Showing papers in "Irish Journal of Medical Science in 1993"

Atrial myxoma: national incidence, diagnosis and surgical management.

Abstract: Despite being the most common benign intracardiac tumour with an excellent prognosis after surgical excision the incidence of atrial myxoma (except at autopsy) is unknown. We reviewed all patients admitted to the National Cardiac Surgery Unit (n = 26) with an atrial myxoma over a fifteen year period (1977-1991) to compile national incidence data and assess pre-operative diagnosis, management, surgical technique, and outcome. Preoperative symptoms were: congestive cardiac failure (12 patients), embolism (8 patients), constitutional (3 patients), asymptomatic (2 patients) and tachyarrhythmia (1 patient). The diagnosis was confirmed by 2D echocardiography alone in thirteen patients and by a combination of echocardiography and angiography in thirteen patients. At operation the site of the tumour was left atrial in 24 patients and bi-atrial in two patients. All cases were confirmed by histology. All patients made a good post-operative recovery, although one patient survived a pulmonary embolus and one patient developed a deep venous thrombosis. There has been one late death (five months after surgery) from a cerebrovascular accident. Serial echocardiography has revealed one recurrence to date (8 years after surgery). The surgical incidence of these tumours in the Republic of Ireland over the study period was 0.5 atrial myxomas/million population/year. Although rare atrial myxomas are the most important cardiac tumours to diagnose as the results from surgery are excellent.

Prevalence of metronidazole-resistant helicobacter pylori in dyspeptic patients

Abstract: Susceptibility to metronidazole of 213 clinical strains of H. pylori from dyspeptic patients was determined by a plate dilution method. Seventy two (33.8%) of the strains were resistant to metronidazole (MIC > 8 mg/L), 20 of these were from 24 patients who had received previously metronidazole (83.3%), giving a primary (pretreatment) resistance rate of 27.5% (52/189). The resistance rate was higher in women than in men, especially aged 50 to 59 years old (43.6% vs 23.3%, p < 0.001). The resistance rate was lower in patients at 60 or over (9.8%), but similar between the younger patients groups (38.8% - 49.0%). There was no difference in the resistance rate between peptic ulcer disease (32.6%) and nonulcer dyspepsia (34.7%). These data indicated that metronidazole resistance in H. pylori is absolutely associated with previous use of the drug, and the higher resistance rate in women may be due to the more frequent prescription of the drug for their gynaecological infection or operation. Therefore, testing of susceptibility of H. pylori to metronidazole is important. A new susceptibility testing technique, the E-test was evaluated in this study and found to give comparable results to the plate dilution method and also had the advantage of being simple to perform.

Interferon-gamma and tumour necrosis factor production in patients with Helicobacter pylori infection

Abstract: The production of the cytokines, interferon-gamma and tumour necrosis factor by human antral mucosa cells and stimulated peripheral blood mononuclear cells were determined by enzyme linked immunosorbant assay and L929 bioassay respectively. Tumour necrosis factor production by peripheral blood mononuclear cells in response toHelicobacter pylori stimulation was depressed inHelicobacter pylori positive individuals, compared toHelicobacter pylori negative individuals (P < 0.05). There was no difference in tumour necrosis factor production by peripheral blood mononuclear cells in response to purified protein derivative. However, tumour necrosis factor production by cells isolated from gastric mucosa during short term culture was significantly higher inHelicobacter pylori positive patients (P < 0.05) than negative patients, indicating a probable macrophage response. Levels of interferon-gamma did not differ significantly in the gastric explant culture from the two groups. The results show thatHelicobacter pylori negative patients have a stronger peripheral cellular immune response toHelicobacter pylori infection. The higher levels of tumour necrosis factor production by antral mucosa cells inHelicobacter pylori positive patients may reflect the infiltration of T lymphocytes and macrophages within the local mucosa.

Cell proliferation in breast tumours: analysis of histological parameters Ki67 and PCNA expression.

Abstract: Ki67 and Proliferating Cell Nuclear Antigen (PCNA) are antigens expressed in the nucleus during various phases of cell division, which can be detected immunohistochemically using monoclonal antibodies. Thirteen fibroadenomas and 39 carcinomas were examined for expression of Ki67 and PCNA. A staining index was calculated for each tumour as the percentage of positive cells in the areas of highest density. The mean index for both antibodies was significantly lower in fibroadenomas than in malignant tumours. A wide range of proliferation rates was seen in the malignant group; the mean Ki67 index of Grade I carcinomas was 9% +/- 4.4 (mean +/- SD), of Grade II 14.3 +/- 8.7 and of Grade III 26.2 +/- 15.7. These differences are statistically significant. In malignant tumours there was a good correlation between the mitotic count and the Ki67 index (r = 0.61, p < 0.005) but none between the mitotic count and PCNA index. There was a weak correlation between the Ki67 and the PCNA indices (r = 0.38 p < 0.005), but no correlation was found between either index and oestrogen receptor status, patient age or tumour size. Ki67 immunohistochemistry is a convenient method for assessing cell proliferation, applicable in most laboratories. The validity of measuring proliferation in this way has yet to be established but the wide variation of expression even within the conventional grading categories may help to discriminate prognostically distinct subgroups. Expression of PCNA appears to correlate poorly with Ki67 expression in breast tumours and not with mitotic count; therefore its usefulness as a marker of proliferative activity, on current evidence, appears to be limited.

The increasing incidence of infantile hypertrophic pyloric stenosis

Abstract: Several reports have suggested that there is an increasingincidence of infantile hypertrophic pyloric stenosis (IHPS). We examined the incidence of IHPS in a stable population in the West of Ireland over a ten year period (1981–1990). During the 10 years of the study the number of live births per year did not alter significantly. The incidence of IHPS increased significantly from 0.87/1000 live births in 1981 to 5.10/1000 in 1990 (p < 0.001, Student’s t test), peaking in 1989 at 6.8/1000. There was no statistical correlation between the increasing incidence and feeding habits, birth rank, family history or gender distribution. The reason(s) for this increase remain unclear.

M.D.M.A. ("Ecstasy"); a case of possible drug-induced psychosis.

Abstract: 3, 4, Methylenedioxymetamphetamine (M.D.M.A., Ecstasy) is a modified amphetamine with stimulant and hallucinogenic properties. Ecstasy has been increasingly abused in Dublin in recent years. It is commonly perceived by users as a safe drug. We report a case of prolonged psychosis following brief recreational use of Ecstasy.

Spontaneous rupture of a splenic artery aneurysm in the third trimester

Abstract: Due to the difficulties in the diagnosis of ruptured splenic artery aneurysm in pregnancy both maternal and fetal mortality continue to be high. A case is presented of a 37 year old woman who ruptured a splenic artery aneurysm at 29 weeks gestation. The presentation of the disease, its risk factors and treatment, as well as a review of the literature are presented here.

Six year follow up of forty five pregnant opiate addicts.

Abstract: Forty five pregnant addicts had attended the National Drug Treatment Centre between 1984 –1986. At that time they received intensive counselling, low dose Methadone maintenance and both ante natal and post natal care. Our aim was to follow these women six years later focusing on their drug use and outcome of their children. The women were followed up by chart review, individual interviews and liaison with the social and probation services. Results indicate that a high proportion of the women abused chaotically (50%). There is a worrying high incidence of HIV positive patients (53.4%) and a mortality figure of 15.5% (7). However only 13 women (28.6%) have had further children and 22 women (49%) are currently using some form of contraception. Only 23 women (51.1%) have had further contact with probation services. Five children (11.3%) are under formal care order and 4 children have become HIV positive in their own right. In conclusion, while these women have benefitted in certain areas e.g. family planning, contact with probation services, in other areas they have remained chaotic e.g. continued drug abuse or HIV risk taking behaviour. Thus the authors believe that future programmes should concentrate more directly on detoxification and rehabilitation after pregnancy. We also believe that because of the chaotic nature of these women some review of an “at risk” register for the children should be carried out.

Percutaneous endoscopic gastrostomy — results of an irish single unit series

Abstract: The technique of percutaneous endoscopic gastrostomy (PEG) was first described in 1980, as an alternative to traditional surgical methods. The main indication for PEG is the need for longterm nutritional support. It is reported to have many advantages over surgical gastrostomy, being safer and cheaper. We reviewed our experience with the first 44 patients referred to our unit for PEG. The most common indications for referral were stroke, head injury and post brain surgery. There was a success rate of 97.6% and a complication rate of 13.8%. One patient (2.3%) suffered major complications as a result of early tube displacement. There were no procedure related deaths in our series and no deaths as a result of an underlying disease process within 30 days, reflecting appropriate patient selection. All patients benefited nutritionally from PEG placement. Two patients recovered sufficiently to no longer require a gastrostomy and the tube was easily removed in both cases.

Fatal trauma: a five year review in a Dublin hospital.

Abstract: The autopsy reports and clinical data of 96 patients presenting to St. James’s Hospital with trauma of fatal outcome, between January 1, 1986 and December 31,1990, were analysed. Eightyone (84%) deaths were due to road traffic accidents and all were the result of blunt trauma. Ninety-five (99%) had an Abbreviated Injury Scale (AIS) score ≥ 3 in at least one anatomical category. Cerebral trauma (41 %) and shock and haemorrhage secondary to multiple injuries (40 %) were the commonest causes of death. Sixty-eight (71%) patients were dead on arrival at the hospital. Of the twenty-eight deaths occurring after admission to hospital nine (32%) were potentially preventable. The mean (sem) Injury Severity Score (ISS) for those with preventable deaths was 24.1 (3.8). These data have implications for the development of trauma care facilities in Ireland.

Microalbuminuria does not predict cardiovascular disease in a normal general practice population.

Abstract: Recent studies have suggested that microalbuminuria is relatively common (9.4%) in non-diabetic subjects and that it is an excellent marker for increased cardiovascular risk. In an attempt to assess the prevalence of microalbuminuria in Northern Ireland where there is a high incidence of coronary heart disease, we studied 400 males, age 35-65 years, chosen at random from a Belfast general practice. There was a 73% response rate (n=273). Sixteen per cent of the population has ischaemic heart disease. Microalbuminuria was defined as an increased urinary albumin excretion rate of 20-200 ug min-1. Thirteen subjects (4.7 %) had an albumin excretion rate of 20 ug min-1 or more. After exclusion of subjects with diabetes mellitus or renal diseases, the group with microalbuminuria (n=8), was compared to those without microalbuminuria (n=256) There was no significant difference in the incidence of ischaemic heart disease between the two groups, nor did the group with microalbuminuria have a more adverse profile of vascular risk factors, apart from serum triglyceride (1.8 ± 0.2 v 1.3 ± 0.0 mmol 1-1, p<0.05) and plasma glucose (53 ± 0.3 v 5.1 ± 0.3 mmol 1-1, p<0.05) levels. We conclude that in a general practice from an area at high risk of ischaemic heart disease, the prevalence of microalbuminuria was low. Contrary to previous reports, microalbuminuria was not helpful in predicting subjects at risk of ischaemic heart disease.

An audit of the E.N.T. casualty service at the Royal Victoria Eye and Ear Hospital.

Abstract: The only specialised Accident and Emergency unit for ENT in Ireland is at The Royal Victoria Eye and Ear Hospital, Dublin. This provides a service for the entire Republic, operating on a 9 am to 5 pm, Monday to Friday, basis. The aim of the present study was to define the role of this specialised unit. A prospective study of the service over a one month period was conducted. During this time 779 patients were seen of which 350 (45%) were new patients and 429 (55%) were return patients. Fifty two per cent were self referred, 35% were referred by their General Practitioners, 8% by other hospitals and 5% from other sources. The most common diagnosis was otitis externa (21% of new patients and 63% of returns), followed by ear wax (15% of new patients), and epistaxis (9% of new patients). Five per cent of patients required removal of foreign bodies from their ear, nose or oesophagus, and 3% received treatment for trauma to these regions. Of note during this period six new cases of head and neck cancer were detected. From these figures it is the authors' opinion that many of the problems seen could have been dealt with by General Practitioners or as non-emergency referrals to the out-patient department. This indicates the need for further training for primary care physicians and expansion of the present outpatients services. The specialised casualty service should continue to exist to provide a genuine emergency service and valuable training in the speciality.

Indices of obesity and body fat distribution in arteriographically defined coronary artery disease in men.

Abstract: Anthropometric measurements descriptive of obesity, body fat distribution and body build were made in 186 males undergoing diagnostic coronary arteriography Using stepwise multiple logistic regression analysis, two indices of body fat distribution were independently associated with coronary disease, while the widely used indices of obesity, namely body mass index and percentage body fat, were not A significant association with disease was found for the ratio of waist to thigh circumferences (waist/thigh ratio), which emerged in the first step of the multivariate model (p < 0005) The ratio of waist to hip circumferences (waist/hip ratio), a widely used index of body fat distribution, was found to have a negative association with disease (p < 005) This study suggests that use of body fat distribution indices may assist in the assessment of the risk factor profile of cardiac patients

A comparison of SPECT and planar ventilation perfusion lung scanning.

Abstract: In order to define the role of Single Photon Emission Computed Tomography (SPECT) in the diagnosis of pulmonary embolus; SPECT and Planar ventilation and perfusion lung studies were performed consecutively on eleven patients referred with suspected embolus. Three patients were shown to have ‘high probability’ ventilation perfusion mismatches. SPECT imaging allowed segmental localisation of the perfusion defect and revealed additional defects not seen on planar scans. SPECT lung study was performed with minimal technical difficulty and was well tolerated by all patients studied. SPECT is likely to become the method of choice for investigating patients referred with suspected pulmonary embolus.

Post traumatic intussusception in an adult.

Abstract: Intussusception is a rare cause of intestinal obstruction in adults. When seen most cases have identifiable pathology. Intussusception following blunt abdominal trauma is extremely rare. This report presents a case of double jejuno-jejunal intussusception in a patient who sustained such an injury. There was no other intra-abdominal abnormality and manual reduction resulted in a complete recovery. The coincidental discovery of Q-fever may be etiologically relevant.

A modified technique of delayed primary closure using a povidone iodine wick: influence on wound healing in an experimental model.

Abstract: We report a modified technique of delayed primary wound closure using a wound wick. A rodent model was used to determine its influence on healing. After loose primary closure of two paravertebral incisions on the dorsum of male rats, a 10 cm length of ribbon gauze, soaked in either saline or 1% povidone-iodine, was inserted into the right sided wound. Wicks were soaked daily with the same solution until removal on the third post-operative day. The inclusion of a wick soaked in saline had an early transient effect on healing. A more prolonged impairment of healing was demonstrated in povidone-iodine wicked wounds and their respective controls. These data suggest that povidone-iodine impaired healing not only in the wicked wound, but also inhibited healing in the adjacent unwicked wound which was not directly exposed to the antiseptic. The observed delay in healing in povidone-iodine wicked wounds must however be balanced against its beneficial effect on wound infection rates. We suggest that further evaluation of this method of closure in contaminated wounds is warranted.

Endophthalmitis as a presentation of meningococcal septicaemia

Abstract: Meningococcal infections can present in diverse clinical forms ranging from fulminant, occult, chronic meningococcaemia to meningitis. Rare presentations may include conjunctivitis, sinusitis, pneumonia, pericarditis, arthritis, and osteomyelitis(1). We present a very unusual case of meningococcaemia presented as an endophthalmitis.

Renal replacement therapy in multiple myeloma and systemic amyloidosis.

Abstract: Renal failure frequently complicates both multiple myeloma and systemic amyloidosis. Renal replacement therapy (RRT) may be poorly tolerated and its role in such patients is not clearly defined. Of fifty patients (26 males and 24 females) referred to a single centre because of renal failure associated with multiple myeloma or systemic amyloidosis 37 progressed to end-stage renal failure and 30 of these patients received RRT. Nine patients have been treated by CAPD, 13 by haemodialysis, and 8 patients have required both forms of dialysis. Overall one year and two year survival rates were 66% and 57% respectively. The median duration on RRT was 7.5 months (range 1-96 months) with a 51% one year, and a 46% two year survival rate. Of 7 patients with amyloidosis who underwent renal transplantation, 3 died within 6 months of transplantation. Undiagnosed cardiac involvement contributed to this early mortality. We conclude that renal replacement therapy is appropriate for some patients with multiple myeloma and systemic amyloidosis who develop endstage renal failure. Careful assessment and selection of patients is necessary prior to renal transplantation.

Lower prevalence of anti-hepatitis C antibody in dialysis and renal transplant patients in Ireland.

Abstract: It is well recognised that haemodialysis and renal transplant patients are at increased risk of developing non-A, non-B hepatitis. Recently the genome of hepatitis C virus (HCV), the major causative agent for non-A, non-B hepatitis, has been isolated.

Cardiopulmonary resuscitation skills in non consultant hospital doctors--the Irish experience.

Abstract: We assessed the Cardiopulmonary Resuscitation (CPR) skills in 30 Non Consultant Hospital Doctors (N.C.H.D.’s) chosen randomly from a total of 110 on the staff of a university associated teaching hospital. The candidates filled out a questionnaire and were asked to perform initial assessment and CPR on a mannikin for two minutes. None of the candidates followed the recognised airway, breathing and circulation ABC sequence and only one provided effective CPR. We suggest there is a need for encouragement for doctors to undergo CPR training with subsequent certification and ongoing refresher courses during their career.

A comparison of antimicrobial sensitivities of urinary pathogens for the years 1980 and 1990

Abstract: Urinary tract infection is a major cause of morbidity in both the hospital and community which often requires empirical therapy. We have retrospectively studied laboratory diagnosed urinary tract infections for the years 1980 and 1990 to document the common pathogens and antimicrobial susceptibility patterns. In 1990 a significantly lower proportion of specimens yielded Proteus sp. or Klebsiella sp. than was the case in 1980. This was true of specimens from both the hospital and the community. There was an increase in the proportion of specimens yielding Pseudomonas sp. and coagulase negative Staphylococci (CNS). Significant changes in the antimicrobial susceptibility of urinary pathogens are also noted. In particular a greater proportion of isolates from the community were sensitive to cephalothin in 1990, while fewer isolates were sensitive to nalidixic acid and gentamicin. A greater proportion of isolated from hospital practice were sensitive to ampicillin, to cephalothin and to trimethoprim in 1990 while fewer isolates were sensitive to gentamicin. In relation to nitrofurantoin no significant change was noted. In respect of isolates from both community and hospital practice the agents ofloxacin, co-amoxiclav (not available in 1980) and gentamicin are those which are most consistently active.

Assessment of cognitive function in patients with systemic lupus erythematosus

Abstract: The spectrum of central nervous system manifestations of systemic lupus erythematosus (SLE) is very broad and has been found to include subtle subclinical cognitive dysfunction which may be detected only by the lengthy process of detailed neuropsychological evaluation. This study reports the value of estimating premorbid intelligence as a simple yet effective means of screening for subclinical cognitive dysfunction. Twenty one female patients with clinically quiescent SLE underwent neuropsychological examination at entry to the study. In all patients, this examination included measurement of full-scale intelligence quotient (IQ), verbal and performance IQ as well as verbal and visual memories. In addition, premorbid intelligence was estimated using the Schonell graded word reading test. Nine patients (43%) gave a history of neuropsychiatric (NP) disease. No difference was identified between the results of the neuropsychological evaluation in these 9 patients and in either the other SLE patients or in age and sex matched control patients. Sixteen patients were re-evaluated 1 year later. A comparison of measured full-scale IQ with the estimated premorbid intelligence identified a subgroup of 3 patients who demonstrated a significant reduction in intelligence. Unlike the other 13 patients, these 3 patients had multiple (3 or more) other features of cognitive impairment.

ERCP in the management of patients having laparoscopic cholecystectomy: Re-Appraising current indications

Abstract: This study assessed the ability of biochemical tests and ultrasound to predict the presence of ductal calculi, and thereby refine the indications for ERCP, in patients before or after laparoscopic cholecystectomy Thirteen of fifty-three patients investigated before laparoscopic cholecystectomy, and four of seventeen investigated after had stones confirmed at ERCP The most sensitive indices for stones were raised serum alkaline phosphatase (076), aspartate transferase (075) and alanine transferase (076) The most specific indices were an abnormal ultrasound (092), raised serum amylase (078) and raised bilirubin (075) Serum bilirubin, amylase and ultrasound were all normal in twenty-seven patients and all of these had normal ERCPs If patients with normal bilirubin, amylase and ultrasound were not referred for ERCP, no stones would have been overlooked and the number of ERCPs could have been reduced by 39%

Management of ductal carcinoma in situ of the breast

Abstract: Ductal carcinoma in situ (DCIS) of the breast is thought to represent a number of biologically different processes, ranging in clinical presentation from a palpable mass to a mammographically-detected abnormality The optimal management of DCIS is controversial We reviewed our experience in 40 patients with DCIS, 26 with gross disease and 14 with microscopic disease Treatment was by total mastectomy (n = 21), complete local excision (n = 16), and local excision followed by radiotherapy (n = 3) At a mean follow-up of 34 months (range 3-120), 35 patients (88%) are disease-free All patients treated by mastectomy remained disease-free, but 3 patients (16%) treated by breast conservation surgery have had local recurrences All local recurrences were in the same area as the original lesion, two manifesting the same subtype of DCIS and one an invasive carcinoma The margins of excision were close to the resection margin in all cases that recurred All four recurrences were successfully managed by mastectomy Mastectomy is still the most secure and reliable management for DCIS, but pathologically verified wide local excision may be appropriate

Cholecystectomy and oesophageal pathology: is there a link?

Abstract: Symptoms persist in a significant proportion of patients following cholecystectomy, some of which may have an oesophageal aetiology. The oesophagus has not previously been studied in this patient group. In this study all patients who had undergone cholecystectomy over a four year period were invited for review and symptoms were documented. Oesophageal function was examined and compared with normal controls. Patients were subdivided into symptomatic and asymptomatic subgroups and their findings compared. Symptoms were present in 53 percent of the postcholeystectomy group. The mean (sem) DeMeester acid score was higher in the post-cholecystectomy group -20.6 (3.6) than in controls - 6.7 (0.9) (p=0.01). The incidence of oesophagitis and gastritis were also increased in this group. There was a trend towards increased reflux and oesophagits in the symptomatic compared with the asymptomatic subgroup. Other findings confined to the post-cholecystectomy group included nutcracker oesophagus in 4 and irritable bowel syndrome in 3. It is suggested that cholecystectomy may be associated with changes in oesophageal function which, in turn, may be associated with persistent symptoms.

Glandular differentiation in cardiac myxomata.

Abstract: We present a case of cardiac myxoma associated with Carney's complex in which histological examination revealed numerous well formed glandular structures at the base of the lesion. Immunoperoxidase studies showed these glands to be epithelial-like with positive staining for EMA, CEA and CAM 5.2. Mucin stains were also positive. The presence of these gland-like structures within a cardiac myxoma, unless recognised as part of the tumour, may lead to the erroneous diagnosis of secondary adenocarcinoma. We reviewed eighteen further cardiac myxomata of which two were associated with Carney's complex. Of these eighteen tumours only one, not associated with Carney's complex, contained glandular structures and these were poorly formed.

Height, body weight, skinfold thickness and endurance fitness of children attending national schools in Ireland.

Abstract: Height, body weight, the thickness of triceps, biceps, subscapular and supra-iliac skinfolds and the six-minute run-walk test of aerobic endurance were measured on 1163 National school children between the ages of 7 and 13, who were attending rural or urban schools in counties Cork, Galway, Limerick, Mayo, Waterford and Wexford. Height, weight and the sum of triceps and subscapular skinfolds were compared with 11 to 13 year-olds from Northern Ireland, for whom the same data is available. Endurance scores were compared with international norms. Although of the same height as other European children, the subjects were heavier and had higher skinfold thicknesses. Aerobic endurance scores averaged about 80% of international norms.

Endoscopic balloon sphincteroplasty for benign papillary stenosis--an alternative to surgical or endoscopic papillotomy?

Abstract: Benign papillary stenosis is an uncommon but well recognised cause of recurrent biliary pain usually in post-cholecystectomy patients characterised by biliary dilatation without bile duct calculi or malignancy. Endoscopic or surgical papillotomy is the recommended treatment but may be associated with a higher complication rate than when performed for bile duct stones. We report 2 cases of papillary stenosis treated by endoscopic balloon dilatation or “sphincteroplasty”, as a less traumatic intervention which improved biliary drainage and provided symptomatic relief. Our preliminary experience suggests more widespread evaluation of balloon sphincteroplasty should be considered for papillary stenosis.