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.     

Molecular characterisation of human campylobacteriosis in Northern Ireland: evidence of clonal stability

Background

No study has comparedCampylobacter isolates from a human source in Northern Ireland over an extended period of time.

Aim

To investigate the clonal stability of thermophilic campylobacters isolated from acute bacterial enteritis in Northern Ireland from 1992 to 1999.

Methods

Human isolates (n=272), originating from faeces, were characterised at the sub-species level using enterobacterial repetitive intergenic consensus sequence (ERIC2) — random amplification of polymorphic DNA (RAPD) typing.

Results

Thirteen genotypes were identified where three types, namely ERIC A, ERIC C and ERIC I, accounted for 28.3%, 14.3% and 13.6%, respectively. There were no significant associations (p>0.05) between sex, age groupings and year of isolation and ERIC2 genotype, with the exception of ERIC D, which showed a significant decline in isolation with time (p=0.019).

Conclusions

ERIC genotypes were stable over this period, except genotype C which was lost during this time. Previous molecular typing methods showed campylobacters to be heterogeneous but this study suggests that the local humanCampylobacter population consists of several common and stable genotypes. This study has established a database of local ERIC2 genotypes. This methodology may allow the establishment of an all-island database of clinical campylobacters that would be valuable in reducing human campylobacteriosis in Ireland.     

Pregnancy in Irish renal transplant recipients in the cyclosporine era

Background

The effect of renal transplantation on pregnancy in Irish women not receiving CyA has been reported previously.

Aim

To examine all pregnancies occurring in Irish female renal transplant recipients since the introduction of CyA.

Methods

Using a community based approach, we identified 29 pregnancies in 19 women, aged between 16 and 45, mean age 30.3 years.

Results

These pregnancies ended in four miscarriages (13%), two intra-uterine deaths (6.9%) and 23 live births (79.3%). Of these live births, 73.9% were premature (≤36 weeks) and 65.2% were of low birth weight (<2500g). Admission to the neonatal intensive care was necessary in 61%, and two babies (8.7%) died in the neonatal period. Mean gestational age was 34 weeks, and mean birth weight was 2190g. There was no change in graft function during pregnancy, with a small rise in serum creatinine post-partum (+9.64μmol/L). The renal graft failed in three women (15.8%) by the end of the follow-up period. Compared with the precyclosporine era, the live birth rate was higher (79.3% versus 58%) with a trend towards lower birth weight and shorter gestation.

Conclusion

Renal transplantation with CyA use is not a contraindication to pregnancy, but it is associated with increased risk, especially when the serum creatinine is >175μmol/L.     

Elective surgery: a comparison of in-patient versus day surgery practices in Ireland

Background

Currently, there is a paucity of research which has assessed practices at the point of care for day surgery patient.

Aim

To outline the patient journey from first referral for surgery and identify structures and processes which facilitate or constrain the provision of day surgery.

Method

A retrospective medical charts review of 200 consecutively presenting patients undergoing elective surgery in two Irish teaching hospitals. Data collection was completed from January 2009 to March 2009. This analysis spanned from first referral to the hospital until discharge and follow up.

Results

Great variability was noted in practices between the two hospitals. While some of the differences in practice become barriers to increased rates of day surgery, others did not have an impact.

Conclusion

This study echoes findings of other similar studies in that management of patients undergoing elective surgery which varies significantly across Irish hospitals.     

Molecular genotyping of human cryptosporidiosis in Northern Ireland: epidemioiogical aspects and review

Background

Cryptosporidium parvum is the most common of the protozoal pathogens associated with gastrointestinal disease in Northern Ireland. Genotyping techniques are valuable in helping to elucidate sources and modes of transmission of this parasite. There have been no reports on the prevalence of genotypes in Northern Ireland, mainly due to a lack of discriminatory genotyping techniques, which recently have become available.

Aim

To investigate the genotype ofC. parvum oocysts isolated from human faeces in sporadic cases of cryptosporidiosis in Northern Ireland.

Methods

Thirty-nine isolates ofC. parvum, representing 79.6% of the total 1998 laboratory reports for the Eastern Health and Social Services Board, were investigated. Following DNA extraction from oocysts the thrombospondinrelated adhesive protein 2 (TRAP-C2) locus was amplified by polymerase chain reaction (PCR) and subsequently sequenced.

Results

The majority of isolates (87.2%) were classified as bovine genotype II with the remainder (12.8%) being the human genotype I.

Conclusions

There is a high prevalence of the bovine genotype II parasite in sporadic cases around the greater Belfast area. Epidemiologically, this suggests that the most frequent mode of transmission may be from animals to humans, but does not suggest a high proportion of human to human spread.     

Vitamin B12 status, homocysteine and mortality amongst community-dwelling Irish elders

Background

Vitamin B12 deficiency is associated with hyperhomocysteinaemia, which is associated with atherosclerosis and increased mortality. High levels of vitamin B12 have also been associated with increased mortality in certain patient populations.

Aims

We examined vitamin B12 and homocysteine status and mortality rates in a population of Irish community-dwelling elders over a 3-year period.

Methods

Prospective, community-based observational cohort study.

Results

Subjects in the highest quartile of homocysteine had increased mortality rates (14.68 vs. 7.32%, relative risk 2.09). This relationship was attenuated when controlled for the presence or absence of a history of stroke or myocardial infarction. There was no relationship between vitamin B12 status and mortality during the observation period.

Conclusion

Vitamin B12 levels are not associated with death rates in Irish community-dwelling elders. Homocysteine levels are associated with mortality and may act via the mechanism of atherosclerotic disease.     

A budget impact analysis of natalizumab use in Ireland

Background

Multiple sclerosis is the commonest cause of disability in young Irish adults. Natalizumab reduces disability progression in those patients with relapsing remitting multiple sclerosis who are suitable for it. First line disease modifying therapies are given in the community and are paid for by the hi-tech drug scheme. Natalizumab is given in hospital and is paid for from the hospital??s budget. Access to natalizumab has been problematic in some Irish hospitals. A budget impact analysis was performed to look at the overall cost to the Health Service Executive of giving natalizumab.

Methods

A budget impact analysis was performed from the perspective of the Health Service Executive comparing the use of natalizumab with first line disease modifying therapies for 2009?C2011.

Results

The study showed that currently, the use of natalizumab is likely to be cost saving to the Health Service Executive overall, because some of the costs for natalizumab are borne by private insurers, whereas, all of the costs of disease modifying therapies are borne by the Health Service Executive.

Conclusions

Although the use of natalizumab is cost saving, current funding arrangements in the Health Service Executive do not allow for the transfer of money saved from drugs paid for in the hi-tech scheme, to hospitals who are supplying alternative treatments.     

Primary torsion dystonia due to the TOR1A GAG deletion in an Irish family

Background

Early, limb-onset primary torsion dystonia (PTD) is commonly due to a trinucleotide GAG deletion in the TOR1A (DYT1) gene on chromosome 9q34. The majority of carriers of this mutation conform to a characteristic phenotype that is similar in different ethnic populations.

Aim

To describe the clinical features of affected members of a large Irish family with PTD due to the TOR1A deletion.

Methods

Fourteen consenting family members from three generations were examined according to a standardised protocol.

Results

Five affected individuals were identified. Two had a somewhat atypical phenotype with focal and segmental upper-limb dystonia without further progression.

Conclusion

The authors describe the clinical features of PTD due to the TOR1A GAG deletion in an Irish family illustrating the presence of intrafamilial phenotypic variability.     

Does domperidone, a D2-antagonist alter gastric emptying rates and appetite sensations in healthy adults with high-fat meal? A block-randomised, single-blind placebo-controlled study

Background

Accelerated gastric emptying (GE) may lead to reduced satiation, increased food intake and is associated with obesity and type 2 diabetes. Domperidone is a dopamine 2 (D₂) receptor antagonist with claims of gastrointestinal tract pro-kinetic activity. In humans, domperidone is used as an anti-emetic and treatment for gastrointestinal bloating and discomfort.

Aim

To determine the effect of acute domperidone administration on GE rate and appetite sensations in healthy adults.

Methods

A single-blind block randomised placebo-controlled crossover study assessed 13 healthy adults. Subjects ingested 10?mg domperidone or placebo 30?min before a high-fat (HF) test meal. GE rate was determined using the ¹³CO₂ octanoic acid breath test. Breath samples and subjective appetite ratings were collected in the fasted and during the 360?min postprandial period.

Results

Gastric emptying half-time was similar following placebo (254?±?54?min) and 10?mg domperidone (236?±?65?min). Domperidone did not change appetite sensations during the 360?min postprandial period (P?>?0.05).

Conclusions

In healthy adults, acute administration of 10?mg domperidone did not change GE or appetite sensations following a HF test meal (NCT01347814).     

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 inclement weather on trauma orthopaedic workload

Background

Climate change models predict increasing frequency of extreme weather. One of the challenges hospitals face is how to make sure they have adequate staffing at various times of the year.

Aims

The aim of this study was to examine the effect of this severe inclement weather on hospital admissions, operative workload and cost in the Irish setting. We hypothesised that there is a direct relationship between cold weather and workload in a regional orthopaedic trauma unit.

Methods

Trauma orthopaedic workload in a regional trauma unit was examined over 2 months between December 2009 and January 2010. This corresponded with a period of severe inclement weather.

Results

We identified a direct correlation between the drop in temperature and increase in workload, with a corresponding increase in demand on resources.

Conclusions

Significant cost savings could be made if these injuries were prevented. While the information contained in this study is important in the context of resource planning and staffing of hospital trauma units, it also highlights the vulnerability of the Irish population to wintery weather.     

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.     

Approach to biliary imaging amongst consultant and specialist registrars in gastroenterology in a national setting

Background

Radiological investigation plays an important role in the management of conditions affecting the hepatobiliary system. However, multiple imaging modalities exist and inappropriate requesting can lead to delays in diagnosis and subsequent treatment.

Aims

To assess the approach to biliary imaging amongst Irish gastroenterologists across a number of scenarios, and examine and seek to explain any variations.

Methods

A survey to determine “best practice” radiological investigation of real-life clinical scenarios was designed and distributed to fully trained and trainee gastroenterologists nationally.

Results

The responses to scenarios ranged from near unanimity, with up to 97% agreement, to notable lack of consensus amongst both registrars and consultants.

Conclusion

An algorithm for the management of hepatobiliary disease was formulated.     

Prescribing of antidiabetic therapies in Ireland: 10-year trends 2003–2012

Background

Over the last decade there have been significant changes in the prescribing of antidiabetic therapies. It is of interest to know about these trends and variations in the Irish population so that future prescribing patterns can be estimated.

Aims

To examine the trends in prescribed antidiabetic treatments, including variations across age, gender, socioeconomic status and regions in the Irish population over the last 10 years.

Methods

The Irish national pharmacy claims database was used to identify patients ≥16 years dispensed antidiabetic agents (oral or insulin) from January 2003 to December 2012 through the two main community drug schemes for diabetes. The rate of prescribing per 1,000 population was calculated. Logistic regression was used to examine variations in prescribing in patients with diabetes.

Results

There was a significant increase in the prescribing of fast and long-acting insulin analogues with a rapid decline in the prescribing of human insulin (p < 0.0001). Increased prescribing of metformin, incretin modulators and fixed oral combination agents was observed (p < 0.0001). Females and older aged patients were more likely to be prescribed human insulin than other insulins. Metformin was less likely while sulphonylureas were more likely to be prescribed in older than younger aged patients. Socioeconomic differences were observed in increased prescribing of the newer and more expensive antidiabetic agents in the non-means tested scheme. Regional variations were observed in the prescribing of both insulin and oral antidiabetic agents.

Conclusion

There has been an increase over time in the prescribing of both insulin and oral antidiabetic agents in the Irish population with increasing uptake of newer antidiabetic agents. This has implications for projecting future uptake and expenditure of these agents given the rising level of diabetes in the population.     

Antibiotic prophylaxis for transrectal ultrasound biopsy of the prostate in Ireland

Introduction

Prostate cancer is the most common solid cancer affecting men in Ireland. Transrectal ultrasound (TRUS) biopsies of the prostate are routinely performed to diagnose prostate cancer. They are, in general, a safe procedure but are associated with a significant risk of infective complications ranging from fever, urinary tract infection to severe urosepsis. At present, there are no recommended national guidelines on the use of antibiotic prophylaxis to minimise the risk of infective complications post-TRUS biopsy.

Aim

To review the antibiotic prophylaxis for TRUS biopsy used in Irish hospitals.

Method

We used a standard telephone questionnaire to establish what antibiotic protocol is in use in each hospital.

Results

40 hospitals were contacted, of which 29 perform TRUS biopsies. In the majority of hospitals, TRUS biopsies are carried out in the radiology department. All hospitals administer antibiotic prophylaxis but there is wide variation in the protocols used. There are five different antibiotics prescribed, ciprofloxacin being the most common. Treatment protocols vary from 1 to 10?days antibiotic cover post procedure.

Conclusion

There is a lack of standardisation of antibiotic prophylaxis in Irish hospitals. There is a need for guidelines to clarify the most appropriate antibiotic, route of administration and duration of treatment.     

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.     

Prevalence of left-sided melanomas in an Irish population

Background

A predominance of melanomas on the left side of the body has recently been described. No associations between tumour laterality and gender, age or anatomical site have been identified.

Aim

The aim of this study was to investigate the prevalence of left-sided melanomas in an Irish population and to examine potential associations with various patient and tumour characteristics.

Methods

A retrospective chart review of patients with cutaneous melanoma who were treated over a 10-year period was carried out. Lateral distribution of melanoma on either side of the body was compared using χ² analysis and evaluated by gender, age group, anatomic location, histologic subtype and Breslow depth.

Results

More melanomas occurred on the left side (57%, P = 0.015), and this finding was particularly significant in females. For both genders combined, there were no statistically significant differences in laterality by age group, anatomic location, type of melanoma and Breslow depth. There were significantly more superficial spreading melanomas on the left side in both men and women.

Conclusions

This study demonstrates a predominance of left-sided melanomas in Irish patients. While a number of demographic and molecular associations have been proposed, further research is required to fully explain this phenomenon.     

The advent of successful organ transplantation in the Irish HIV positive cohort

Background

Liver disease is an increasing cause of morbidity and mortality in Human immunodeficiency virus (HIV) positive patients.

Aim

To describe the first cases of organ transplantation in HIV positive patients in Ireland.

Method

We report the Irish patients with HIV who received liver transplantation and performed a chart review.

Result

Two patients received liver transplantation for end stage liver disease caused by Hepatitis C, with survival at 2?years of 100%.

Conclusion

Liver transplantation is a feasible treatment for patients with HIV and end stage liver disease. The success of transplantation in the HIV positive population should encourage the provision of other medical and surgical interventions previously not offered to patients with HIV.