Alcohol screening and brief intervention among drug users in primary care: a discussion paper

Background

Problem alcohol use is common among problem drug users (PDU) and associated with adverse health outcomes. Primary care has an important role in the overall stepped approach to alcohol treatment, especially screening and brief intervention (SBI).

Aim

To discuss three themes that emerged from an exploration of the literature on SBI for problem alcohol use in drug users attending primary care.

Methods

Material for this discussion paper was gathered from three biomedical databases (PubMed, PsycINFO and Cochrane library), conference proceedings and online resources of professional organisations or national health agencies.

Results

Themes discussed in this paper are: (a) the potential of primary care for delivery of alcohol SBIs to PDUs, (b) screening methods and (c) application of brief interventions to PDUs.

Conclusions

Although SBI improves health outcomes associated with problem alcohol use in the general population, further research is needed among high-risk patient groups, especially PDUs.     

Problem alcohol use among problem drug users: development and content of clinical guidelines for general practice

Background

Problem alcohol use is common and associated with considerable adverse outcomes among patients who attend primary care in Ireland and other European countries for opiate substitution treatment.

Aims

This paper aims to describe the development and content of clinical guidelines for the management of problem alcohol use among this population.

Methods

The guidelines were developed in three stages: (1) identification of key stakeholders, (2) development of evidence-based draft guidelines, and (3) determination of a modified ‘Delphi-facilitated’ consensus among the group members.

Results

The guidelines incorporate advice for physicians on all aspects of care, including (1) definition of problem alcohol use among problem drug users, (2) alcohol screening, (3) brief intervention, and (4) subsequent management of patients with alcohol dependence.

Conclusions

Primary care has an important role to play in the care of problem alcohol use among problem drug users, especially opiate substitution patients. Further research on strategies to inform the implementation of these guidelines is a priority.     

Assessment of complications following strictureplasty for small bowel Crohn’s Disease

Background

Surgical intervention is required in a significant proportion of patients with small bowel Crohn’s disease (CD). Strictureplasty is an effective bowel-sparing alternative to resection.

Aim

The aim of this study is to assess the primary complications of small bowel strictureplasty for CD (bleeding and leakage). Other postoperative complications encountered, postoperative duration of hospital stay, 30-day mortality, and the incidence of reoperative surgery are also discussed.

Methods

A retrospective review of patients undergoing small bowel strictureplasty at The Royal Hospital between 1992 and 2007 was conducted. Twenty-seven patients underwent 34 laparotomies and 100 strictureplasties.

Results

There was no procedure-specific morbidity and mortality. Other common complications encountered were ileus (3/34) and surgical site infection (3/34).

Conclusion

Most of the patients in this study have recurrent diffuse intestinal CD requiring synchronous bowel resection. Strictureplasty is a safe and effective bowel-sparing surgical option in this group of patients.     

Rapid, early and sustained virological responses in a cohort of Irish patients treated with pegylated interferon and ribavirin for chronic hepatitis C virus infection

Background

The response to the treatment with pegylated interferon (PEG IFN)-?? combined with ribavirin in chronic hepatitis C virus (HCV) infection varies with some patients having a rapid or early response which is not sustained.

Aims

To investigate the rates of rapid virological response (RVR), early virological response (EVR) and sustained virological response (SVR) in an Irish cohort of HCV infected patients receiving IFN-??/ribavirin.

Methods

Rates of RVR, EVR and SVR were examined in 123 patients undergoing standard treatment for chronic HCV infection between 2001 and 2007 at a Dublin Teaching Hospital.

Results

The rates of RVR, EVR and SVR in genotype 1 patients were 48, 68 and 50%, while in genotype 2/3 patients they were 87, 93 and 87%, respectively. The positive predictive values (PPV) of RVR for SVR in genotype 1 and genotype 2/3 patients were 90 and 92.4%, respectively.

Conclusion

The rates of response to PEG IFN-??/ribavirin in Irish patients are consistent with other international reports. We support the regular monitoring of rapid and early virological response as a standard of care in treating chronic hepatitis C patients.     

What is the role of general practice in addressing youth mental health? A discussion paper

Background

Mental and substance use disorders are a leading cause of morbidity among young people. Policy and clinical services in Ireland are endeavouring to address these twin issues.

Aims

To review the emerging literature on the role of general practice in addressing youth mental health and to discuss the implications of this literature for further research, education and service delivery.

Methods

We conducted a review of ??PubMed?? and a web search of relevant national/international primary/mental healthcare agencies and professional bodies.

Results

Although general practice has an important role in addressing youth mental health, there are challenges in how young people seek help. Specifically, young people do not engage with healthcare agencies and many factors which act as barriers and enablers in this regard have been identified. The detection and treatment of mental and substance use disorders by GPs can be improved and implementing interventions to improve screening and early intervention are likely to be valuable.

Conclusions

General practice is a central agency in addressing youth mental health and complex multifaceted interventions (education, clinical guidelines, and promoting awareness) are likely to support its role. Further research exploring this issue is a priority.     

Evolution of mycotic aortic aneurysm treatment by endovascular repair

Introduction

Endovascular intervention for mycotic aortic aneurysms is now an alternative treatment option.

Case report

An 83-year-old male presented with confusion and pyrexia of unknown origin. Acute deterioration and subsequent computed tomography scan of the abdomen revealed a contained rupture of a mycotic aortic aneurysm for which the patient had a successful endovascular repair.

Conclusion

Endovascular management of aortic mycotic aneurysms provides an alternate and potentially safer method of intervention, particularly in patients deemed unsuitable for open repair.     

Utility of bronchoalveolar lavage in the diagnosis of pulmonary infection in children with haematological malignancies

Background

Fibre-optic bronchoscopy with bronchoalveolar lavage (BAL) is a safe procedure and is associated with low morbidity and mortality in immunocompromised children. Although many studies have highlighted the advantages of positive BAL results in the diagnosis of pulmonary infections, there have been few reports examining the impact of a negative BAL result on clinical management in immunocompromised children on empiric broad-spectrum antimicrobial therapy.

Aim

The aim of this study was to evaluate BAL in the diagnosis of pulmonary infections in children with haematological malignancies who develop pneumonia unresponsive to empiric antimicrobial therapy, and also to determine whether a negative BAL result contributed to the clinical management of these patients.

Materials and methods

A retrospective review of 44 BAL procedures performed in 33 children with haematological malignancy diagnosed and treated at Our Lady’s Children Hospital, Crumlin, Dublin 12, Ireland, over a 10-year period was carried out.

Results

We identified a pathogen causing pneumonia in 24 of 44 BAL procedures (54.5 %). The BAL procedure resulted in modification of antimicrobial treatment after 20 of 24 procedures with positive results (83.3 %) in 16 of 20 patients (80 %). Management was changed after 8 of 20 procedures with negative results (40 %) in 8 of 18 patients (44.4 %). The procedure was well tolerated in all patients.

Conclusions

Our study supports the use of bronchoscopy with BAL as a diagnostic intervention in this patient population. We consider BAL a safe procedure from which both positive and negative results contribute to the patient’s clinical management.     

Non-attendance at counselling therapy in cocaine-using methadone-maintained patients: lessons learnt from an abandoned randomised controlled trial

Background

Recently, the authors commenced a randomised controlled trial to study the effectiveness of cognitive behavioural coping skills (CBCS) to reduce cocaine usage in methadone-maintained patients?? in a clinical setting by assessing attendance at treatment sessions and outcomes in terms of cocaine use. However, recruitment into the study stopped when it became apparent that attendance at counselling sessions was poor.

Aims

The aim of the current study was to determine the reasons for both non-attendance and attendance from a patient??s perspective at counselling sessions.

Methods

A cross-sectional design was employed whereby participants who were recruited for the original study were interviewed utilising a semi-structured interview format.

Results

Motivational inconsistencies were most frequently cited as the reason for dropping out of counselling, whereas a good relationship with staff was cited by attenders as the most important factors which aided their attendance at counselling sessions.

Conclusions

Selecting opiate-dependent methadone-maintained cocaine abusers on the basis of their urine toxicology and offering them counselling as a way of reducing their harmful drug use did not prove efficacious. Attempting to address cocaine misuse within this cohort may need a more stepped approach including brief interventions, such as motivational interviewing, or other enhancers of motivation before we can test the effectiveness of CBCS in this population.     

Experience of a high-risk aortic valve clinic in Ireland

Background

The advent of transcatheter aortic valve implantation (TAVI) has broadened the management options for severe aortic stenosis. The indications for TAVI are narrow. Selecting those that will benefit most from this intervention warrants careful consideration and input from cardiologists, anaesthetists and cardiac surgeons familiar with TAVI and surgical aortic valve replacement (SAVR).

Aims

The aims of this paper were to assess the feasibility of establishing a high-risk aortic clinic in Ireland, and report stratification of the referred group into those suitable for SAVR, TAVI and conservative management.

Methods

Patient data was prospectively collected by a dedicated clinical nurse specialist. ANOVA was used to assess variance in means between groups. Analyses were performed using IBM SPSS v20 (Armonk, NY: IBM Corp.).

Results

A total of 105 patients were assessed. Eighty-five patients were deemed suitable for TAVI, 9 (10.5 %) died awaiting the procedure and a further 6 (7 %) declined intervention. Eleven (10.5 %) underwent conventional SAVR, 1 (0.9 %) a balloon valvuloplasty, 4 (3.8 %) entered surveillance and 4 (3.8 %) were declined treatment.

Conclusions

Establishment of a high-risk aortic clinic is feasible in the Irish context. The advent of TAVI has reduced the proportion of patients denied intervention to a minority. Despite being considered high risk, a number of patients were suitable candidates for SAVR. Measuring frailty continues to provide a challenge; a TAVI-specific frailty assessment tool would be advantageous to patient stratification.     

Coracoid Impingement Syndrome: A treatable cause of anterior shoulder pain

Background

Coracoid Impingement Syndrome is a relatively uncommon but generally treatable cause of anterior shoulder pain that can be easily overlooked. It typically presents with anterior shoulder joint pain in activities involving forward flexion, adduction and internal rotation.

Aims

To assess the outcome of a cohort of patients diagnosed with Coracoid Impingement Syndrome.

Methods

Patients were investigated clinically and radiologically. They received appropriate therapeutic measures and were followed-up in an orthopaedic outpatient setting.

Results

Twelve patients were identified over a four-year period. All patients have made good progress. Thus far, none have needed operative intervention for symptom relief.

Conclusion

Coracoid impingement syndrome is an uncommon cause of anterior shoulder pain but diagnosed patients can expect good symptomatic relief following referral to a dedicated shoulder unit. An increase in clinical awareness of the condition may prevent undue diagnostic delay in such cases.     

Percutaneous renal artery angioplasty and stenting: indications, technique and results

Background

Percutaneous interventions for renal arterial disease can be used to treat a variety of conditions including both atherosclerotic and non-atherosclerotic renal artery stenosis (RAS) as well as endovascular management of renal artery aneurysms (RAA).

Aim

We sought to examine the indications, techniques and results of percutaneous renal angioplasty and stenting in our institution over a 6-year period and review the current evidence for practice.

Methods

Patient demographics, procedure indications, technical procedural details, complications, baseline and follow-up renal profile indices were analysed.

Results

The most common indication for intervention was atherosclerotic RAS (69.2 %) followed by RAS secondary to fibromuscular dysplasia (15.3 %) and RAA (15.3 %). There was a 100 % technical success in our cohort of patients. The majority of patients (84.6 %) had cross-sectional imaging in the form of computed tomography or magnetic resonance angiography prior to intervention.

Conclusion

When performed in appropriate settings following close liaison with referring physicians, percutaneous renal angioplasty and stenting remains an important treatment modality for renovascular disease.     

Inappropriate use of proton pump inhibitors

Background

Proton pump inhibitors (PPIs) are widely used expensive medications.

Aims

We performed a cross-sectional study to determine the extent and indication of PPI use in Irish acute medical wards.

Methods

Fifty-five medical charts were reviewed at the beginning and end of 1 month.

Results and conclusions

Thirty-three patients were prescribed PPIs; 26 prior to admission. The prescribing of PPIs was concordant with guideline recommendations in only 30% of cases. Two-thirds of PPI use was unlicensed.     

The effect of intramuscular vitamin D (cholecalciferol) on serum 25OH vitamin D levels in older female acute hospital admissions

Introduction

Many studies have demonstrated the prevalence of vitamin D insufficiency in the older population.

Objective

This study sought to determine whether supplementation with intramuscular vitamin D improved 25OH vitamin D levels significantly.

Subjects

Ninety female inpatients aged over 65 years were assigned to receive 300,000 IU of intramuscular vitamin D3 (cholecalciferol) or no intervention.

Methods

Baseline 25OH vitamin D and intact parathyroid hormone (iPTH) levels were taken and repeated 3 months after supplementation.

Results

Patients who received treatment showed a significant improvement in 25OH vitamin D levels, from 25.5 to 81 nmol/L with 11% remaining deficient. No patient became hypercalcaemic after treatment.

Conclusions

Vitamin D deficiency is common throughout all age groups in the Irish population and particularly the older female population who have increased risk of osteoporosis and fractures. Intramuscular vitamin D significantly improves 25OH vitamin D levels compared to no treatment and may combat non-compliance with oral medication.     

A survey of complementary and alternative medicine in Iran

Objective:To survey the use,capability and satisfaction of complementary and alternative medicine(CAM)in comparison with conventional medicine in Iran.Methods:In this national survey,a cross-sectional study was designed,5,000 people were surveyed to identify predictors of Iranian traditional medicine(ITM)use compared with conventional medicine.Data were collected through a questionnaire that covered three different predictor categories: demographic information,patient’s viewpoint,and patients’ experiences.Results: Most of the participants preferred government owned hospitals rather than other places.Praying for one’s own health was the most frequent and favorable ITM domain(P=0.017)based on patients’ interests,both in low-(P=0.08)and highlevel (P=0.011)educated subjects.Among the participants,97.8%had previous conventional medicine history due to their chronic diseases Conclusions:Iranian patients resort to ITM as a choice at the late stage of the disease.Current deficiency in integration of CAM and conventional medicine is in contrast to the increasing demand on patients’ side.Health care organizers should be facilitating the CAM services by tuition of CAM practitioners and supporting eligible CAM centers for diagnosis and treatment of patients.     

The provision of a semen cryopreservation service for male cancer sufferers in the Republic of Ireland

Background

Chemotherapy, radiotherapy and surgery for cancer all carry risks of sterility. Semen cryopreservation would allow procreational ability to be preserved.

Methods

A human-assisted reproduction unit was set up in the Rotunda Hospital where semen was cryopreserved and stored for use.

Results

Semen was frozen for procreational potential during 1998 from 58 males about to have oncology therapy likely to render them sterile. The planning for this service and the modus operandi now in place are described. While cryopreservation was not unsuccessful in any case, substandard samples were obtained from 14 men. Pre-freeze viral tests tested positive for CMV in six patients. One pregnancy is already on-going utilising IVF with thawed semen. One patient’s death has been notified and the frozen semen disposed of.

Conclusion

The service is, at present, outside public purse provision. It is hoped that in the near future this will change, as the deficit between charges and costs cannot be sustained in-house forever.     

A single institution experience of streptozocin/fluorouracil combination chemotherapy: a case series

Background

The combination chemotherapy regimen of streptozocin and 5-fluorouracil (FU/STZ) has been used for the treatment of metastatic neuroendocrine tumours.

Aim

The aim of this study was to analyse the use of this regimen in a tertiary oncology referral centre over a 10-year period.

Method

We retrospectively analysed nine cases from February 2000 to May 2010. Patient demographics, chemotherapy schedule, toxicities, progression-free and overall survival were tabulated for each patient.

Result

The median progression-free survival was 17?months (range 3?C48+?months), and overall survival 31?months (range 12?C53+?months) with no toxicity related deaths.

Conclusion

FU/STZ was a well-tolerated regimen that produced significant benefit in the setting of metastatic and progressive disease. Our case series demonstrated comparable progression-free survival and overall survival in relation to randomized controlled studies and previous case series.     

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.     

Acute intestinal failure in surgical patients: an audit of incidence, management and outcomes in an irish hospital, and compliance with ASGBI guidelines

Background

Acute intestinal failure (AIF) is defined as an inability to tolerate 80% of nutritional requirements delivered enterally for a minimum of 48?h. In surgical patients it commonly relates to abdominal sepsis, intestinal obstruction, or ileus. The prevalence of AIF in surgical units in Ireland has not previously been studied.

Methods

We retrospectively audited the general surgical and ICU departments in St James??s Hospital over a 3-month period to identify patients with AIF and followed their management and outcomes focusing on the need for artificial nutrition and surgical intervention.

Results

Fifty-four surgical patients (11.4% of surgical emergency admissions) were diagnosed with AIF over the 3-month period. Of these, 30 (55.6%) required nutritional support; 26 (48.2%) had surgical?±?radiological intervention and 6 (11.1%) had radiological intervention alone. Abdominal sepsis was present in 17 (31.5%) patients, a group that required significantly longer parenteral (14.6 vs. 6.7?days, p 0.029) and enteral (13.9 vs. 2.2?days, p 0.005) nutrition than AIF patients without abdominal sepsis. AIF also took longer to resolve in (5.8 vs. 4.2?days, p 0.024) in sepsis versus nonsepsis patients. The majority of patients (n?=?43, 80%) were referred to clinical nutrition teams early after having symptoms for 3.77?days (range 1?C21) and 72% had complete nutritional assessment clearly documented.

Conclusion

AIF is common, and can often be treated conservatively. Early linkage with nutrition services is recommended. Early diagnosis of abdominal sepsis is important as this cohort of patients can be particularly difficult to manage.     

A survey of upper and lower limb tourniquet use among Irish orthopaedic surgeons

Background

Tourniquet use in orthopaedic surgery is common practice. However, the technique varies among Irish orthopaedic surgeons and there are no standard guidelines.

Aim

To analyse trends in tourniquet use among Irish orthopaedic surgeons.

Methods

Ninety-two Irish orthopaedic consultants were sent a 15-survey question about tourniquet use by post.

Results

Sixty respondents returned a completed survey, of which 49 (81 % of respondents) used both upper arm and thigh tourniquets. A variation in tourniquet pressure settings and techniques used was reported. Thirty-nine surgeons (65 % of respondents) use a tourniquet pressure range of 201–250 mmHg for the upper arm and 30 surgeons (50 % of respondents) use a range of 251–300 mmHg for the thigh. Thirty-six surgeons (60 % of respondents) experienced a complication secondary to tourniquet use, the most common complications being nerve and skin injury.

Conclusions

Based on published studies of limb occlusion pressures, this study suggests that some of the tourniquet cuff inflation pressures used may be higher than necessary. Guidelines for optimising cuff pressure and technique should be established to minimise the risk of complications. This study may help determine direction for future research on tourniquet use.