of physical assault 1 day previously. On arrival, she complained of drowsiness and weakness. She had obvious facial injuries, her behaviour was agitated and uncooperative. Initial examination revealed mild tenderness of the central abdominal area and left ribcage, with no guarding or rebound tenderness. Vital signs were stable. CT brain and X-ray facial bones were performed with a view to discharge pending normal results. Ten hours later, on discharge, she began to complain of new onset abdominal pain and became suddenly hypotensive, tachycardic and increasingly drowsy. Repeat abdominal exam revealed significant left upper quadrant, left iliac fossa and left chest tenderness. Urgent CT abdomen diagnosed grade IV splenic laceration with active extravasation of contrast, subcapsular haematoma and hemoperitoneum. The patient underwent emergency open splenectomy. Splenic injury is very common and can occur with minimal trauma. The absence of classical presenting symptoms does not rule out splenic injury, as demonstrated in the initial presentation of this case. Thorough physical exam with low threshold for imaging studies is essential to prevent delayed diagnosis and allow for prompt management of life-threatening haemorrhage.

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 References: Cathey KL, Brady WJ, Butler K, Blow O, Cephas GA, Young JS (1998) Splenic trauma: characteristics of patients requiring urgent laparotomy. Am Surg 64:450–4 Rodriguez A, DuPriest RW, Shatney CH (1982) Recognition of intraabdominal injury in blunt trauma victims: a prospective study comparing physical examination with peritoneal lavage. Am Surg 48:456–9 Sikka R (2004) Unsuspected internal organ traumatic injuries. Emerg Med Clin North Am 22:1067–80

Evaluating the Need for Bone Scintigraphy in Breast Cancer Patients Selected for Systemic Staging in the Era of Multidetector Ct Scanning MacDermott R1, McCartan DP1, Prichard RS1, Rothwell J1, Geraghty J1, Evoy D1, Quinn C2, Skehan S3, O’Doherty A3, McDermott EW1 Departments of Breast and Endocrine Surgery1, Pathology2 and Radiology3, St Vincent’s University Hospital, Elm Park, Dublin 4; Intern Network; UCD Background: Approximately 7 % of women will have distant metastases when presenting with breast cancer. NCCP guidelines for systemic staging suggest both a bone scan and CT TAP. Whether the combination of modalities is necessary remains unclear. The aim of this study was to evaluate the additional diagnostic yield from bone scintigraphy in addition to CT staging of the thorax, abdomen and pelvis in patients with newly diagnosed breast cancer selected for systemic staging. Methods: Patients with newly diagnosed breast cancer who underwent systemic staging with CT-TAP and bone scintigraphy in 2012 and 2013 were included. Results of biopsy and staging investigations were correlated. Criteria for staging included: • • • • •

Locally advanced or inflammatory breast cancer Neoadjuvant therapy Biopsy proven axillary nodal metastases on US axillary staging Patients undergoing mastectomy Symptoms suggestive of metastatic disease

Results: Five-hundred and ninety-five of the 903 patients (66 %, median age 59) underwent systemic staging. Seventy-two patients (12 %) had distant metastases and twenty-one (29 %) had metastases to multiple organs. Bone was the most common site for single organ metastases (37 of 51). Of those presenting with bone metastases only, 11 of the 37 (30 %) patients had a single site of bone metastasis. All but three of these were to the axial skeleton. CT-TAP alone with omission of bone scintigraphy would have resulted in a false negative rate of 0.5 %. Conclusion: In patients with newly diagnosed breast cancer selected for systemic staging, multi-detector CT is a satisfactory stand-alone investigation.

A Necrotising Fight Barter C, Regan P Department of Surgery (Plastic and Reconstructive Surgery), University College Hospital Galway, Newcastle Road, Galway; Intern Network: West North West-NUI Galway

S339 Introduction: Necrotising fasciitis (NF) is a rare and potentially life threatening infection of the subcutaneous tissues caused by a number of microbacteria—most commonly Group A Streptococcus. Despite its rarity the incidence of NF has increased dramatically over the last number of years to an estimated 0.40 cases per 100,000 population1. Description: A 58-year-old male patient was admitted for an elective resection of a proximal large bowel polyp on the background of a strong family history of bowel cancer. The procedure was performed laparoscopically with a primary anastomosis and no peri-operative complications. Day two post-operatively he developed an acutely painful abdomen with board-like rigidity, rebound tenderness in the lower left quadrant and associated persistent episodes of hypotension and tachycardia—he remained apyrexial throughout. CT-Abdomen demonstrated no acute intra-abdominal collections and an intact anastomosis. On abdominal examination increasing pain was now accompanied by a rapidly spreading blue-black discolouration progressing from the left flank superiorly, anteriorly and posterior-laterally. Emergency debridement revealed the subcutaneous spreading necrosis cultured to reveal Group A Streptococcus which had entered via the trochar site. Significant debridement to the level of the transversalis fascia was required to arrest the progression and protect the peritoneal cavity. After a prolonged ICU stay post-operatively, as well as two further debridements with concurrent extensive skin grafting and intravenous antibiotics, thankfully, he is currently undergoing rehab in the community. Discussion: Necrotising fasciitis can progress in three patterns, virulently (within hours), acutely (as in this case—within days) and in a progressive sub-acute pattern. Luckily the high index of suspicion in this case prevented further devastation for our patient. Reference: 1. Sharkawy A, Low DE, Saginur R et al (2002) Severe group A streptococcal soft tissue infections in Ontario; 1992–1996. CID 34:454–60

Diabetic Ketoacidosis in a First Presentation of Ketosis Prone Type 2 (‘‘Flatbush’’) Diabetes Mellitus Schelten R, McDermott JH Department of Endocrinology, Connolly Hospital Blanchardstown, Dublin Introduction: Diabetic Ketoacidosis (DKA) is a clinical state characterized by hyperglycaemia, ketonaemia and metabolic acidosis and is typically associated with type 1 diabetes mellitus (DM). In this case a 40-year-old male of African descent with no prior history of diabetes presented with DKA. Aims 1. This case is remarkable as it highlights the diabetes subtype of ketosis-prone type 2 DM. Results: A 40-year-old male of African descent without prior history of diabetes presented with a 4 day history of polydipsia, polyuria, vomiting and malaise. Laboratory measurements included serum glucose 41.6 mmol/l and ketones 7.0 mmol/l. The arterial blood pH was 7.23. The patient was treated according to DKA protocol. He recovered well and was discharged on Metformin 500 mg twice daily and subcutaneous basal-bolus insulin treatment. Subsequently, C-peptide was measured at 1.67 ng/mL, indicating endogenous insulin secretion. Anti-GAD antibodies were normal at 3.3 l/mL. The patient was weaned from insulin treatment, successfully maintaining target glucose levels with oral antidiabetic medication alone.

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S340 Conclusion: Ketosis prone type 2 diabetes is an important clinical entity, and should be considered in patients presenting with DKA who are older, obese, or of non-Caucasian ethnicity. Patients with this condition can frequently be successfully treated without insulin following resolution of DKA. Absence of pancreatic autoantibodies can be useful in distinguishing between ketosis-prone type 2 DM and type 1 DM.

Delayed Post-Polypectomy Bleeding after Large EMR in Spite of Prophylactic Hemoclip Application Rafferty S, Yadav A, Sengupta S Department of Gastroenterology, Our Lady of Lourdes Hospital, Drogheda Background: Delayed bleeding following polypectomy is a well known complication of the procedure and has been shown to occur up to 29 days post-polypectomy1,2. We report a case of delayed postpolypectomy bleeding after endomucosal resection (EMR) of a greater than 5 cm polyp. Aims: A 55-year-old healthy female with no background illness, underwent a colonoscopy for recent onset irregular bowel movements with a strong family history of colorectal cancer in three first-degree relatives. Results: At colonoscopy a large [5 cm superficially elevated polyp was noted in the ascending colon. Successful piecemeal EMR of the entire polyp was performed. No immediate bleeding or complications occurred. Since the resulting defect from the EMR was large, eight prophylactic hemoclips were applied to prevent post-polypectomy bleeding. Six days post-procedure the patient had melaena with clots of blood passed per rectum. The following morning she had a repeat colonoscopy with phosphate enema bowel preparation. Although no active bleeding was noted from the previous polypectomy site, old blood and clots were noted in the ascending colon. The polypectomy site was sprayed with polysaccharide haemostasis system (EndoClot) to attempt haemostasis. The patient was discharged the same day and since has not reported further bleeding per rectum. Conclusion: Patients undergoing polypectomy should be made aware of the delayed bleeding risk. Prophylactic application of haemoclips do not necessarily reduce the incidence of delayed post-polypectomy bleeding. EndoClot application is effective in achieving haemostasis following post-polypectomy bleeding. References 1. Singaram C, Torbey CF, Jacoby RF (1995) Delayed postpolypectomy bleeding. Am J Gastroenterol 90(1):146–7 2. A Sonnenberg (2012) Management of delayed postpolypectomy bleeding: a decision analysis. Am J Gastroenterol 107(10)339–42

Subclinical Hypercortisolism and Adrenal Incidentalomas: When the Biochemistry and Imaging Don’t Meet the Clinical Picture Cassidy H, Khamis A Intern Network: Letterkenny General Hospital, West/North West Hospital Network Introduction: There is a lack of clear agreement on how to biochemically diagnose subclinical hypercortisolism (SH) and approach

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 the bothersome phenomenon of the ‘adrenal incidentaloma’. Subclinical Cushing’s syndrome is becoming more and more prevalent with patients tending to be hypertensive, diabetic, obese, osteoporotic and dyslipidaemic. Considering that obesity or the ‘metabolic syndrome’ can be so problematic for health, perhaps identifying and tackling a causative/contributing factor like hypercortisolism will lead to significantly improved metabolic outcomes. Description/case presentation: A 47-year-old morbidly obese female was recurrently admitted for problems directly/indirectly related to her obesity. BMI was estimated 61 and complex history included diabetes, hypertension, obstructive sleep apnoea, hyperlipidaemia/-cholesterolemia. Synacthen showed a high basal cortisol level and CT thorax identified a 3.5 cm adrenal gland low-attenuation lesion. 1 mg (low dose) DST which showed lack of suppression, and 24 h urinary cortisol was high. Despite these positive markers of hypercortisolism, the patient’s pattern of obesity, lack of other specific clinical features and question of functionality of adrenal lesion leave us in doubt of how to proceed. SH suggested to be present in 0.2–2 % of the adult population. Firstly, to confirm the diagnosis the 1 mg DST is the most valuable agreed screening tool. Studies have looked at the potential to determine functionality of adrenal lesions by identifying clinical demographic variables. Surgical management seems to improve the metabolic consequences in patients with subclinical hypercortisolism however larger and longer-running trials are needed. If this is proven, screening obese people for SH may be a beneficial tactic in the future.

Vancomycin Hypersensitivity Reaction Triggered by Morphine Sulphate: a Case Report Fathil I, Garrahy A, O’Regan A Department of Respiratory Medicine, University College Hospital, Galway-Intern Network: WNW Introduction: Vancomycin is a glycopeptide antibiotic used to treat infections with methicillin resistant staphylococcus aureus (MRSA) and in cases of severe penicillin allergy1. It is a relatively commonly prescribed antimicrobial agent with 23 % of S. aureus being MRSA in 20132. Vancomycin can result in a range of reactions from local skin irritation to Red Man Syndrome (RMS), the later characterised by flushing, erythema and pruritis due to mast cell degranulation and histamine release. This process can be augmented by other drugs which also stimulate mast cell activation including opioids3. Case presentation: A 96-year-old male was admitted with bilateral obstructive uropathy requiring bilateral nephrostomy insertion and haemodialysis. He subsequently went on to have anterograde uretic stenting performed after which he became unwell with fevers and rising CRP. Urine and blood cultures were positive for MRSA and he was commenced on Vancomycin with an improvement in his condition. On day 11 he was given oral morphine sulphate overnight for foot pain. The following morning he was noted to have oedema of the hands and feet, lip swelling and was hypotensive. He was treated with fluids, regular antihistamine and hydrocortisone. Vancomycin was held and he completed the required course with Daptomycin. His angioedema settled within 24 h. Conclusion: We report a case of hypersensitivity reaction to Vancomycin precipitated by the administration of opioids which trigger mast cell activation and histamine release. While rare, it is important for physicians to be aware of this association between two commonly prescribed drugs.

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 References: 1. Wong JT, Ripple RE, MacLean JA, Marks DR, Bloch KJ (1994) Vancomycin hypersensitivity: synergism with narcotics and ‘‘desensitization’’ by a rapid continuous intravenous protocol. J Allergy Clin Immunol 94(2 Pt 1):189–94 2. http://www.hpsc.ie/ 3. Levy JH, Mart AT (1993) Vancomycin and adverse drug reactions. Crit Care Med 21(8):1107–8

Dilemma of MRI Imaging in Distinguishing Between Wernicke’s Encephalopathy and Central Pontine Myelosis Saha T, Egan B Mayo General Hospital-Intern Network: NWN Galway/Castlebar Introduction: Wernicke’s encephalopathy is clinically diagnosed when there is evidence of ophthalmoplegia, ataxia and confusion. In this case report, we discuss a case where an MRI report shows a mixed picture of Wernicke’s Encephalopathy and Central Pontine Myelosis. Description/case presentation: This is a case of a 56-year-old male who was brought in my an ambulance to the Emergency Department of our hospital due to chest pain which started that morning but resolved on arrival. He has a significant history of alcohol abuse and was a heavy smoker. On examination, patient was confused and agitated and subsequently a neurological exam revealed bilateral nystagmus, ataxic broad based gait and intention tremor. His lab results are as follows: sodium 129 mmol/L, potassium 3.8 mmol/L, glucose 5.3 mmol/L, urea 13.3 mmol/L, creatinine 103, troponin \3. His CT Brain showed mild diffuse involutional change, no intra or extra-cranial hemorrhage, collection or mass. His MRI showed diffuse sulcal widening in the frontal and temporal lobe and cerebellar vermis. The focus of diffusion was restricted centrally within the pons with subtle associated hyper intensity on Flair imaging. There was also evidence of background atrophic changes. The working diagnosis was Wernicke’s Encephalopathy along with Korsakoff’s psychosis. His MRI 1 month later showed high attenuation centrally within the pons and attenuation in the thalami unchanged from the previous MRI. In this case, although the subtle flair hyper-intensity in medial thalami bilaterally suggest early changes of WE, restricted diffusion centrally within the pons also suggest CPM. A pontine infarct is unlikely due to central distribution of enhancement. CPM seems like an unlikely diagnosis in this patient who presented with a sodium level of 129 meq/L, 131 meq/L the next day and 136 meq/L 2 days later.

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Audit on the Completion of Care Plans of Patients in St. Vincent’s Hospital Fairview Abbas A1, Ni Mhurchu C1, Noonan A2 1

UCD Intern Network, 2St. Vincent’s Hospital, Fairview

Introduction: The Mental Health Act (MHA) 2001 states that approved centres (psychiatric hospitals or psychiatric units within general hospitals) must ensure care plans are carried out in consultation with patients that include the setting of appropriate goals. Objective: To measure adherence to standards set by the Mental Health Commission on care planning. Design/methods: The completion of care plans was initially audited on 18/08/2014. New care-plans were introduced in September 2014 (1st intervention), their completion was re-audited on 10/10/2014 and the results were discussed at the Medical Board Meeting (2nd intervention). Care plans were re-audited for the second time on 12/12/ 2014. Results: 1st audit: 78 % of patients had care plans and none were signed by the patients. Only 16 % of care plans had evidence of MDT involvement and only 16 % of care plans had reference to the therapeutic services. Re-Audit: Seventy-four percent of patients had care plans and 30 % were signed by the patients. 85 % of care plans had evidence of MDT involvement. 70 % of care plans had reference to the therapeutic services. 2nd Re-Audit: 100 % had care plans and 57 % were signed by the patients. 90 % of care plans had evidence of MDT involvement. 48 % had reference to the therapeutic services. Conclusions: This completed audit cycle has improved the compliance of the service with a legal requirement. It has raised awareness of the staff involved. Further improvement is required and a repeat of this audit is planned.

Trouble in the Trachea Lynham RS, Timon C Cork Univeristy Hospital Introduction: Inflammatory myofibroblastic tumours, previously known as plasma cell granulomas are a challenge to all specialities of surgical oncology. Newly found to be of lung parenchymal origin more and more research is going into this benign growth. Extra pulmonary sites are rare yet we found such a case. Diagnosis can be difficult as three unique morphologies can be present in a single mass and treatment even more so, often both medical and chirurgical management is required. Excision is often hampered by this tumours preference to locate in close proximity to vital structures.

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S342 Description/case presentation: We present the case of a patient with an IMT in one such location; the trachea, and whose histopathology proved to be a predicament to surgical oncologists internationally. Based on the initial bronchoscopic biopsy, initial surgical management was decided upon, a 3-ring tracheal resection was preformed and the mass excised. This specimen was then frozen and examined by consultant pathologists in St. James Hospital. Due to the unusual staining and morphology of this mass, a definitive diagnosis could not be decided upon and external help was sought: our unique sample contained all three variants of IMT’s, a rarity within a rarity. Currently no guidelines exist as to how to manage an IMT. The understanding of this neoplastic variant is still in its infancy. We have currently achieved a full resolution of this patients symptoms, but whether this is one of the 3 % that are malignant or one of the 10 % that resurface elsewhere only time will tell.

What is a Bilimeter Worth? A Cost Analysis of the Introduction of a Transcutaneous Bilirubinometer in a Large Tertiary Maternity Centre Ryan E1, Craven S1, Diskin C2, O Sullivan A2, Miletin J1,2 1

Department of Paediatrics, University College Dublin, Dublin; Coombe Women and Infants University Hospital, Dublin; Network: Dublin Mid-Leinster

2

Objectives: A transcutaneous bilirubinometer (bilimeter) was introduced to Postnatal Wards in a tertiary maternity centre with over 8000 deliveries per year. Following an initial outlay of 15,000 euro (three bilimeters costing 5000 euro each), it was postulated that it would lead to a reduction in laboratory costs. To evaluate whether the bilimeter demonstrated sustained cost efficiency in a tertiary maternity centre. Methods: We evaluated the number of bilirubin samples sent to Biochemistry Laboratory before and after introduction of bilimeter and calculated potential cost saving. Result: The number of Serum Bilirubin samples sent to the laboratory from December 2011 to February 2012 was evaluated. In total 544 samples were sent. In a 3-month-period (October–December 2013), 18 months following introduction of transcutaneous bilirubinometer, 170 bilirubin samples were sent to the laboratory. That reflected a reduction of 374 samples sent to the laboratory following introduction of bilimeter to Postnatal Wards. The average cost of bilirubin measurement is 8 euro and over the 3-month study period, cost reduction of 2992. If we apply these figures over the 18-month-period following introduction of bilimeter, there is a total reduction of 2244 samples taken and associated cost saving of 17,952 euro. Conclusion: In the 18-month-period following their introduction to the transcutaneous bilimeter economically justified the initial outlay along with additional benefits of reduced phlebotomy for staff and patients. Extension of bilimeter into additional clinical areas such as the Outpatient Department and Neonatal Centre may be warranted.

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‘Non-Resolving C. Difficile Infection Cured by Transplant’ Stanley E, McNamara D Trinity College Dublin Clostridium difficile is the main cause of infectious diarrhoea in hospitalised patients. Prolonged courses of antibiotics, increasing age, severe co-morbidity and ITU admissions are some of the risk factors associated with disturbing the natural microbiome of the gut, which can result in C. difficile infection. C. difficile infections prolong hospital stay and are a huge burden on an already stretched healthcare system. A non-resolving Clostridium difficile infection was diagnosed in an 81-year-old lady, with multiple presentations of watery diarrhoea, increased frequency of bowel motions, abdominal pain and faecal incontinence. Management of diarrhoea from first presentation involved oral metronidazole and oral vancomycin administered in various regimes as recommended by microbiology. A gastroenterology consult recommended fidaxomicin, administered for 10 days with no effect. The patient was then worked up for a Faecal Microbiota Transplant. Faecal Microbiota Transplant (FMT) is the process of transferring a sample of human faeces from a healthy donor to a patient. A donor was obtained, screened for infectious diseases and protocols were reviewed and implemented to facilitate FMT on the ward. Donor faeces were transplanted with resolution of symptoms and patient was reviewed 2 months later diarrhoea free with a vastly improved quality of life. This FMT was the first of its kind in Tallaght Hospital and it was a great success, involving a multidisciplinary approach from Gastroenterology, Microbiology and Nursing specialties. Faecal transplanting has facilitated research in the area of microbiome replacement and could change the way we treat many common GI pathologies in the future.

Observational Study of Daily Dietary Calcium to Identify Feasibility to Cease Calcium Supplementation in a GP Patient Population Hearne E, Griffin M GP Practice, Johns Square, Limerick Background: Calcium supplements have been reported by metaanalysis to be associated with a twofold increased risk of myocardial infarction1. The relative risk of MI if VitD is co-prescribed is 1.24 (95 % CI 1.07–1.45)2, i.e., calcium with vitamin D is proven to be less risky than calcium alone. Another study demonstrated total dietary calcium intake to yield a significantly reduced MI risk, with a hazard ratio of 0.69 (95 % CI 0.50–0.94)3. Aims: Identify whether there is a significant trend of calcium prescribing that requires either to be altered or eradicated, and whether

Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 Ca2+ and VitD is being co-prescribed. The ultimate aim is to reduce coronary events associated with Ca2+ . Methods: Inclusion Criteria—all 65–85-year-old osteoporotic females prescribed calcium supplements. Method—observational study—face to face questionnaire calculating daily dietary calcium (ethical approval—MWRH Ethics Committee). VitD prescription status was gathered from the patients’ files. Results: 50/71 suitable patients participated. 27 % could stop supplementation. 24 % were one glass of milk per day short to completely stop the supplementation. 29 % could halve the supplementation. 18 % were one glass of milk per day short of being able to halve their supplementation. 2 % (one patient) had negligible dietary calcium intake. 100 % were taking Vitamin D concurrently. Mean calcium intake: 916 mg (one glass of milk short of requirement). Conclusions: The results show that calcium supplementation is not always required and its correlating cessation should have a positive public impact if instituted. References: 1. Bolland MJ, Avenell A, Baron JA, Grey A, MacLennan GS, Gamble GD, Reid IR (2010) Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: metaanalysis. BMJ 341:c3691 2. Bolland MJ, Grey A, Avenell A et al (2011) Calcium/vitamin D supplements and cardiovascular events: a re-analysis of the Women’s Health Initiative limited access dataset, and metaanalysis of calcium with or without vitamin D. BMJ 342:d2040 3. Li Kuanrong, Kaaks R, Linseisen J et al (2012) Associations of dietary calcium intake and calcium supplementation with myocardial infarction and stroke risk and overall cardiovascular mortality in the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition study (EPIC-Heidelberg). Heart

An Audit of Pre-dose Vancomycin Level Monitoring on General Medicine and Surgical Wards Hodgins SJ, Griffin L Department of Medicine, Mid-Western Regional Hospital, Limerick and Graduate Entry Medical School, University of Limerick Background: Vancomycin is an antibiotic commonly used in clinical practice to treat many serious infections. Due to the risk of nephrotoxicity the monitoring of its concentration in the blood is required. Trough levels are considered to be the most accurate and should be drawn less than 30 min prior to the next dose1. Methods/Design: In this study we obtained a list of patients on vancomycin at University Hospital Limerick (UHL) on the medical and surgical wards and used the hospital lab data system as well as the drug kardex and chart to collect data. The parameters measured were correct loading dose, appropriate sample interval, true pre-dose sample and whether the target level was achieved. We also compared pre-dose sampling in the day (defined as 8 am–6 pm) to the night. We reviewed 10 patients for which 71 samples were taken.

S343 Results: It was found that most patients received the correct loading dose (9/10). Pre-dose Vancomycin levels were taken at the correct time 36 % of the time and when day samples were compared to night, 15/37 day samples were true pre dose versus 6/21 night samples. Conclusions: This study illustrates that sampling of vancomycin in UHL is accurate 36 % of the time. This could affect patient outcomes as monitoring has been shown to increase efficacy and reduce nephrotoxicity previously2. This study also showed that sampling was more accurate during the day. We recommend that teams try to create a monitoring schedule where samples are drawn during the day. Further changes may be required in order to increase pre-dose accuracy and a re-audit is also recommended. References: 1. Rowden M, Thompson L (2009) Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectio. ASHP Ther Position Statements 1(1):1 2. Zhi-Kang Ye, Hui-Lin Tang, Suo-Di Zhai (2013) Benefits of therapeutic drug monitoring of vancomycin: a systematic review and meta-analysis. Public Libr Sci 10(1):1371

Bilateral Lumbar Pedicle Fractures in the Absence of a Neurological Deficit or Concomitant Osseous Injury Neary C, Hurley R, Baker J, Jadaan M Department of Orthopaedic and Trauma Surgery, University College Hospital Galway Bilateral lumbar pedicle fractures in the absence of a neurological deficit or concomitant osseous injury. Isolated fractures of the lumbar spine pedicles are very rare in the context of simple trauma (Guo et al.). Elsewhere in the spine they are well-reported, occurring iatrogenically or as stress fractures. (Awad et al.; Kim et al.). In one reported case the zone of injury was wider with the immediately caudad vertebral body also being fractured (Singh et al.). A 61-year-old male with recurrent syncopal episodes presented 4 months after a low-energy fall in which he sustained a lower back injury. He has a past medical history of COAD. No investigations were performed, and he improved symptomatically. Unfortunately he suffered a second fall and was attended the orthopaedic service due to new-onset lower back pain, right L3 radiculopthy and weakness of knee extension. Computed tomography lumbar spine revealed healing fractures of the L3 pedicles. Magnetic resonance imaging showed a large disc prolapse at L3/4 with cephalad migration. The STIR sequence on magnetic resonance imaging revealed low signal at the fracture sites suggesting healed fractures. Our impression is that he sustained the pedicle fractures at the initial injury with a possible subclinical injury to the L3/4 disc. Only at the time of a second fall did the disc prolapse and neurological signs developed. Right sided decompression, L3/4 discectomy with instrumentation at L2 and L4 was performed, avoiding violating the healing fractures. The patient’s neurological symptoms resolved subsequently.

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Seasonal Influenza Vaccination Uptake Among Patients Admitted to St. Luke’s Hospital, Kilkenny Gildea D, Bolger K, Aftab Ahmad M DSE-Tallaght Hospital Objectives: To assess the uptake of the seasonal influenza vaccine, among patients admitted to hospital. We assessed if the vaccine was indicated in patients, and if so, had they received it. If patients had not received it, we looked at the reasons why. Further analysis included; the role of reminders to patients in whom the vaccine was indicated, and the specific indications for the vaccine. Design/methods: A questionnaire was compiled and all patients admitted to a general medical team in St. Luke’s Hospital between 4/11/14 and 2/12/14 were surveyed. The data was analysed using Microsoft Excel. Results: A total of 43 patients were surveyed. Vaccination was indicated in 37 (86 %) patients. 24 (65 %) of these had received the vaccine. Of the 24, 21 had received a reminder about the vaccine this year [from their GP in the majority of cases (14)]. 13 patients had not received the vaccine. 11 out of the 13 had not received a reminder. Of these 11 patients, 6 did not intend on getting the vaccine this year, the most common reason for this being that subjectively, they did not feel they were candidates for it. Of the 11; 10 had attended their pharmacy in the previous month and 10 had attended their GP practice in the previous 2 months. Age was the most common indication for vaccination with 27 (63 %) patients being aged 65 or more. This was followed by chronic heart disease in 19 (44 %) patients and chronic lung disease in 13 (30 %). Conclusions: The vaccine uptake rate of 65 % is in keeping with national data from the HSE and ICGP. We found the use of reminders to be very effective in increasing uptake rates. All 23 patients who had received reminders either had already received the vaccine or intended to do so. Interestingly, for all 11 of the patients who had neither received the vaccine nor a reminder, there had been opportunities to do so. With increased awareness of healthcare professionals of the effectiveness of reminders, the rate of influenza vaccine uptake can be increased further.

SDHB Mutation in a Metastatic Non Secreting Paraganglioma Madaleno A, Sherlock M Adelaide and Meath incorporating the National Children’s Hospital (AMNCH); Dublin 24 Introduction: Paragangliomas are tumours derived from extra-adrenal chromaffin cells of the sympathetic paravertebral ganglia of thorax, abdomen, and pelvis. While their aetiology is multifactorial, some of the most common familial genetic abnormalities include SDHx mutations. While there is currently no ‘silver bullet’ for its treatment, MIBG radiotherapy and Tyrosine kinase inhibitors may be

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Ir J Med Sci (2015) 184 (Suppl 7):S249–S344 used in its treatment together with symptomatic management of metastases. Recent guidelines for the staging and management of Phaechromocytomas and Paragangliomas are also discussed. Description/case presentation: PC is a 37-year-old male that presented with over 6/12 of right hip pain with no other previous medical history. Of note, there was an extensive oncological family history but no significant lifestyle risk factors. On initial investigations, PC was found to have a non secreting paraganglioma with widespread bone metastases including a lyric lesion in his right acetabulum. Exploratory laparotomy of the primary lesion showed significant IVC and aorta involvement and the lesion was therefore deemed unrespectable. A Harrington’s procedure was carried out for spinal stabilisation and the patient was referred to an outside institution for MIBG Radiotherapy. The current management options for PPGLs are discussed. Recent screening guidelines are similarly reviewed. The efficacy of supportive measures and multidisciplinary involvement regarding quality of life issues is highlighted. A brief overview of translational research on the pathophysiology of PPGLs and specifically the role of SDHx mutations is presented.

The Evolving Cost of HIV Care in CUH: An Investigation of the Costs of Pharmaceutical Intervention Farrelly S, Horgan M Department of Infectious Disease, Cork University Hospital Objectives: To determine the pharmaceutical costs of treating the HIV infected cohort in Cork University Hospital with HAART therapy and subsequently identify populations who are predisposed to increased pharmaceutical costs. Design/Methods: Details of patients’ treatment regimens were obtained via a retrospective chart review in CUH. Costing data was obtained from the Pharmacy Department. Information on the demographics of the cohort, including age, sex, HIV viral load, and hospital admissions, were obtained from the Pharmacy Department, CUH internal databases and Hospital Inpatient Enquiry Dept. Results: From a sample size of 384 patients, the predicted yearly costs, based on information from August 2013, is €5.1 million. The average cost of treatment is €13,269.90 per person per annum. There were 175 patients prescribed the more expensive Protease Inhibitor regimens with the remaining 209 on Non-Protease Inhibitor based regimens. Females are 2.5 times more likely to be on a Protease Inhibitor based regimen compared to males, while patients are 6 % less likely to be prescribed a Protease Inhibitor for each increase in year of age. Conclusions: The pharmaceutical cost of treating patients with HIV infection in CUH is €5.1 million. The cohort is well controlled with the vast majority virally suppressed. The information presented here aims to inform governing bodies with regard to resource provision, allowing the most effective strategic distribution of diminishing resources to achieve maximum benefit.