Showing papers by "Connolly Hospital Blanchardstown published in 2016"

Methodology and technology for peripheral and central blood pressure and blood pressure variability measurement: Current status and future directions - Position statement of the European Society of Hypertension Working Group on blood pressure monitoring and cardiovascular variability

Abstract: Office blood pressure measurement has been the basis for hypertension evaluation for almost a century. However, the evaluation of blood pressure out of the office using ambulatory or self-home monitoring is now strongly recommended for the accurate diagnosis in many, if not all, cases with suspected hypertension. Moreover, there is evidence that the variability of blood pressure might offer prognostic information that is independent of the average blood pressure level. Recently, advancement in technology has provided noninvasive evaluation of central (aortic) blood pressure, which might have attributes that are additive to the conventional brachial blood pressure measurement. This position statement, developed by international experts, deals with key research and practical issues in regard to peripheral blood pressure measurement (office, home, and ambulatory), blood pressure variability, and central blood pressure measurement. The objective is to present current achievements, identify gaps in knowledge and issues concerning clinical application, and present relevant research questions and directions to investigators and manufacturers for future research and development (primary goal).

Hypertension types defined by clinic and ambulatory blood pressure in 14 143 patients referred to hypertension clinics worldwide. Data from the ARTEMIS study.

Abstract: Objective:The Ambulatory blood pressure Registry TEleMonitoring of hypertension and cardiovascular rISk project was designed to set up an international registry including clinic blood pressure (CBP) and ambulatory blood pressure (ABP) measurements in patients attending hypertension clinics in all five continents, aiming to assess different daily life hypertension types.Methods:Cross-sectional ABP, CBP and demographic data, medical history and cardiovascular risk profile were provided from existing databases by hypertension clinics. Hypertension types were evaluated considering CBP (140/90mmHg) and 24-h ABP (130/80mmHg).Results:Overall, 14143 patients from 27 countries across all five continents were analyzed (Europe 73%, Africa 3%, America 9%, Asia 14% and Australia 2%). Mean age was 5714 years, men 51%, treated for hypertension 46%, cardiovascular disease 14%, people with diabetes 14%, dyslipidemia 33% and smokers 19%. The prevalence of hypertension was higher by CBP than by ABP monitoring (72 vs. 60%, P<0.0001). Sustained hypertension (elevated CBP and ABP) was detected in 49% of patients. White-coat hypertension (WCH, elevated CBP with normal ABP) was more common than masked hypertension (elevated ABP with normal CBP) (23 vs. 10%; P<0.0001). Sustained hypertension was more common in Europe and America and in elderly, men, obese patients with cardiovascular comorbidities. WCH was less common in Australia, America and Africa, and more common in elderly, obese women. Masked hypertension was more common in Asia and in men with diabetes. Smoking was a determinant for sustained hypertension and masked hypertension.Conclusion:Our analysis showed an unbalanced distribution of WCH and masked hypertension patterns among different continents, suggesting an interplay of genetic and environmental factors, and likely also different healthcare administrative and practice patterns.

Untangling the Diverse and Redundant Mechanisms of Staphylococcus aureus Biofilm Formation.

Abstract: A major challenge in the management of device-related infections (DRIs) involving microbial biofilms derives from the rapid coating of implanted biomaterials by host-derived glycoproteins and other macromolecules. The performance of modified biomaterial surfaces that limit bacterial colonisation under laboratory conditions is difficult to predict in this in vivo milieu. Biofilms formed by staphylococci have for many decades been recognised as the most frequent cause of biofilm-associated infections with Staphylococcus epidermidis and Staphylococcus aureus being the two main species of staphylococci associated with DRI. Advances in our understanding of staphylococcal biofilm mechanisms have made one fact clear: namely, that this important pathogen has adopted the mantra "to stick to surfaces at all costs" and employs a remarkable array of adherence mechanisms to achieve this goal. Here we will review these diverse biofilm mechanisms, raise questions about why such redundancy exists, and outline potential implications for the development of new biofilm-targeted therapeutics.

Vitamin D3 for uncontrolled childhood asthma: A pilot study

Abstract: Background Observational and mechanistic data suggest a role for vitamin D in childhood asthma. However, subsequent interventional trials have been inconsistent. We aimed to assess the effect of 15 weeks of vitamin D3 supplementation compared with placebo (PL) in Irish children with asthma. Methods We conducted a double-blind, randomized, PL-controlled trial of vitamin D supplementation (2000 IU/day) in 44 urban, Caucasian children at high latitude. Assessments were completed at baseline and after 15 weeks of supplementation. Outcome measures were lung function, subjective asthma control and biochemical parameters of total vitamin D, allergy, immunity, airway inflammation, and systemic inflammation. Finally, parents/guardians completed a weekly diary during the trial. Results There was no significant difference in baseline 25(OH)D levels, but there was a significant increase in median 25(OH)D in the vitamin D3 group (57.5–105 nmol/l) compared with the PL group (52.5–57.5 nmol/l) (p < 0.0001). There was no significant difference between groups regarding subjective asthma control. Compared with PL, there was a significant decrease in school days missed due to asthma (1 vs. 5 days, p = 0.04) and alkaline phosphatase (−3.4 vs. +16; p = 0.037) in the vitamin D3 group, but there were no beneficial effects regarding several other secondary end-points. However, there were non-significant, advantageous changes in the PL group compared with the vitamin D3 group in subjective asthma control and lung function, particularly percentage of predicted forced expiratory volume in 1 s (+2.5 vs. −4; p = 0.06). Conclusion Vitamin D3 supplementation led to a significant increase in serum 25(OH)D and decreased school days missed (p = 0.04), but no other advantageous changes in asthma parameters compared with PL. The potential adverse effect of vitamin D deficiency on growth and the potential negative effect of high serum 25(OH)D on pulmonary function warrant further investigation.

Serum Vitamin D Is Significantly Inversely Associated with Disease Severity in Caucasian Adults with Obstructive Sleep Apnea Syndrome.

Abstract: STUDY OBJECTIVES To evaluate vitamin D (25(OH)D) levels in obstructive sleep apnea syndrome (OSAS) and possible relationships to OSAS severity, sleepiness, lung function, nocturnal heart rate (HR), and body composition. We also aimed to compare the 25(OH)D status of a subset of OSAS patients compared to controls matched for important determinants of both OSAS and vitamin D deficiency (VDD). METHODS This was a cross-sectional study conducted at an urban, clinical sleep medicine outpatient center. We recruited newly diagnosed, Caucasian adults who had recently undergone nocturnal polysomnography. We compared body mass index (BMI), body composition (bioelectrical impedance analysis), neck circumference, sleepiness (Epworth Sleepiness Scale), lung function, and vitamin D status (serum 25-hydrpoxyvitamin D (25(OH)D) across OSAS severity categories and non-OSAS subjects. Next, using a case-control design, we compared measures of serum 25(OH)D from OSAS cases to non-OSAS controls who were matched for age, gender, skin pigmentation, sleepiness, season, and BMI. RESULTS 106 adults (77 male; median age = 54.5; median BMI = 34.3 kg/m(2)) resident in Dublin, Ireland (latitude 53°N) were recruited and categorized as non-OSAS or mild/moderate/severe OSAS. 98% of OSAS cases had insufficient 25(OH)D (< 75 nmol/L), including 72% with VDD (< 50 nmol/L). 25(OH)D levels decreased with OSAS severity (P = 0.003). 25(OH)D was inversely correlated with BMI, percent body fat, AHI, and nocturnal HR. Subsequent multivariate regression analysis revealed that 25(OH)D was independently associated with both AHI (P = 0.016) and nocturnal HR (P = 0.0419). Our separate case-control study revealed that 25(OH)D was significantly lower in OSAS cases than matched, non-OSAS subjects (P = 0.001). CONCLUSIONS We observed widespread vitamin D deficiency and insufficiency in a Caucasian, OSAS population. There were significant, independent, inverse relationships between 25(OH)D and AHI as well as nocturnal HR, a known cardiovascular risk factor. Further, 25(OH)D was significantly lower in OSAS cases compared to matched, non-OSAS subjects. We provide evidence that 25(OH)D and OSAS are related, but the role, if any, of replenishment has not been investigated.

Leflunomide Use and Risk of Lung Disease in Rheumatoid Arthritis: A Systematic Literature Review and Metaanalysis of Randomized Controlled Trials

Abstract: Objective. To evaluate the relative risk (RR) of pulmonary disease among patients with rheumatoid arthritis (RA) treated with leflunomide (LEF). Methods. We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials to April 15, 2014. We included double-blind randomized controlled trials (RCT) of LEF versus placebo or active comparator agents in adults with RA. Studies with fewer than 50 subjects or shorter than 12 weeks were excluded. Two investigators independently searched both databases. All authors reviewed selected studies. We compared RR differences using the Mantel-Haenszel random-effects method to assess total respiratory adverse events, infectious respiratory adverse events, noninfectious respiratory adverse events, interstitial lung disease, and death. Results. Our literature search returned 5673 results. A total of 8 studies, 4 with placebo comparators, met our inclusion criteria. There were 708 respiratory adverse events documented in 4579 participants. Six cases of pneumonitis occurred, all in the comparator group. Four pulmonary deaths were reported, none in the LEF group. LEF was not associated with an increased risk of total adverse respiratory events (RR 0.99, 95% CI 0.56–1.78) or infectious respiratory adverse events (RR 1.02, 95% CI 0.58–1.82). LEF was associated with a decreased risk of noninfectious respiratory adverse events (RR 0.64, 95% CI 0.41–0.97). Conclusion. Our study found no evidence of increased respiratory adverse events in RCT of LEF treatment.

In vitro approach for identification of the most effective agents for antimicrobial lock therapy in the treatment of intravascular catheter-related infections caused by Staphylococcus aureus.

Abstract: Infection of intravascular catheters by Staphylococcus aureus is a significant risk factor within the health care setting. To treat these infections and attempt salvage of an intravascular catheter, antimicrobial lock solutions (ALSs) are being increasingly used. However, the most effective ALSs against these biofilm-mediated infections have yet to be determined, and clinical practice varies greatly. The purpose of this study was to evaluate and compare the efficacies of antibiotics and antiseptics in current clinical use against biofilms produced by reference and clinical isolates of S. aureus Static and flow biofilm assays were developed using newly described in vivo-relevant conditions to examine the effect of each agent on S. aureus within the biofilm matrix. The antibiotics daptomycin, tigecycline, and rifampin and the antiseptics ethanol and Taurolock inactivated established S. aureus biofilms, while other commonly used antistaphylococcal antibiotics and antiseptic agents were less effective. These findings were confirmed by live/dead staining of S. aureus biofilms formed and treated within a flow cell model. The results from this study demonstrate the most effective clinically used agents and their concentrations which should be used within an ALS to treat S. aureus-mediated intravascular catheter-related infections.

Rates, Predictors, and Outcomes of Early and Late Recurrence After Stroke: The North Dublin Population Stroke Study

Abstract: Background and Purpose—Few recent studies have investigated the rates and predictors of early and late stroke recurrence using prospective population–based methodology. We investigated recurrent st...

Dietary nitrate increases exercise tolerance in patients with non-ischemic, dilated cardiomyopathy-a double-blind, randomized, placebo-controlled, crossover trial.

Abstract: Dietary nitrate increases exercise tolerance in patients with non-ischemic, dilated cardiomyopathy—a double-blind, randomized, placebo-controlled, crossover trial Conor P. Kerley, BSc, James O. O’Neill, MD, Venu Reddy Bijjam, MD, Ciara Blaine, BSc, Philip E. James, PhD, and Liam Cormican, MD From the Department of Clinical Cardiology, Connolly Hospital, Blanchardstown, Dublin, Ireland; School of Medicine and Medical Sciences, University College Dublin, Belfield, Dublin, Ireland; Respiratory and Sleep Diagnostics Department, Connolly Hospital, Blanchardstown, Dublin, Ireland; and the Wales Heart Research Institute, Cardiff University Medical School, Cardiff, UK.

A Rare Case of Bilateral Patellar Tendon Ruptures: A Case Report and Literature Review.

Abstract: Bilateral patellar tendon ruptures are rare. The majority of case reports describing bilateral patellar tendon ruptures have occurred in patients with predisposing factors to tendinopathy. We describe a case of bilateral patellar tendon rupture sustained following minimal trauma by a patient with no systemic disease or history of steroid use. Due to the rarity of this injury, clinical suspicion is low. It is reported that 38% of patellar tendon ruptures are misdiagnosed initially. Therefore careful history taking and physical examination is integral in ensuring a diagnosis is achieved for early primary repair. We discuss the aetiology of spontaneous tendon rupture and report a literature review of bilateral patellar tendon ruptures.

Listeria meningitis complicating a patient with ulcerative colitis on concomitant infliximab and hydrocortisone

Abstract: Infliximab, a monoclonal antibody directed against tumour necrosis factor, is an effective therapy for moderate-to-severe ulcerative colitis and Crohn's disease. Uncommonly, serious opportunistic infections have occurred in patients after infliximab administration. Here, we describe meningitis caused by Listeria monocytogenes developing in a 37-year-old man with ulcerative colitis refractory to intravenous corticosteroids 10 days after receiving his first infusion of infliximab. With the increasing use of tumour necrosis factor-α-neutralizing agents, clinicians should be aware of the risk of opportunistic infections caused by L. monocytogenes in patients with inflammatory bowel disease following infliximab treatment. The half-life of infliximab is 9.5 days; therefore, patients tend to be more susceptible in the immediate period following infusion. Patients receiving anti-TNF therapy should be advised to avoid foods such as soft cheeses and unpasteurized dairy products.

Isolated anterior mediastinal tuberculosis in an immunocompetent patient

Abstract: The differential diagnosis of a mediastinal mass is a common challenge in clinical practice, with a wide range of differential diagnosis to be considered. One of the rarer causes is tuberculosis. Atypical presentations of tuberculosis are well documented in immunocompromised patients, but should also be considered in the immunocompetent. This case outlines a previously healthy 22 year-old immunocompetent male presenting with worsening chest pain, positional dyspnea, dry cough and dysphagia. Chest x-ray showed evidence of an isolated anterior mediastinal mass, which was confirmed on computed tomography. A mediastinoscopy was diagnostic as histology revealed necrotizing granulomatous inflammation and the presence of acid-fast bacilli, indicating mediastinal tuberculosis. Typically the underlying presentation of mediastinal tuberculosis is mediastinal lymphadenitis. This case was unusual in that we detected an isolated large anterior mediastinal mass accompanied by a relatively small burden of mediastinal lymphadenitis. Cases similar to this have been documented in immunosuppressed patients however in our case no evidence of immunosuppression was found. This case report emphasizes the importance that a detailed and logical pathway of investigation is pursued when encountering a mediastinal mass.

Tailored ultrasound learning for acute care surgeons: a review of the MUSEC (Modular UltraSound ESTES Course) project

Abstract: The European Society for Trauma and Emergency Surgery (ESTES) identified the need for general and trauma surgeons involved in the management of critically ill surgical patients to embrace and learn both basic and advanced US skills. A steering group was created to address this deficit. Modular UltraSound ESTES Course (MUSEC) is a modular blended-learning course. It incorporates pre-test/post-test examinations, pre-course online materials, didactic and interactive lectures, interactive case scenarios discussion with pathological US clips, hands-on practice on healthy volunteer models, and on original phantoms for simulating both pathological US findings and practicing US-guided interventional maneuvers. Four independent modules were provided. Surgical decision-making didactics were also included in the course curriculum. Learning gain (Δ of the rating of pre-test and post-test) was calculated for each module. An anonymous post-course satisfaction survey was also administered (16 questions with a Likert’s 5-point scale of evaluation). Twenty-three MUSEC Courses were run in a 30 months period, training 416 doctors from 29 countries. A total of 52 modules were delivered. The mean pre-test and post-test grades were 8.3/12 and 10.7/12, respectively, yielding a significant mean learning gain of 28.9 % (p = 0.001). Post-course satisfaction survey got an overall ranking of 4.5/5. MUSEC is an effective and original educational format, enjoyed by candidates, that fills an educational gap for tailored US education as a procedural skill to acute care surgeons. Ongoing revisions should reduce the current limitations and increase the educational value, in terms of number of modules and post-course credentialing.

5-Hydroxyethyl-3-tetradecanoyltetramic acid represents a novel treatment for intravascular catheter infections due to Staphylococcus aureus.

Abstract: Objectives: Biofilm infections of intravascular catheters caused by Staphylococcus aureus may be treated with catheter lock solutions (CLSs). Here we investigated the antibacterial activity, cytotoxicity and CLS potential of 5-hydroxyethyl-3-tetradecanoyltetramic acid (5HE-C14-TMA) compared with the related compounds 3-tetradecanoyltetronic (C14-TOA) and 3-tetradecanoylthiotetronic (C14-TTA), which are variants of quorum sensing signalling molecules produced by Pseudomonas aeruginosa. Methods: Antibacterial activity and mechanism of action of 5HE-C14-TMA, C14-TOA and C14-TTA were determined via MIC, bacterial killing, membrane potential and permeability assays. Susceptibility of S. aureus biofilms formed in the presence of plasma in vitro was investigated, MTT cytotoxicity testing was undertaken and cytokine release in human blood upon exposure to 5HE-C14-TMA and/or S. aureus biofilms was quantified. The effectiveness of 5HE-C14-TMA as CLS therapy in vivo was assessed using a rat intravascular catheter biofilm infection model. Results: MICs of 5HE-C14-TMA, C14-TOA and C14-TTA ranged from 2 to 4 mg/L. 5HE-C14-TMA and C14-TTA were bactericidal; all three compounds perturbed the staphylococcal membrane by increasing membrane permeability, depolarized the transmembrane potential and caused ATP leakage. Cytotoxicity and haemolytic activity were compound and target cell type-dependent. 5HE-C14-TMA reduced S. aureus biofilm viability in a dose-dependent manner in vitro and in vivo and did not trigger release of cytokines in human blood, but inhibited the high levels of IL-8 and TNF-α induced by S. aureus biofilms. Conclusions: 5HE-C14-TMA, C14-TOA and C14-TTA are membrane-active agents. 5HE-C14-TMA was the most potent, eradicating S. aureus biofilms at 512–1024 mg/L both in vitro and in vivo as a CLS.

Determining rates of smoking cessation advice delivered during hospitalisation and smoking cessation rates 3 months post discharge: a two-hospital survey.

Abstract: Background: Hospitalisation is an ideal time to implement smoking cessation interventions. However, little is known about the extent to which inpatients receive such advice, or the impact it has on motivation to quit and quitting behaviours post-hospitalisation. Aims: This study aimed to determine the prevalence of smoking and cessation advice received by inpatients in two teaching hospitals in Ireland, and the impact of cessation advice on smoking at 3 months post discharge. Methods: We surveyed 1001 inpatients across two hospital sites, over a six-month period. Demographic details, clinical history, smoking history, motivation to quit, cigarette dependence, and recent quitting history were assessed. Results: Prevalence of smoking within the sample was 23.4% (235/1001). Only 32% (75/235) of smokers reported that smoking cessation was discussed during admission. Smokers’ mean Fagerstrom nicotine-dependence score was 3.7 (SD = 2.7), indicating low dependence levels. At 3 months, 17% (25/146) of smo...

Beware of Non-Traumatic Chylothorax.

Abstract: A chylothorax occurs when lymph fluid accumulates in the pleural space due to disruption or obstruction of the thoracic duct. The following illustrates such a case. A 34 year old lady, current smoker presented with a 3-day history of worsening shortness of breath on exertion. She had no past medical history and was on no medication. There was no significant family history and she was unemployed. All her vitals were normal. Positive clinical findings on examination revealed reduced breath sound at the base of her left lung which was dull on percussion. CXR confirmed a moderate left sided pleural effusion. Her FBC, U&E, LFT and CRP were all normal. 1.5L of the pleural fluid were drained under ultrasound guidance. The fluid was milky white in appearance and the sample was sent to the lab for analysis. The fluid triglyceride came back as 17 mmol/L, fluid pH was 7.5, fluid LDH was 704 U/L, fluid glucose was 4.2 mmol/L and fluid protein 64 g/L. Cytology came back as predominantly lymphocytic in content. CT Thorax,Abdomen and Pelvis revealed a pericardial effusion with prominent thoracic mediastinal lymph node. After discussion at the Lung multidisciplinary meeting, the patient was then referred to the cardiothoracic team for a mediastinoscopy for lymph node sampling which eventually turned out to be a lymphoma.

FRI0612-HPR The Development of Physiotherapy-Led Musculoskeletal Triage Services in Ireland

Abstract: Background In 2012, funding was approved for twenty-four Advanced Practice Physiotherapy (APP) posts in Ireland through the Clinical Strategy and Programmes Directorate of the HSE. These posts were to provide orthopaedic and rheumatology triage clinics across 16 hospitals throughout the country. Objectives The aims of these clinics were to reduce the waiting time for outpatient consultation for orthopaedic and rheumatology patients; to establish a diagnosis and triage patients along the most appropriate care pathway according to their diagnosis. Methods Initially 18 APPs were recruited in 2012 and currently there are 22.5 in post nationally. Guidelines regarding inclusion for attendance at these clinics were disseminated to APPs recruited to posts. Clinical governance for APP clinics is provided by either a consultant orthopaedic surgeon or a consultant rheumatologist who provide support with clinical diagnosis; with the ordering of investigations and with management of patients as appropriate. Results From January 2012 to May 2015 48,279 patients have been removed from orthopaedic and rheumatology waiting lists nationally. In orthopaedic clinics APPs reviewed 33,092 new patients and discharged 25,917 (78%); in rheumatology clinics APP9s reviewed 7,550 new patients and of this 5,417 (72%) were discharged following their review. Conclusions Advanced Practice Physiotherapist9s can assist in the management of orthopaedic and rheumatology waiting lists. These services provide patients with early access for a specialist opinion and management and therefore prevent chronicity of symptoms. It can be hypothesized that prevention of chronicity would result in a reduction in the use of health care resources by this subgroup of patients. Disclosure of Interest None declared

A Less Known Stroke Mimic: Posterior Reversible Encephalopathy Syndrome

Abstract: Posterior reversible encephalopathy syndrome (PRES) is a clinico-neuro-radiological diagnosis, which can complicate a wide range of conditions. Clinical features include generalised and/or focal neurological deficits. These features are also present in neurovascular disorders, such as stroke. Currently, emphasis in the management of hyperacute stroke is thrombolysis, and it is important to bear in mind stroke mimics as a possible cause of clinical features. The Authors present the case of a 66-year-old man, who presented with acute focal neurological deficit. His brain imaging and history were consistent with PRES.

The Association Between 25 Hydroxyvitamin D and Airway Obstruction in Asthma.

Abstract: Since Vitamin D has anti-inflammatory effects we wondered whether the association between low serum 25OHD and airway obstruction in moderate persistent asthma might be explained by inflammatory pathways that worsen asthma. All subjects examined were Irish Caucasians with moderate persistent asthma and none took systemic steroid therapy. In addition to computerized spirometry, we measured BMI, serum 25-hydroxyvitamin D (25OHD), total IgE, Eosinophil Cationic Protein (ECP), and high sensitive C- reactive protein (hs-CRP). One hundred (47 male) subjects completed the testing. Within single level of asthma severity, 25OHD levels were related to post-bronchodilator FEV1/FVC (r = 0.26, p< 0.01), but multiple linear regression analysis demonstrated that the association was not explained by obesity or inflammatory markers. We find a relationship exists between airway obstruction and 25OHD levels in asthmatic adults, and the effect is not explained by the presence of potential confounders such as obesity, allergy and systemic inflammation.

Is Heart Rate a Norepiphenomenon in Heart Failure

Abstract: There has been an increased focus on heart rate as a target in the management of cardiovascular disease and more specifically in heart failure with preserved ejection fraction in recent years with several studies showing the benefit of a lower resting heart rate on outcomes. This review paper examines the pathophysiology behind the benefits of lowering heart rate in heart failure and also the evidence for and against the pharmacological agents available to achieve this.