Day of surgery admission for the elective surgical in-patient: successful implementation of the Elective Surgery Programme

Background and aims

The aim of this prospective cross-sectional study was to determine the impact of (1) ring fencing in-patient general surgical beds and (2) introducing a pre-operative assessment clinic (PAC) on the day of surgery admission (DOSA) rate in a single Irish institution. The secondary aim was to analyse the impact of an increased rate of DOSA on cost efficiency and patient satisfaction.

Methods

An 18-month period was examined following ring-fencing of elective and emergency surgical beds. A PAC was established during the study period. Prospectively collected data pertaining to all surgical admissions were retrieved using patient administration system software (Powerterm Pro, Eircom Software) and a database of performance information from Irish Public Health Services (HealthStat).

Results

Ring-fencing and PAC establishment was associated with a significant increase in the overall DOSA rate from 56 to 85 %, surpassing the national target rate of DOSA (75 %). Data relating specifically to general surgery admissions mirrored this increase in DOSA rate from a median of 5 patients per month, before the advent of ring-fencing and PAC, to 42 patients per month (p < 0.0387). 100 patient surveys demonstrated high levels of satisfaction with DOSA, with a preference compared to admission one night pre-operatively. Cost analysis demonstrated overall savings of 340,370 Euro from this change in practice.

Conclusion

The present study supports the practice of DOSA through the introduction of ring-fenced surgical beds and PAC. This has been shown to improve hospital resource utilisation and streamline surgical service provision in these economically challenging times.     

Pre-operative testing for pregnancy in Dublin Day Surgery Units

Background

The safety of anaesthetic agents in early pregnancy cannot be guaranteed. Certain types of surgery, particularly gynaecological, may also be dangerous. It is therefore important to ensure that, female patients are not inadvertently pregnant when undergoing elective surgery. Different hospitals have different policies and guidelines in place to determine female patients’ pregnancy status prior to elective surgery.

Aims

This study aims to evaluate practices in Ireland with regard to methods used to exclude pregnancy in premenopausal women attending for day surgery.

Methods

Postal questionnaires were sent to all consultants in Gynaecology and General Surgery. E-mail questionnaires were sent to all registrar trainees in both specialties. Letters were sent to nine Dublin teaching hospital day surgery units and followed up by telephone consultations.

Results

The overall response rate was poor at 34.3 %. Eighty per cent of respondents in the gynaecology specialty have encountered a preoperative patient with a positive pregnancy test at least once during their career versus 28.6 % in the surgical specialty. Only 35 % of gynaecology respondents would routinely inform female reproductive age patients of the need to avoid pregnancy prior to surgery versus 14.3 % in the surgical specialty. On the day of elective surgery, 90 % of gynaecologists would determine the LMP (last menstrual period) versus 35.7 % of surgeons. The policy at all nine Dublin teaching hospitals is to perform a urinary HCG preoperatively but, their policies vary as to whether the patient’s LMP, age and medical history are considered when performing a urinary HCG test.

Conclusion

It is important that, female patients are counselled appropriately regarding the importance of using adequate contraception or, abstinence in order to avoid pregnancy prior to elective surgical procedures. Our survey shows that, gynaecologists are more likely to give this advice compared to our surgical colleagues. Nevertheless, the number of gynaecologists who do this is surprisingly low (35 %). Urinary HCG is still the standard test used in most units to exclude pregnancy.     

Treatment of seborrheic dermatitis: comparison of sertaconazole 2 % cream versus pimecrolimus 1 % cream

Objective

Seborrheic dermatitis (SD) is an inflammatory skin disorder affecting the scalp, face, and trunk. The treatment of SD is an important issue in dermatology. This study aimed at comparing the efficacy of sertaconazole 2 % cream versus pimecrolimus 1 % cream in the treatment of SD.

Methods

In this clinical trial study, 60 patients suffering from SD were studied. Thirty patients received local sertaconazole 2 % cream and in control group, 30 patients received pimecrolimus 1 % cream. Patients were recommended to use the cream twice a day for 4 weeks. At the beginning of referring and also 2 and 4 weeks after first visit, the patients were examined by a dermatologist to control improvement of clinical symptoms.

Results

The mean age of members of the sertaconazole and pimecrolimus groups was 30.12 ± 12.56 and 34.67 ± 10.98 years, respectively. The highest level of satisfaction (90 %) was observed 28 days after sertaconazole application since it was 80 % in pimecrolimus group. The relationship between patients’ satisfaction and receipt of sertaconazole cream (on the 28th day) was statistically significant (P = 0.006).

Conclusion

Sertaconazole 2 % cream may be an excellent alternative therapeutic modality for treating SD.     

Identification of patients with low-risk pulmonary embolism suitable for outpatient treatment using the pulmonary embolism severity index (PESI)

Background

There is increasing evidence that outpatient treatment of patients with low-risk stable pulmonary embolism (PE) is safe, effective and potentially reduces costs. It is not clear how many patients presenting to an Irish Emergency Department (ED) are potentially suitable for outpatient management.

Aims

To identify how many patients presenting to our ED over a 1-year period who were diagnosed with acute PE are potentially suitable for outpatient treatment.

Methods

A retrospective observational study was conducted over a 1-year period. Clinical notes for patients who had a positive computed tomographic pulmonary angiogram (CTPA) within 24 h of presentation to the ED were examined to risk stratify the patients according to the pulmonary embolism severity index (PESI).

Results

Forty-seven patients who presented to our ED were diagnosed with a PE. Clinical notes were missing for 3 cases, and 44 cases were analysed further. The mean age was 64.3 (±16.8 SD) years and 24 (54.5 %, 95 % CI 40–68.3 %) were males. Six patients (13.6 %, 95 % CI 6.4–26.7 %) had a background of cancer. Fifteen cases (34.1 %, 95 % CI 21.9–48.7 %) were deemed to be low risk as they were categorised as PESI risk class I or II. Our study found that 61/420 (14.5 %, 95 % CI 11.5–18.2) of CTPAs done were positive for PE.

Conclusion

This study suggests that a significant percentage of patients diagnosed with acute PE are low risk as per PESI and therefore potentially suitable for outpatient management.     

Effects of sildenafil treatment on patients with Peyronie’s disease and erectile dysfunction

Introduction

It has been shown on experimental rat models that type 5-phosphodiesterase isoenzyme (PDE₅) inhibitors have anti-fibrotic effects for Peyronie’s disease (PD); however, this issue has not been addressed clinically. The aim of this study was to document the effects of PDE₅ inhibitors used for erectile dysfunction (ED) seen in PD patients on the main course of the PD clinically.

Methods

A total of 39 PD patients with ED were divided into two groups. Patients in Group 1 (n = 18) served as controls and received 400 IU vitamin E per day. Those in Group 2 (n = 21) received 50 mg sildenafil per day for 12 weeks. Penile plaque volume was assessed by palpation and by duplex ultrasound. Erectile capacity, penile deformity and plaque characteristics were assessed by the International Index of Erectile Function questionnaire form (IIEF-5) and penile duplex ultrasound.

Results

Statistically significant improvement in all parameters was observed within both groups except for IIEF score in Group 1 when compared with the initial values. Significant reduction in plaques and pain were observed in 7 (33.3 %) and 14 (66.6 %) patients in Group 2 and 6 (33.3 %) and 9 patients (42.8 %) in Group 1, respectively. At the end of the therapy, improvement in IIEF score and reduction in pain were statistically significant in Group 2 compared with Group 1 (p = 0.028 and p = 0.045, respectively).

Conclusion

We conclude that continuous administration of oral PDE₅ inhibitors may be a candidate for medical treatment of PD; however, more controlled studies are needed.     

Ultrasound predictors of malignancy in indeterminate thyroid nodules

Background

Asymptomatic thyroid nodules are an increasingly common clinical problem. Lesions greater than a centimetre require cytological assessment. Indeterminate lesions often need surgical excision to establish a definitive diagnosis and plan further management. If a definitive diagnosis could be accurately predicted pre-operatively, the most appropriate surgical procedure could be performed at the initial operation.

Aim

The aim of this study was to identify whether specific thyroid ultrasound features could predict malignancy in indeterminate thyroid nodules.

Methods

A retrospective review of all patients undergoing surgery for an indeterminate thyroid lesion between 2006 and 2012 was performed. Demographic features, surgical intervention and final histological findings were determined. Pre-operative ultrasound findings and final histology were correlated and the ultrasonic markers predictive of malignancy were determined.

Results

A total of 40 patients were identified as having undergone surgical intervention for indeterminate thyroid nodules. The majority of patients were diagnosed with a follicular adenoma (n = 22; 55 %). Papillary thyroid carcinoma was identified in three patients (7.5 %) and follicular carcinoma in a further 3 (7.5 %). Ultrasound features associated with malignancy included poorly defined nodule borders and increased vascularity. The presence of malignancy was not related to nodule size, echogenicity or the presence of calcifications.

Conclusions

The majority of indeterminate thyroid lesions are benign on final histological assessment. High nodule vascularity associated with ill-defined borders is associated with malignancy. Further research is warranted to identify predictors of malignancy in indeterminate nodules in order to avoid unnecessary or repeated procedures.     

The profile of patients attending a triaged eye emergency service

Background

Galway University Hospital provides a 24-h referral eye emergency service for patients triaged by a primary health network.

Aims

A prospective study was designed to evaluate the profile of patients referred to the eye emergency service and an attempt was made to compare the data recorded to those of a walk-in eye casualty.

Methods

All cases seen in Galway University Hospital eye emergency service over five consecutive weeks in 2012 were recorded and analyzed.

Results

Four hundred and eight cases were seen in total. 312 (76.5 %) were seen during normal working hours and 96 (23.5 %) after-hours. 33.3 % of cases were inflammatory and 31.9 % traumatic. Anterior uveitis [39 cases (9.6 %)] and corneal abrasion [37 cases (9.1 %)] were the most common diagnosis, while bacterial keratitis [9 cases (2.2 %)] and globe rupture/penetration [4 cases (1 %)] were the most serious. 85.6 % of patients were seen within 30 h from referral. A&E department was the main referral source (35 % of cases seen during normal hours and 70.8 % of those seen after-hours). 42.5 % of patients needed to be followed-up in the clinics. Seventy-two patients (17.6 %) were seen after 5 pm, Monday to Monday. Twenty-one were traumatic, 4 required admission and only 9 were deemed inappropriate after assessment.

Conclusions

Serious eye pathology presents after normal working hours. The triage process results in lower number of minor complaints being referred to the service. Compared to a walk-in casualty, a triaged service manages greater percentage of complex pathology.     

In-situ emergency pediatric surgery in the intensive care unit

Background

The role of surgery in the intensive care unit (ICU) remains unclear. Although previous studies have not shown any increase in morbidity when operating on patients in the ICU for surgical procedures; there remains a reluctance to operate on sick patients in the ICU.

Aim

We did a retrospective study of critically ill children and neonates who underwent in-situ surgery (ISS) to further evaluate its safety and potential. Surgery was aided with the use of operative loupes and high-intensity headlight.

Methods

The medical records of all patients who had undergone surgical procedures in the pediatric ICU over an 11-year period from January 1998 till December 2008 were retrospectively reviewed. We reviewed our experience looking specifically at wound infection rates along with other morbidities in 543 patients.

Results

Our morbidities were comparable with that of operations performed in the operating theater, with low wound infection rates (1 %) for all surgeries undertaken in the pediatric ICU.

Conclusion

ISS avoids the risks of transfer to the operative theater and the potential delays in theater access. Our results suggest that ISS in a tertiary-level pediatric surgical hospital is safe and does not impact adversely on clinical outcome.     

Breast clinic referrals: can mastalgia be managed in primary care?

Background

Centralisation of breast cancer services in Ireland has resulted in a significant increase in the number of patients attending symptomatic breast units (SBU). A considerable proportion of patients referred to SBU present with non-suspicious symptoms and fall into a “low-risk” category for breast cancer. It has been proposed that consideration be given to a primary care-delivered service for these patients.

Aim

To evaluate SBU attendances and correlate with diagnosis to identify a cohort of patients who may be suitable for management in the primary care setting.

Methods

Data were collected from a prospectively maintained database on patients attending SBU at two tertiary referral centres (Beaumont Hospital and University College Hospital Galway) from January 2011 to 2012. Reasons for attendance, outcome of triple-assessment and incidence of malignancy were analysed.

Results

14,325 patients underwent triple assessment at the SBU in this time period. 5,841 patients were referred with mastalgia, of whom 3,331 (57 %) reported mastalgia as the only symptom. The incidence of breast cancer in patients presenting with mastalgia alone was 1.2 %. All patients diagnosed with breast cancer in this cohort were over 35 years of age.

Conclusion

The incidence of breast cancer in patients referred to SBU with mastalgia as an isolated symptom is extremely low. Patients under 35 years of age, with mastalgia as an isolated symptom do not require breast imaging and have a sufficiently low risk of breast cancer that they may be suitable for management in the primary care setting.     

Intensive care in a general hospital: demographics,utilization and outcomes

Introduction

Intensive care units (ICU) in Irish academic centres are known to fare as well as their international counterparts. Our aim in this study was to characterise the role and outcomes of an ICU in a smaller Irish hospital and to compare these to international best practice.

Methods

We reviewed admissions of patients to the ICU of St. Luke’s Hospital, Kilkenny. Patient demographics, indications for admission, and outcomes were all recorded and analysed. Sequential organ failure assessment (SOFA) scores were calculated.

Results

Forty-three patients were included in our study, 33 (76.7 %) of which were emergency admissions. Median length of stay was 2 days. The observed mortality rate in our cohort was 20.9 %. The median SOFA score in patients admitted was 7. Higher median SOFA scores on admission were predictive of mortality. The ICU occupancy rate during the duration of our study was 98 %, with only 15 (35.7 %) of admissions to ICU occurring within core working hours.

Conclusion

Critical care can be provided safely and in line with current best practice in smaller Irish hospitals. There is a cohort of patients for whom care may be best provided in a tertiary centre, how best to provide for these patients will likely be achieved by early identification (e.g. with SOFA score). Bed capacity issues remain problematic.     

A retrospective audit of 200 cases of CNS tumours and their surgical management in a tertiary care centre

Aims

To study the nature of the tumours managed in the Irish population.

Methods

This audit research was completed via a retrospective medical review on 200 patients with CNS tumours managed in a tertiary care centre between 2008 and 2009.

Results

The mean age was 53 years. The male:female ratio was 2:1. The majority were glioblastomas and astrocytomas. Grade IV tumours were predominant (65.5 %). Headaches (37 %), motor weakness (32 %) and seizures (25.5 %) were the highest presentations. The commonest sites affected were the left parietal and left temporal lobes. There were 17.5 % operative morbidities with motor weakness (22.9 %), seizure (14.3 %) and thrombo-embolism (14.3 %) dominating and significant association to surgical radicality (p = 0.041). 3.5 % operative mortalities were reported. 52.5 and 62.5 % of patients received adjuvant chemotherapy and radiotherapy, respectively.

Conclusions

Patients with CNS tumours typically had multiple presentations. More extensive surgical resection was associated with higher postoperative morbidities (p = 0.041). The 30-day postoperative morbidity (17.5 %) and mortality (3.5 %) were concordant with the currently available literature.     

Contamination of blood pressure cuffs by methicillin-resistant Staphylococcus aureus and preventive measures

Background

Although blood pressure cuffs are commonly used and shared in medical facilities, their routine disinfection is performed infrequently.

Aims

We investigated the contamination of blood pressure cuffs by methicillin-resistant Staphylococcus aureus (MRSA).

Methods

The MRSA level on the inner side (the surface in contact with patients’ skin) of blood pressure cuffs used in the wards and outpatient clinics of a university hospital (733 beds) was determined using the gauze and swab wiping methods.

Results

Using the gauze wiping method (n = 35), the MRSA contamination rate was 31.4 %, and the MRSA contamination level was 1,702.6 ± 9,996.1 (0–58, 320) colony-forming units (cfu)/cuff. No MRSA was detected on blood pressure cuffs after washing (n = 30) or wiping with 80 vol% ethanol (n = 18).

Conclusions

Blood pressure cuffs are frequently contaminated by MRSA.     

Basic surgical training in Ireland: the impact of operative experience, training program allocation and mentorship on trainee satisfaction

Background

Application to the Irish basic surgical training (BST) program in Ireland has decreased progressively over the past 5 years. We hypothesised that this decline was secondary to dissatisfaction with training correlated with reduced operative experience and lack of mentorship among BSTs.

Methods

An anonymous 15 question electronic survey was circulated to all BSTs appraising their impression of the operative experience available to them, their mentorship and their opinions of critical aspects of training.

Results

Fifty trainees responded to the survey. At the commencement of training 98 % (n = 43) intended to stay in surgery, decreasing to 79 % (n = 34) during the BST. Trainees who felt they had a mentor were three times more likely to be content in surgical training (OR 3.11; 95 % CI 0.94–10.25, P = 0.06). Trainees satisfied with their allocated rotation were more likely to be content in surgical training (OR 4.5; 95 % CI 1.03–19.6, P = 0.045). Individual trainee comments revealed dissatisfaction with operative exposure.

Conclusion

Mentorship and satisfaction with allocated training rotation had a positive impact on trainee satisfaction and correlated with contentedness in surgical training. Operative experience is the main element that trainees report as lacking. This highlights the need for reform of the training system to improve current levels of mentorship and increase operative exposure to enhance its attractiveness to the best quality medical graduates.     

The effect of a Rapid Access Prostate Cancer Clinic on prostate cancer patient and disease characteristics,primary treatment and surgical workload

Background

In 2009, Rapid Access Prostate Cancer Clinics (RAPC) were introduced to St. James’s Hospital to improve the access and organisation of patients to prostate cancer investigations and treatment.

Aims

To observe the effects of the RAPC on prostate cancer diagnosis, primary treatment and overall workload.

Methods

Using a prospectively designed patient database, the records of all prostate cancer patients between 2007 and 2011 were retrieved and analysed. Data were obtained for age, PSA, biopsy Gleason score and primary treatment modality and charted for the observation and comparison of trends.

Results

Seven hundred and eighty-nine patients had a new diagnosis of prostate cancer between 2007 and 2011. The median PSA prior to the RAPC was 9.7–13.1 ng/ml, which decreased to 7.79–9 ng/ml after the RAPC. Prior to the RAPC, 77–81 biopsies were performed annually versus 149–271 in the post-RAPC era. Annual requirements for radical prostatectomy also increased from 12 to 27 in the post-RAPC era. Conversely, an initially increasing percentage of patients for radiotherapy was reversed in the post-RAPC period. An increasing trend for higher grade PCa (Gleason score 4 + 4 and higher) was also reversed.

Conclusions

The introduction of a RAPC improves the overall pathological characteristics of patients with prostate cancer. However, RAPCs are also associated with a considerable increase in surgical workload. These are important considerations for units considering the incorporation of a similar facility in their institutions.     

Management of recalcitrant urethral strictures with self-dilatation balloon catheter

Introduction

Urethral strictures constitute a significant clinical problem that often requires long-term management.

Objective

To report the long-term outcomes of adjuvant home self-urethral dilatation of recurrent urethral strictures using a balloon catheter.

Materials and methods

Male patients (N = 11), performing self-dilatation with a balloon catheter (minimum 24 months) were assessed by patient-reported outcome measures (PROMs) health questionnaire specific for post treatment assessment of men with urethral stricture disease.

Results

Median duration of balloon catheter use is 46.5 months, IQR (24–150). Patients performed self-balloon dilatation on average 1.4 times a week, median 1, IQR (1–2) to maintain the patency of their urethra. The mean PROMs LUTS score of the patients was 2.45, median 2, IQR (1–4). The median and mean Peeling score was 2 IQR (1–2). 100 % patient reported that they either very satisfied or satisfied with the overall outcome and QoL.

Conclusions

Our initial experience of outpatient self-dilatation with a balloon dilatation is encouraging and is an acceptable inexpensive and simple treatment for patient maintains urethral patency and potentially decreases stricture recurrence.     

Bench and Bedside? Surgeons’ views on the role of research in surgical training

Aims

Internationally, surgical training is facing the challenge of balancing research and clinical experience in the context of reduced working hours. This study aimed to investigate trainees and trainers’ views on surgeons participating in full-time research during surgical training.

Methods

An anonymous voluntary survey was conducted of surgical trainers and trainees in two training systems. To examine surgeons’ views across two different training schemes, surgeons were surveyed in Ireland (Royal College of Surgeons in Ireland) and in a Canadian centre (University of Toronto) between January 2009 and September 2010 (n = 397 respondents).

Results

The majority of respondents felt that time spent in research by trainees was important for surgery as a specialty, while 65 % felt that research was important for surgical trainees (trainers 79 %, trainees 60 %, p = 0.001). A higher proportion of Canadian surgeons reported that they enjoyed their time spent in research, compared to Irish surgeons (84 vs. 66 %, p = 0.05). Financial worries and loss of clinical time were common demotivating factors. Full-time research was more popular than part-time options to obtain a post-graduate degree.

Conclusions

Most agree that research remains an important component of surgical training. However, there are significant differences in opinion among surgeons in different countries on the precise role and structure of research in surgical training.     

Ventilator-associated pneumonia in patients using HME filters and heated humidifiers

Background

Ventilator-associated pneumonia (VAP) is a clinical form of hospital-associated pneumonia, which may develop within 48 h in patients on mechanical ventilation who had no pre-existing pneumonia at the time of intubation.

Objective

The objective of this study was to compare the incidence of VAP among patients who started receiving treatment with heat and moisture exchanger (HME) filters and heated humidifiers (HHs) for mechanical ventilation.

Methods

Patients who were on the first day of intubation, did not have pre-intubation pneumonia, presented to the healthcare centre with no infections at the time of presentation, were not on antibiotic treatment for pulmonary infections and did not have evidence of infiltration with chest radiography were included in the study. Data were evaluated using Fischer’s exact, Mann–Whitney’s U and t tests.

Results

The patients in the HME filter and HHs groups had a mean age of 47.9 ± 2.2 and 44.5 ± 2.1 years, respectively. Infiltration on chest radiography was identified on day 6.33 for the patients in the HME filter group and on day 5.8 in the HHs group. Patients using HME filters and HHs did not differ significantly with regard to the day of mechanical ventilation and number of days hospitalized (p > 0.5). Comparison of the two groups with regard to presence of fever during the first 24 h, however, demonstrated higher than expected values for the patients using HHs, with a significant difference (p = 0.001).

Conclusion

There were no significant differences between the groups on HME filters and heated humidifiers in terms of infection development; although pulmonary radiography showed delayed average days to infiltration development for subjects using HME filters.     

Aggressive giant cell granuloma of the jaws treated with interferon alpha: a report of two cases

Background

Giant cell granulomas (GCGs) are benign tumours of the jaws of unknown aetiology. Aggressive lesions are difficult to manage and demonstrate a tendency to recur after surgical curettage. In the early 1980s, interferon alpha-2a was found to inhibit angiogenesis through a series of laboratory experiments and was subsequently used to treat a child with pulmonary haemangiomatosis. It has been hypothesised that GCGs are proliferative vascular lesions and would, therefor, be expected to respond to antiangiogenic therapy. The purpose of this study is to report a treatment protocol consisting of enucleation, followed by subcutaneous interferon alpha.

Methods

Patients with a biopsy-confirmed giant cell lesion satisfying criteria for “aggressive” giant cell tumours were included. All lesions were enucleated, and the patients commenced interferon alpha-2a (3,000,000 units/m²) 48–72 h post-operatively.

Results

Two patients satisfied the criteria for aggressive giant cell lesions. All tumours were enucleated. There were no post-operative complications, and all patients tolerated the interferon therapy well. To date, there has been no evidence of tumour recurrence. The follow-up periods were 144 and 81 months, respectively.

Conclusion

Antiangiogenic therapy, in combination with curettage, has proven to be a useful strategy for the management of these tumours. The use of interferon alpha-2a, following enucleation of these lesions, resulted in complete remission of all lesions, and decreased operative morbidity compared with conventional treatment.     

Comparison of prescribing and adherence patterns of anti-osteoporotic medications post-admission for fragility type fracture in an urban teaching hospital and a rural teaching hospital in Ireland between 2005 and 2008

Introduction

Poor adherence reduces the potential benefits of osteoporosis therapy, lowering gains in bone mineral density resulting in increased risk of fractures.

Aim

To compare prescribing and adherence patterns of anti-osteoporotic medications in patients admitted to an urban teaching hospital in Ireland with a fragility type fracture to patients admitted to a rural hospital in the North Western region.

Methodology

We identified all patients >55 years admitted to Sligo General Hospital between 2005 and 2008 with a fragility fracture (N = 744) using the hospital in-patient enquiry system (HIPE). The medical card number of those patients eligible for the primary care reimbursement services scheme (PCRS) facilitated the linkage of the HSE-PCRS scheme database to the HIPE database which enabled a study to identify persistence rates of patients prescribed osteoporosis therapy after discharge. The results were compared to the findings of a similar study carried out in St. James’s Hospital, Dublin.

Results

The 12 months post-fracture prescribing increased from 11.0 % (95 % CI 9.6, 12.4) in 2005 to 47 % (95 % CI 43.6, 50.3) in 2008 in the urban setting and from 25 % (95 % CI 21.5, 28.9) to 39 % (95 % CI 34.5, 42.7) in the rural setting. Adherence levels to osteoporosis medications at 12 months post-initiation of therapy was <50 % in both study groups. Patients on less frequent dosing regimes were better adherers.

Conclusion

The proportion of patients being discharged on anti-osteoporosis medications post-fragility fracture increased between 2005 and 2008 in both patient groups. Sub-optimal adherence levels to osteoporosis medications continue to be a major concern.     

Therapy with omalizumab for patients with severe allergic asthma improves asthma control and reduces overall healthcare costs

Background

Patients with asthma who have persistent symptoms despite treatment with inhaled steroids and long-acting beta agonists are considered to have severe asthma. Omalizumab is a monoclonal antibody directed against IgE, which is used as an add-on treatment for patients who have severe persistent allergic asthma.

Aims

The aim of this study was to assess the clinical benefit and healthcare utilisation of patients who responded to omalizumab therapy and to establish an overall cost implication.

Methods

This was an observational retrospective cohort study designed to investigate the effect of omalizumab on exacerbations of asthma before and after 6 months of treatment in Irish patients.

Results

Centres who had treated patients with severe allergic asthma for the 6 months prior and post omalizumab treatment were audited with a standardised assessment tool. Sixty-three (32 male) patients were studied. In the 6 months prior to omalizumab 41 of 63 (66%) had been hospitalised, and this fell to 15 of 63 (24%), p < 0.0001 in the 6 months after treatment was started. Hospital admissions reduced from 2.4 ± 0.41 to 0.8 ± 0.37 and the mean number of bed days occupied was reduced from 16.6 ± 2.94 to 5.3 ± 2.57 days, p < 0.001. The number of oral corticosteroid doses used fell from 3.1 ± 0.27 to 1.2 ± 0.17, p < 0.001. The overall cost saving per omalizumab responder patients for 6 months was €834.

Conclusions

Six months therapy with omalizumab reduced the number of bed days, the number of hospitalisations and the use of oral corticosteroids compared to the 6 months prior to commencement. Despite the cost of the additional therapy there were overall savings in health costs.