ROYAL ACADEMY OF MEDICINE IN IRELAND IRISH JOURNAL OF MEDICAL SCIENCE

Proceedings of the RAMI Section of Interns Study Day

30th January 2016 Royal College of Physicians of Ireland

Irish Journal of Medical Science Volume 185 Supplement 5 10.1007/s11845-016-1467-x

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299

Disclosure Statement This supplement has received no external funding or sponsorship

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 DOI 10.1007/s11845-016-1467-x

Intercollegiate Communication: An Audit in Methotrexate Monitoring Ryan N1, Carberry C2, Bury G3 1 Dr Niamh Ryan, Medical Intern, Midlands Regional Hospital, Portlaoise, Co Laois; 2Dr Crea Carberry, Lecturer in General Practice, UCD School of Medicine, Coombe Family Practice, Dolphins Barn Street, Dublin 8; 3Prof Gerard Bury, Professor of General Practice, UCD School of Medicine, Coombe Family Practice, Dolphins Barn Street, Dublin 8

Background: Methotrexate is a folic acid antagonist. It is used in rheumatoid arthritis, psoriasis, psoriatic arthritis, crohns disease. It is a drug that requires a high grade of monitoring. The British society of rheumatologists state FBC, U + E, LFT should be undertaken every 2 weeks until stable for 6 weeks; thereafter monthly until stable for 1 year. I chose to audit the practice I worked into highlight any area for change. Aim: The aims of my audit were to (1) Determine adherence rates in my practice. (2) Identify where and when the majority of blood monitoring was being undertaken. (3) To identify communication avenues and make recommendations for change. Method: The SOCRATES database was searched using ‘Methotrexate’, ‘Rheumatoid Arthritis’, ‘Psoriasis’, ‘Crohns disease’, ‘Acute lymphoblastic leukaemia’, ‘Non Hodgkins Lymphoma’, ‘Choriocarcinoma’, ‘Breast cancer’. The search spanned 2 years and excluded any deceased individuals. Results: 18 % of patients were having 6 weekly bloods, 50 % having 2 monthly bloods and 31 % having 3 monthly bloods. 68 % of monitoring bloods were being taken in a hospital setting with 9 % being undertaken between hospital and GP. Of the 22 % who were solely monitored in GP: 100 % had FBC and U + E taken, 80 % had LFTs done. 45 % of individuals had no blood monitoring frequency mentioned at any stage in hospital correspondence. Of the remaining 55 %, half were following the designated blood monitoring frequency. 33 % never had a copy of blood results sent to the GP, once blood results were faxed a number of blood abnormalities were noted. 40 % had sent a copy of bloods within the last year. Conclusion: There is a need for improved communication between General Practice and hospitals. Recommendations included a letter faxed to relevant consultants asking for regular copies of bloods. Reminders were added to SOCRATES and the practice will be reaudited in 1 year’s time.

A Surgical Approach to Endometrial Cancer in a Single Institution August 2006–July 2014 McCarthy M, Hewitt M Cork University Maternity Hospital, Cork Endometrial cancer is the most common gynecological cancer affecting Irish women, with an annual incidence of 391.1 The standard approach is TAH/BSO ± lymphadenopathy. Current evidence suggests that the minimally invasive laparoscopic approach is comparable to traditional laparotomy in terms of outcomes.2 CUMH commenced a robotic surgical programme in 2008.

Prior to this, laparotomy or straight-stick laparoscopy was the modality of choice. The aim of this study was to compare post-operative recovery measured by of length of hospital stay in women who had a TAH/BSO versus a minimally invasive approach. We performed a retrospective case review using surgical log books, pathology reports and computerised bed management system from a single institution and surgeon. Between April 2006 and August 2014, 133 patients received surgery for endometrial cancer. Of these, 89 received a robot-assisted laparoscopy, 5 a straight-stick laparoscopy, 38 a laparotomy and one vaginal hysterectomy. Prior to the introduction of the robot in July 2008, the surgeries were done via laparotomy (76.19 % n = 16) or straight stick procedure (23.81 %, n = 5). Since, abdominal procedures have declined over time and no straight stick procedures have been performed. Between January and July 2014, 87.5 % (n = 16) of surgical approaches for endometrial cancer were by robot-assisted laparoscopy. The median stay following robotic surgery was 1 day (mean 2.12 days, range 1–25, n = 89). This compares to a mean of 4 days (range 1–8, n = 5) for straight-stick procedures and median of 6 days for abdominal (mean 6.67 days, range 2–21). The robotic approach was demonstrated to be associated with better postoperative recovery in terms of earlier discharge, inline with international findings2. References: 1. National Cancer Registery Ireland, 2013, Accessed 23/11/2015 http://www.ncri.ie/. Galaal, K., Bryant, A., Fisher, A.D., AlKhaduri, M., Kew 2. F. & Lopes, A.D., 2012, Laparoscopy versus laparotomy for the management of early stage endometrial cancer, Cochrane Database Syst Rev 12;9 [PubMed]

The Relationship Between Change in pre- and PostHysterectomy Haemoglobin and the Modality and Duration of Surgery McCarthy M. & Burke C. (Cork University Maternity Hospital) Introduction: Retrospective observation of haemoglobin change from pre- and post-hysterectomy can indicate the effect of intraoperative blood loss. A 2005 Cochrane Review1 showed vaginal hysterectomy to be associated with less blood loss than laparoscopic surgery, which is associated with less blood loss than laparotomy. A 2010 study2 demonstrated an association between operative times and blood loss. Aims and methods: The aims of this audit were to investigate the change in haemoglobin pre and post-hysterectomy over a 9-month period, comparing total abdominal, Results and conclusions: There were 167 Hysterectomies in the period studied, 65 didn’t repeat a haemoglobin postoperatively, one patient had no haemoglobin recorded. For laparoscopic procedures 50 % (n = 3) had post-op bloods reordered, 93 % of open (n = 53) did, 33 % of robot-assisted (n = 18) did and 52 % (n = 26) of vaginal-procedures did. The average change for abdominal approaches was -1.53, for vaginal -1.14, for straight-stick -1.07, and for robot assisted -0.82. In both the vaginal and straight-stick approaches, longer operative times were associated with greater fall in haemoglobin.

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S190 However in abdominal and robot-assisted surgeries, the reverse was true, contrary to hypothesis. Interestingly, our study showed vaginal procedures to be associated with greater fall in haemoglobin, contrary to previous studies1 showing vaginal was associated with greater blood loss. 1. Nieboer, T.E., Johnson, N., Lethaby, A., Tavender, E., Curr, E., Garry, R., Van Voorst, S., Mol, B.W.J. & Kluivers, K.B., (2010) Surgical approach to hysterectomy for benign gynaecological disease (Review), The Cochrane Library, 12, Online at http://apps.who.int/rhl/reviews/CD003677.pdf (11/11/2015) 2. Mu¨ller, A., Thiel, F.C. Renner, S.P., Winkler, M., Ha¨berle, L. & Beckmann, M.W., (2010) Hysterectomy: A Comparison of approaches, Dtsch Arztebl Int. 107(20): 353–359.

The Operating Times and Hospital Stay for Robotic Radical Hysterectomies in a Single Institution: A Case Series (2008–2015) McCarthy M, Hewitt M Cork University Maternity Hospital Background: Radical hysterectomy is the recommended treatment for stage 1B cervical cancer. Traditionally the procedure was performed by laparotomy, however a laparoscopic approach provides a quicker recovery, shorter hospital stays and lower morbidity, while affording all the advantages of the open procedure (1)(2)(3)(4). CUMH commenced a robotic surgical programme in 2008. Aims and methods: This study aims to evaluate the operating times via retrospective case review of the theatre log books from a single institution and single surgeon. Results: As of Sept 2015, 32 cases have been performed. The median operating time in our study 200 min, was lower than that reported by Lowe et al. (5), of 215 min. There was a clear trend of decreasing duration of surgery with surgical times of 317 min for the initial procedure and 155 min for the most recent. Mean surgical time was 214. 6 min (range 108 to 340 min). Mean surgical times vary from 328. 5 min in 2008 (n = 3), to 246 min in 2009 (n = 5), to 234 in 2010 (n = 3), to 258 in 2011 (n = 4), to 204. 75 in 2012 (n = 4), to 206. 75 in 2013, to 161. 67 (n = 6) in 2014, to 157. 25 in 2015 (n = 4). Our reduction of 48 % in surgical time between years 1 and 8, compares with a reported reduction of 58 % after 20 cases (1) and a reported reduction from 410 to 171 and 132 min after 9 and 34 procedures (3). Mean hospital stay was 2. 34 nights (range 1–8), mode was 2. Hospital stays in our institution were, in general shorter than other intuitions observed, we observed a mean of 2.34 nights compared to 3.8 in a Norwegian study (2) and median stay of 2 nights compared with 3 in a Swedish study (3).. References: 1. Schreuder, H.W.R, Zweemer, R.P., & and Verheijen R.H.M. From open radical hysterectomy to robot-assisted laparoscopic radical hysterectomy for early stage cervical cancer: aspects of a single institution learning curve, Gynaecology Surgery, Sept 2010, 27(3), 253–258 2. Sert, M.B., & Abler, V.,‘‘Robot-assisted laparoscopic radical hysterectomy: Comparison with total laparoscopic hysterectomy and abdominal radical hysterectomy; one surgeon’s experience at the Norwegian Radium Hospital’’ Gynaecologic Oncology 121 (2011) 600–604

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 3. Persson, J., Reynisson, P, Borgfeldt, C., Kannisto, P., Lindahl, B., & Bossmar, T., Robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy with short and long term morbidity data, Gynaecologic Oncology, 113 (2009) 185–190 4. Renato, S., Mohamed, M., & Riccardo S., Robot-Assisted Radical Hysterectomy for Cervical Cancer: Review of Surgical and Oncological Outcomes Obstetric. Gynaecology. 2013 January 10; 2013 5. Lowe MP, Chamberlain DH, Kamelle SA, Johnson PR, Tillmanns TD. A multi-institutional experience with robotic-assisted radical hysterectomy for early stage cervical cancer. Gynaecologic Oncology. 2009;113(2):191–194.

The Operating Times for Robot-Assisted Trachelectomies in a Single Institution: A Retrospective Case Series (2008–2015) McCarthy M (CUMH) and Dr Matt Hewitt (CUMH) Background: Trachelectomy with concurrent cerclage is an established fertility-sparing procedure to treat early stage cervical cancer. Robot-assisted abdominal trachelectomy is a suitable alternative to the traditional vaginal approach, offering similar accuracy in terms of cervical length and more precise placement of the cerclage. Cork University Maternity Hospital commenced robotic trachelectomies in 2013. Between December 2013 and October 2015 ten women underwent the procedure. We evaluated the operating times via retrospective case-review of theatre log books. Aims and methods: Postoperative recovery was assessed via inpatient records, investigating length of stay and whether readmission within 6 weeks was required. Results: There was a trend of decreasing operating times with subsequent surgeries performed, though this has appeared to plateau even at this early stage. The initial procedure performed was 290 min with the most recent being 215. The mean operating time was 203. 4 min (range 110–290 min). This trend of decreasing operating times is comparable with data observed by Persson et al1. Mean operating times in our institution were shorter in duration than those reported by Persson (297 min, range 242–430 min). The mean hospital stay was 1. 4 nights; two nights for four women and one night for six. One woman required readmission 2 weeks later for a post-op haemorrhage, which was related to undiagnosed ITP. This patient was also the only subject with a positive parametrial node. So far there have been no resulting pregnancies, with two known to be actively trying to conceive. There have been no recurrences. References: 1. Persson. J., Imboden, S. Reynisson, P., Anderson, B., Borgefeldt, C, & Bossmar, T., Reproducibility and accuracy of robot-assisted laparoscopic fertility sparing radical trachelectomy, Gynecologic Oncology 127 (2012) 484–488

Severe Bleeding Due To Acquire Hypoprothrombinaemia-Lupus Anticoagulant Syndrome (HLAS) McEnroe Y1, L O Donnell2 1

Department of Gastroenterology, Mayo General Hospital, Castlebar, Co Mayo; 2NUI Galway Intern Training Network

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Introduction: Acquired Lupus anticoagulant-hypothrombinaemia is a rare disease due to the association of lupus anticoagulant and factor II deficiency. Although it is rare patients can present with life threatening bleeding complications if not recognised. Description: A 92 year-old gentleman presented to Emergency Department with his first episode of frank PR bleeding. On examination the patient had ecchymosis on his lower face and over his right hand with no history of any trauma. He also had some gum mucosal bleeding. PR exam showed no abnormality apart from fresh blood in the perianal region. The Patient was also not on any anticoagulation. Laboratory results revealed Plts of 130, an INR of 4.8, a prothrombin time (PT) of 50 s (normal 12–15 s) and an activated partial thromboplastin time (aPTT) OF 93 (normal 21–33 s). On the advice of Haematology mixing studies, coagulation factors, lupus antibodies were all requested. The results of above tests showed a Lupus anticoagulant positive and factor II (Prothrombin) under 2 u/dl (normal 70–146 l/dl). The Consultant Haematologist diagnosed an acquired factor II deficiency secondary to a lupus anticoagulant and advised commencing on treatment regimen. During admission the patients Haemoglobin dropped from 12 to 4 g he was transfused ten units of red cell concentrates and admitted to ICU to await transfer to a University Hospital. Conclusion: This case highlights the importance of a multidisciplinary approach. As of yet there are no standardized recommendations for treating hemorrhage associated with HLAS but literature suggests corticosteroids as a first-line treatment option. Like the above patient many report long term remission as achievable. Studies support the following treatment; intravenous immune globulin, prednisone and rituximab with follow up set as a priority. [1] References: 1. Paschal RD, Neff AT (2012) Resolution of Hypoprothrombinaemia-Lupus Anticoagulant Syndrome (HLAS) after multidrug therapy with rituximab: a case report and review of the literature. Haemophilia 19(2): 62–65

S191 PCI was performed via radial artery access on the Left Main Stem and Left Anterior Descending Arteries. PCI has been shown to an effective intervention in elderly patients, reducing cardiac mortality irrespective of baseline characteristics. After elderly patients undergo PCI a move away from cardiac to non-cardiac causes of mortality is observed[3]. Following successful coronary revascularisation the patient underwent Endovascular Aneurysm Repair, the surgery was tolerated well. This case highlights the new age of interventional medicine where life saving procedures can be performed in elderly patients with minimal invasion with excellent results. Technological advances allow treatment of ‘‘high-risk’’ patients with minimally invasive techniques with excellent safety profile and long-term results. References: 1. Antman EM, Cohen M, Bernink PJL, McCabe CH, Horacek T, Papuchis G, Mautner B, Corbalan R, Radley D, Braunwald E. The TIMI Risk Score for Unstable Angina/Non–ST Elevation MI: A Method for Prognostication and Therapeutic Decision Making JAMA. 2000; 284(7):835–842. 2. Fox KAA, Dabbous OH, Goldberg RJ, Pieper KS, Eagle KA, Van de Werf F, Avezum A, Goodman SG, Flather MD, Anderson Jr FA, Granger CB. Prediction of Risk of Death and Myocardial Infarction in the 6 Months After Presentation with Acute Coronary Syndrome: Prospective Multinational Observational Study (GRACE). BMJ. 2006 Nov 25; 333(7578):1091. 3. Spoon DB, Psaltis PJ, Singh M, Holmes Jr DR, Gersh BJ, Rihal CS, Lennon RJ, Moussa ID, Simari RD, Gulati R. Trends in Cause of Death After Percutaneous Coronary Intervention. Circul. 2014 Mar 25; 129(12):1286–94.

Monitoring in the Clozapine Clinic in a Dublin Based Hospital in 2015 Dunlea S, Buckely E, Walsh C

Case Report: Damned If You Do? Damned If You Don’t! Interventional Medicine in the Elderly Murphy T, Matiullah S, Sharif F Department of Cardiology, Galway University Hospital, Galway, Ireland 91 year old gentleman referred by GP with abdominal discomfort and pulsatile mass in the umbilical zone of the abdomen. CT-Aortogram showed an 8 cm Abdominal Aortic Aneurysm (AAA) with a focal dissection of the Supra-Renal Aorta. During Anaesthetic pre-operative assessment the patient admitted to angina symptoms. Echocardiogram showed Normal LV size and function with an EF = 50–55 %. Angiography showed Severe Three Vessel Coronary Artery Disease (CAD) which included significant Left Main Stem disease. The application of risk assessment scores of mortality for CAD showed TIMI score[1] of 5, giving a 26 % risk at 14 days of allcause mortality or severe recurrent ischaemia requiring urgent revascularization. The GRACE score[2] was calculated as 149 points, giving this patient a 17 % chance of death at 6 months. This emphasised the need for urgent coronary revascularisation. Percutaneous Coronary Intervention (PCI) was chosen because of advanced age, faster recovery and presence of a pulsatile AAA. The

Dept. Of Psychiatry, St. Vincent’s University Hospital, Dublin 4 Introduction: Clozapine is considered the most effective of all antipsychotic medications and is the treatment of choice for treatmentresistant schizophrenia. As with all anti-psychotic medication it is associated with numerous side effects, including agranulocytosis and several other metabolic side effects. Aims: To complete an audit on how the standard of monitoring of patients in a Dublin based hospital compares with those of the clinical gold standard, the Maudsley Prescribing Guidelines. Materials and method: In this initial phase of what will be a complete audit cycle 20 patients charts were selected at random and were reviewed to compare the level of monitoring with those outlined in the Maudsley Guidelines. Results: The anaylsed data revealed that 100 % of the population involved in the study had their FBC, BP and weight taken at every visit to the clinic. However interestingly none had their pulse rate, temperature or BMI documented at any stage. Only 16.7 % of patients had an ECG performed on a 12 monthly basis and 94.1 % never had an ECG on changing of their clozapine dose. 90 % of patients in their first year had their fasting glucose and lipids measured at baselines but thereafter monitoring of bloods was sporadic with poor adherence to the guidelines. Documentation was also found to be poor. Conclusion: From the results it is apparent that a monitoring gold standard is not being strictly adheared to in the clinic. While tests are being carried out in the clinic they are not being performed at the time intervals dictated by the Maudsley guidelines which could lead to detrimental effects for patients.

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S192 The results also show that there is an absence of documentation of blood results in the notes and filing of these results appears to be one of the main barriers to the sucess of this audit.

The Role of Aripiprazole in Treatment of Antipsychotic Induced Hyperprolcatinaemia Dunlea S, Guerandel A

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 monoclonal plasma cells that are derived from B cells in the bone marrow2. Bone pain is a common presentation of the disease with 70 % of patients presenting with it5,6. Hypercalcemia is the number one metabolic complication of the disease7. Fifty percent of patients have concomitant renal dysfunction at presentation. Also patients with MM often present with infections. 73 % of patients with MM suffer with anaemia at presentation9, our patient did present with anaemia. However his anaemia was mild and anaemia is not specific for this disease. Other than anaemia and PUO, this case presented with very little clinical features suggestive of MM and therefore he was a diagnostic challenge.

Dept. Of Psychiatry, St. Vincent’s University Hospital, Dublin 4 Case presentation: Mr. JD is a 30 year gentleman diagnosed with treatment resistant paranoid schizophrenia. He was a long term patient in SVUH awaiting a hostel bed to become available. On routine 6 monthly examination, it was noted his prolactin levels were elevated at 1311 nm/mL (reference range 2–18 ng/mL) secondary to being treatment with Amisulpiride 400 mg od for the previous 2 years. Amisulpride is an atypical antipsychotic of the benzamide class which is a highly selective D2/D3 dopamine antagonist leading to its association with elevated prolactin levels. On examination of the patient at this time there was no evidence of gynaecomastia or testicular atrophy and the patient denied any other symptoms related to hyperproloctinaemia such as impotence or loss of libido. Discussion/learning point: Previous research1 had shown the potential benefit for treatment with Aripiprazole, a different class of atypical antipsychotic in in treating antipsychotic induced hyperprolactinaemia as it acts as a partial D2 dopamine agonist. It was decided to trial Mr. JD on this alternative treatment and monitor his response. He was commenced on 10 mg od and this dose was slowly increased as the dose of Amisulpride was tapered off. Repeat bloods at monthly intervals showed decreasing levels of prolactin over the following months from the initial 1311 ng/mL in 07/2015, to 1253 ng/mL in 08/2015 to 992 ng/mL in 09/2015. References: De Berardis D, Fornaro M, Serroni N, Marini S, Piersanti M, Cavuto M, Valchera A, Mazza M, Girinelli G, Iasevoli F, Perna G, MArtinotti G, Di Giannantonio M (2014) Treatment of antipsychotic-induced hyperprolactinemia: an update on the role of the dopaminergic receptors D2 partial agonist aripiprazole. Recent Pat Endocr Metab Immune Drug Discov. 2014 Han; 8(1): 30–7

Visual Assessment and Falls Risk in the Older Patient: An Audit Doolan E, Cassidy T, O’Shea D, Noone I, Clifford G St. Vincent’s University Hospital Introduction: The British Geriatrics Society recommends that all patients undergoing a falls assessment should be screened for visual impairment (as defined by a visual acuity of 6/12 or less)[1]. Patients identified as suffering from a visual impairment should be assessed by an optometrist. Optometric examination can determine if spectacles or required and detect pathology which can then be referred to ophthalmological services. Aim: To audit visual assessment in a stroke/care of the elderly ward in an acute hospital. Methods: Our Lady’s Ward is an acute stroke/care of the elderly ward in SVUH with a capacity of 20 beds. A Snellen chart was installed on the ward. Ten patients were visually assessed. This assessment included measurement of visual acuity, contrast sensitivity (an independent risk factor for falls), confrontation testing and fundoscopy. Patients selected were mobile and deemed to be at risk of falling. Results: None of the patients on the ward had their visual acuity formally assessed prior to the audit. Following installation of the Snellen chart 10 patients were visually assessed. • • • •

Atypical Presentation of Multiple Myeloma Reddin G, Doolan E, Makki H St. Vincent’s University Hospital, Dublin, Ireland We present a case of a 58-year-old gentleman who was diagnosed with Multiple Myeloma after several erroneous preliminary diagnoses because of his extremely atypical presentation and constellation of symptoms that were more easily explained by other pathologies. Initially he was diagnosed with Infective Endocarditis because of his presenting symptoms of: PUO, atrial flutter, pericardial effusion and functional bicuspid valve. His scalp tenderness and raised ESR was another red herring that delayed his definitive diagnosis. Multiple Myeloma is not common; it compromises approx. 1 % of all types of cancer and 10 % of all hematologic malignancies2. It is a disease of older age; the median age at diagnosis is 70-year-old3. It is a hematologic malignancy that is caused by a proliferation of

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7 were visually impaired 2 of these visually impaired patients were in hospital without their spectacles. 4 had known eye disease 4 had not had an eye examination within the past 2 years.

Conclusions and interventions: Visual acuity was not formally assessed on the geriatric ward prior to audit. Interventions which have been put in place: • • • •

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Installation of Snellen chart Training of nursing staff to record visual acuity Patients’ family members encouraged to bring in patients’ spectacles Information leaflets placed on ward detailing the importance of regular eye examinations and how to access them in the community Visits from external domiciliary optometrists arranged for stroke/care of the elderly ward at regular intervals

References: 1. Kenny RA et al. (2011) Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 59 (1), 148–157.

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Risk of Avascular Necrosis During Proximal Humerus Open Reduction and Internal Fixation Hintze JM1, Morrissey D1, Molony D1 1

Department of Orthopaedics, Tallaght Hospital, Dublin, Ireland

Introduction: Proximal humeral fractures are common, representing 5 % of all fractures presenting to the emergency department. Avascular necrosis (AVN) may occur in 0–77 % of proximal humeral fractures and is a common cause of fixation failure. Several risk factors for AVN have been identified, including the fracture position, calcar length and integrity of the medial hinge1. We routinely perform an intra-articular biceps tenotomy with tenodesis at the level of the pectoralis major to facilitate fragment identification and to aid postoperative pain relief. Concern exists that tenotomising the biceps damages the adjacent arcuate artery, potentially increasing the rate of AVN2. Methods: We retrospectively reviewed 88 proximal humeral fractures that were surgically treated using the above fashion over a 52-month period for radiological signs of humeral head AVN. We excluded revision or tumour cases and those utilising a deltoid splitting. 61 fractures satisfied the inclusion criteria and were suitable for review. We radiographically assessed each fracture according to Neer’s classification, analysed the calcar length and integrity of the medial hinge. Results: 20 fractures (32 %) were three-part, 1 was two-part (1.6 %) and 40 (65 %) were four-part fractures. 37 (61 %) had a calcar length less than 8 mm and 26 (42 %) had loss of the medial hinge. The mean radiographic follow-up was 5 months. There was no radiographic evidence of avascular necrosis in any of the 61 cases, although two cases did require revision surgery for collapse and screw penetration. 5 cases (8 %) had tuberosity avascular necrosis, but no evidence of humeral head necrosis. Conclusion: Avascular necrosis remains a troublesome complication following proximal humeral fractures. Several risk factors have been identified, including fracture pattern and surgical approach1. In our experience, intra-articular biceps tenotomy with the deltopectoral approach was not associated with a significant risk of avascular necrosis of the humeral head, even in complicated four-part fractures. References: 1. Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. Journal of shoulder and elbow surgery. 2004 Jul-Aug;13(4):427–33. 2. Patel S, Colaco HB, Elvey ME, Lee MH. Post-traumatic osteonecrosis of the proximal humerus. Injury. 2015 Oct;46(10): 1878–84.

Pulmonary Sarcoidosis Presenting After the Initiation of Peginterferon Alfa-2a for the Treatment of Hepatitis C Connolly N, O Regan, A West Northwest Intern Training Network Abstract: A number of new diagnoses of sarcoidosis have recently been described amongst patients undergoing interferon treatment for Hepatitis C. In this previously unpublished case, notable for a family

S193 history of sarcoidosis in two first-degree relatives, first symptomatic presentation was marked by a productive cough, weight loss and fatigue on initiation of interferon therapy. Prolonged symptoms and persistent abnormal radiological findings led to cessation of therapy. Lung biopsy confirmed granulomatous interstitial pneumonia and termination of interferon treatment resulted in some symptomatic relief, although the patient experienced an ongoing chronic sputum production. There has been no radiological progression since interferon therapy was discontinued.

An Investigation into the Association Between Demographic and Morbidity Factors, and Sleep Disturbance Mullane N1, Bradley C2 Introduction: The recognition of sleep disorders is important because in the long term they are associated with numerous deleterious health outcomes. Despite the high prevalence of sleep disorders, they are widely under-diagnosed at general practice level. Aim: To investigate the association between demographic and morbidity factors, and self reported sleep disturbance symptoms in adults. Methods: A quantitative cross sectional study design was used. The data collection tool was an anonymous questionnaire titled the ‘‘Sleep Symptom Checklist’’ originally designed by a Canadian research group. This consisted of 22 sleep symptoms categorised into four subscales: (1) Insomnia, (2) Daytime Distress, (3) Sleep Disorder, and (4) Psychological Distress. Participants were adults C18 years of age randomly selected from five general practice sites, sampled over a 2 week period. Results: 281 questionnaires were included in analysis (70.3 % response rate). Participants with a diagnosis of depression and those who reported experiencing low mood ‘’very frequently’’ had significantly higher median scores on all four sleep subscales. Those with a B.M.I. (body mass index) [30 kg/m2 had a higher median score on Subscale 3, compared to those with a lower B.M.I. Current smokers had higher median scores on Subscales 1–3 when compared to nonsmokers. Participants [65 years of age had lower median scores on all four subscales when compared to younger participants. Married participants had lower median scores on Subscales 1–3 when compared to unmarried participants. 37 % (n = 104) reported that they would be willing to participate in an overnight sleep study. 5.3 % (n = 15) had been formally diagnosed with a sleep disorder. 14.9 % (n = 42) were currently taking sleep promoting medication. Conclusions: A number of factors are significantly associated with sleep disturbance, particularly depression, low mood, elevated BMI and smoking. General practitioners should consider these factors in order to correctly categorise patients who would benefit from sleep disorder investigation. 1. Dr Niamh Mullane, Medical Intern, South Network 2. Professor Colin Bradley, Professor of General Practice University College Cork

Pyrexia of Unknown Origin: A Case Based Review of Diagnosis and Treatment in the Paediatric Setting Doireann E, Lowry C Temple street Hospital, Paediatric Rheumatology

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The evaluation children with pyrexia of unknown origin (PUO) is challenging. This can lead to delayed diagnosis of the underlying condition [1]. Below are two such cases. Case1: A 23 month old girl presented with pyrexia [39C and irritability for 13 days. On examination she had signs of respiratory tract infection. Urinalysis and renal ultrasound suggested a urinary tract infection also. Blood tests showed neutrophilia and raised CRP. Case2: A 6-year-old boy presented with an 18-day history of pyrexia. He had recently stayed on a farm in rural Moldova. On examination he was lethargic, dehydrated, and had crepitations in the right middle zone. He had tender swelling of the left ankle. He underwent a septic workup which showed a neutrophilia, elevated inflammatory markers, and deranged LFTs. He was treated for pneumonia and secondary sepsis. In both cases, the pyrexia persisted despite treatment of the infections. Investigations for typical and atypical infections, echocardiogram and autoimmune screen were negative. Both children were given IVIG for possible Kawasaki with no effect. They were then commenced on Methylprednisolone after which they rapidly improved. Diagnoses of systemic JIA were made. At 3 month review, Case1 was in remission on Methotrexate monotherapy. Case2 had multiple joint swellings, but was pain and pyrexia free on Prednisolone and Methotrexate. In the diagnosis of JIA, a high index of suspicion is needed, joint pathology may not be present, and it can be difficult to distinguish from Kawasaki disease [2, 3]. Careful assessment and early diagnosis improves outcomes [4].

outline the following as a standard to be met in the management of hip fractures: ‘‘All patients with hip fracture who are medically fit should have surgery within 48 h of presentation, and during working hours’’. Objectives: 1) To audit the length of time from presentation in ED to definitive operative management for hip fracture patients in MMUH from February to July 2015, and compare this to the BOA recommendation. 2) To audit the percentage of patients who had surgery during working hours, defined as 08.00–17.59. Methods: Data was obtained for 81 patients from the HIPE database using emergency department admission documents and theatre procedure notes. Results: The overall mean time from admission to operative procedure was 40.8 h (standard deviation 29.75 h). 71 % of patients were operated on within the recommended time of 48 h, with 53 % of those undergoing the definitive procedure within the first 24 h. 89 % of patients were operated on within standard working hours. Conclusions: While the average time from admission to definitive procedure for hip fracture patients in MMUH was within the recommended timeline, over a quarter of patients were operated on beyond 48 h. The March 2015 Performance Report produced by the HSE as part of a new Accountability Framework reports percentage of emergency hip fracture surgery carried out within 48 h as 86 % and a target of 95 % in Irish hospitals. Thus we are below the national average in the same time period.

1. Hay AD, Ilowite NT. Systemic juvenile idiopathic arthritis: a review. Pediatr Ann. 2012 Nov;41(11). doi:10.3928/0090448120121022-10. 2. Dogra S, Gehlot A, Suri D et al. Incomplete Kawasaki disease followed by systemic onset juvenile idiopathic arthritis- the diagnostic dilemma. Indian J Pediatr. 2013 Sep;80(9):783–5. doi: 10.1007/s12098-012-0893-7. Epub 2012 Oct 10. 3. Dong S1, Bout-Tabaku S2, Texter K et al. Diagnosis of systemiconset juvenile idiopathic arthritis after treatment for presumed Kawasaki disease. J Pediatr. 2015 May;166(5):1283–8. doi: 10.1016/j.jpeds.2015.02.003. Epub 2015 Mar 11. 4. Van Dijkhuizen EH, Wulffraat NM2. Early predictors of prognosis in juvenile idiopathic arthritis: a systematic literature review. Ann Rheum Dis. 2015 Nov;74(11):1996–2005. doi: 10.1136/annrheumdis-2014-205265. Epub 2014 Jun 24.

References: Irish Hip Fracture Database National Report 2013 March 2015 Performance Report—HSE quality guidelines. Blue Book—‘The care of patients with fragility fractures’ produced by the British Orthopaedic Association.

Audit of the Timing of the Most Recent Thyroid Function Test of Each of the Patients of the Navan Road Family Practice Who take Levothyroxine/ Eltroxin as a Treatment for Hypothyroidism McCall A1, Brophy P2, Brophy F3 1

A Retrospective Internal Audit of the Time from Presentation to the Emergency Department (ED) to Definitive Operative Procedure for Hip Fracture Patients from February to July 2015 Morris S1, Keogh S1, Sweeney AM1, Lyons F1 Department of Orthopaedic Surgery, Mater Misericordiae University Hospital Background: Hip fractures account for over 3000 admissions to Irish hospitals per year, and have been identified as a central challenge in the current epidemic of osteoporotic fractures. This is largely due to the impact this injury has on the patient’s quality of life, as well as the related morbidity and mortality, and the associated cost to the healthcare system. The ‘‘Blue Book standards’’ are a set of guidelines published by the British Orthopaedic Association (BOA) and British Geriatrics Society (BGS) relating to the care of patients with fragility fractures. They

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Dr. Ashley McCall, Intern, Dublin/Mid-Leinster Intern Training Network; 2Dr. Patrick Brophy, Partner, Navan Road Family Practice, 213 Navan Road, Dublin 7; 3 Dr. Fionnuala Brophy, Partner, Navan Road Family Practice, 213 Navan Road, Dublin 7 Introduction and aims: The UK guidelines for the use of thyroid function tests (TFTs) state that patients taking Levothyroxine/Eltroxin as a treatment for hypothyroidism should have a TFT once every 12 months. The aim of the audit described below was to examine the rate of compliance of the Navan Road Family Practice with this guideline. Method: A retrospective standards-based audit of the patient records of the Navan Road Family Practice was carried out. The inclusion criteria for the audit yielded a sample size of 130 patients. The timing of the most recent TFT for each of the patients in the sample was ascertained. Results: Of the 130 patients in the sample, 96 (74 %) had had a TFT carried out within the previous 12 months and 110 patients (85 %) had had a TFT carried out within the previous 18 months. Conclusion: The Navan Road Family Practice has a 74 % rate of compliance with the UK guidelines for the use of TFTs in patients who take Levothyroxine/Eltroxin as a treatment for hypothyroidism.

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Factors Influencing the Provision of HIV Testing in General Practice in Ireland Doyle AE1, Cotter S2, Horgan M3 UCC and Dept of Infectious Diseases CUH Background: Rates of HIV testing in primary care have been increasing worldwide but remain low compared to other test settings. There is little published data on HIV testing in general practice in Ireland despite significant numbers of late presentations of HIV here. This study sought to explore factors that promote or reduce the provision of HIV testing during general practitioner [GP] consultations. Methods: An anonymous survey was distributed online to GPs seeking information on their experience with HIV patients and potential barriers to HIV testing. Appropriate statistical analyses were undertaken. Results: 164 GPs took part in the survey, 120 qualified GPs and 44 GP trainees. 74 % had HIV positive patients in their practice. Urban practices had greater numbers of HIV positive patients than mixed or rural practices. 71 % of GPs had submitted an HIV test within the past month. GPs identified lack of time for pre or post-test counselling, language and cultural barriers and patient perceived to being in a low risk group as barriers to offering a HIV test. Conclusion: Missed opportunities for HIV diagnoses in general practice remain. Lengthy pre or post-test counselling, communication barriers and perceiving the patient to be in a low risk group all deter GPs from offering HIV tests. A standardised risk assessment tool and streamlined pre-test counselling for patients could increase rates of HIV testing in general practice and reduce late presentations of HIV.

Development of a Rating Tool to Determine Prognosis in Psychogenic Non-Epileptic Seizures Deasy E, Costello D, Cassidy E, Linehan T Department of neurology, CUH Introduction: Psychogenic non-epileptic seizures (PNES) are defined as episodes of altered movement, sensation or experience similar to epilepsy but caused by a psychological process and not abnormal electrical discharges in the brain. 25–40 % of patients evaluated for intractable epilepsy have PNES and prognosis has traditionally been poor. Aim: To develop and validate a rating tool for use in determining prognosis in patients with PNES Methods: A 21 point rating tool was developed according to clinical expertise and available evidence. A descriptive, quantitative, crosssectional study design was used. Medical records of patients with video-EEG confirmed PNES were analysed retrospectively using the tool. The patients were then contacted by telephone to assess their current seizure status. Results: 54 patient records were reviewed. Patients not contactable were removed from analysis, leaving a sample of 42 patients. It was established that the only statistically significant variable was ‘Time to Establish Diagnosis’, with a Pearson Chi Square of 3.857 and a two-sided significance score of 0.05. The ‘Co-Existing Epilepsy’ variable had a Pearson Chi Square of 2.143 and a significance of 0.143. This was not significant but was not as non-significant as the other excluded variables. All other variables were highly non-significant. These results were reinforced by a logistical regression

S195 analysis which indicated that the only significant variable is ‘Time to Establish Diagnosis’, with an adjusted R-square value of 0.12. Conclusion: A length of time greater than 6 months required to establish a diagnosis of PNES is the most statistically significant factor in determining prognosis in this condition. All other factors do not appear significant, rendering the usefulness of a rating tool questionable. However, all conclusions are based on a small sample size—a larger scale study may be required to further investigate the significance of the factors. Notwithstanding the limitations of this pilot study, it suggests that barriers to recognition and establishment of a secure diagnosis of PNES need to be identified and overcome.

An audit of Laxative Prescribing in Patients Prescribed Opioids in Croom Orthopaedic Hospital, Limerick Burke G, Harmon D Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, University Hospital Limerick Background: Constipation is a very common, predictable and troublesome side effect of oral opioids. Some data has suggested that the side effects can be worse than the pain itself. Consequently, clinical guidelines recommend regular use of laxatives to prevent opioidinduced constipation. An Analgesic Policy was developed in University Hospital Limerick in 2009 detailing principles and guidelines for a wide variety of pain issues. This includes recommendations for prescribing laxatives with oral opioids; ‘Always prescribe regular laxatives for patients on strong opioids and anti-emetics as required. e.g. Senna 2–4 tablets or 10–20 ml of syrup at night plus Movicol 1 sachet daily with 125 mls of water’. Method: A kardex review was carried out on all inpatients in Croom Orthopaedic Hospital, reviewing prescriptions for opioids and laxatives. The results were compared to the hospital guidelines. Results: All 26 inpatients were currently prescribed ‘as required’ oral oxycodone. Twenty three patients were prescribed sustained release oxycodone twice a day. A total of 18 patients were prescribed laxatives, 7 of whom were in line with the analgesic policy. There was no stop data for opioids on any kardex. Discussion: Laxatives were not routinely prescribed to adults in the post-operative setting in Croom Orthopaedic Hospital. Routine prescribing of laxatives to post-op patients on opioid therapy may improve the safety and therefore the effectiveness of opioid pain management. This will be highlighted at the departmental teaching, and a reaudit will take place to complete the audit cycle.

IgA Nephropathy Masquerading as Post Streptococcal Glomerulonephritis in a 10-Year-Old Boy McKnight K, Baggot R, Moylett E Department of Paediatrics, University College Hospital Galway Introduction: Diagnosis of post-streptococcal glomerulonephritis (PSGN) is based upon findings of acute nephritis and evidence of recent beta-haemolytic group A strep (GAS) infection. Resolution is

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S196 rapid and recurrence rare. Repeated or non-resolving haematuria therefore prompts consideration of alternative glomerulopathies. Case description: A 10-year-old boy represented to ED with odynophagia and gross haematuria 4 weeks post hospital admission for treatment of presumed PSGN. First admission was preceded by a short history of fever and sore throat followed by passage of dark-coloured urine. Pustular pharyngitis noted on examination; throat swab isolated GAS, renal ultrasound demonstrated bright echo-texture in keeping with glomerulonephritis; peak creatinine; 268 lmol/L. IV benzylpenicillin was instituted however, not tolerated, and changed to oral co-amoxiclav. Creatinine returned to normal but haematuria persisted following discharge. Second presentation, the patient’s vitals were stable. Normotensive with urine output [30 ml/kg. No oedema or dysuria. Peak creatinine; 178 lmol/L; gross haematuria and 3 + proteinuria noted; no casts; protein-creatinine-ratio;198 mg/mmol; complement levels normal; ANA negative; serum IgA; 2.73 mg/dL (0.7–2.5); ASOT [200 IU/ml. Given previous positive throat-swab result, IV benzylpenicillin prescribed. Further deterioration in renal function prompted renal biopsy, demonstrating IgA nephropathy and an allergic interstitial nephritis with penicillin implicated as likely precipitant. Penicillin antibiotics were withdrawn and corticosteroid therapy commenced with marked improvement. Discussion: IgA nephropathy is the most common form of primary glomerulonephritis with peak incidence in the 2nd to 3rd decades of life, male:female ratio as high as 6:1 in the western hemisphere. In childhood disease, the recurrent macroscopic haematuria coincident with upper respiratory infection is clinically distinguished from PSGN by shorter latency period between onset of respiratory illness and haematuria and the tendency for recurrence. Diagnosis requires renal biopsy demonstrating IgA glomerular deposition. In this case, recent streptococcal infection complicated diagnosis at second presentation. In addition, penicillin and subsequent allergic interstitial nephritis resulted in further complexity. Reference: James V. Donadio, J. P. G., September 5th 2002. IgA Nephropathy. New England Journal of Medicine, 347; (738–748).

Adherence to 2012 European Society of Cardiology Guidelines (2012) for Management of Hyperlipidaemia in Patients Undergoing PCI

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 below the recommended. The average total plasma cholesterol was 4.07 mmol/L, with a standard deviation of ±1.18 mmol/L. However, these patients have established Coronary Artery Disease. For this cohort the ESC guidelines recommend a LDL of \1.8 mmol/ L, this was achieved in 10 (23 %) patients who underwent PCI. The average LDL level was 2.23 mmol/L with a standard deviation of ± 1.06 mmol/L. Conclusion: In patients with High Risk Coronary Artery Disease optimising their modifiable risk factors is of utmost importance. At the time of intervention, a minority (23 %) of patients included in this audit had LDL within the recommended guidelines. Given their high risk status, these patients should have a target LDL cholesterol \11.8 mmol/L or a reduction of LDL cholesterol of greater than or equal to 50 %. A follow up audit is planned to assess these high risk patients 1 year post PCI. Reference 1. Perk J., De Backer G., Gohike H., Graham I., Reiner Z., Verschuren W.M.M., Albus C., Benlian P., Boysen G., Cifkova R., Deaton C., Ebrahaim S., Fisher M., Germano G., Hobbs R., Hoes A., Karadeniz S., Mezzani A., Prescott E., Ryden L., Scherer M., Syvanne M., Scholte Op Reimer W.J., Vrints C., Wood D., Zamorano J.L., Zannad F., Cooney M.T., Bax J., Baumgartner H., Ceconi C., Dean V., Deaton C., Fagard R., Funck-Brentano C., Hasdai D., Hoes A., Kirchhof P., Knuuti J., Kolh P., McDonagh T., Moulin C., Popescu B.A., Reiner Z., Sechtem U., Sirnes P.A., Tendera M., Torbicki A., Vahanian A., Windedecker S., Funck-Brentano C., Sirnes P.A., Aboyans E.A. ‘European Guidelines on cardiovascular disease prevention in clinical practice (version 2012)’ The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts) Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2012;33:1635–1701.

Handover Rates Among Doctors in Portiuncula Maternity Hospital; How Effective is It? Dortie N1, Brassil M2 Obstetrics and Gynaecology Department, Portiuncula Hospital, Ballinasloe, Galway. NWN Network

Murphy T, Murphy L, MacNeill B Department of Cardiology, Galway University Hospital, Galway, Ireland Background: The 2012 European Society of Cardiology Guidelines (2012)[1] suggest a target Low-Density Lipoprotein (LDL) of \1.8 mmol/L in patient with established Coronary Artery Disease. This audit aims to examine the cholesterol levels of patients undergoing PCI in a tertiary referral hospital. Methodology: This was a retrospective audit including all patients over a 1 month period who underwent PCI and who had their cholesterol level checked at the time of the intervention. This was a single centre audit in the cardiology department of Galway University Hospital. Results: 44 patients were included in this study, 37 (84 %) males and 7 (16 %) females. In general the ESC recommends a total plasma cholesterol of 5 mmol/L, 38 (86 %) patients had cholesterol levels

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Introduction: Poor clinical handover is associated with adverse incidents, delayed treatments, lack of continuity of care and death3. This audit is aimed at seeing how often handovers are done during morning ward rounds in Portiuncula Maternity Hospital, how effective the handovers are, how many doctors attend and if the handovers were consultant led. The audit covered a 8 month period (January to August). Method: A one page A4 handover sheet was used. It contained spaces for attendance, admission made (\37/40 pregnant), bloods checked and signed after ordering, pending bloods, radiology discussed and other handover details. The effectiveness of the handover was based on inpatients handovers and any investigations done or pending transferred to the on-call team. Results: A total of 39 handovers (16.05 % of 243 ward rounds) were done over the 8 months. An average of four doctors attended each handover with 95 % of these handovers been consultant led. August saw the highest handover rate with 13 (33.3 %) and March saw the

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 lowest (2.6 %). January 15.4 %, February 7.7 %, April 12.8 %, May 18 %, June and July both 5.1 % The effectiveness of handover was poor in general as there were no inpatient handovers in March and May saw the highest (10). Also investigations done or pending were not transferred to the on-call team in March. August saw the highest number of ‘bloods checked’ (9) and May the highest ‘radiology discussed’ (9) and awaiting bloods (9) handed over. Conclusion: The rate, quality and effectiveness of the handover were poor among doctors in the maternity ward. This could be improved upon by having the form easier to pick up and constant reminder by everyone in the team. References: 1. Intern, North West North Network 2. Head of department, Obstetrics and Gynaecology Department, Portiuncula Hospital, Ballinasloe, Galway 3. [ONLINE] Available at http://health.gov.ie/wp-content/uploads/ 2015/01/National-Clinical-Guideline-No.-5-Summary-ClinicalHandover-Nov2014.pdf. [Accessed 05 October 2015].

Utility of Aspergillus Blood PCR as a Screening Tool for Presence of Invasive Aspergillosis in a Cohort of High Risk Children M Willoughby, Canton B, Maoldomhnaigh C O, Storey L, Rush R, Butler K, Gavin P Department of Infectious Disease, Our Lady’s Children’s Hospital Crumlin Invasive aspergillosis (IA) has a high mortality rate but is difficult to diagnose, particularly in immunocompromised children. Blood PCR offers the promise of earlier diagnosis of IA. Children post-BMT or with primary immunodeficiency are frequently screened for IA using blood PCR. The aim of this study was to assess the utility of Aspergillus blood PCR as a screening tool for the presence of IA in a cohort of high-risk children. A retrospective case–control study was undertaken of 100 children at high risk of IA (50 patients with C1 positive Aspergillus PCR and 50 children with C1 negative PCR) randomly selected from the microbiology database from 2003 to 2013. Radiology and pathology databases, microbiology culture and Galactomannan immunoassay results were interrogated for presence of EORTC criteria (2008) for proven, probable or possible. A systematic review and meta-analysis of PCR in 2009 showed sensitivity of 0.88 and specificity 0.75 of PCR for one positive sample and 0.75 and 0.87 for two consecutive positive PCR (1). Our results showed sensitivity of 0.78 and specificity of 0.53 of PCR for one positive and 0.43 and 0.78 for two consecutive positive PCR. 28 of the 50 patients that had a positive PCR result had appropriate radiological investigations within 3 weeks of the date of the PCR. A greater number of the patients (31 out of 50) with negative PCR result had radiological investigations within 3 weeks. Diagnosis of IA remains problematic, with the Aspergillus blood PCR currently lacking the high-level of sensitivity required for a routine screening test. PCR testing was negative in 22 % of children that fulfilled criteria for IA. However, consistently negative Aspergillus blood PCR has high NPV. 44 % of children with a positive result did not have appropriate radiological investigations suggesting that a lack of clinical suspicion may supercede a positive test result.

S197 Reference: 1. Mengoli, Carlo. Cruciani, Mario. Barnes, Rosemary A. Loeffler, Juergen. Donnelly, Peter. 2009. Use of PCR for diagnosis of invasive aspergillosis: systematic review and meta-analysis. Lancet Infect Dis 2009; 9: 89–96

Kaposi Varicelliform Eruption in Two Sisters with Darier Disease Delaney F1, Bourke J1 Dermatology Department, South Infirmary Victoria University Hospital Cork Darier disease is a rare dominantly inherited genodermatosis characterized by loss of intercellular adhesion and abnormal keratinisation. Clinically it most commonly manifests as multiple erythematous, hyperkeratotic papules with a yellowish brown crust that can coalesce to form plaques in the seborrheic areas of the face and chest. It is among the dermatoses susceptible to a widespread viral eruption by the herpes simplex virus, a phenomenon known as Kaposi varicelliform eruption. HSV superinfection is associated with severe Darier disease and increased risk of hospitalisation. The case of a 32-year-old woman with Darier disease who developed a Kaposi varicelliform eruption is presented here. Having presented with an impetiginised vesicular eruption on an erythematous base over the abdomen and chest, she required hospitalisation under dermatology and intensive intravenous and topical treatment over the course of 6 days, following failed treatment in the primary care setting. Empiric antibacterial and antiviral therapy was used initially. Herpes simplex type 1 was subsequently identified as the causative agent. Interestingly, she also developed a concurrent viral conjunctivitis requiring ophthalmology consultation. This patient’s sister, also a Darier disease patient, had developed a Kaposi varicelliform eruption 1 week prior to her presentation but had been successfully managed as an outpatient.

Urgent Inter-Hospital Cardiology Transfers to a Tertiary Centre in Ireland: A Retrospective Review Delaney F1, Kearney P1 1 Cardiology Department, Cork University Hospital Introduction: The tertiary referral centre model relies on an effective network of inter-hospital transfers. There is little knowledge of how such systems work in Ireland. Invasive tertiary management, and with it inter-hospital transfer, is becoming increasingly important within cardiology. We aimed to characterise and assess a system of urgent inter-hospital cardiology transfers to a regional tertiary cardiology centre, with particular focus on: nature and appropriateness of referrals, system responsiveness times, and communication. Methods: This was a retrospective observational study of urgent inter-hospital cardiology transfers to Cork University Hospital (CUH) over a 6 month period. Data was collected from CVIS (the cardiovascular information system database in CUH), patient hospital charts, a paper-based log of referrals and a faxed communication repository. Descriptive statistical analysis was performed with

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S198 variables expressed and evaluated as counts, means, medians and percentages. Results: Excluding STEMIs, there were 269 urgent inter-hospital cardiology transfers to CUH in the 6 month period. The most frequent working diagnosis was acute coronary syndrome (n = 108, 78 %). The second largest category was arrhythmias (n = 8, 6 %). Communication and documentation was unclear in 23 % of transfers with no working diagnosis on referral documented in 11 % of cases. Communication format was highly variable. The median response time was 1 day and two thirds of cases were transferred back to the source hospital on the same day. All transferred patients underwent invasive management not available at the source hospital. The majority of transfers were judged appropriate. Discussion and conclusions: Urgent inter-hospital cardiology transfers contribute significantly to tertiary centre workload. The performance of this system in terms of response and turn-around times was good, and the majority of transfers were appropriate. Refinement of the transfer protocol, including standardised communication and documentation methods, offers potential for future improvement.

Back Pain Not on the Back Burner: A Case of Atypical AAA Presenting as Renal Colic McMonagle E, Casserly L, Moloney T UHL, Midwestern Intern Training Group Introduction: Back pain can be one of the most difficult ailments to diagnose and treat, especially when longstanding. We are sometimes guilty of failing to adequately investigate back pain, often quickly writing it off to a MSK issue. However, there is always that time when the zebra emerges from the stable, and the diagnosis can be made even more difficult when the presentation is atypical. Description/case presentation: Mrs D, 63-year-old lady with a past medical history significant for IgA nephropathy and hypertension. She was admitted 1 week post discharge for the administration of high dose steroids and cyclophosphamide. There was a 3/7 history of nausea, vomiting and gross haematuria, accompanied by a vague back pain, chronic but with an acute component since discharge. At the time of admission her creatine was also 500. The working diagnosis was dehydration causing AKI on CKD with uremic symptoms. Radiological investigation of the back pain was insignificant at admission, and a working diagnosis of cystitis was made. On day three of admission, a change in the character of the pain was noted by the patient. The pain had now progressed to loin to groin distribution, with ‘‘spasmic’’ character, rated 6/10. A CT KUB and subsequent CT EVAR diagnosed a leaking 4.4 cm [AP] aneurysm with disruption of lateral wall and para-aortic fat infiltration. An emergency EVAR was performed successfully. Discussion: Abdominal aortic aneurysms are notoriously difficult to diagnose, often only caught with the classical dissection pain of ‘tearing’, where the mortality is highest. However, this was a case of a ruptured AAA presenting in an unusual loin-to-groin pain presentation for an infra-renal aneurysm, highlighting the notion that even pain which appears chronic can have an evolving acute component. It also highlights the variability in the presentation of these often fatal aneurysms [1]. References: 1. Chaikof EL, Brewster DC, Dalman RL, et al. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg 2009; 50:S2.

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The Evaluation of Adult Procedural Sedation Practices in the Emergency Department Ryan J, Cusack S Emergency Medicine Department, Cork University Hospital, Cork Introduction: Documentation is essential for safety, education, audit, medico-legal reasons, and continuity of patient care. However, in the complex environment of the emergency department documentation has consistently been demonstrated to be below standard (1). Procedural sedation is now widely used in Emergency Departments (ED). A number of international bodies have released guidelines for procedural sedation in the ED (2, 3). However, there remains a lack of literature regarding the topic of documentation of procedural sedation in the ED. Aim: To evaluate the quality of documentation of procedural sedation and to describe adult sedation practices in the ED. Methods: 52 medical charts from January 2013 to August 2014 were retrospectively reviewed. All patients were over the age of 18.The data collection sheet included 30 key content items which should be documented during each sedation episode. Gender, age, indication for sedation, the sedation agent used and adverse events were also recorded. Results: In total 8/30 key content items were documented in more than 80 % of cases. Risk assessment was recorded in 8 % of cases. Fasting status was recorded in 12 % of cases. Observations every 5 min were documented in 50 % of cases. Weight was not documented in any of the patients. Shoulder dislocation was the most common reason for sedation in this sample. Propofol was the most commonly used sedation agent (65 %). There were no adverse events documented in this sample. Conclusion: There were no adverse events recorded in this sample of patients undergoing ED sedation. However, documentation did not meet previously described standards. There is a clear need for standardised documentation, audit and training of all staff involved in procedural sedation in Cork University Hospital ED. 1. Leape LL, Brennan T, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991; 324:377–384. 2. Innes G, Murphy, Nijssen-Jordan C, Ducharme J, Drummond A. Procedural sedation and analgesia in the emergency department. Canadian Consensus Guidelines. J Emerg Med. 1999 JanFeb;17(1):145–56 3. Greaves D, Gemmell L, Gray A, Lloyd G, Norris A, Strachan Lay R, Telford R. Safe Sedation of Adults in the Emergency Department. Royal College of Anaesthetists and College of Emergency Medicine Working Party, September 2012. Accessed January 2015.

A Rare Cause of Ventricular Tachycardia in a Postmenopausal Female Roy E1, Osuafor C2, Daly T13 Medicine for the Older Person, Mater Misericordiae University Hospital, Dublin 7, Ireland(1-3) Introduction: First described in Japan in the late 1990’s, Takotsubo’s cardiomyopathy is an acute myocardial infarction mimic characterised by transient systolic and diastolic left ventricular dysfunction

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 accompanied by a variety of wall motion abnormalities. The condition is often preceded by an intense emotional or physical trigger and affects mostly women1. Here, we present the clinical outcome of one such case in a postmenopausal female presenting acutely with chest pain. Case report: An 81-year-old female (with no previous cardiac history) transferred for management of bilateral lower limb ulceration and cellulitis experienced acute onset chest pain and dyspnoea 21 days into her hospital admission. Of note, she had recently been suffering from both physical and emotional stress due to increasing pain from the ulceration and a recent decision for long term care, respectively. Electrocardiogram findings initially demonstrated monomorphic ventricular tachycardia and subsequently ST segment elevation associated with grossly elevated cardiac markers. Coronary angiography revealed non obstructed coronary arteries, whilst left ventriculography demonstrated apical ballooning with anterior and inferior akinesia. The Japanese term ‘‘Takotsubo’’ can be translated to ‘‘Octopus pot’’ in the English language, drawing comparison to their similar appearance (circular base with a slender neck) on imaging, as was found on ventriculography in this case. A subsequent echocardiogram completed 12 days post the cardiac event demonstrated complete resolution of the ventricular wall abnormality and a normalized ejection fraction. Discussion: Though a rare condition, accounting for approximately 2.2 % of cases of query acute coronary syndrome, Takotsubo’s cardiomyopathy has recently been increasingly reported in the literature2. Due to differing medical management in comparison to ACS, clinicians should consider the disorder as a rare differential for chest pain. This is especially the case in postmenopausal females who may not possess typical cardiac risk factors or have undergone recent stressors. 1. Sato HTH, Uchida T, Dote K, Ishihara M. Tako-tsubo-like left ventricular dysfunction due to multivessel coronary spasm. In: Kodama K, Haze K, Hori M, eds. Clinical aspect of myocardial injury: from ischemia to heart failure. Tokyo: Kagakuhyoronsha Publishing, 1990:56–64. 2. Bybee KA, Prasad A, Barsness GW, Lerman A, Jaffe AS, Murphy JG, Wright RS, Rihal CS. Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome. Am J Cardiol 2004; 94:343– 346.

An Audit of Computed Tomography Scanning in Addition to Basic Malignancy Screening in Unprovoked Venous Thromboembolism ´ inle F4 Barrett A1, Hall P2, Breslin T3, Nı´ A

S199 malignancy based on CT-TAP. Secondary outcomes included incidental lesions on CT-TAP requiring further investigation. In the primary analysis, 66 of 171 VTEs were found to be unprovoked (39 %). Of these, 53 had a CT-TAP performed for investigation of malignancy and 24 were found to be normal. 15 had incidental findings requiring further investigations to be performed, for example pulmonary nodules. Three had a cause for the VTE identified on CT-TAP. One had an occult colon cancer necessitating treatment, however this patient had presented with weight loss and abdominal pain. One had new metastases from a previously cleared rectal cancer, and one person had May-Thurner anatomy which did not affect management. No patients have yet been diagnosed with malignancy that was not picked up on the primary screen in either of the groups. No additional patients were diagnosed with malignancy using correct application of the NICE guidelines (the cases that were, were diagnosed using clinical judgement) and therefore this data supports the call for revision of the guidelines in this area.

Confusion and Thrombocytopaenia in a 43-Year-Old Man Barrett A1, Fay M2 Mater Misericordiae University Hospital(1-2) M.F. is a 43-year-old gentleman who presented to the haematology service of MMUH with a 2 week history of progressive confusion associated with abdominal pain, haematuria, malaise and leg pain. He was a smoker but had no other background history of note and was undergoing treatment with rifampicin and flucloxacillin for radial osteomyelitis due to an infected prosthesis. His general practitioner performed basic blood tests which showed a platelet count of eight and a haemoglobin of ten and he was immediately admitted. A blood film showed thrombocytopaenia and schistocytes indicating a microangiopathic haemolytic anaemia. He had a negative septic screen, faecal culture, Coombs test and vasculitic screen and on further analysis he was found to have less than five per cent activity of the protein ADAMTS-13, and quadruple the normal activity of the antibody against this protein, confirming a diagnosis of thrombotic thrombocytopaenic purpura. He suffered complications including acute coronary syndrome, acute renal failure and a small haemorrhagic stroke and was managed in the coronary care unit. He underwent same-day plasma exchange and had a total of 8 days of plasma exchange as well as reducing-high-dose prednisolone and two doses of rituximab. He improved greatly from a clinical perspective and was discharged after 11 days in hospital. A repeat ADAMTS13 test showed the levels of both the protein and the antibody back to normal limits.

Mater Misericordiae University Hospital(1-4) Recent evidence published in August 2015 in the New England Journal of Medicine suggests that there is no diagnostic or survival benefit to performing computed tomography scanning of the thorax, abdomen and pelvis (CT-TAP) in addition to basic screening in the workup of unprovoked venous thromboembolism (VTE) for occult malignancy, as recommended by the NICE guidelines. This study was a retrospective analysis of 171 patients presenting to the emergency department of MMUH over a 21 month period who received a diagnosis of VTE. Of those without a clear provoking factor for the VTE, in the investigation for occult malignancy as a possible cause it was recorded whether they underwent CT-TAP as well as blood tests, chest X-ray and gender-specific breast, cervical or prostate screening. The primary outcome of the study was a positive screen for

Treatment in the Absence of Guidelines: Ketoconazole Successfully Resolves HypercalcaemiaAssociated Acute Kidney Injury (AKI) in SteroidResistant Sarcoidosis: a Case Report O Farrell M1, Sharif M3, McLoughlin M1, Mulcahy E2, Stack A4 1

Department of Nephrology, University Hospital Limerick, Limerick; Department of Histopathology, University Hospital Limerick, Limerick; 3Graduate Entry Medical School, University of Limerick, Limerick; 4Health Research Institute, University of Limerick, Limerick 2

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S200 Introduction: Sarcoidosis is a multisystem granulomatous disease of unknown etiology characterized by the presence of non-caseating granulomas. The prevalence of sarcoidosis in Ireland is one of the highest in the world approximated at 850 per million population (1). Hypercalcaemia associated with sarcoidosis exhibits seasonal variability with peak incidence during summer months associated with elevated production of 1, 25 (OH)2 Vitamin D(2). The impact of this on short-term and long-term kidney function and the extent to which it can be managed with corticosteroid treatment is poorly understood. Case presentation: Herein, we report on the case of a 64 year male who presented to our unit with acute kidney injury (AKI) (peak creatinine 300 lmol/L) and moderate hypercalcaemia (peak calcium 3.3 mmol/L) on a background of sarcoidosis, chronic kidney disease (CKD) and type II diabetes. Serum calcium levels failed to normalize despite 2-weeks of high dose oral corticosteroid therapy and high volume normal saline infusion. Treatment with oral ketoconazole 200 mg once daily resulted in an immediate and sustained reduction in serum calcium levels with subsequent resolution of his AKI. A careful review of the patient’s previous 10-year medical history revealed a seasonal pattern to his hypercalcaemic episodes, corresponding with maximum daylight hours and triggering severe acute kidney injuries. Interestingly, each AKI episode was followed by incomplete resolution of kidney function back to original baseline. A trajectory of progressive deterioration in kidney function was evident over time progressing from Stage II to Stage IV CKD. Conclusion: This report demonstrates the need for (1) vigilant monitoring of serum calcium levels among patients with sarcoidosis especially during summer months, (2) normalization of hypercalcaemia to prevent AKI, (3) the efficacy of ketoconazole in steroidresistant hypercalcaemia, and the need for (4) frequent longitudinal surveillance of kidney function. References: 1. Donnelly SC, Walters M. Reply to: Increased prevalence of sarcoidosis in Ireland. Irish journal of medical science. 2013;182(1):149. 2. Taylor RL, Lynch HJ, Jr., Wysor WG, Jr. Seasonal influence of sunlight on the hypercalcemia of sarcoidosis. Am J Med. 1963;34:221–7.

Determining the Anthropometric and Metabolic Effects of a Milk-based Intensive Lifestyle Intervention in Severely Obese Diabetic Adults: The SODA MILIS Cohort Study Murphy C1, Kilkelly K1, Brassil C1, Cunningham K1, McGrath R1, Griffin H1, O Shea PM1, Finucane F M1 1 Galway Diabetes Research Centre, HRB Clinical Research Facility, NUI Galway, Ireland

Abstract: Therapeutic options for diabetic patients with severe obesity are limited. Low energy meal replacement regimes can induce significant short-term weight loss and improve glycaemic control. We sought to estimate the effect size on adiposity and diabetes control and treatment of a relatively inexpensive and straightforward 24 week regime based on meal replacement with semi-skimmed milk in severely obese diabetic adults. A retrospective cohort analysis showed that of 36 patients in our hospital-based bariatric medicine service who started, 20 (56 %) completed the programme and underwent an initial milk-based weight

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 loss phase, followed by weight stabilisation and weight maintenance phases, each lasting 8 weeks. Patients were seen every 2 weeks by the bariatric physician, nurse and dietitian. We compared outcomes in completers (who had similar baseline characteristics to non-completers) at time 0, 8, 16 and 24 weeks. 60 % of completers were female, mean age was 54.2 ± 9.9 years. BMI decreased from 48.8 ± 8.1 to 43.2 ± 8.2, 41.3 ± 8.3 and 41.3 ± 8.3 kg m2 at 0, 8, 16 and 24 weeks, respectively (p \ 0.001 with repeated measures ANOVA), equivalent to 21 kg weight loss and a reduction in excess body weight from 95.4 ± 32.5 to 65 ± 32.9 %, p \ 0.001 over 24 weeks. HbA1c decreased from 65 ± 22.2 to 53.5 ± 16, 47.2 ± 12.1 and 49.1 ± 13.4 mmol/mol, p = 0.046. Insulin was stopped in 4 of 7 patients, with a 71 % reduction in total daily insulin dose in the three remaining on it (p = 0.02). There were very significant reductions in all other diabetes medications, except for metformin. These preliminary findings suggest that a 24-week milk-based meal replacement programme can have large effect sizes on important outcomes in severely obese diabetic adults. However attrition was high. A more formal assessment of the efficacy of the intervention as well as its safety, feasibility and cost-effectiveness seems warranted.

The Reliability of Early Postoperative Pain as a Prognostic Indicator in Arthroscopic Tibiotalar Arthrodesis Mohan K1, Moriarity A1, Ellanti P1, Bayer T2, McKenna J1 1

Department of Trauma and Orthopaedics, Saint James’s Hospital, James’s Street, Dublin 8, Ireland; 2Midland Regional Hospital, Arden Road, Tullamore, Co. Offaly, Ireland Introduction: Arthroscopic ankle arthrodesis has shown high rates of union and less postoperative morbidity in comparison to those who undergo open arthrodesis. The most recent literature suggests a nonunion rate of 10 %. Aims: The primary objective of this study was to determine whether the presence or absence of postoperative pain could be used as an early prognostic indicator of non-union in arthroscopic ankle arthrodesis. Materials and methods: A study of 75 patients who underwent arthroscopic ankle arthrodesis between 2012 and 2015 was hence undertaken. Patients were routinely examined and radiographed at 2, 6, 12 and 24 weeks postoperatively. The time to arthrodesis was determined by radiographic and clinical examinations. Radiographic evidence of fusion was determined by trabeculation across the joint space. Clinical evidence of fusion was determined, on examination, by the absence of pain and motion with attempted movement of the joint, and no warmth or swelling on palpation of the joint. Analgesic requirements were monitored postoperatively. Functional ability was evaluated both pre- and postoperatively by means of the self-reported foot and ankle score (SEFAS). Results: Fusion occurred in 71 of 75 ankles with an overall rate of 94.7 %. At 1 week postoperatively, 68 of the 71 (95.8 %) fused ankles had no pain and required no analgesia. The 4 ankles that did not fuse all continued to have pain similar to their preoperative state at 12 weeks postoperatively. The mean time to union was 9.8 weeks and the mean age was 60.2 (28–85). Conclusion: Pain in the early postoperative period can be considered as a simple and reliable method of predicting fusion in arthroscopic ankle arthrodesis.

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299

A Study Of Bilateral Non-Simultaneous Hip Fractures in a Large Irish Metropolitan Hospital Mohan K1, Memon A1, Ellanti P1, Hogan N1, McCarthy T1 1 Department of Trauma and Orthopaedics, Saint James’s Hospital, James’s Street, Dublin 8, Ireland

Introduction: In modern healthcare, hip fractures are a significant cause of morbidity and mortality in the elderly population. With improved healthcare and longer survival, patients with non-simultaneous bilateral hip fractures are increasingly numerous. Aims: The objective of this study was to investigate non-simultaneous bilateral hip fractures, their anatomical type and the time interval between two fractures. Materials and methods: A retrospective study of all patients that sustained a neck of femur or a pertrochanteric hip fracture presenting to Saint James’s Hospital between January 2007 and December 2010 was undertaken. Patients under the age of 60, with high-energy trauma, pathological or subtrochanteric fractures were excluded. Demographic data of age, sex and type of fracture was recorded. Additionally, in patients with a previous contralateral hip fracture, the age of initial fracture, the type of 1st and 2nd fracture and the time in months between the two fractures was noted. Results: A total of 749 hip fractures were treated during this time, of which 630 were over the age of 60. 462 were females (73.5 %) and 167 males (26.5 %), with a mean age of 79.9 years (60–99). There were 457 neck of femur fractures and 173 pertrochanteric fractures. Of this cohort, 40 patients had a previous contralateral hip fracture. The average age at first and second fracture was 82.4 and 88.6 years, respectively. The average time interval between fractures was 70 months (1–75). 66 % of fractures were intracapsular in both episodes. The majority of patients had a similar fracture type at the second incident. Conclusion: Our findings show that 2nd hip fractures occur at similar anatomical location in most patients, on the contralateral side. The average time interval between fractures is 5 and 6 years. Risk factors for 2nd hip fractures are numerous and a multidisciplinary approach is of paramount importance in their management.

An Unusual Case of Recurrent Ovarian Mucinous Cystadenoma O Riordan N, Mansoor N, Keane D Gynaecology Department, St. Vincent’s University Hospital; UCD intern Network Introduction: Mucinous cystadenomas are benign mucin-containing epithelial ovarian tumours. They comprise 20 % of all benign ovarian tumours. Data regarding the recurrence of benign ovarian mucinous cystadenomas post cystectomy is limited. Only nine cases of recurrence are documented in the literature from 2001 to present. As recurrence is rare management post-cystectomy is challenging, especially in young patients. Description: A 40-year-old female was admitted to the Emergency Department with a 1 day history of severe abdominal pain with dark urine. Her background history was significant for recurrent urinary tract infections, a right sided pyeloplasty for PUJ obstruction, three lithotripsies due to recurrent urolithiasis and two previous ovarian cystectomies for benign mucinous cystadenomas. On examination, her abdomen was soft but tender in the left iliac fossa. Urinalysis was strongly positive for blood. Ultrasound pelvis was performed as the

S201 clinical picture was consistent with a repeat PUJ obstruction or urolithiasis, and it revealed a large mass, of mixed cystic and solid nature arising from the left adnexa. A laparotomy and left salpingoophorectomy was performed in order to fully excise the large adnexal mass. Despite its abnormal macroscopic appearance with mixed cystic and solid components, histology confirmed the mass as a mucinous cystadenoma with no signs of invasive malignancy. The patient recovered well in the post-operative period and was asymptomatic at follow-up in the gynaecology out-patient clinic 6 weeks later. Discussion: This case illustrates an unusual recurrence of benign mucinous cystadenoma. The patient underwent two ipsilateral ovarian cystectomies prior to her eventual salpingoophorectomy. The aim of this case report is to raise awareness regarding the risk of recurrence of benign mucinous cystadenomas and the importance of follow up of those who have undergone cystectomy. This will in turn facilitate early detection of recurrences, minimising the risk of neoplastic transformation and of potentially preventable salpingooophorectomy. References: 1. Baksu, B., Akyol, A., Davas, I., Yazgan, A., Ozgul, J. and Tanık, C., 2006. Recurrent mucinous cystadenoma in a 20-year-old woman: Was hysterectomy inevitable? Journal of Obstetrics and Gynaecology Research, 32(6), 615–618 2. Ben-Ami I, Smorgick N, Tovbin J et al. (2010) Does intraoperative spillage of benign ovarian mucinous cystadenoma increase its recurrence rate? American Journal of Obstetrics and Gynecology, 202(2) 142-e1 3. Gotoh, T., Hayashi, N., Takeda, S., Itoyama, S., Takano, M. and Kikuchi, Y., 2004.

Phosphate levels in Paediatric Patients in University Hospital Limerick: Are the Reference Values Appropriate Johnson J1, Linnane B1 1

Department of Paediatrics, University Hospital Limerick

Background: The reported phosphate levels in paediatric patients appear to be abnormally high in a significant proportion of the population to raise the question are the current reference ranges in University Hospital Limerick (UHL) appropriate. Aim: To test the hypothesis that the current references ranges for inorganic phosphate used in UHL are inaccurate for the paediatric population. Method: Phosphate levels from all of our inpatients and outpatients from a 6-week period were elevated. Biochemistry results from the last year where used, any test done before 1/12/14 were excluded. Out of a total of 173 patients only 27 patients with appropriate samples were identified (15 were female, average age 5.3 years, age range 6 weeks–16 years). The remaining patients were excluded either due to no measured phosphate level or the result was before 1/12/14. Results: The reference range for the inorganic phosphate used in UHL is currently 0.8–1.5 mmol/L. Of the 27 paediatric patients with measured phosphate levels, only 14 patients (52 %) had a phosphate level which was reported as normal. 48 % of the phosphate levels were found to be abnormally high. The mean phosphate level was 1.5 ± 0.21 mmol/L. Conclusion: A significant percentage of the phosphate levels were found to be abnormal. Of interest the mean phosphate level was 1.5 mmol/L, which is at the upper limit of the current normal reference range. Limitations of this study include the small sample size of the patients with phosphate levels measured.

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Functional Exercise Testing During Pregnancy Duffy A, Daly N, Turner M UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital Research regarding exercise testing during pregnancy is limited. In elderly patients, studies have demonstrated associations between functional exercise testing with adverse health outcomes. Pregnancy is a time when women reduce their physical activity, and potentially lose functional strength. There are no established safe fitness or functional tests for use in pregnant women. In pregnant women with an ongoing singleton pregnancy, we aimed to perform four tests of function: the chair rise, step test, balance test and grip strength. Women were recruited at their first antenatal visit. Body composition was measured using bioelectrical impedance analysis. Women were screened for suitability for exercise using the ParMed-X questionnaire. Resting heart rate was determined prior to and after testing. Each patient underwent a one-minute step test, a chair-rise test, a balance test and a grip strength test. Of 47 women recruited, 3 were excluded for multiple gestation and 1 for gestation beyond 16 weeks and 6 days. Of 43 included, the mean age was 31.2 years, mean BMI was 27.1 kg/m2 and 16 (37.2 %) were primiparous. The mean number of steps-per-minute was 27.0 ± 4. The mean sit-to-stand time was 27 ± 4 s. The mean grip strength was 21.7 ± 5.3 kg. Only 5 (11.6 %) women were able to balance on one leg with their eyes closed. The mean heart rates pre-and post-step test were 80 ± 6 and 116 ± 16 bpm. Only one participant’s heart rate exceeded the RCOG modified heart rate target zones for exercise during pregnancy. Overall, modified exercise testing during pregnancy is safe and acceptable. These results give means and ranges against which pregnant women’s’ fitness may be compared in the future.

Colposcopy Clinic Non-attendance at Tallaght Hospital Duffy A, Osman A Gynaecology Department, Tallaght Hospital National data from the Cervical Check 2012–2013 report revealed that non-attendance rates at colposcopy clinics stand at 11.8 %. The aims of this audit were to identify the factors that influence DNAs and to establish the non-attendance rates at Tallaght Hospital colposcopy clinics. This retrospective study investigated the time period between July 2014 and June 2015. During this time there were 1238 DNA episodes. 100 patients were randomly selected and data was collected by means of short phone interviews. This data was subsequently analysed using excel. The mean age of participants was 37.8 years. DNAs were higher amongst the follow-up cohort. Non-attendance was more common in morning clinics with people most likely to DNA before 10.30 (n = 38). In the afternoon, DNAs were most common between 12.30 and 14.30 (n = 26). The month of June had the greatest number of DNAs (n = 12). The reason mostly commonly cited for non-attendance was the patient being unaware of the appointment (no letter and or text; n = 30). Illness (n = 11) and childcare (n = 7) were also common explanations for DNAs. The overall non-attendance rate was 16 %, higher than the national figures.

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 In an effort to improve rates of attendance at Tallaght Hospital colposcopy clinics, it is recommended that (1) morning clinics commence at 10 am and afternoon clinics at 14.30 pm to facilitate the school run and minimise DNAs due to traffic, (2) phone calls are made to patients who DNA more than once to establish the correct address, (3) a hospital cre`che is developed to enable out-patients to attend appointments without the added concern of childcare, (4) communication with the follow-up group is improved as this cohort are more likely to DNA. * DNA—did not attend.

An Interesting Case of Congenital Adrenal Hyperplasia Kelleher K1, Twomey J1, O Connell S2 1

Department of Paediatrics, University Hospital Limerick, Limerick; Department of Paediatrics, Cork University Hospital, Cork

2

Introduction: Congenital adrenal hyperplasia (CAH) is an autosomal recessive disease affecting one in 15,000 live births. Typically, the severe salt-wasting forms present with failure to thrive, recurrent vomiting, dehydration, hypotension, hyponatraemia, hyperkalaemia, and shock. Alternatively it can present with hyponatraemia, hyperkalaemia, and hypoglycaemia. Genital virilisation is also common. Rarely, there have been cases of familial CAH. They have been due to a variety of novel mutations, including x-linked forms caused by mutations in NR0B1 (DAX1). Case presentation: A 16 day old boy presented with a 12 h history of poor feeding and lethargy. He initially had no other signs or symptoms of illness, normal stools and urine and no sick contacts. There were two male cousins with CAH in his family history. Exam and investigations revealed a metabolic acidosis, and were suggestive of pseudohypoaldosteronism or hypoaldosteronism secondary to sepsis, with CAH and metabolic disorder in the differential. During the course of his illness he was noted to have one episode of hypoglycaemia (of 2.7 mmol/l) which was treated with 10 % dextrose. He recovered well and his bloods normalised with triple antibiotics and IV fluids. He had a normal ultrasound of his abdomen, however 17-hydroxyprogesterone was greater than 400 nmol/L. He was then commenced treatment for CAH. Conclusion: This is an example of an unusual presentation of CAH, as his only classical finding was of electrolyte disorder. This study is an important reminder that CAH should be maintained in the differential diagnosis of any neonate with hyponatraemia and hyperkalaemia until ruled out definitively with a 17-hydroxyprogesterone level. In addition, consideration of x-linked forms of the CAH should be considered in male children diagnosed with the condition. Further investigation of this interesting family would be needed to discover if this represents an Irish case of X-linked familial CAH.

An Audit of Abdominal X-rays; if Their Indications are Appropriate, in Particular for Constipation, in a Paediatric Population Kelleher K1, Ahmed I1 1

Department of Paediatrics, University Hospital Limerick, Limerick

Background: Abdominal x-rays (PFAs) are regarded as an overused radiological test. The majority of PFAs have results that are negative or non-specific, and so are unhelpful in diagnoses.

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Universally, the guidelines for diagnosis and treatment of constipation suggest that PFAs are of very limited value. Similarly, radiology guidelines for PFAs do not site constipation as an indication. Our aim was to establish whether the paediatric department of the University Hospital Limerick is using PFAs in an appropriate manner, thereby facilitating a high diagnostic yield. Methods: Retrospective analysis of all PFAs (n = 38) performed on paediatric inpatients and day ward patients over a 136-day period (between January and May 2015). The standard used to determine the appropriateness of the PFAs indications was The Royal Children’s Hospital Melbourne’s clinical practice guidelines for radiology. They were also reviewed by a consultant paediatrician who deemed several others appropriate or inappropriate on the basis of clinical judgement. The reports were evaluated to determine the percentage of abnormal findings and to identify any association between the appropriateness of the study ordered and the diagnostic yield. Constipation was considered separately. Results: Of the 38 PFAs included in the study, 55 % of the indications were deemed inappropriate. 68 % were reported as NAD or normal for the patient. 82 % were reported as NAD or faecal loading. The indication for 14 of the 38 PFAs included constipation. Of these, 79 % were deemed inappropriate. 93 % were reported as either NAD or faecal loading. Only one (7 %) PFA for constipation had a positive finding. Conclusions: PFAs have a low diagnostic yield, particularly when ordered for constipation. PFAs should be avoided during the investigation of constipation. In addition, local and international radiology guidelines should be adhered to when investigation abdominal pain. However, guidelines should never replace good clinical judgement.

In-Patient Variceal Bleeding Carries a Higher Mortality Rate than Outpatient Presentation: Time for More Aggressive Management in Cirrhotic InPatients? Fennessy S1, Dillon A1, Stewart S1 1

Centre for Liver Disease, Mater Misericordiae University Hospital

Introduction: Variceal bleeding has a reported in hospital mortality of 10–15 %. It is not known if developing a variceal bleed while an in-patient increases mortality in comparison to presenting with a variceal bleed. Aims: The aim was to determine if there is a mortality difference between presenting with, or developing a variceal bleed whilst an inpatient. Methods: A retrospective chart review was performed on all patients admitted with an acute variceal bleed between 2003 and 2013 admitted to our institution. Results: 98 patients, with 116 acute variceal bleeding episodes were included (median age 52.5 years, range 24–87). 65 % (76) patients were known to have cirrhosis at presentation, with 60 % of these known to have varices. Of those with known varices, only 23 % were on beta-blocker therapy on admission. 106 (91 %) presented with a variceal bleed and only 10 (9 %) patients developed a variceal bleed while an in-patient. Total in-patient mortality was 19 % and 3 month mortality was 26 %. There was a significant difference in in-hospital mortality between those who presented with a variceal bleed and those who developed a bleed during admission (16 vs 50 %, p = 0.009).

S203 Conclusion: When variceal bleeding develops in in-patients, they have a higher mortality. There is a need to improve recognition of high risk in-patients and to develop more aggressive portal hypertension management with beta-blockers and should perhaps be considered for primary endoscopic variceal ligation or early TIPS insertion.

Smoking Cessation Facilitation in a Respiratory Outpatient Clinic in University Hospital Limerick Mannion R1, Casserly B2 1 University Hospital Limerick, Dooradoyle, Limerick City, Limerick, Ireland; 2University Hospital Limerick, Dooradoyle, Limerick City, Limerick, Ireland

Objective: To achieve 100 % standards in smoking cessation facilitation in Respiratory Outpatient Clinic as per National Institute of Clinical Excellence (NICE) smoking cessation guidelines [PH10] 2008. Methods: Inclusion criteria were patients who want to quit smoking in the Respiratory Outpatient Clinic. There were no exclusion criteria. Information was collected from smoking cessation stickers and chart review from the Respiratory Outpatient Clinic. Results: They were 54 patients in the Respiratory Outpatient Clinic over two consecutive weeks. In total there were 12 patients documented as currently smoking. One patient was documented as not interested in quitting. Of the other 11 patients who wanted to quit smoking, verbal support was given to 5 patients and written support was given to one patient. One patient was referred to the smoking cessation clinic. Nicotine replacement therapy was prescribed to one patient. No other smoking cessation pharmacotherapy was prescribed and no contraindication to pharmacotherapy was recorded. Conclusions: Smoking cessation facilitation in this clinic did not achieve standards defined by the NICE guidelines. In response to this we have presented the results to the healthcare professionals in this clinic and we are taking efforts to improve this area. A written document supporting people who want to quit smoking is currently being drafted. When this is introduced to this clinic we will complete the second cycle of this audit.

Adherence with Falls Prevention Education in an Acute Setting Bolger MP, McDonnell, M Clifford, G Hurson Department of Trauma and Orthopaedics, St. Vincent’s University Hospital, Dublin 4 UCD Intern Training Network

Introduction Education is a core component of an inpatient Falls Prevention Programme. There are no agreed standards as to what the content, or how frequent offered, falls prevention education should take. SVUH have developed and introduced a falls prevention mnemonic (FALLS) for all staff treating patients at risk of falling; Footwear, cAll bell, gLasses,

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S204 toiLeting, and walking aidS. The aim of this study is to determine adherence with falls prevention education in an acute setting. Methods: A convenience sample of 150 admitted patients, over 50 years old, and their bed spaces were selected. Patients and bed spaces were reviewed between 09:00 and 12:00 over a 2 week period until the sample size was achieved. Descriptive statistics was used. Results: Twelve patients were off the ward and were excluded from analysis. Of the patients in bed (n = 95), half had their bedrails up. Of the patients sitting out (n = 43), 80 % had their footwear on; half of which were deemed unsafe. Of all patients on the ward (n = 138), a third had a functioning call bell within reach. Of the patients who required glasses (n = 105), 73 % were within reach. Of the patients who required a walking aid (n = 90), only 30 % were within reach. Implications: This study represents a ‘snap shot’ of patients on wards during a busy morning period. Unsafe footwear, glasses and walking aids out of reach, and an inability to contact healthcare staff represent significant falls risks. A number of hospital-wide quality improvement initiatives have begun as a result, such as a stand-alone bedrail policy and a daily call-bell check by healthcare attendants (HCA). It is envisaged that HCA will audit adherence monthly to improve reliability of the falls prevention programme.

A Case Report of Life-Threatening Bleeding From an Infected, Ruptured Femoral Pseudoaneurysm in an Intravenous Drug User; Lessons Learned About Definitive Management Kane G1, Herron C1, Dowdall J1 1 Department of Vascular Surgery, St. Vincent’s University Hospital, Dublin, Ireland

Introduction: Femoral artery pseudoaneurysms are a known complication of intravenous drug abuse. The aim of this case report is to contribute to the current insubstantial body of evidence on definitive management approaches to femoral pseudoaneurysms in this patient cohort. Case presentation: This case is of a 37 year old gentleman who presented to the emergency department at St. Vincent’s University Hospital bleeding from his right groin and with a decreased level of consciousness. He had a background history of: Intravenous Drug Use, Hepatitis C, recent DVT in his left lower limb (he was on Rivaroxiban at the time of presentation) and a chronic, infected, discharging sinus in his right groin. Two months prior to admission, the patient described the progressive formation of a painful ‘pimple’, in the groin area, swelling and localised redness. On the night of his presentation he was found surrounded in blood with needles nearby. On examination he was haemodynamically unstable and had no palpable distal pulses in the right lower limb. The patient was comprehensively resuscitated by our Emergency Department colleagues and was then prepared for theatre for surgical exploration, with the top differential being a ruptured, infected femoral pseudoaneurysm. Discussion: All case reports, case series and research papers concerning the management of infected ruptured/non-ruptured femoral pseudoaneurysms in intravenous drug users were examined. It became evident that the two most common approaches to definitive management are (1) Ligation of affected vessels and debridement of the pseudoaneurysm and (2) debridement and immediate/delayed revascularisation techniques.

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Conclusion: Our case report and the relevant literature in this area support the theory that ligation of vessels and excision of the pseudoaneurysm without revascularization is safe and effective in this patient population, most likely due to the presence of increased collateral vessels. Vessel ligation is more effective than revascularisation techniques which are plagued by complications, most notably that of graft infection and failure.

‘See Me, Hear Me, Speak to Me’ Clesham K1, Maksoud A Al1, Ahmed I2, Harte P3 1 WNW Intern Training Network; 2Surgery Department, Sligo University hospital; 3Clinical Audit Team, Sligo University hospital

Objectives: Obtaining a patient’s consent is a process that begins with providing information followed by a detailed discussion and concludes on signing a consent form. Our aim was to evaluate the patients’ experience of the consent process for an operative procedure and identify areas of potential improvements. Design/method: We carried out a prospective audit including patients who had an elective surgery at Sligo Regional Hospital during September 2015. All patients were asked, post-operatively, to answer a standard questionnaire related to the information they were given as a part of the standard informed consent process. Results: All patients were given information about the reasons for their operation. Out of this 93.8 % received the right amount of information and 93.75 % of people were given information about the risks and side effects of their operation. Half of patients did not receive any extra sources of information to help them make their decision and 15 % of patients did not read the consent form before signing. Interestingly, 40 % of patients did not get information about any alternative treatment options and 87.5 % of people received information about what recovery to expect post-op. Conclusions: Most patients felt they had enough information about their surgery to give consent. However, patients felt less well informed about any alternative treatment options and the expected recovery time. Giving the patient other sources of information such as leaflets, websites and videos could easily be implemented at the outpatient clinic to help them better understand the procedure and risks involved. Also since the consent form is a legal document, patients should be given the opportunity to read or take home a copy of the form for their own use.

Analgesic Use in an Elderly Inpatient Population Post-Orthopaedic Injury—How Well are We Prescribing? Corbett G, Healy-Evans S, Inch K, Connolly W, Tiernan C, Hayden C, Kyne L, Cogan L Setting: SPARC unit, The Royal Hospital, Donnybrook, Dublin 4 Introduction: Pain management and the appropriate use of analgesia is an important part of patient care following acute orthopaedic injury. Older patients are at increased risk of harmful medication side effects due to altered pharmacokinetics and drug- drug interactions. The risk

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 of potential over treatment is therefore high in elderly patients on multiple analgesics following an acute injury. Aim: This audit was designed to assess our current practice of analgesic prescribing and monitoring in the Royal hospital in a postacute short stay elderly rehabilitation unit. Methods: A detailed retrospective chart review was carried out. Patients who had been treated for an orthopaedic injury and had been discharged from the SPARC unit between November and December 2014 were selected. 35 charts were reviewed and data was collated using Microsoft excel. Results: Total number of patients n = 35, 37 % male (n = 13). On average patients were admitted with one analgesic medication prescribed (0–7) and discharged on 1 analgesic medication (0–4). 23 % of patients were discharged on more analgesia than at admission (n = 8). All patients had a documented review of their medication by the medical team with an average of 2 reviews per admission (range 1–6). A pain chart with visual analogue pain scale was documented in 66 % of cases (n = 23). Pain scores were recorded on average 14 times per patient with a wide range of (1–45). Laxatives were prescribed in 72 % of cases (n = 25). Laxatives were prescribed for 94 % of patients taking opiates. Conclusion: There is currently a good practice of regular medication review in the Royal hospital Donnybrook. The results conclude a low use of NSAIDs and a strong rate of opiate deprescribing in this department over the course of admission. Encouraging the use use of pain charts could improve the depresciption rate.

An Audit of Compliance with MRSA Screening of Patients Admitted from Other Hospitals Farrell A1, Flynn A2, FitzGerald S2 1

Dublin South East Training Network, St. James’s Hospital, Dublin 8; Department of Microbiology, St. Vincent’s University Hospital, Dublin 4

2

Abstract: Hospital admission is a risk factor for the acquisition of MRSA. The national guidelines recommend that all patients being transferred between hospitals are screened for MRSA on admission. This helps identify patients with MRSA so that appropriate treatment and infection control measures can be implemented to reduce the risk of transmission to other patients. This was carried out to assess compliance with MRSA screening on transfer. A retrospective study was carried out on all admissions to SVUH from other hospitals from 1st January to 30th September 2014. A list of these admissions was generated. The laboratory information system (APEX) and PAS were used to determine the admission date, whether MRSA screening was performed and, if so, how long after admission. There were 599 admissions during the study period, transferred from a total of 40 hospitals and admitted to 27 different wards in SVUH. Two thirds (64 %) of transferred patients were screened for MRSA within 48 h of admission to SVUH and a further 6 % were screened after 48 h of admission. Screening for MRSA was not performed at any time during the in-patient stay of 30 % of patients. Of those who were screened, 4 % were MRSA positive; 89 % were screened within 48 h of admission. Two patients were not screened in the first 48 h of admission. It is possible that these patients were colonised with MRSA at the time of transfer; however, this could not be determined as screening was delayed. Further efforts to increase compliance with MRSA screening of patients transferred from other hospitals is required.

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Educational Interventions to Teach Recognition and Management of Post Partum Haemorrhage: a Systematic Review McHugh D, Garry N, McAuliffe F, Higgins M UCD School of Obstetrics and Gynaecology Introduction: Post partum haemorrhage (PPH) is a common complication in obstetrics and a leading cause of both maternal morbidity and mortality. Multiple reports have stressed the need for high quality and repetitive educational interventions to teach clinicians how to recognize and manage a PPH. The aim of this study was to systematically review the evidence studying the effect of educational interventions teaching recognition and management of a PPH. Methods: An extensive search of multiple sources was performed, including databases (MEDLINE, EMBASE, Educational Resource Information Center (ERIC), British Educational Index (BEI), PsycINFO, Cochrane and Campbell Collaboration) and hand searching of relevant journals. On-line searching was performed in July 2014, to include literature published from 1980 to June 2014. Abstracts were reviewed and full articles were retrieved. The search strategy used the PICO (participants, intervention, comparison, and outcome) framework. MeSH and free text search terms were used. Quality of the studies was assessed, reviewing the question asked, rationale used, objectives, study design, intervention, evaluation and results published. Results: Two hundred and twelve papers were retrieved, and abstracts reviewed; full text was reviewed in 23. Thirteen papers met the criteria for inclusion, of which seven compared different educational interventions and six analysed the outcomes of one intervention. All the papers were either medium or high quality. Five papers reviewed clinical outcomes. There was significant heterogeneity between the studies in both clinical applicability and study outcomes. Conclusion: PPH is a common complication of delivery, but there is a paucity of studies reviewing the effectiveness of educational interventions to recognise and manage the condition. Despite this, and despite the heterogeneity of the studies, it is clear that there is a positive effect of education on participant confidence, knowledge, behaviour, and ultimately on clinical outcome.

A Close Call for a Urinary Catheter Enright R, Darcy F Department of Urology, West North West Network, University College Hospital Galway Introduction: An 80 year old female was admitted medically with anaemia secondary to urogenital bleeding of undetermined etiology. The Urological Team were consulted when the sited urinary catheter to determine the source of the bleeding was found to be misplaced. Case presentation: This lady was a morbidly obese, diabetic with a background of recurrent UTIs and a previous CVA. On admission, as the source of bloody discharge was unclear, the patient was catheterized and blood was noted in the bag. Subsequently she began to complain of right flank pain. Routine bloods showed Haemoglobin 10.3 and Creatinine 101. A CT abdomen showed the misplaced catheter in the right ureter complete with inflated balloon and hydronephrosis. The urological team was consulted and proceeded to deflate the catheter balloon and withdraw it back to the bladder. A

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S206 repeat CT with contrast, to outrule a ureteric perforation; demonstrated the ureter to be intact. For completion, cystoscopy was performed showing a large right congenital megaureter which the cystoscope was easily able to negotiate and without evidence of significant trauma. Patient was reassured and discharged back to the medical team. A Hysteroscopy demonstrated the source of bleeding to be benign uterine fibroids. Discussion: Although rare, similar cases of inadvertent ureteric catheterization have been reported with varying complications1-5. To our knowledge, this case report is the first related to an underlying congenital megaureter. It highlights one of the serious adverse events associated with a procedure widely regarded as routine and benign6. Up to 30 % of inpatient catheterisations may not be necessary7. Newly appointed interns have a higher incidence of adverse events, shown to decrease if a structured training program is implemented8. Further reduction in complications may be achieved by implementing strategies to identify and reserve catheterisation for those who absolutely need it9. 1. K.S. Baker, B. Dane, Y. Edelstein, et al. Ureteral rupture from aberrant Foley catheter placement: a case report J Radiol Case Rep, 7 (2013), pp. 33–40 2. M.K. Kim, K. Park Unusual complication of urethral catheterization: a case report J Korean Med Sci, 23 (2008), pp. 161–162 3. Modi, P.K.a, Salmasi, A.H.a, Perlmutter, M.A.b Inadvertent foley catheterization of the ureter Canadian Journal of Urology Volume 21, Issue 3, June 2014, Pages 7326–7329 4. A.W. Shindel, M.J. Cox, T.L. Bullock Unintentional transurethral Foley catheterization of the right renal pelvis Urol Nurs, 28 (2008), pp. 1–3 5. Kato, H. (1997) Incorrect positioning of an indwelling urethral catheter in the ureter. Int. J. Urol. 4(4), 417–418 6. http://www.uptodate.com/contents/complications-of-urinarybladder-catheters-and-preventive-strategies 7. Fakih MG, Watson SR, Greene MT, Kennedy EH, Olmsted RN, Krein SL, Saint S. Reducing inappropriate urinary catheter use: a statewide effort. Arch Intern Med. 2012 Feb 13;172(3):255–60 8. J.F. Sullivan, J.C. Forde, A.Z. Thomas, T.A. Creagh Avoidable iatrogenic complications of male urethral catheterisation and inadequate intern training: A 4-year follow-up post implementation of an intern training programme The Surgeon Volume 13, Issue 1, February 2015, Pages 15–18 9. Krein SL, Kowalski CP, Harrod M, Forman J, Saint S. Barriers to reducing urinary catheter use: a qualitative assessment of a statewide initiative. JAMA Intern Med. 2013 May 27;173(10): 881–6. doi:10.1001/jamainternmed.2013.105

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 surgery, from February 2015 to September 2015. A checklist was made of nine criteria in the ERAS guideline. Data was analyzed using Microsoft Excel. Results: Adherence to ERAS criteria: • • • • • • • • •

Carbohydrate loading of two drinks on morning of surgery (100 %) Bowel preparation of phosphate enema on morning of surgery (90 %) Nasogastric tube out on day one (80 %) Pro-kinetic agent lactulose after day one (70 %) Mobilization in the first 3 days (70 %) Patient controlled analgesia day one and/or day two only Catheter out on day one (20 %) Water sips on day one (60 %) and light diet on day 2 (40 %) Allied health professional (AHP) referral (50–60 %).

Conclusions: Factors that affected compliance to ERAS include lack of referral to AHP including dietician, physiotherapist, pain nurse specialist and stoma care nurse. Other areas for improvement include earlier catheter removal and earlier introduction of light diet. This should be implemented and a subsequent re-audit conducted. References: 1. J. Nygren, J. Thacker, F. Carli et al. Guidelines for Perioperative Care in Elective Rectal/Pelvic Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg 2013; 37(2)285–305. 2. Geltzeiler CB, Rotramel A, Wilson C, et al. Prospective study of colorectal enhanced recovery after surgery in a community hospital. JAMA Surg 2014;149(9)955–961 3. Nicholson A, Lowe MC, Parker J, et al. Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. Br J Surg 2014; 101(3):172. 4. Varandhan, KK et al. The enhanced recover after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized trials. Clin. Nutr 2010. 29(4):434–440 5. Muller S, Zalunardo MP, Hubner M, et al. A fast-track program reduces complications and length of hospital stay after open colonic surgery. Gastroenterology 2009; 136(3):842–847.

A Rare Case of Pyogenic Liver Abscess Complicating Acute Cholecystitis in a Patient with Acromegaly Lyons-Mehl L1, Khan I2

Audit of Enhanced Recovery After Surgery (ERAS) Guideline Adherence in Elective Colorectal Surgery Lyons Mehl L1, Waldron R2 NUI Galway, West North West Intern training network; 2Mayo University Hospital (MGH), Castlebar, Co. Mayo

1

Introduction and objective: The ERAS guideline is a perioperative care pathway1. Benefits include a reduction in both length of hospital stay and post-operative complications by up to 50 %2,3,4,5. ERAS has been implemented in MGH since 2012. The objective is to audit the adherence to ERAS guideline in patients undergoing elective colorectal surgery. Methods: A retrospective clinical audit with a prospectively maintained database was performed. A review of medical/nursing notes was conducted evaluating ten patients admitted for elective colorectal

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1

NUI Galway, West North West Intern training network; 2Mayo University Hospital (MGH), Castlebar, Co. Mayo West Northwest Intern Training Network

Introduction: Pyogenic liver abscess is a complication of acute cholecystitis1. An intra-hepatic gallbladder perforation results in an intra-hepatic abscess formation. Gallbladder perforation is seen in 0.8–3.2 % of acute cholecystitis cases2. Intrahepatic perforations leading to liver abscesses are even rarer. Mortality of liver abscess is 5–30 %3. The annual incidence is 2–3 cases per 100,000 population4. Risk factors include age greater than 60 years, hepatobiliary disease and male gender4. Case report: A 61 year old gentleman presented to the emergency department with right upper quadrant (RUQ) pain for 1 day and associated nausea and vomiting for 3 days with background history of Acromegaly. The patient was on lanreotide and cabergoline. His

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 abdomen was tender in RUQ and Murphy’s sign positive. The impression was acute cholecystitis. On admission the ultrasound abdomen showed debris in the gall bladder. Subsequent CT abdomen pelvis showed acute cholecystitis. Five days post admission an MRI MRCP showed a sealed GB perforation in the liver. CT abdomen pelvis showed an intrahepatic abscess measuring 11 9 4.7 cm. US guided drainage of hepatic abscess was performed and 250 ml of frank pus aspirated from the cavity. The patient was discharged 1 week post drainage with outpatient follow-up scheduled. Discussion: This case highlights liver abscess as a rare complication of cholecystitis. This patient was taking a somatostatin analogue and was therefore at increased risk of acute cholecystitis5. Somatostatin analogues suppress gallbladder contractility causing the formation of bile sludge, gallstones and cholecystitis. Gallstones develop in about 50 % of patients after 1 year of treatment6. References 1. Zerman G1, Bonfiglio M, Borzellino G, Guglielmi A, Tasselli S, Valloncini E, Di Leo A, de Manzoni G. Liver abscess due to acute cholecystitis. Report of five cases. Chir Ital. 2003;55(2): 195–8 2. Kumkum Singh, Amit Singh, Shivaji H Vidyarthi, Satyaprakash Jindal, and Chandra Kumar Thounaojam Spontaneous Intrahepatic Type II Gallbladder Perforation: A Rare Cause of Liver Abscess—Case Report J Clin Diagn Res. 2013 Sep;7(9):2012–4 3. Ruben Peralta, Liver Abscess [Internet] Medscape 2015[Updated 2015 Sep 28 cited 2015 Oct 2] Available from: URL http:// emedicine.medscape.com/article/188802-overview 4. Davis J, McDonald M, Pyogenic liver abscess Literature review 2014[updated: 2014 Jan 1. Cited 2015 Oct 2] Available from: URL http://www.uptodate.com/contents/pyogenic-liver-abscess 5. Shi YF1, Zhu XF, Harris AG, Zhang JX, Dai Q Prospective study of the long-term effects of somatostatin analog (octreotide) on gallbladder function and gallstone robot-assisted laparoscopic, straight-stick laparoscopic and vaginal approaches, and to observe the effect that duration of surgery. Surgical logbooks and computerised laboratory results were utilised to obtain data. formation in Chinese acromegalic patients. J Clin Endocrinol Metab. 1993 Jan;76(1):32–7. 6. Peter P. Michielsen, Herbert Fierens, Yvan M. Van Maercke Drug-Induced Gallbladder Disease Incidence, Aetiology and Management Drug Safety January 1992, 7(1):pp 32–45

S207 This case report describes the presentation of Mucormycosis in an immunocompromised patient, the means by which the diagnosis was made and the subsequent management. Description/case report: CD a 59 year old lady was referred by her GP to the Emergency Department with an 8 week history of a swelling in her neck. The swelling was in the right posterior triangle of her neck and had been progressively enlarging. CD had not experienced any weight loss, fevers, night sweats, fatigue, cough, dysphagia, loss of appetite or change in bowel habit in the preceding year. On examination CD had four non tender cervical lymph nodes. Initial investigations revealed a marked leucocytosis, CT neck showed bilateral cervical lymhpadenopathy and bone marrow biopsy and flow cytometry confirmed the diagnosis of T-Cell Acute Lymphoblastic Leukemia. 4 weeks after admission and after one cycle of chemotherapy CD developed fevers and rigors. Chest X rays showed a right middle lobe infiltrate. These persisted despite broad spectrum antimicrobial therapy. Broncho-Alveolar lavage provided specimens for histopathology which demonstrated evidence of Mucormycosis. Treatment with IV Posiconazole over 3 months led to clinical resolution. Discussion/conclusion: Mucormycosis is an extremely rare opportunistic infection. A literature review contains few population based studies of the prevalence and outcomes of Mucormycosis infections. A 2007 study in Spain identified the prevalence as just 0.43/1,000,000 inhabitants1. Infections most commonly present as pulmonary disease or rhinocerebral disease in patients with diabetes or hematological malignancies. It has an extremely high mortality rate. Isolated pulmonary Mucormycosis has a mortality rate of 65 %, disseminated disease carries a mortality rate of 96 %2. High clinical suspicion and the pursuit of invasive testing to establish a diagnosis in combination with appropriate anti-fungal therapy can improve survival amongst these patients. References: 1. Torres-Narbona M, Guinea J, Martinez-Alarcon J, et al. Impact of mucormycosis on microbiology overload: a survey study in Spain. J Clin Microbiol 2007;45:2051 2. Pulmonary mucormycosis: results of medical and surgical therapy. AUTedder M, Spratt JA, Anstadt MP, Hegde SS, Tedder SD, Lowe JE SOAnn Thorac Surg. 1994;57(4):1044.

Intern Practices in Counselling Patients on Smoking Cessation at University College Hospital Galway (UCHG): A Cross Sectional Survey Pulmonary Mucormycosis: A Rare Cause of Opportunistic Infection in a Patient with T Cell Acute Lymphoblastic Leukemia 1

2

O Connell J , Dempsey S , Fleming C

3

O Connell J1, Laffan J2, Lyons CM1, O Regan A2 1 University College Hospital Galway; 2Department of Respiratory Medicine University College Hospital Galway

University College Hospital Galway, [email protected]. Department of Infectious Disease Medicine, University College Hospital Galway. 3 Department of Infectious Disease Medicine, University College Hospital Galway.

West Northwest Intern Training Network

Intern Network: West Northwest Intern Training Network

1. All patients should be asked about their smoking status. 2. All patients who smoke should be advised to quit and the health benefits of quitting explained to the patient. 3. All patients who smoke should have their readiness to quit assessed. 4. Assist through stage-matched support to quit. 5. Arrange appropriate treatment.

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2

Introduction: Mucormycosis is a rare cause of fungal opportunistic infection.

Background/introduction: UCHG aims to follow the guidelines set out by the National Standard for Tobacco Cessation Support Program (NSTCSP). The NSTCSP utilizes the Brief Intervention Framework. It consists of the 5A’s (Ask, Advise, Assess, Assist and Arrange):

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S208 The aim of this study was to assess interns compliance with the above framework. Methods: The study is a quantitative study, utilizing a questionnaire survey to investigate smoking cessation counselling practices. 34 interns, both medical and surgical, were surveyed over a 1 week period at UCHG. Results: 34/35 (97.1 %) interns asked patients admitted under their service about their smoking status. 29/35 (82.9 %) interns quantified how much their patients smoked when assessing their smoking status. Only 23/34 (67.6 %) interns said they advised the patients they identified as smokers to quit with 11/34 (32.4 %) interns not advising them to quit. 11/34 (32.4 %) interns assessed their patient’s readiness to quit. 23/34 (67.6 %) interns did not assess their patient’s readiness to quit. 13/34 (38.2 %) interns informed patients who wanted to quit about the available pharmacological and non-pharmacological therapies. 5/34 (14.7 %) interns said they provided patients who were not ready to quit with the support to motivate future quit attempts. Conclusions/discussion: Interns at UCHG are adhering to the NSTCSP framework when assessing patient’s smoking status. A majority of interns at UCHG were not advising patients to quit, assessing patient’s readiness to quit, providing information on available therapies or providing support to patients for future quit attempts which is at variance with the NSTCSP framework.

An Audit of Headache Assessment in the Acute Assessment Unit of Sligo Regional Hospital and Development of a Pathway for Appropriate use of Investigations Brannick S1, O’Malley G2 1 WNW Intern Training Network; Email: [email protected]; 2Consultant Geriatrician and Acute Assessment Unit Lead, Sligo Regional Hospital

West Northwest Intern Training Network Objectives: – Audit of the current use of investigations in the assessment of headaches in the AAU of Sligo Regional Hospital against best practice outlined in the SIGN guidelines1. – Development of a pathway for appropriate use of investigations in headache assessment. Design/methods: This is a retrospective analysis of headache presentations to the AAU over a 2 month period in 2014. Discharge summaries, CT Brain orders and reports, and laboratory investigations were accessed for the 34 patients who presented with the primary complaint of headache(s) out of a total of 913 patients presenting during this period. Data was collected under the headings of red flags, neurological examination, ESR, time to CT Brain, results of CT Brain, and lumbar puncture. Results: Headache represented 3.7 % of all presentations. The ratio of females to males was 4:1 while 35 % of patients were aged 50 or over. ESR was measured in accordance with best practice1,2 in 100 % of patients over the age of 50 presenting with new-onset headache. 94 % of patients had a CT Brain to help rule out any underlying pathology; two (6 %) CT Brains showed an acute abnormality. The majority of CTs were done within 12 h of presentation. LPs were performed appropriately3 in 100 % of cases reviewed. 35 % of patients were admitted while the majority of patients (76 %) were discharged with the non-specific diagnosis of headache.

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Conclusions: Headaches are a common AAU presentation requiring admission. This preliminary data suggests assessment of headaches adheres to best practice in the majority of patients. Suggested improvements include increased consideration regarding the use of CT and careful evaluation of red flags. This data will be used to help develop an AAU pathway in order to enable more precise diagnoses. Limitations of this audit include small sample size; and a full chart review was not completed. References: 1. National Health Service. Diagnosis and management of headache in adults. Scottish Intercollegiate Guidelines Network; November 2008. 2. Duncan C, Gerrie L, Wilkinson S. Treatment of acute nontraumatic headache protocol. NHS Grampian; April 2013. 3. Beithon J, Gallenberg M, Johnson K, Kildahl P, Krenik J, Liebow M et al. Diagnosis and Treatment of Headache. Institute for Clinical Systems Improvement; January 2013. http://bit.ly/Headache0113

Renal Colic in the ED: Are We Imaging Correctly? Damla A1,2, Flood H1, Giri S1, Kelly N1, Haroon UM1, Leao J1, Ryan D2 1 Urology Department, University Hospital Limerick; 2Retrieval, Emergency and Disaster Medicine and Development Unit (REDSPoT), Emergency Department, University Hospital Limerick

University Hospital Limerick Intern Network Introduction: The appropriate radiological investigation of renal colic varies from center to center. According to the Royal College of Radiologists and the British Association of Urological Surgeons, CTKUB is the investigation of choice when investigating acute renal colic, unless contra-indicated. The aim of this audit is to assess local practice of radiological approach to renal colic presenting to the ED department at the University Hospital Limerick. The comparison standard used for this audit is 100 % for CT KUB as investigation tool for renal colic without contra-indications. Methods: All radiological investigations ordered between May and July 2015 were assessed in this study. Cases were selected for those radiological investigations ordered with the purpose of investigating renal colic within the Emergency Department. 179 consecutive cases were identified in this way. Data was analyzed for imaging modality of initial investigation and for final diagnostic study ordered. Analysis was carried out using Microsoft Excel. Results: Results of Initial study ordered are as follows: US 1.7 %, XR Abdomen 35 %, XR IVP 63 %, CT-KUB 0.56 %. Results of diagnostic investigation ordered are as follows: US 2.8 %, XR Abdomen 24 %, XR IVP 58.7 %, CT-KUB 14.5 %. Conclusions: The rationale of maintaining best-practice guidelines for renal colic are to standardize management, decrease ED waiting time, prevent potentially unnecessary admissions to hospital, avoid multiple investigations, and maximize sensitivity. The low rate of CTKUB as a diagnostic tool in UHL ED highlights the need for the formulation of a business plan demonstrating efficiency of CT KUB as first line imaging modality for patients with ureteric colic. Following the discussion and approval by relevant stakeholders, a new ureteric colic guideline will be implemented in the ED. A re-audit will be planned following these changes to establish adherence in using CT-KUB as the diagnostic investigation of choice. References: 1. HSE (2015). Kidney stone [online]. Available at: http://www.hse. ie/eng/health/az/K/Kidney-stones/

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 2. Turk, C. et al. (2015). Guidelines on urolithiasis. European Association of Urology. pg.11 3. Al-Hindawi, A. et al. (2014). A local clinical audit of CT KUB for the assessment of obstructive urinary calculi [image]. 2014 CSM. Poster Presentation

Get SMART, An Audit of Documentation Practices at the University Hospital Limerick Emergency Department Damla A1, Ryan D1 1 Retrieval, Emergency and Disaster Medicine Research and Development Unit (REDSPoT), Emergency Department, University Hospital Limerick

University Hospital Limerick Intern Network Introduction: Clinical Records have a pivotal role in maintaining safepractice in medicine. They facilitate diagnosis and treatment, allow communication of information between caregivers, and serve as an important defense in medical-legal disputes. The Medical Practitioners Act 2007, Section 43 legislates that physician Name, Registration Number, and Role are mandatory constituents of every medical record. In order to promote compliance to these standards, the SMART guideline was implemented at UHL in 2011 to ensure Surname, MCRN Number, Alias, Role, Time and Date were correctly documented. The aims of this audit were to assess ED physician compliance to SMART guidelines, re-educate staff on SMART guidelines, and assess for change in compliance following intervention. Methods: Patient charts were assessed for each of the SMART headings between September 9–14, 2013 and then November 19–25, 2013. Charts were sorted by ascending attending time and every 10th chart was selected for audit. 100 total charts were selected in this way. Data was Ordinal, assessing SMART entries as either being Legible (1), Illegible (2), or Not Documented (3). Data was analyzed using Microsoft Excel. Results: Completion of audit cycle demonstrated an improvement of Signature documentation from 23 to 34 %, MCRN from 25 to 26 %, Alias from 33 to 46 %, Time/Date from 39 to 49 %, and Disposition from 56 to 62 %. Documentation of Role declined from 16 to 13 %. Full compliance to guidelines improved to 8 % from 3 %. Conclusions: SMART documentation is beneficial because it is a short and simple way of providing document standardization, avoiding medico-legal complications, and improving efficiency in the ED. Recommendations for the future are to continue to educate staff about the SMART guidelines, advocate the use of rubber stamps for signing, suggest SMART boxes to organize where entries should be made, and re-audit again to monitor improvement to compliance. References: 1. Carlos, S., Kleinman, K., Simon, S. (2002). Quality and correlates of medical record documentation in the ambulatory care setting. BMC Health Services Research. 2(22), pg.1–7 2. Murphy, B. (2001). Principles of good medical record documentation. Medical Practice Management. 1(1), pg.258–260. 3. Office of the Attorney General. (2007) Medical statute book 2007. Irish Statute Book. 25(1), pg.43(8) 4. Wijewardene, D., Whooley, P., McNamara, R., Ryan, D. (2011). Get SMART: How to improve your medical note keeping!, PowerPoint presentation, MWRHL, Limerick 5. Medical Charts, n.d, photograph, viewed 4 October, 2015. Available at: http://www.physiciansproviso.com/wp-content/ uploads/2014/07/P2_medical-charts.jpg

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What About the Men? An Audit of DEXA Scans in University Hospital Limerick Tierney E, Shanahan E, Lyons D, Carew S, Costelloe A, Sheehy T Department of Therapeutics and Ageing, University Hospital Limerick, Dooradoyle, Limerick Background: Osteoporosis is the most common metabolic bone disease and is a leading cause of morbidity and mortality in older people. However, it often goes under-recognised and untreated as it is clinically silent. It is frequently forgotten about in males who are presumed less at risk than females. The current prevalence of osteoporosis in Ireland is 6.2 % in males and 20 % in females (Svedbom, 2013). Approximately 25 % of fragility fractures occur in men (Finkelstein, 2015).Therefore, surely the proportion of Dual Energy X-ray Absorptiometry (DEXA) scans should reflect this incidence of fracture? Aims: To analyse DEXA scans performed in University Hospital Limerick (UHL) between January 1st and July 31st for the years 2005 and 2015 in order to elicit the proportion of scans being done in male patients and to highlight any potential interval change. We also wanted to compare the age range of scans in men and women. Methods: All data from DEXA scans performed in the clinical age assessment unit in UHL is manually input into the system at the time of scanning. This dataset from Jan 1st to July 31st for the years 2005 and 2015 was analysed retrospectively using SPSS. Results: There were 1771 DEXA scans performed in the first 6 months of 2005. 90.7 % of these were in women with only 8.9 % being done in men. 2015 had a total of 2377 scans performed between January and July with women representing 89.9 % and men a mere 10.1 %. Conclusion: We are failing to meet ideal standards in measuring bone mineral density (BMD) in men. Epidemiological data shows that 20–30 % of fragility fractures occur in men, yet only 10 % of DEXA scans performed in UHL are on men. Therefore it is imperative to promote awareness of osteoporosis in men in order to reduce overall morbidity, mortality and indeed economic burden.

Isolated Internal Iliac Artery Aneurysm Rupture: A Case Report Heywood S1, Merrigan A2 1

Mid-West Intern Training Network, UHL, Dooradoyle, Limerick, Department of Surgery, University Hospital Limerick

2

Introduction: We present the case of acute unilateral rupture of an Isolated Internal Iliac Artery Aneurysm (IIIAA) with associated primary ilio-rectal fistula occurring on a background of recurrent rectosigmoid diverticulitis and bilateral IIIAA resulting in catastrophic rectal haemorrhage and death. Case: An 83-year-old patient with a history of recurrent rectosigmoid diverticulitis and bilateral IIIAAs for 2 years presented to the Emergency department with rectal bleeding. A Computed Tomography (CT) scan revealed a large haematoma adjacent to the right IIIAA almost indistinguishable from the adjacent rectosigmoid, consistent with a ruptured IIIAA and an ilio-rectal fistula. The fistula was of primary vascular enteric type and was accentuated by the inflammation arising from diverticulitis. The patient’s response to primary resuscitation was poor, he deteriorated quickly and it was

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S210 decided he was not for surgical intervention. He passed away within 3 h from the point of presentation. Discussion: Isolated Internal Iliac Artery aneurysms (IIIAA) are rare with an incidence of 0.3 to 0.5 % among intra-abdominal aneurysms. An associated ilio-rectal fistula is even less common to 0.5 % among intra-abdominal aneurysms. To date, only 55 cases of isolated IIAA have been reported in the literature as these aneurysms most commonly coexist with aortic aneurysms. Vascular-enteric fistulas are primary when arising denovo (spontaneous or due to infection, malignancy or radiotherapy) and secondary when occurring in patients with a history of vascular surgery/prosthetic grafts. Primary aorto- or ilio-enteric fistulas are less common than secondary with an incidence of only 0.07 % in the general population. The sequence of events which occurred in this case is unusual and to our knowledge has not been reported previously.

An Interesting Cause for a Distressing Cough in a Patient with COPD Leao J1, Mulloy E1 Respiratory Medicine, St John’s hospital, Limerick Abstract: The Respiratory Medicine service at St John’s hospital, Limerick sees many patients with COPD. For many, exacerbations are frequent and treatment is effective. For one 70 year old male patient it wasn’t so straight-forward. Following admission for an exacerbation of COPD, little benefit was gained from the use of intravenous antibiotics, steroids and chest physiotherapy. Continuing episodes of desaturation, witnessed respiratory difficulty during bouts of coughing and unresolving signs on clinical examination sparked us to expand our differential diagnosis. Following CTPA imaging to rule out a pulmonary embolus, posterior tracheal narrowing was detected. Still unclear whether a posterior mass or a tracheal abnormality was the cause, flexible bronchoscopy was carried out. During bronchoscopy, surprisingly, a marked improved in SpO2 was observed. Based on this we postulated that the bronchoscope was splinting open the patient’s collapsible airways during the investigation. A diagnosis of tracheomalacia was confirmed during this procedure as we saw the trachea fully collapse during episodes of coughing. With tracheal stenting planned in the coming weeks, this patient is doing well with home BiPAP and advice to avoid coughing too hard.

An Unusual Presentation of Acute Cholecysitis… Hyland SE1, Heneghan HM1, Geraghty J1 1 Department of General and Breast and Endocrine Surgery, St Vincent’s University Hospital, Elm Park, Merrion Road, Dublin

Typhoid Fever, a severe febrile illness caused by the gram-negative bacillus Salmonella typhi, is infrequently encountered currently in the developed world; therefore awareness of the severity and spectrum of this illness is low. Surgical complications of typhoid fever have been described since the 1800’s, including enteric perforation, gastrointestinal bleeding, cholecystitis (often acalculous) and gallbladder perforation.

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 We present the case of a healthy 35-year old Indian female, a resident in Ireland for many years, and presented to our Emergency Department with a 5-day history of right upper abdominal pain and vomiting. She also described a 3-week history of non-bloody diarrhea. Of note, she had returned from a 2-week stay in India 10-days prior to this presentation. Her physical examination was significant for pyrexia, marked tenderness in the right upper abdomen, and a positive Murphy’s sign. Laboratory investigations revealed a normal leucocyte count and liver profile, however C-reactive protein was significantly elevated at 277 mg/L. Stool samples were sent for culture. She was resuscitated and commenced on broad-spectrum intravenous antibiotics (Piperacillin/tazobactam), with a working diagnosis of biliary sepsis secondary to acute cholecystitis. Urgent radiological investigations included a gallbladder Ultrasound and MRCP which confirmed the presence of calculous cholecystitis. Despite 24-h of empiric treatment she remained febrile and unwell with increasing frequency of diarrhea. After 24-h, stool and blood cultures isolated Salmonella typhi, confirming a diagnosis of Typhoid Fever complicated by cholecystitis. After consultation with Infectious Disease physicians her antimicrobial regimen was modified to intravenous Cefotaxime and Metronidazole for 7-days. She defervesced after 5 days, abdominal symptoms resolved after 7 days and she had no further complications of Typhoid fever. She was discharged on oral antibiotics for a further 7-days. An elective cholecystectomy is planned given that bile and gallbladder calculi sequester the S.typhi organism, therefore she remains a chronic typhoid carrier until then.

A Comparison of the Lighthouse (LH) Test with Other Bedside Tests of Attention in Elderly Medical Inpatients O’Regan C1, Meagher, D2 1 Mid-west Intern network, University Hospital Limerick, Limerick. Ireland; 2Department of Psychiatry, Univeristy Hospital Limerick, Limerick, Ireland

Background and aims: The accurate assessment of attention is a key challenge in everyday clinical practice yet is prone to error by medical and nursing staff. The Lighthouse App is a new electronic application designed for use on a smart phone or tablet that assesses the ability to direct, focus and sustain attention. Method: A random sample of 50 inpatients over 65 years at the University Hospital Limerick was selected. These patients were asked to complete the Lighthouse App test as well as Months Backward Test (MBT), Serial Sevens, WORLD backwards, Digit Span Test Forward (DSF) and Backwards (DSB). The Mini Mental State Exam (MMSE) assessed general cognitive functioning at the time of testing with a MMSE score of B 23 indicative of cognitive impairment. Results: The 50 patients [mean age 77 ± 6.5; 50 % female] included fifteen (30 %) with MMSE score of B23. Overall, accurate recognition of the Lighthouse was 64 %. The Lighthouse test had modest concordance with conventional tests of attention and performed less well in terms of identifying patients with significant cognitive impairment as per MMSE score. Despite this, the LH App was the preferred test of attention amongst elderly medical patients. Conclusion: The Lighthouse Application was the test of choice in our sample of elderly medical inpatients. The current prototype of the LH requires further modification to enhance its sensitivity and specificity for cognitive difficulties.

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299

Malignant Intussusception in Adults Hintze JM1, O Connor DB1 1

Department of Surgery, Tallaght Hospital, Dublin, Ireland

Introduction: Small bowel obstructions are common, making up 15 % of all acute surgical admissions. Postoperative adhesions make up 84.9 % of cases, followed by abdominal herniae in 3.3 % and malignancies in 2.5 %1. Case report: A 71-year-old woman presented to the emergency department with complete constipation. Her surgical history was significant for a malignant melanoma excision from her right arm 9 years prior to her presentation. On examination she had a grossly distended abdomen and high-pitched bowel sounds. A CT scan showed a proximal small bowel obstruction and intussusception. There were also multiple mucosal-enhancing lesions in the stomach, duodenum and small bowel consistent with metastases. She was brought to the operating theatre where three areas of intussusception were identified and manually reduced. Biopsies at the time of surgery revealed melanotic cells and a subsequent diagnosis of metastatic melanoma was made. Discussion:Small bowel malignancies account for 5 % of all gastrointestinal malignancies2. Malignant melanoma (MM) of the gastrointestinal tract (GIT) is rare, with most cases occurring as metastasis from cutaneous lesions. Among intestinal malignancies, MM is the 5th most common malignancy, accounting for 1–3 %3. It is considered to be the extra-intestinal malignancy most likely to metastasise to the GIT. The most common site is the small intestine, owing to its rich blood supply4. The most common presentation of small intestinal MM is obstruction secondary to intussusception3. While intussusception is common in children, it only causes between 1 and 5 % of all obstructions in adults. MM is the most common malignancy to cause intussusception5. Management of such cases consists mainly of surgical intervention to resolve the obstruction. In cases where metastatic disease is limited to a single enteric metastasis, a metastatectomy can be considered. MM metastatic to the small bowel is rare, but a malignant cause of small bowel obstruction should be considered in cases where no previous surgeries or herniae can be identified. References: 1. O’Connor DB, Winter DC. The role of laparoscopy in the management of acute small-bowel obstruction: a review of over 2000 cases. Surgical endoscopy. 2012 Jan;26(1):12–7. 2. Haselkorn T, Whittemore AS, Lilienfeld DE. Incidence of small bowel cancer in the United States and worldwide: geographic, temporal, and racial differences. Cancer causes and control. 2005 Sep 3. Blecker D, Abraham S, Furth EE, Kochman ML. Melanoma in the gastrointestinal tract. The American journal of gastroenterology. 1999 Dec;94(12):3427–33. 4. Gill SS, Heuman DM, Mihas AA. Small intestinal neoplasms. Journal of clinical gastroenterology. 2001 Oct;33(4):267–82. 5. Slaby J, Suri U. Metastatic melanoma with multiple small bowel intussusceptions. Clinical nuclear medicine. 2009 Jul;34(7):483–5.

Absence of Melanocytes Does Not Mean Absence of Melanoma Hintze JM1, Hayden RE2 Tallaght Hospital, Dublin, Ireland; 2Mayo Clinic, Scottsdale, Arizona, USA

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S211 Introduction: Tumoral melanosis (TM), describes a microscopic finding of a nodular collection of dermal melanophages, macroscopically appearing like melanoma, however histologically lack positivity for melanocytic markers1. The finding of TM is significant as a risk identifier for completely regressed malignant melanoma. It may pose a diagnostic challenge, and given its potential to represent an underlying malignant pathology, should be managed as malignant melanoma2. Case report: A 48-year-old man was found to have a pigmented scalp lesion with histological examination of the excised lesion revealing a dermal collection of pigmented macrophages. Immunohistochemical analysis revealed an absence of melanocytes within the lesion. He was subsequently found to have metastatic melanoma of his cervical lymph nodes, and TM of his primary site without melanocytic cells. Ultimately he underwent right suboccipital neck dissection and right neck, with the final pathology showing 2 nodes positive for metastatic melanoma. Discussion: Tumoral melanosis is a rare finding that may indicate regressed melanoma. Regression of melanoma is a well-described phenomenon, occurring in 10–35 % of cases. While survival among patients with regressed melanoma is highly variable, it has been suggested that regression is a poor prognostic factor3. Given the potential consequence that TM may present malignant melanoma, it should be treated as such. Another implication of regression is that the primary lesion cannot be identified or classified. It prevents the assessment of the Breslow depth, mitotic rate or ulceration, prognostic indictors. This can lead to mismanagement and under treatment. Knowledge of this pathological entity is critical, as to not miss a potential diagnosis of malignant melanoma. TM is an infrequent clinical and pathological diagnosis that can have significant implications, in the form of regressed malignant melanoma. There is a definite need for awareness of TM and completely regressed melanoma, as this finding necessitates further evaluation and monitoring for metastatic melanoma. References: 1. Malafronte P, Sorrells T. Lymph node melanosis in a patient with metastatic melanoma of unknown primary. Archives of pathology and laboratory medicine. 2009 Aug;133(8):1332–4. 2. Satzger I, Volker B, Kapp A, Gutzmer R. Tumoral melanosis involving the sentinel lymph nodes: a case report. Journal of cutaneous pathology. 2007 Mar;34(3):284–6. 3. High WA, Stewart D, Wilbers CR, Cockerell CJ, Hoang MP, Fitzpatrick JE. Completely regressed primary cutaneous malignant melanoma with nodal and/or visceral metastases: a report of 5 cases and assessment of the literature and diagnostic criteria. Journal of the American Academy of Dermatology. 2005 Jul;53(1):89–100.

Mycotic Splenic Vessel Aneurysm Leading to Massive GI Bleed: Abstract Casey L, Kelly J, Conneely J Department of General and Hepatobiliary Surgery in the Mater Misericordiae Hospital, D7 Background: Immunosuppression is a known risk factor for complicating an aneurysm with infection. Splenic artery aneurysm is the most common visceral aneurysm, however, splenic vein aneurysm is far less observed. Mucormycosis is an infection by the Mucorales order of fungus, for which immunosuppression is a risk factor. We

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S212 present the case of a 48 year-old immunocompromised woman with mycotic abscess causing ruptured splenic vessel pseudoaneurysm. The case: A 48 year-old woman presented to the emergency department 1 month post double lung transplant for idiopathic pulmonary fibrosis with massive and unstable upper GI bleed. She underwent an emergency exploratory laparotomy which revealed gastric ulceration eroding into the splenic hilum. She then underwent enbloc distal gastrectomy + splenectomy with gastrojejunostomy formation. Histology showed a mycotic abscess involving the splenic hilum, caused by mucormycosis. Discussion: True mycotic aneurysm refers to those that originate from septic vegetations in the heart, or those caused by fungi. Mucorales order in particular is ubiquitous in nature, but mostly poses threat to immunocompromised or diabetic patients. Though it has a propensity for vascular invasion, rhino-orbital and respiratory infections are far more often described. The source of mucormycosis is unclear in this patient, but is assumed to be nosocomial. Splenic vein aneurysm is extremely rare, with increased portal pressure the proposed main underlying mechanism. The presentation of the disease is varied with rupture in this case. Treatment involves removal of risk factors, infected tissue removal and targeted anti-fungal agents such as amphotericin B. Removal of immunosuppression in transplant patients increases risk of organ rejection, thereby complicating treatment. Conclusion: Mycotic aneurysms of the splenic vasculature caused by mucormycosis are exceedingly rare. Nonetheless, they pose a lifethreatening risk when present and in the case of solid-organ transplant patients present a therapeutic challenge as reducing immunosuppression increases risk of rejection.

A Case of H. Pylori Induced Menetrier’s Disease Complicated by Bilateral Pulmonary and IVC Thrombi Neary B, Moran C, Duignan J, Doherty G Department of Gastroenterology, St Vincent’s University Hospital, Dublin Introduction Me´ne´trier’s disease is a rare hyperproliferative proteinlosing gastropathy of the gastric foveolar epithelium, thought to be associated with CMV or H Pylori infection. Case presentation: A 53-year-old male presented with a 2 week history of shortness of breath on exertion. Routine bloods revealed a microcytic, iron deficiency anaemia (Hb 6, Ferritin 6) and hypoalbuminaemia (19 mg/dL) CT Imaging revealed bilateral 2nd order pulmonary emboli and a large IVC clot extending to the common iliac veins and a grossly dilated stomach, with diffuse circumferential wall thickening. These findings were consistent with those seen on Gastroscopy (diffusely nodulated stomach wall) and EUS (diffuse nodular thickened gastric fold pattern). Antral biopsies were positive for H. Pylori. There was no evidence of malignancy but foveolar hyperplasia and cystically dilated foveolar glands consistent with Menetrier’s disease. Management involved blood transfusion, therapeutic anti-coagulation and triple therapy for H. Pylori with repeat OGD and biopsy following treatment to assess resolution. Discussion: The patient in this instance presented with the typical radiological and histological findings of Menetrier’s disease with hypoalbuminaemia in the setting of a H. Pylori infection. However, only rarely has it been seen with an associated thrombosis as in this

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 instance. The mechanism is thought to be similar to the pro-thrombotic state in Nephrotic syndrome secondary to protein loss. Ann Trop Paediatr. 2011;31(2):141–7.Menetrier’s disease associated with Helicobacter pylori: three cases with sonographic findings and a literature review. Fretzayas A1, Moustaki M, Alexopoulou E, Nicolaidou P. V. G. McDermott, C. E. Connolly, P. Finnegan. Menetrier’s disease presenting with deep venous thrombosis, iron deficiency anaemia and early evolution to atrophic gastritis. Irish Journal of Medical Science, 1986, Volume 155, Number 2, Page 53 Polga, J; Spencer, R. Menetrier’s Disease with Occlusion of Splenic and Brachial Arteries. Clinical Nuclear Medicine, 1982, Issue 11

Eosinophilic Granulomatosis with Polyangiitis: A Case Report Yoo LJH1, Molloy E2 UCD Intern Training Network; 2Department of Rheumatology, St Vincent’s University Hospital, Elm Park, Co. Dublin

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Introduction: Eosinophilic granulomatosis with polyangiitis (EGPA) is a multisystem anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis disorder characterised by asthma, eosinophilia and eosinophil-rich infiltrates affecting small to medium vessels with an annual incidence ranging between 0.5 and 4.2 per million in Europe1. The American College of Rheumatology identified six criteria, of which 4 is required for the diagnosis of EGPA: asthma, eosinophils [10 %, neuropathy, migratory lung infiltrates, paranasal sinus abnormalities and extravascular eosinophils on biopsy2. Case presentation: We present a case of a 33 year old man with no history of asthma or chronic rhinosinusitis, who presented with polyarthralgia, myalgia, palpable purpuric rash affecting his elbows, ankles and feet, oral ulceration, hemoptysis, epistaxis and night sweats. Blood count revealed normochromic normocytic anaemia and 21 % eosinophilia. Urine dipstick showed 2+ blood and 1+ protein with normal kidney function. Chest X Ray showed multifocal infiltration with left hilar lymphadenopathy. CT thorax showed diffuse ground glass opacities. Bronchoalveolar lavage confirmed diagnosis of diffuse alveolar haemorrhage. Immunoglobulin E (IgE) levels were raised at 200 and ANCA positive with antibodies directed against PR3 with a cytoplasmic staining pattern. Anti-nuclear antibody and anti-glomerular basement membrane antibody were negative. IgG, A, M and Complement 3 and 4 levels were normal. Skin biopsy showed dermal vasculitis with fibrinoid necrosis and prominent eosinophils, in keeping with a diagnosis of EGPA affecting the lungs, kidneys, skin and joints. Patient was given blood transfusion, systemic glucocorticoids, therapeutic plasma exchange and rituximab infusion. An excellent response resulted with his Birmingham vasculitis activity score of 24 at the time of diagnosis reduced to 3 at his 1 month follow up. Conclusion: This case report highlights the importance of prompt recognition and treatment of systemic vasculitis. The use of biologic agents such as Rituximab have shown to be a promising alternative therapy, especially its ability to achieve long-term remission without the requirement of maintenance therapy3-5. References: 1. Watts RA, Scott DGI. What is known about the epidemiology of the vasculitides? Best Practice and Research Clinical Rheumatology 2005; 19(2): 191–207

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 2. Masi AT, Hunder GG, Lie JT, et al. The American college of rheumatology 1990 criteria for the classification of Churg-Strauss Syndrome (Allergic granulomatosis and angiitis). Arthritis and Rheumatism 1990; 33(8): 1094–1100 3. Stone JH, Merkel PA, Spiera R, et al. Rituximab versus cyclophosphamide for ANCA-associated vasculitis. N Engl J Med 2010; 363(3): 221–232 4. Jones RB, Tervaert JW, Hauser T, et al. Rituximab versus Cyclophosphamide in ANCA-associated Renal Vasculitis. N Engl J Med 2010; 363(3): 211–220 5. Cartin-Ceba R, Fervenzab FC, Specks U. Treatment of ANCAassociated vasculitis with Rituximab. Curr Opin Rheumatol 2012; 24(1): 15–23

A Case of Colonic Atresia with the Passage of Meconium in Galway University Hospital; A Case Report Hehir, L1, Moylett, E2 Case summary: Baby M is a Female infant born 21/09/2015 in Galway University Hospital by vaginal delivery to a 26 year old primagravida with an uncomplicated pregnancy and normal antenatal scans. Presenting complaint: On day 2 of life, Baby M presented with abdominal distension, bilious vomiting and delayed passage of meconium. On Exam, abdomen was distended and tympanic, bowel sounds were infrequent and high pitched. Baby was having bilious vomit. The anus was patent. Investigations: FBC and U and Es were normal. Lactate was 1.9, Cultures were negative. PFA showed marked distension of small bowel loops. Management: Baby M was admitted to NICU and placed NPO, Empirically started on IV benzylpenicillin and gentamycin. She was transferred to Crumlin paediatric services on 22/09/15. An upper GI contrast study showed colonic atresia. She proceeded to theatre on 24/09/15 for a colonic atresia repair and colostomy formation. Findings: At surgery, atresia of the transverse colon was identified with a massively dilated proximal ascending colon and a very small atretic splenic flexure. An end colostomy was formed and the distal atretic splenic flexure was brought out as a mucous fistula. Post op: Prior to discharge a rectal suction biopsy was performed to exclude Hirschprung’s disease which was negative. Baby M was discharged on 26/10/15 with the aim to plan stoma reversal in the future.

The Prevalence of Burnout and Error in Interns in Ireland: Is There a Link? Layla Hehir1, Angela O’Dea2, Paul O’Connor3, Sinead Lydon3, Dara Byrne1,3 West Northwest Intern Training Network, 2Royal College of Surgeons in Ireland; 3National University of Ireland, Galway

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Background: Burnout constitutes a significant problem among physicians which impacts negatively upon both the doctor and their patients. Previous research has indicated that burnout is prevalent

S213 amongst junior doctors, and there may be a link between burnout and medical error. Aims: To identify levels of burnout among interns in Ireland, and evaluate whether the risk of burnout is higher among interns who have made a medical error. Methods: The Maslach Burnout Inventory-Human Services Survey (MBI- HSS) was distributed to all interns in the Republic of Ireland following ethical approval from all intern training networks. The survey was anonymous and distributed online. Results: In total, 228 interns (response rate of 38 %) completed the survey. Of these, 47.2 % reported high levels of emotional exhaustion, 44.2 % scored high on depersonalisation and 53.8 % presented with low levels of personal accomplishment. In total, 20.2 % presented with all three symptoms, fulfilling the criteria for burnout. A total of 66.7 % of the respondents had made a medical error in the last 3 months that had played on their mind. The risk of burnout for those interns that reported making a medical error was no higher than those that did not report making a medical error. Conclusions: A considerable portion of interns in Ireland report high levels of emotional exhaustion and of depersonalization, and low levels of personal accomplishment. These findings suggest that Irish interns are at a higher risk of burnout than interns in other countries. The study is ongoing and longitudinal but the initial data demonstrates that there is a need to examine how the risk of burnout can be reduced in the intern population. An understanding of the causes and the risks of burnout and its association with making an error, is not only relevant during internship, but is important as interns progress in their medical careers. References: Nason, G. J., Liddy, S., Murphy, T., & Doherty, E. M. (2013). A cross-sectional observation of burnout in a sample of Irish junior doctors. Irish journal of medical science, 182(4), 595–599.

Graphic Graft Surgery: Extra-Anatomic Graft Obstruction Complicated by Abscess Formation Abdullah N, Allen M Department of Surgery, Beaumont Hospital, Dublin 9, Dublin North East Intern Training Network Description: A 82 year old lady transferred from OLOL to Beaumont Hospital complaining of a swelling near the right groin with seropurulent discharge. She has a background history of an axillofemoral and fem–fem cross over graft 6 years ago, periperhal vascular disease, hypertension and hypercholesterolaemia. She also has a significant smoking history. On examination vital signs were stable. Abdomen was soft and non tender. The swelling in right iliac fossa was 2 9 2cms, located above the right groin with seropurulent discharge. Periperhal vascular examination: Bilaterally cold feet, decreased capillary refill. Periperhal pulses were non palpable. Doppler signals right femoral artery present, weak left femoral artery and distal signals absent. The patient’s blood tests showed haemoglobin concentration 10.9 g/dl (11.7–16.0), white cell count 10.2 9 109/L (4.00–11.00) and C reactive protein 40.3 mg/L (0.0–5.0). The patient was commenced on broad spectrum intravenous antibiotics Cefuroxime 1.5 g TDS and Metronidazole 500 mg TDS. An urgent CT Thoracic Abdomin and Pelvis revealed a thrombosed infected axillobifem graft, a collection surrounding the graft in the subcutaneous tissue of the lateral chest and flank. Also incidently found a right hilar mass lesion. CT Angiogram confirmed an obstructed graft with extensived collaterals supplying the lower limbs.

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S214 The patient underwent subtotal graft excision. Cuffs of the graft were left in situ, the small cuffs of the prosthetic graft were oversewn to maintain patency and allow adequate perfusion of the lower limbs through important collaterals. Hydrogen Peroxide was used to sterilize the cavity and incision sites. 3 Jackson-pratt drains were left insitu at the incision sites. The removed graft and pus sample was sent for culture and sensitivity. Post op feet were warm but no doppler signs present.

Treatment Resistant Post-Operative Pain in the Context of Thoracotomy O Carroll L, Redmond K Cardiothoracic Surgery, Mater Misercordiae University Hospital, Dublin, Ireland Introduction: Pain is an expected outcome of surgery, however uncontrolled or inadequately controlled acute pain is both a complication of surgery and a predisposing factor for developing further complications. It has been associated with increased length of stay, immobility, respiratory tract infections and the development of complex chronic pain. Patients who undergo thoracic surgery are at high risk of severe post-operative pain and pain related complications, due to the anatomy of the surgical sites and chest wall. Case report: A 44 year old male had right middle lobectomy in the context of recurrent lower respiratory tract infections (LRTI) with persistent right middle lobe consolidation, thoracic lymphadenopathy and intermittent severe right sided chest pain. He was an active smoker with a 30 pack year history. His physical examination was normal with the exception of poor air entry to the right middle lobe. On bronchoscopy there was a cherry red mass protruding into the right middle lobe bronchus. He was given a tentative diagnosis of pulmonary carcinoid. On histology, it was found the mass was a hamartoma. He had a difficult surgery, necessitating right thoracotomy and large airway resection. In the immediate post-operative period, his epidural failed and his pain was uncontrolled on opioid patient controlled analgesia, paracetamol and analgesic adjuvants in combination. He was slow to mobilise and developed post-op LRTI. His stay was prolonged for antibiotic treatment and effective pain control. Comments: Improvements to thoracic surgery including neuroleptic premedication for high risk candidates, VATS lung resection, enhanced recovery clinical nurse specialists, dedicated acute pain services and defined doctor and nurse specific protocols for pain management have greatly reduced the burden of post-operative pain in this patient cohort. This case illustrates some of the potential outcomes of uncontrolled post-operative pain and highlights the value of effective mechanisms for ensuring adequate analgesia.

An Unwanted Christmas PRESent; A Rare Case of Posterior Reversible Encephalopathy Syndrome Lambe J1, Tubridy N2 1,2 Department of Neurology, Saint Vincent’s University Hospital, Dublin 4; UCD Intern Training Network

Introduction: Posterior Reversible Encephalopathy Syndrome (PRES) is an extremely rare condition, with an unknown incidence

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 and reported only through various case studies. The term encapsulates a clinical radiographic syndrome of heterogenous aetiologies, in which patients present with combinations of headache, altered levels of consciousness, seizures and/or visual changes. PRES has been associated with various medical conditions, including hypertension, eclampsia and use of immunosuppressive therapies, and is characterised by posterior cerebral white matter oedema on neuroimaging [1]. Case description: A 61 year-old female presented shortly before Christmas with a 3–4 week history of severe, global headache of insidious onset, with associated nausea/vomiting for 10 days, and increasing confusion and disorientation. She reported no recent illness, and her medical history was significant for a left axillofemoral bypass. On admission her blood pressure was 203/112, with other vital signs stable. On examination the patient was encephalopathic, with 4/5 power on her right side, and brisk reflexes bilaterally. DWI MRI revealed diffuse white matter abnormality with more prominent changes in the left occipital region reflecting hypertensive encephalopathy, and evidence of multifocal lacunar infarcts. There were several small aneurysms in the left basilar, internal carotid, and posterior communicating arteries on CT Angiogram, with CT TAP revealing right renal artery stenosis and an atrophic right kidney. CSF markers were normal. The patient was commenced on amlodipine, with gradual improvement in clinical symptoms. Discussion: As PRES remains a typically treatable syndrome, this case demonstrates the importance of prompt recognition and treatment of the underlying disorder in order to prevent the occurrence of potentially permanent damage. References: 1. Hinchey J, Chaves C, Appignani B, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med 1996; 334:494.

Auditing the Contents of Trolleys for Venepuncture and Cannulation in Inpatient Wards of Saint Vincent’s University Hospital Lambe J1, Callanan I2 1,2 Clinical Audit Department, Saint Vincent’s University Hospital, Dublin 4; UCD Intern Training Network

Background: NCHD’s spend a significant portion of their working day inserting cannulae and taking blood samples from patients. Inadequately stocked storage trolleys for venepuncture and cannulation is a source of frustration for junior doctors due to time wasted in gathering equipment, and therefore potentially compromises patient care. Inconsistency in layout of these trolleys is a particular issue for on-call doctors unfamiliar with certain wards. Aim: To audit the contents of venepuncture and cannulation trolleys, and evaluate the need for improvement in stocking and layout of these trolleys. Methods: Every trolley for storage of venepuncture and cannulation equipment in all inpatient wards in Saint Vincents University Hospital was audited using a standardised checklist. Layout of contents was compared to the standardised index page recommended for all such inpatient trolleys in the hospital. Results: No trolley of the 30 audited was perfectly stocked. On average 66.17 % of recommended contents were present in each trolley. Additionally, of the equipment present, 27.7 % was misplaced within the trolley.

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Conclusions: With less than two thirds of the necessary equipment present on average, there is a large scope for improvement in the stocking of inpatient venepuncture and cannulation trolleys in Saint Vincents University Hospital. Proper stocking, as well as an increased drive towards the proper implementation of a standardised layout of trolley contents, could potentially increase NCHDs’ efficiency, and ultimately patient safety [1]. Reference: 1. Lindley S, Robertson I. A standardised storage solution for venepuncture/cannulation equipment could save an NHS hospital the equivalent of a whole junior doctor. BMJ Qual Improv Report 2013; 2.

Audit of the Inpatient Psychiatric Unit Detoxification Service in Saint Vincents University Hospital 1

Lambe J, 2Joyce M, 3Clarke C, 4Rogers C

1,2,3,4 Department of Psychiatry, Saint Vincent’s University Hospital, Dublin 4; UCD Intern Training Network

Background: Patients undergoing alcohol detoxification are often chronically deficient in Thiamine. The process of medically assisted withdrawal can precipitate further acute loss of this vitamin, potentially leading to acute issues- such as Wernicke’s Encephalopathy- as well as irreversible conditions such as Korsakoff’s Psychosis. Aim: To review the treatment records of all inpatients admitted to the acute psychiatric unit in Saint Vincents University Hospital who underwent alcohol detoxification over a 3-year period (01/12/ 2012–30/11/2015). In doing so we hoped to retrospectively assess whether appropriate detoxification protocols are being adhered to. This was a re-audit of a similar project carried out in 2008. Methods: Treatment records of all inpatients who underwent an alcohol detoxification regimen in Saint Vincent’s Elm Mount Unit between 01/12/2012 and 30/11/2015 were analysed against the Saint Vincents University Hospital Medical Guidelines 2012 and the Maudsley Guidelines (12th edition) [1, 2]. Results: Of 18 alcohol detoxifications carried out in this timeframe, 5 patients (28 %) received the minimum recommended 3 days of parenteral Pabrinex supplementation, with 10 patients (55 %) receiving no parental supplementation at all. 16 cases (89 %) received oral thiamine supplementation. 14 (78 %) were prescribed the minimum 5 days of chlordiazepoxide, with 2 patients (11 %) receiving no benzodiazepine treatment. Conclusion: While the majority of patients are being prescribed an adequate regimen of chlordiazepoxide, only 28 % are receiving the recommended parenteral prophylaxis to prevent Wernicke’s Encephalopathy and associated complications of alcohol misuse. While this represents a slight increase on figures reported in 2008 (24 %), further improvement is required in our alcohol detoxification service. This could be achieved by increasing awareness of current protocols among NCHDs, assessed via a future re-audit. References: 1. Knox R. Alcohol Detoxification [Intranet]. Dublin: Saint Vincents University Hospital; 2012. Available from: http://intranet/ uploadedFiles/ Med%20Guide204.1.1%20Alcohol%20Detoxification.pdf 2. Taylor D, Paton C, Kapur S. The Maudsley Prescribing Guidelines in Psychiatry. 12th Edition. London: Wiley-Blackwell; 2015

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Orthostatic Hypotension and Efforts to Manage a Difficult Case Stankard A1, Walsh T2 1

University Hospital Galway; 2Consultant in Geriatrics and Stroke Medicine, Galway University Hospitals Intern Network: West Northwest Intern Training Network

Introduction: Orthostatic hypotension is prevalent in *6 % of the elderly living in the community.1 The following case illustrates the difficulty in managing orthostatic hypotension presenting to hospital without identifiable cause. Case: EOC is a 73 year old female who presented to the ED after experiencing an unwitnessed fall at home, with a history of numerous falls in the preceding weeks. EOC had a past medical history of haemochromatosis, hyperthyroidism, and depression. An initial falls workup, consisting of CT Brain, MRI Brain, ECHO, telemetry monitoring, was normal. During admission, worsening postural BP drops caused numerous dizzy spells and falls. Potentially causative medications were withdrawn, without improvement. Cognitive blunting, as measured by Addenbroke Cognitive Examination, also accelerated during admission. Mobility became increasingly impaired, but no convincing signs of Parkinson’s Disease were noted. Multiple specialties were involved to try and achieve a unifying diagnosis. Further investigations including a CT TAP, EEG, phaeochromocytoma screen and 24 h BP monitoring did not bring one closer. Tilt-table testing showed significant orthostatic hypotension without an increase in the heart rate. Non-pharmacological measures (Grade II Compression stockings and abdominal binders) were used, with limited success, to manage dizziness and falls. Midodrine and Fludrocortisone were commenced in consultation with the family and the Falls and Blackout Clinic in SJH. Fludrocortisone was discontinued after supine SBPs rose to [200 mmHg. EOC was discharged with plans for 24 h care in place. One month following discharge EOC presented with a haemorrhagic stroke, and midodrine was discontinued. Discussion: Orthostatic hypotension is a feature of autonomic dysfunction that may result from neurodegenerative disease affecting the central and peripheral nervous systems. Management poses a challenge to both patient and doctor with the above case illustrating the risks posed by pharmacological interventions to manage postural hypotension, which are advised after non-pharmacological interventions have been implemented.2 1. Freeman R, Wieling W, Axelrod FB (2011) Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clinical Autonomic Research. 21 (2): 69–72 2. Metzler M, Duerr S, Granata R (2013) Neurogenic orthostatic hypotension: pathophysiology, evaluation, and management. Journal Neurol. 260(9): 2212–2219.

Take Note!: An Audit of Clinical Record Keeping in a Dublin University Hospital Dempsey PJ1, Kenny G2, O Malley K3 (Mater Misericordiae University Hospital) Background: Healthcare record keeping is a key element of patient care. It is essential for communication between professionals, ensuring continuity of care and demonstrating the duty of care has

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S216 been fulfilled. Adequate information must be recorded in order for notes to serve these functions. The HSE has established standard recommendations for the documentation of medical notes. An audit was undertaken to measure adherence to these standards within a university teaching hospital. Methods: A retrospective audit was undertaken. The presence or absence of 9 individual pieces if information (patient name, medical record number (MRN), date, time, doctor’s name, doctor’s title, signature, medical council number or bleep and legibility) was recorded per note entry. Results: 300 individual note entries were examined from a random selection of charts in both medical and surgical wards. The most commonly omitted item was time of entry (only 44 % of notes contained this). Patient name, MRN, doctor’s name and doctor’s title were all absent in over one third of notes. Date was the most commonly recorded item (present in 99 %), followed by signature (present in 94 %) then medical council number/bleep (present in 80 %). 91 % of notes were considered legible. Conclusion: Vital elements of healthcare records are often missing. These findings suggest that further education and reinforcement regarding the required standards of healthcare record keeping is merited.

A Case of Recurrent Venous Thromboses Ryan S1, Marrinan A2 Consultant: Dr. Martin Mulroy

Department of Medicine, Our Lady of Lourdes Hospital, Drogheda, Co Louth; DNE Intern Training Network Summary: 43-year-old female presenting with neck pain, recurrent headache and visual disturbances secondary to cerebral venous thrombosis A 43-year-old female presented to A&E with neck pain, recurrent bilateral frontal headache and flashing lights and black spots in her visual fields. On presentation, she was hemodynamically stable and CNS exam was unremarkable. Her background history was notable for essential thrombocytosis, previous splenic arterial and sagittal sinus thromboses, and Budd Chiari for which she was on warfarin. In light of this, there was a concern there may be a recurrent cerebral venous thrombosis. CT and MRI brain were normal, while CT venogram confirmed progression of a previously identified filling defect within the right sigmoid sinus and right internal jugular vein. Neurological, haematological and ophthalmlogical input were sought, and subsequently revealed mild papilledema for which acetazolamide was commenced. The patient was treated symptomatically with paracetamol plus difene PR on alternating days, and topiramate was trialled as headache prophylaxis. Warfarin was to be continued indefinitely. Maintaining a therapeutic INR of 2.5–3.5 was of primary importance, thus the use of an NSAID required caution. As such, the patient was discharged with CIT for INR levels, to be continued until levels were therapeutic for 2 consecutive days. She was discharged asymptomatic a week later after admission, to be followed up by the admitting Doctor and ophthalmology. Conclusion: Cerebral venous thrombosis is an uncommon cause of cerebral infarction relative to arterial disease, but is an important consideration because of its potential morbidity.

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An Itch in Time Saves Lives: A Case of Alcoholic Liver Disease Ryan S1, Marrinan A2 Consultant: Dr. Martin Mulroy

Department of Medicine, Our Lady of Lourdes Hospital, Drogheda, Co Louth; DNE Intern Training Network Summary: A 47-year-old female presenting with polydypsia, polyuria, pruritis and multiple bleeding lesions on a background of eczema, later diagnosed with decompensated alcoholic liver disease. A 47-year-old female presented to A&E with polydypsia, polyuria, multiple bleeding lesions and an 18-month history of worsening itch, what she reported to be unresolving eczema. History and examination revealed an alcohol intake of 42 units per week and distended abdomen. Bloods were remarkable for elevated bilirubin and GGT and haemoglobin of 7.6. A diagnosis of decompensated alcoholic liver disease was made following US and CT abdomen. As per the GI team, lactulose, vitamin K, rifaximin, and spironolactone were commenced and PPI’s held to circumvent SBP. OGD showed grade 1 varices, but a decision was made to transfuse only if haemoglobin dropped below 7. Daily weights revealed little improvement despite days of strict fluid and salt restriction, and diuretics. Spironolactone was increased from 50 to 75 mg, and later 100 mg BD, again with poor results. An ascitic tap was scheduled but repeatedly delayed due to a high INR that was insufficiently responsive to vitamin K. Following FFP, fibrinogen and albumin cover, 9 L of fluid was drained. In the interim, hepatitis and autoimmune screens returned negative. The patient was discharged with GI follow-up, instruction to continue vitamin K until such a date, and a vow to abstain from alcohol. Conclusion: Alcoholic related liver disease is becoming increasingly common amongst women and often goes undetected. It is important to keep an open approach to all differentials when considering a diagnosis in order to reach prompt diagnosis and implement timely management.

A Case of Small Cell Lung Cancer: Under the Shawl of Dermatomyositis Marrinan A1, Ryan S2, Murray G3 Consultant: Dr Emmet McGrath

Professorial Respiratory Unit, St. Vincent’s University Hospital, Dublin Summary: 64 year old male presenting with troublesome myalgia and a macular rash, secondary to small cell lung cancer A 64 year old male with a 50 pack year smoking history was referred to rapid access lung clinic with an incidental suspicious opacity on CXR in the absence of respiratory symptoms. He also had a 6 week history of a new macular rash involving the tops of his shoulders, extending down both arms, muscle weakness, fatigue, and progressive dysphagia. Blood tests revealed elevated WCC, CK, LDH, ALT and AST. A diagnosis of dermatomyositis was formed, with the classic

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 ‘‘Shawl Sign’’ noted, and 1 mg/kg prednisolone was commenced. Symptoms of muscle weakness, and dysphagia progressed, and he was admitted for inpatient evaluation. PFTs, Electromyography, and a CT TAP were performed, revealing reduced FEV1, fibrillation potentials, and suspicious right upper lobe, mediastinal and adrenal nodules, respectively. His serum CK levels and muscle strength continued to improve with continued high dose prednisolone, tapered to a maintenance dose of 60 mg OD. A PET CT was conducted. In the interim, autoantibody screen results returned negative anti-Mi2, antiJo1, anti-Ro, anti-Sm, thus increasing suspicion of a primary neoplastic process with dermatomyositis as a complication. PET CT revealed increased uptake in the previously imaged nodule in the right upper lobe and 4R node in the mediastinum. Subsequent pathological analysis post EBUS biopsy led to a diagnosis of small cell lung cancer with secondary dermatomyositis. Patient was subsequently referred to oncology team for radiation and adjunctive chemotherapy treatment. Conclusion: This is a rare example of a neoplastic process causing a secondary dermatomyositis, which was the primary reason for presentation.

Empty Sella Syndrome: Close to the Heart Marrinan A1, Ryan S2, Murray G3 Consultant: Dr. Rachel Crowley

Professorial Endocrinology Unit, St. Vincent’s University Hospital, Dublin Summary: 53 Y/O female presenting with pleuritic chest pain due to pericardial and pleural effusions, found to have panhypopituitarism due to Empty Sella Syndrome. 53 year old female presented to A&E with central pleuritic chest pain, with associated shortness of breath and orthopnea, a productive cough, and weight loss. Vital signs were normal, clinical exam remarkable for reduced air entry at both lung bases with dullness to percussion. CXR showed bilateral pleural effusions. CTPA revealed a pericardial effusion, bilateral pleural effusions with minor bilateral pulmonary oedema. Subsequent echocardiogram demonstrated global pericardial effusion without evidence of tamponade. 3 weeks later, she developed worsened shortness of breath and chest pain. Clinical signs of tamponade were present, CXR showed the classic boot shaped heart sign, and an echocardiogram confirmed cardiac tamponade. A pericardial drain was inserted. Exudative pattern fluid obtained, with abundant neutrophils present, which was negative for malignant cells and acid fast bacilli on cytology and microbiological analysis. Endocrinology team were consulted to assess low sodium (120), and low cortisol (48). IV fluid therapy commenced to replace Na and IV hydrocortisone commenced for steroid deficiency. Bloods were remarkable for low FSH, low LH, and secondary hypothyroidism. MRI pituitary showed empty sella syndrome. Patient commenced on levothyroxine, oral hydrocortisone, with a working diagnosis of pituitary insufficiency causing secondary hypothyroidism leading to pericardial and pleural effusions. Conclusion: Empty sella syndrome is a rare cause of pituitary dysfunction and secondary hypothyroidism, but early identification and treatment can prevent a hearty number of complications.

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Imaging Studies and Linkage to Care of Hepatitis C in the Midwest Keating P1, Mooka B1 1

University Hospital Limerick

Introduction: In Ireland and in other countries hepatitis C infection is recognised as a significant public health problem as there is a burden associated with advanced stage infection including liver disease, liver failure, liver cancer and death. Studies to estimate the prevalence of chronic hepatitis C in the population indicates prevalence is likely to be 0.5–0.7 % (20,000–30,000). Recently new pharmacological treatment regimens have been developed which have demonstrated high rates of viral clearance in clinical trials, however the cost of these drugs is resulting in a significant burden on health care systems worldwide. The Irish government, like many other countries have adopted the approach of prioritisation based on clinical need of infected patients. In order to prioritise patients they require imaging studies to assess their disease progression and level of liver damage. Aim: To identify patient subgroups with poorer linkage of care. Methods: Using a database of 483 patients with a positive hepatitis C serology result, attending University Hospital Limerick, 200 patients were randomly selected for analysis. Using the National Integrated Medical Imaging System (NIMIS), names and date of births were used to search whether a patient has had an imaging study, how recent it was and what was the result. Results: 28.73 % of patients on the database had a liver ultrasound, equally split male and female. 44.31 % of the database were of nonIrish origin. This group was less likely to have had a liver ultrasound, compared to those of Irish origin (25.64 % vs. 31.25 %). The majority of those who had scans were in the age group 31–50 (48 %). 78 % of those who had a scan, had one in the last 5 years. 58 % had normal scans. Conclusions: Patients of non-Irish origin comprise almost half of the database, and these patients are less likely to have an ultrasound. Most of those receiving scans were middle aged. Efforts must be made to ensure non-Irish and younger patients with hepatitis C are adequately followed up and have scans arranged, to allow their treatment to progress.

Longstanding, Untreated Hypercalcemia in a 72-Year-Old Lady McLoughlin M1, Stack A1 1

University Hospital Limerick

Introduction: Hypercalcemia is a common but non-specific lab finding. Elevated serum calcium’s origins can be found in several potential systems in the body, including excess GI absorption, accelerated bone reabsorption or decreased renal exertion. Primary hyperparathyroidism, a disorder defined by excess parathyroid hormone secretion, most commonly manifests as small elevations in serum calcium and is typically the result of an adenoma within the parathyroid itself. Case presentation: A 72-year-old female with known multifactorial Stage 3 CKD, referred from the orthopaedics services with a notably

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S218 raised creatinine and urea following a proximal femoral replacement procedure. An AKI secondary to a UTI was diagnosed and treated, but an incidental finding of raised serum calcium (Ca2+=2.84 mmol/ L) was noted on admission. On further investigation, it was discovered that her serum calcium had been consistently abnormal since at least 2008, but had never been formally investigated. In the clinical context of her prolonged hypercalcemia, renal stone disease and elevated PTH, a differential diagnosis of primary hyperparathyroidism was investigated. Whilst ultrasound and CT were unsuccessful in visualising any lesions, a parathyroid MIBI scan ultimately identified a parathyroid adenoma on the lower pole of the left thyroid. Conclusion: This case is an example of primary hyperparathyroidism, the harbinger of which was a persistently raised serum calcium, remaining undiagnosed from as early as 2008. This study is an important reminder that even seemly incidental findings must be investigated and placed into the clinical context. The patients’ medical history included kidney stones, generalised aches and pains, recurrent AKI’s and a rising serum calcium that coincided with a steadily decreasing eGFR value. Once identified, multiple imaging modalities were employed until the adenoma was identified, an abnormality we were confident existed given the clinical picture and lab values at hand.

Chronic, Progressive Dysphagia in an 85-Year-Old Lady McLoughlin M1, Peters C1 1

University Hospital Limerick

Introduction: Zenker’s Diverticulum are rare oesophageal outpouchings of unknown etiology that form at the level of the hypopharynx, most commonly seen in the elderly population. Located within the anatomical boundaries of the Killian Triangle, the pouch forms in the posterior midline at the cleavage plane between the thyropharyngeus muscle and the cricopharyngeus muscle. Zenker’s Diverticulum typically present with regurgitation, progressive dysphagia, the globus sensation and halitosis. If untreated, the most common complication is aspiration, with other complications including oesophageal obstruction and fistulisation into local blood vessels or into the trachea. Case presentation: An 85-year-old lady presented with worsening cough productive of sputum. Diagnosis on admission was a LRTI, for which treatment was commenced, but a collateral history incidentally revealed progressively worsening dysphagia over the last 2–3 months. On the wards, the patient was intermittently regurgitating undigested food and medication, to the point that conventional oral intake posed a considerable aspiration risk. The patient was made NPO and a NG tube was passed to allow for nutritional intake. A subsequent OGD was unable to pass the proximal oesophagus, with collected food debris and a possible oesophageal pouch noted on the report. As recommended, a barium swallow was conducted shortly afterwards, which diagnosed a Zenker’s Diverticulum. Conclusion: This case of a rare Zenker’s Diverticulum, discovered as an incidental finding to a LRTI admission, serves as an important reminder to consider it as a differential in any history of progressive dysphagia in an elderly patient. Whilst symptoms of the diverticulum were not the primary presenting complaint on admission, a thorough history and careful clinical observation on the wards allowed us to diagnose and intervene before further complications are allowed to develop.

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An Audit of Laxative Prescribing Practices with Opioid Analgesics Post Hip Fracture Repair, University Hospital Limerick (UHL) White D, O Sullivan F Objectives: This audit was conducted to assess the compliance of laxative co-prescription with opioids for patients over 65 admitted with acute hip fracture. Background: Adequate analgesia is essential in the care pathway of hip fractures. Opioids are commonly necessary. However between 40 and 95 % of patients develop opioid induced constipation leading to haemorrohoids, rectal pain, bowel obstruction, bowel perforation and death, particularly in an immobile elderly population1. UHL local policy currently recommends prescription of laxatives with all strong opioids and consideration with weak opiods. Methods: Anonymised data was collected from hip fracture patients (n = 21) on the acute trauma ward across five consecutive weeks. Data collected included the frequency, dose, route and date commenced for any opioid prescribed (oxycodone-naloxone combinations excluded). The frequency, route, dose and commencement date of any laxatives co-prescribed were recorded. Results: Opioids prescribed: oxycodone controlled relaese and immediate release preparations only. Laxatives prescribed: Lactulose PO (12), Senna PO (8), movicol PO (7), Glycerin PR (3). 100 % were prescribed at least one opioid. 23.8 % (5) were prescribed three classes of laxatives; 23.8 % (5) were prescribed two classes of laxative and 23.8 % (5) were prescribed a single laxative agent. 28.5 % (6/21) were not prescribed a laxative. Of the 15 prescribed laxatives, 3 did not receive them—in each case laxatives were prescribed as PRN only. In total, 43 % of hip fracture patients receiving opioids did not get any laxative. Conclusions: This audit shows a deficit in practice with regard to laxative/opioid co-prescription. Furthermore, it highlights that laxatives should be presciribed in the regular section rather than the PRN section of a patient’s drug kardex to ensure administration. To address this printed guidelines will be posted on the trauma ward with a re audit to be performed. Furthermore, a guideline will be included in the upcoming intern guidebook. References: 1. Benyamin R, Trescot AM, Datta S, Buenaventura R, Adlaka R, Sehgal N, Glaser SE, Vallejo R. Opioid complications and side effects. Pain Physician. 2008; Mar; 11(2 Suppl):S105–20.

An Audit of ‘‘Diabetic RetinaScreen’’: The National Diabetic Retinal Screening Programme in Type 2 Diabetics in Ireland Travers E1, Hannigan A2 1

Graduate Entry Medical School, University of Limerick; Department of Biomedical Statistics, Graduate Entry Medical School, University of Limerick

2

Abstract Aim: To assess the participation rates in Diabetic Retina Screen- The National Diabetic Retinal Screening Programme in type 2 diabetics in Ireland and to determine if participation rates are in line with targets set by the Framework for the development of a diabetic retinopathy screening programme for Ireland. Methods: Data was collected on a sample of type 2 diabetics from 34 general practices affiliated to the University of Limerick, across three

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 HSE regions (South, West and Dublin Mid Leinster) over the period of January to March 2014. Data was extracted retrospectively using GP practice systems (Health One, Socrates) for the preceding 12 months only, from the date of data extraction. Demographic data and retinopathy data was recorded for those who were registered or attended the National Diabetic Retinal Screening Programme- ‘‘Diabetic RetinaScreen’’ within the last 12 months. Results: Of the 2806 type 2 diabetics who were included in the study, the majority 1963 (74.9 %) have not participated in the national diabetic retinopathy-screening programme at the time of data collection. The majority of patients in HSE Dublin Mid-Leinster have participated in the screening programme, a total of 133 patients (55.4 %) compared to 362 (26.4 %) of patients in HSE South and 163 (16.1 %) of patients in the HSE West (p \ 0.001). Results for individual counties showed that 133 (29.6 %) of patients in Co. Clare participated in screening compared to 30 (5.4 %) of patients in Co. Limerick (p \ 0.001). Conclusion: This audit of ‘‘Diabetic RetinaScreen’’—The National Diabetic Retinal Screening programme in type 2 diabetics is one of the first to look at participation rates in the programme since its initiation in 2013. This research highlights that a majority of participants from a sample of type 2 diabetics have yet to engage with the programme. It also illustrates that screening in certain geographical regions is more developed in comparison to others. Although still in its infancy, this research highlights a number of potential areas of improvement for Diabetic RetinaScreen.

Pseudohyperkalemia in a Patient with JAK II positive Essential Thrombocythemia, Diagnosed Through Use of a Lithium Heparin Plasma Sample Mc Morrow B1, Hodgson A1, Montgomery N1 Sligo University Hospital Description: A 77 year old gentleman presented to Sligo Regional ED, with new onset Atrial flutter, which resolved with commencement of Metoprolol. On day two of admission he was noted to have potassium of 7.2 mmol/L. He was asymptomatic and his ECG had reverted to sinus rhythm. There was no obvious cause for the hyperkalemia. Potassium was monitored, using standard serum samples on the Roche Modular SWA indirect ISE, with hyperkalaemia being observed continuously. Treatment was commenced as per hyperkalemia protocols. On day three an ABG analysis on the Roche b221 blood gas analyser revealed a Potassium of 4.5 mmol/L, treatment was stopped despite serum samples remaining consistently high for potassium. A haematology consult was requested. Bloods were retaken using a plasma sample via a lithium heparin vacutainer, potassium was noted to be 4.5 mmol/L and a diagnosis of pseudohyperkalemia was confirmed. Discussion: Platelet degranulation during in vitro clotting can lead to exaggerated potassium levels in serum samples, the standard measurement used in Sligo Regional Hospital. Patients with high platelets ([500 9 109) from reactive thrombocytosis or myeloproliferative disease, are therefore prone to spurious diagnoses of hyperkalemia. The phenomenon is often overlooked in clinical practice, leading to unnecessary and potentially dangerous interventions. In this case, a ward based whole blood analysis as well as the patient’s lack of symptoms indicated a diagnosis of pseudohyperkalemia. This was confirmed by use of a lithium heparin plasma sample, which prevented the clotting process from giving a falsely elevated potassium value. Conclusion: As a result of this case, an automatic warning system has been placed on all platelet counts [700 9 109, clinicians are advised

S219 to interpret potassium results with caution, and to repeat sampling using a lithium heparin vacutainer if Pseudohyperkalemia is suspected.

Ludwig’s Angina in the Emergency Department O Carroll L, Cunningham K. Harris Intern, Emergency Medicine, Sligo General Hospital West Northwest Intern Training Network Introduction: Ludwig’s Angina was first described in 1836 as a rapidly progressive and often fatal gangrenous cellulitis and oedema of the soft tissues of the neck and the floor of the mouth. This results in an emergency in relation to an impending airway obstruction and further management and multidisciplinary input is needed to help patients with this condition. The most common cause of Ludwig’s Angina is odontogenic infections (90 %). The most commonly found pathogens include Staphylococcus, Streptococcus and Bacteroides species. Description/case report: We present two cases of Ludwig’s angina that presented to our ED in March and July of last year. Our first patient was an 88 year old lady BIBA with shortness of breath and decreased oxygen saturation. On examination she had a mild erythematous rash over her anterior neck. A provisional diagnoses of sepsis secondary to LRTI was made. She was admitted to ICU and intubated for 7 days. She was treated with intravenous steroids and antibiotics. She remained in hospital for 17 days. Our second patient was a 25 year old male presenting with left sided jaw pain and dysphagia. On examination he also had a rash on the anterior neck. He was admitted under the ENT team following assessment of the patient’s airway by the anaesthetic team, and treated with IV antibiotics. He remained in hospital for 6 days. Both patients made a full recovery. Discussion/conclusion: The presentation and severity of Ludwig’s angina to the emergency department varies from case to case. The early recognition and treatment is crucial.

Effectiveness of an Admission Proforma in Improving Prescription of Thromboprophylaxis in Acutely ill Medical Patients McMahon D1, Kelly T1, Saies A2, Spence C2, Watts M1 1 University Hospital Limerick; 2Graduate Entry Medical School Limerick

Introduction: In 2008 the MWRH conducted an audit showing; there was inadequate rates of thromboprophylaxis amongst high and very high risk medical patients. A new acute medical admissions proforma was introduced in October 2012 to help improve the rate of thromboprophylaxis.

The theory was that a prompt in the medical admissions proforma would increase rates of thromboprophylaxis being prescribed. An

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S220 audit after its introduction proved that there was a 39 % increase in thromboprophylaxis in high/very high risk patients. We sought to explore the rates of thromboprophylaxis 3 years after the proformas introduction, and our aim was to ensure thromboprophylaxis rates continued to improve, especially amongst the high/very high risk group. Methods: A cross sectional study was conducted that investigated thromboprophylaxis among all inpatients on medical wards on two allocated days. Any medical patient admitted under medical/geriatric service was included. Patients were excluded if they were already on warfarin, therapeutic anticoagulation or had a contraindication to anticoagulation. We examined the medical proformas to evaluate whether thromboprophylaxis was documented in the patients admission proforma. Secondly we checked each patients drug kardex to determine whether thromboprophylaxis was prescribed. Results: In total 127 medical notes were assessed. 27 patients were excluded based on guidelines. Thromboprophylaxis rates have continued to improve in all acute medical admissions. • •

61 % in the moderate risk patients (compared to 40 % in 2012) 67 % in high/very high risk patients (compared to 65 % in 2012)

The proforma was used in 82/100 enrolled patients, and the rate of thromboprophylaxis in proforma patients is; • •

65 % in moderate risk patients (compared to 20 % in 2012) 71 % in high/very high risk patients (compared to 63 % in 2012)

Conclusions: These figures conclude that a prompt in the admission proforma is significantly improving thromboprophylaxis in both the high/very high risk group and the moderate risk group.

Post-ERCP Pancreatitis Frewen J, Kimura S, Ali N Mid-Western Network The incidence of post-ERCP pancreatitis is 3–5 %. Patient risk factors (RF) include female sex, younger age, normal bilirubin, while procedure-related RF include pancreatic duct injection. This 31 year old female (BMI = 43), was admitted with abdominal pain and vomiting. Initial investigations were US abdomen and bloods (FBC, U + E, LFT, Amylase). US reported multiple (gallbladder) gallstones, and a 6 mm common bile duct (CBD), without choledocolithiasis. LFTs were Bilirubin 45 + , ALT 550 + , ALP 200 + , GGT 350 + and Amylase 20 + . Following diagnosis of acute cholecystitis, she underwent MRCP, reporting multiple small stones in the gallbladder, a 1.3 cm CBD with a positive meniscus sign, and filling defects suggestive tiny calculi. Subsequent ERCP (bilirubin now 17.6) comprised of a sphincterotomy, stent insertion with eventual CBD stone extraction, however was complicated by repeated cannulation and contrast injection of the pancreatic duct. Following the procedure, she developed severe abdominal pain, radiating to the back. Bloods yielded amylase 650 + , erect CXR reported no free air under the diaphragm, and she was diagnosed with post-ERCP pancreatitis (IMRIE score 4). She was treated with aggressive fluid management, IV Vancomycin, Ciprofloxacin, Metronidazole, and Gentamycin and required patient controlled analgesia (PCA). She developed sinus tachycardia and urine output became inadequateanaesthetic assessment was warranted; however she did not require ICU admission. Prolonged IV fluids, antibiotics and analgesia were the mainstay of management. Following recovery she was referred for

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 (a) interval CT, (b) dietetics for weight management, and (c) bariatric surgery re assessment for laparoscopic cholecystectomy. This case of post-ERCP pancreatitis presents a patient with RF outlined in the introduction. The discrepancy in findings between US and MRCP highlights the requirement for MRCP in spite of CBD results from US. The intensive management of pancreatitis, including the issue of fluid balance and microbiology cover, indicates the multimodal input required for the management of pancreatitis.

Loss of the General Paediatric Surgical Service? Darcy L1, Boland M1, Tormey S1, Khan Z1, Lal A1, Merrigan A1, Lowery A1 1

Department of Surgery, University Hospital Limerick

Background: As the number of dedicated paediatric facilities within the Republic of Ireland remains static an increasing volume of paediatric surgery is performed in general hospitals. A lack of dedicated training and increasing demands on general surgeons remain the main challenges for the provision of paediatric surgery within Ireland. Aim: To examine the level of the paediatric surgical workload, both emergency and elective, at the University Hospital Limerick over the period 1st January 2014 until 31st of October 2015. This will allow us to assess how the potential loss of this general paediatric surgical provision in the near future will impact on paediatric surgery in Ireland. Methods: All data used in this report was acquired from the Hospital In-Patient Enquiry System (HIPE). Data collected included the total number of paediatric surgical admissions and the procedures performed. Results: Over the period examined there were a total of 9507 surgical admissions with 1005 (10.6 %) of these being paediatric surgical admissions. Of these 1005 admissions 915 (91 %) were emergency admissions and 90 (9 %) were elective admissions. A total of 423 procedures were performed, 271 (64 %) of these were appendicectomies. Discussion: The paediatric surgical service in this general hospital represents a significant percentage of the general surgical workload. When compared to previous studies it is evident that the volume of this workload has increased over time. This highlights the fact that a continued general paediatric service in general hospitals is a necessity and those future policies regarding paediatric surgical services and general surgical training should be reviewed carefully.

Audit of Non-Attendances to the Infectious Disease Out Patient Clinic at Galway University Hospital O Connell J1, Cronin C1, Mc Donnell K1, Doyle C1, Fleming C1, Tuite H1 Departement of Infectious Diseases, University College Hospital Galway Objectives: Out Patient clinic non-attendances waste valuable resources, extend waiting lists and lead to increased morbidity. The Department of Infectious Diseases (ID) at Galway University Hospital (GUH) serves the West and North West of Ireland and reviews both ID and general medical cases. In 2015 Human Immunodeficiency Virus (HIV), Hepatitis B (HBV) and C (HCV) infections are generally managed in the out patient setting and

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 delivery of routine care can increase life expectancy. The aim of this audit was to identify factors that influence non-attendances to clinic. Methods: Fifteen out patient clinics over a 2-month period (November–December 2014) were reviewed. Data was obtained from a prospectively maintained database, the Patient Administration System and the Electronic Discharge Summaries. Results: 100/451 (22 %) patients did not attend their outpatient appointment at the clinic over this period. 51/100 (51 %) were male and the mean age was 41.9 years. 89/100 (89 %) were ID related cases. 73/100 (73 %) had a prior inpatient admission at GUH and 27/100 (27 %) were admitted under ID. 24/100 (24 %) related to HIV infection, 11/100 (11 %) to HBV infection and 42/100 (42 %) to a general infectious disease. 3/100 (3 %) were non ID related. Conclusion: There is a high rate of non-attendance at 22 % and nearly 40 % are resident outside the greater Galway area. 89 % of non-attendances were ID related cases, 49 % of which had a blood borne viral infection. This audit highlights the need for the development of a strategy to reduce the high rate of non-attendance to the ID clinic; use of an appointment text message reminder has now been implemented with a planned re-audit of non-attendances in 6 months time.

S221 Conclusions/discussion: This study suggest that patients treated with Tysabri were less disabled than controls pre-treatment. Treatment with Tysabri decreased disability. The MSSS scale may be a clinically useful tool in making treatment decisions in MS patients. Larger scale prospective studies are needed to explore these initial findings. References: 1. RH Roxburgh et al. Multiple Sclerosis Severity Score: using disability and disease duration to rate disease severity. Neurology. 2005 Apr 12;64(7):1144–51.

An Audit of Medical Note Documentation on a General Medical Team in St John’s Hospital McKenna F, Lynch K, Cronin C St John’s Hospital, Limerick Midwest

Treatment by Numbers: A Retrospective Study to determine if the Multiple Sclerosis Severity Score has a Clinical Utility in Predicting Patient Responsiveness to TysabriÒ

Objectives:

O Connell J1, Counihan T2

Methods: The medical charts of 20 of inpatients of a single medical team were selected at random over a 3 week period. All notes handwritten during the current admission by members of the team (Intern, two SHOs, Registrar, plus those filling in on the team temporarily) were assessed on a yes/no basis for the presence or absence of 10 features identified in ‘‘HSE Standards and Recommended Practices for Healthcare Records Management’’. Results: Results varied greatly among the criteria. Only one criterion was entirely in line with HSE recommendations: all notes were written in permanent black ink. 75 % (15/20) of charts had all medical team entries containing the date of entry. In 60 % (12/20) of charts, all team notes were entirely clear and legible. There were lower figures for other criteria: only 20 % (4/20) of charts had all team notes displaying the doctor’s medical council number, 10 % (2/20) the printed doctor’s name, 10 % (2/20) the doctor’s job title. 0 % (0/20) a note of the time in 24 h format, and 0 % (0/20) had the time seen by the doctor. Conclusions: There are a number of HSE standards and recommendations for clinical note taking not being met by the team. In addition to there being suboptimal records for possible future litigation or challenges to professional standards, underperformance on certain criteria in particular results in suboptimal communication between physicians, and therefore suboptimal care for the patient.

1

University College Hospital Galway; 2Department of Neurology, University College Hospital Galway West Northwest Intern Training Network Background/introduction: The Expanded Disability Status Scale (EDSS) is a validated tool that allows clinicians to objectively assess a patient’s level of disability. A Multiple Sclerosis Severity Score (MSSS) is calculated using an arithmetically simple method by correcting an individual’s EDSS for disease duration by comparing it with a distribution of scores in cases having equivalent disease progression1. Preparatory to determining whether a validated MSSS might be a useful clinical tool to aid decision-making in treatment escalation for MS patients, our aim was to determine, retrospectively, disability status in patients pre- and post- Tysabri therapy. Methods: This retrospective cohort study tabulated the EDSS from clinical notes in a cohort of 36 patients. The MSSS was calculated using the EDSS and disease duration. Analyses were then conducted using the MSSS tabulated upon starting treatment and finishing treatment. Results: 89 % of patients were female and the remaining 11 % were male. The mean disease duration at the start of treatment was 6.4 years (standard deviation = 5.35). The mean age at the start of treatment was 31 years (standard deviation = 6.91). The mean MSSS pre-Tysabri treatment was 6.81 (standard deviation = 2.47).The mean MSSS post-Tysabri was 3.1 (standard deviation = 2.56) In patients who received greater than 5 years Tysabri: the mean preTysabri MSSS was 5.79 (standard deviation = 2.44) and postTysabri was 1.40 (standard deviation = 1.32) In patients receiving greater than 3 years but less than 5 years Tysabri treatment the mean MSSS pre-Tysabri was 7.32 (standard deviation = 2.61) and post-Tysabri was 4.94 (standard deviation = 2.85)

•

For a medical team in St John’s Hospital, assess the current quantitative coherence of handwritten medical note keeping with standards outlined in ‘‘HSE Standards and Recommended Practices for Healthcare Records Management’’.

Preliminary Results from a Cross-Sectional Audit Comber R1, McManus J2 Orthopaedic department, University Hospital Limerick Background: Oxygen is classified as a prescription drug. It should be prescribed by a licensed prescriber in all instances of use and monitored appropriately. Oxygen therapy is indicated in instances of hypoxaemia to optimise patient outcomes. Conversely, excessive oxygen use can elicit harm. Appropriate prescribing and monitoring guidelines should be adhered to in the hospital setting.

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S222 Aims: To quantify the number of trauma-orthopaedic patients on oxygen therapy in the trauma ward and to assess the concurrent rate of appropriate oxygen prescribing. If necessary based on preliminary findings, a follow-up implementation of educational measures will be utilised with the aim of improving future clinical practice. Methodology: All patients on an acute trauma ward on a given day were assessed for oxygen therapy use. Early Warning Score charts were reviewed and any noted oxygen therapy was correlated with the patient’s medication kardex. All kardexes were also fully reviewed for any documentation of oxygen prescribing. Results: Twenty-eight patients were included in this audit. Of this number 13 (46.4 %) had received recorded oxygen therapy during this acute admission. Upon review of medication kardexes it was established that 9 (69.2 %) of these patients had not had oxygen therapy formally documented representing an appropriate prescription rate of only 30.8 % (n = 4). Conclusion: These results reflect poor practice in acute oxygen prescribing within the trauma-orthopaedics setting. Appropriate educational intervention for all healthcare providers, including nursing staff and doctors, will be initiated. This intervention will be followed up with a re-audit of oxygen prescribing practices in 1 month’s time to assess effective change.

Nasal Oxygen Insufflation and the Apnoeic Period Blaney M1, Moore M2 Department of Anaesthesia, Beaumont Hospital Introduction: We report the use of nasal insufflation of oxygen in a morbidly obese patient with an anticipated difficult airway in order to prolong the time to desaturation during the apnoeic phase at induction of general anaesthesia. Case description: A 37-year-old morbidy obese (BMI 71) patient presented for coiling of an anterior communicating cerebral aneursym following a grade 1 sub-arachnoid haemorrhage 8 h previously. Airway management was anticipated to be difficult and time to desaturation during an apnoeic period extremely short. Following otrovine spray to her nose a 6 mm Naso-FloTM airway was inserted prior to induction of general anaesthesia. The airway was attached to 2 L/min of oxygen. At the same time the patient was pre-oxygenated by face mask for 3 min at 10 L/min. Anaesthesia was induced with propofol followed by suxamethonium and intubation performed with a McGrath video laryngoscope. During intubation oxygenation was maintained with 2 L/min of oxygen via her nasal airway. On confirmation of correct endotracheal tube placement, nasal oxygenation was discontinued. The nasal airway was left in place for the duration of the aneursym coiling. Prior to extubation the nasal airway was reconnected to 2 L/min of oxygen. Anaesthesia was discontinued, muscle paralysis antagonised and when consciousness returned the patient was extubated safely. There were no periods of desaturation. The patient was transferred to the intensive care unit with the nasal airway in situ and it remained in place until her discharge to the ward. Discussion: Our case demonstrates the safe use of nasal oxygen insufflation1 in order to prevent desaturation in a patient with an anticipated difficult airway and an anticipated short apnoea time. 1. Patel A, Nouraei SA. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia. 2015;70(3):323–9.

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Patient Satisfaction in an Outpatient Rheumatology Service Kenny G1, Helbert L2, McCarthy CJ3, McCarthy GM4, Madigan A5 Rheumatology Department, Mater Misericordiae University hospital, Eccles St Dublin 7 Patient satisfaction is increasingly recognized as key indicator of quality of patient care, and a measure of confidence in the health care service. A survey of patient satisfaction was undertaken in a rheumatology outpatient clinic to measure patient satisfaction and identify areas for improvement. Methods: A 10-part questionnaire consisting of 40 individual questions was distributed to patients presenting to the Mater Hospital rheumatology outpatient service between May 2014 and November 2015. Results: 226 completed questionnaires were returned. Overall satisfaction levels with the rheumatology outpatients experience were high (98 % were satisfied with the service, 74 % rating the service ‘‘excellent’’ or ‘‘very good’’). 70 % of respondents rated their interaction with the clinic doctor as 10/10 (on a scale where 1 indicates poor and 10 excellent), and 79 % rated their interaction with the clinic nurse as 10/10. However a number of areas for potential improvement were identified. Almost a third of patients were unhappy with the waiting times, with 6 % stating the wait was ‘‘far too long’’. Almost half the patients who attempted to change their appointment had difficulty, 17 % finding it impossible. 15 % of patients with mobility issues felt the clinic facilities did not meet their needs. 81 % of users of the rheumatology nurse advice line were satisfied with it. However 27 % of return patients were unaware of its presence, and a number of patients felt it was under resourced. A number of recommendations for potential improvement are suggested, aimed primarily at reducing wait times, improving patient ability to contact the clinic and making the waiting area more comfortable. Conclusion: Overall satisfaction with the rheumatology outpatient service is high. However there are a number of areas for potential improvement that could enhance the patient experience and increase clinic efficiency. A cost benefit analysis is indicated based on these observations.

Inpatient Hip Fractures: Are We Compliant With Blue Book Standards? Murphy C1, Joyce M1, Hurson C1, Clifford GT1 1 Department of Orthopaedic Surgery, St. Vincent’s University Hospital, Dublin

Background: An inpatient hip fracture can be a devastating consequence of falling in hospital. There are over 850 inpatient hip fractures annually in the UK. The 30-day and 1-year mortality rates of an inpatient hip fracture are 18 and 47 %, respectively. This is nearly twice the normal rate. The Blue Book Standards give guidance on best practice for hip fracture care. However, the IHFD 2013 does not specify care of admitted patients. The aim of this study was to determine compliance with Blue Book Guidelines of inpatient hip fractures in a large acute teaching hospital. Methodology: All patients who suffered a hip fracture post-fall in the first three quarters of 2015 were included in this retrospective chart review. Descriptive statistics analysis tool was used.

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Results: Twelve subjects were included in the study. Mean age was 80 years (range 32–96). Standard 1: two patients were on an orthopaedic ward within 4 h of fracture. No other patient was transferred before surgery. Standard 2: nine patients had surgery within 48 h. Standard 4: seven patients were not managed on an orthopaedic ward or reviewed by an orthogeriatrician. Standard 5: four patients were assessed and received antireabsorptives. Standard 3 (pressure care) and Standard 6 (falls risk assessment) were fully compliant. Implications: Admitted patients who are suffer a hip fracture should be managed on an orthopaedic ward, have access to orthogeriatric support and be assessed for anti-reabsorptives.

Maternal Smoking During Pregnancy as a Risk Factor for Childhood Overweight and Obesity: A Review of the Literature Ryan S Supervising Consultant: Dr. Liz O’ Mahony

Department of Paediatrics, University Hospital Limerick, Co. Limerick Aims: To perform a structured review of studies reporting on the association between maternal cigarette smoking during pregnancy and overweight and obesity in offspring. This is part of a broader effort to better understand the role of maternal smoking as a risk factor for obesity and develop further research agenda to facilitate early identification and targeted intervention. Methods: PubMed, MeSH and DynaMed were searched up to 26 January 2015 for free full-text human studies published in the last 10 years, relating to maternal smoking during pregnancy and childhood obesity. Reference lists of selected studies were appraised. A total of 47 studies were included in the review. Eligibility criteria included studies that reported an association between maternal smoking during pregnancy and risk of overweight among children at least 2 years of age. Studies using differing anthropometric outcomes for obesity were included (BMI, BMI z-score, body fat, abdominal fat, skin fold thickness). Results: Current epidemiological data strongly support a positive association between maternal smoking during pregnancy and increased risk of childhood overweight or obesity. However, the possibility that residual confounding may explain the association cannot be completely ruled out. There was conflicting evidence for the role of ethnicity, gender and paternal smoking in the association between maternal smoking and obesity. There was a positive association with dose–effect and a positive influence of smoking cessation in early pregnancy. Conclusion: Maternal smoking during pregnancy appears to increase rates of overweight and obesity in childhood. It is a modifiable risk factor identifiable during pregnancy and thus, should be a target of early intervention.

A Rare Case of Mesalazine Induced Myocarditis Maqbool E Mid West Intern Network; University Hospital Limerick Introduction: Cardiac involvement is a rare extraintestinal manifestation of patients with IBD. Most common cardiac involvement of Ulcerative Colitis is myocarditis, which can be related to mesalazine.

S223 Case presentation: CR a 45 year old man presented with squeezing chest pain on waking radiating to back and left arm. Ex-smoker; 20 pack year history, no other risk factors, no family history. Recent diagnosis of left sided colitis with proctitis. Commenced on mesalazine 2 weeks prior to admission. Day 1: Vitals stable, ECG: NSR, CXR clear. Bloods: High sensitivity Troponin T(HSTT): 58 ng/L to 104 ng/L. Treated as NSTEMI, Given morphine sulphate, 300 mg Aspirin, Ticagalor. Angiogram and echocardiogram NAD. CTPA performed to rule out PE. Day 2: HSTT: 705 ng/L, repeat ECG shows T wave inversion in anteriolateral leads.?Myocarditis; manifestation of IBD or rare side effect of mesalazine. Mesalazine 800 mg TDS put on hold. Day 7: Cardiac MRI shows dilated LV with inferolateral hypokinesis. RV dilated with preserved function. Subepicardial late enhancement in basal inferolateral wall consistent with myocarditis. Repeat HSTT: 5 ng/L Day 8: Myocarditis likely secondary to mesalazine, improvement seen with discontinuation.. Discharged home; for follow-up by gastroenterology for management of colitis. Conclusion: Mechanism of action of mesalazine induced myocarditis is unclear, may be due to; direct cardiotoxic effect, cell mediated hypersensitivity, IgE-mediated allergic reaction, or humoral antibody response. Typically presents with symptoms within 2–4 weeks of initiation (can be delayed if concurrent corticosteroid use). Resolution of symptoms with discontinuation of medicine. Cardiac MRI is useful tool for confirmation of diagnosis.

Decompressive Hemicraniectomy in Malignant Middle Cerebral Artery Syndrome O Dwyer L1,2, Singh R1, Walsh T1 1

Department of Geriatrics and Stroke Medicine, University Hospital Galway; 2West North West Intern Training Network Introduction: Malignant middle cerebral artery (MCA) syndrome refers to the development of massive cerebral oedema following a large MCA territory infarct, leading to raised intracranial pressure and brainstem herniation. Malignant MCA syndrome occurs in 10 % of ischaemic stroke and is associated with a mortality of up to 80 % despite optimal medical treatment. Here we present the case of a patient treated surgically with decompressive hemicraniectomy. Case description: A 60 year old woman presented to the Emergency Department at University Hospital Galway 75 min after developing acute left-sided weakness and facial droop. Examination revealed an NIHSS score of 22, with left hemiparesis and facial palsy, left-sided neglect, left homonymous hemianopia, dysphasia and dysarthria. CT brain showed a dense right MCA consistent with acute thrombosis. The patient was thrombolysed with intravenous alteplase 63 min after arrival and transferred to ICU. 24 h post thrombolysis, she developed a right-sided headache with reduction in GCS to 11/15. Repeat CT brain showed evolution of the infarct territory, involving frontal, temporal and parietal lobes, with midline shift of approximately 5 mm and effacement of the right lateral ventricle. She was transferred urgently to Beaumont Neurosurgery for a fronto-temperoparietal craniectomy. She returned to University Hospital Galway 1 week later for ongoing rehabilitation with future cranioplasty. Discussion: Decompressive hemicraniectomy (DH) involves the removal of a bone flap to allow the expansion of oedematous brain tissue. Early DH has been shown to significantly improve survival and favourable functional outcomes in younger patients with malignant MCA syndrome. This case highlights the importance of rapid recognition of malignant MCA syndrome and early consideration of DH as a treatment option in select patients.

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Malnutrition in the Cirrhotic In-Patient: an Audit of Prevalence, Protein-Energy Requirement and the Impact of Clinical Nutrition Kelly C, Tierney A, Chan G, Dunne C, Naimimohasses S, Norris S, McKiernan S Gastroenterology/Hepatology Department, St. James’s Hospital, Dublin 8, Ireland Introduction: Cirrhosis is frequently complicated by protein-energy malnutrition (1), associated with high morbidity and mortality. Clinical nutrition input is essential in the management of these patients. The 2006 ESPEN (European Society for Clinical Nutrition and Metabolism) Guidelines on Enteral and Parenteral Nutrition in Cirrhosis recommend clinical nutritionists use simple bedside tools to identify patients at risk of under-nutrition (2). The guidelines recommend an energy intake of 35–40 kcal/kg body weight/day, and a protein intake of 1.2–1.5 g/kg body weight/day. Supplemental enteral nutrition should be used where patients cannot meet their nutritional requirements orally. Parenteral nutrition is recommended in moderately or severely malnourished patients who cannot otherwise meet requirements (3). Aims/objectives: To audit against the following standards: all patients with cirrhosis should be assessed for risk of under-nutrition. Recommended protein-energy intake and use of supplemental nutrition should reflect ESPEN guidelines. Method: All patients with cirrhosis admitted from 31/10/15 to 31/12/ 15 under the Gastroenterology/Hepatology teams were included. Data was obtained from patients’ charts and the electronic patient record. Results: 18 patients were identified (15 male, 3 female, mean age 59). All were assessed for malnutrition. Mean follow up was 16 days. On admission, 72 and 94 % of patients were not meeting their calorie and protein requirements, respectively. 83 % required supplemental enteral nutrition. On discharge, 56 and 44 % of patients were not meeting calorie and protein requirements, respectively. Conclusions: Most subjects were not meeting nutritional requirements on admission. Use of supplemental nutrition in these patients reflects ESPEN guidelines. Protein-energy intake improved after nutritional consultation. However many patients were still not meeting nutritional requirements on discharge.

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 WNW Objectives: A doctor on call for ward duties at Sligo University Hospital (SUH), being responsible for up to 100 patients, is faced with time management predicaments. To determine the efficacy of patient management, an audit of the amount of bleeps entailing specific tasks during on-call shifts was implemented. Design/methods: Each task required during on-call shifts for the wards of SUH were recorded by non-consultant hospital doctors (NCHDs). The shifts were replicated for comparison (Weekend Long Day Shifts, N = 4; Weekend Night Shifts, N = 3; Week Long Day Shifts, N = 6; Week Night Shifts, N = 8). The number of calls was normalised to working hours minus required breaks in order to compare different length shifts. Statistical analysis was performed using GraphPadPrism Software. Time was recorded when starting the task and when finishing. Breaks and travel time in between patients or wards were not included in the length of time. Results: Calls were significantly higher on the Weekend Long Days (3.773 ± 0.7624 calls per hour) compared to all other shifts (vs. Weekend Nights 1.273 ± 0.1575, p \ 0.01; vs. Week Long Days 2.533 ± 0.8042, p \ 0.05; vs. Week Nights 1.727 0.7925, p \ 0.01). Patient reviews only accounted for 42 % of a doctor’s time where the next greatest amounts were for charting medications, inserting cannulas, and phlebotomy (16, 14, and 12 %, respectively). Conclusions: Weekend Long Day shifts are significantly busier despite only having one junior doctor available for ward duties at that time. This discrepancy suggests that additional NCHD coverage is required for that shift. Furthermore, 26 % of the time was filled by cannula insertion and phlebotomy which do not require qualifications of an NCHD. If this training was extended to other staff (nurses, medical assistants) more time would be allotted for NCHDs to review patients thereby improving patient care.

Infectious Carotid Arteritis as a Complication of Staphylococcus Aureus Septicaemia Secondary to Infected Radiocephalic Arteriovenous Fistula Reddy K1, Damla A2, Moloney A1, Casserly L3 1

References: 1. Moriwaki H., Miwa Y., Tajika M., Kato M., Fukushima H., Shiraki M. Branched-chain amino acids as a protein- and energy-source in liver cirrhosis. Biochemical and Biophysical Research Communications. 2004; 313(2):405–409. doi:10.1016/j.bbrc.2003.07.016. 2. Plauth M., Cabre E., Riggio O., Assis-Camilo M., Pirlich M., Kondrup J. ESPEN Guidelines on Enteral Nutrition: Liver Disease. Clinical Nutrition 24 2006: 285–294 3. Plauth M., Cabre E., Campillo B., Kondrup Jens., Marchesini Giulio., Tatjana Schutz., Shenkin A., Wendon J. ESPEN Guidelines on Parenteral Nutrition: Hepatology. Clinical Nutrition 28 2009; 436–444

How Doctors Spend their Time on Call: A Bleep Audit of Sligo University Hospital Vaughn C*, McKenna R, Nelson M, Whelan B 

Sligo University Hospital, Department of Medicine, Sligo Town, County Sligo, Ireland; National University of Ireland Galway, Galway City, County Galway, Ireland

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Department of Vascular Surgery, University Hospital Limerick; Department of Medicine, University Hospital Limerick; 3Department of Renal Medicine, University Hospital Limerick

2

University Hospital Limerick Intern Network Introduction: Infectious invasion of the carotid artery without aneurysm is an extremely rare cause of a painful neck lump, with less than 50 cases reported1,2. Staphylococcus aureus is the most common causative organism1,3. Case: A 78 year old female presented with sepsis, a painful neck lump, and failure to dialyze from a left radiocephalic arteriovenous fistula. Her history was significant for chronic kidney disease (on dialysis) secondary to diabetic nephropathy. On examination, she had a palpable firm mass in the right cervical area that was exquisitely tender. Her forearm fistula was firm with no palpable thrill and a diminished bruit. Blood cultures were positive for methicillin-sensitive staphylococcus aureus (MSSA). Ultrasound of neck was obtained, which failed to demonstrate any focal abnormality. CT of neck was obtained, which demonstrated a thickened wall with fat stranding surrounding the right common carotid artery and proximal right internal carotid artery, indicative of infective arteritis. Fistulogram of the arteriovenous fistula showed high-grade stenosis and poor flow in the venous limb. The fistula was ligated and the arteritis

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 was managed conservatively with intravenous antibiotics. Post-operative tissue cultures from the fistula were positive for MSSA, identifying it as the most likely source of infection. Antibiotics were continued thereafter and the cervical swelling, pain, and tenderness improved. Follow-up CT scan demonstrated no evidence of infective arteritis. Conclusions: This is the first reported case of infective carotid arteritis seeding from an infected arteriovenous fistula. Once infection occurs in arterial intima there is a significant risk of perforation, suppuration, and false aneurysm3. This case demonstrates the importance of thorough physical examination and investigation of potential sites of seeding in staphylococcus aureus septicaemia. Had the neck not been examined properly and had CT scan not been performed when ultrasound was negative, this complication may have been missed, potentially proving disastrous for the patient. References: 1. Jebara VA, Acar C, Dervanian P, et al. Mycotic aneurysms of the carotid arteries–case report and review of the literature. Journal of vascular surgery 1991; 14(2): 215–9. 2. Fajer S, Karmeli R. Non-typhi Salmonella arteritis of the Carotid Artery in an HIV-positive Patient. EJVES Extra; 6(4): 80–3. 3. Rutherford RB. Infected Aneurysms. In: Reddy DJ, Ernst CB, eds. Vascular Surgery. 5th ed. Philadelphia: WB Saunders Co; 2000: 1383–97.

Assessment of the Patient Pathway for Elderly Patients in the Acute Medical Setting Bradley M Project supervisor: Dr Gemma Browne

Research conducted in Mercy University Hospital, Cork Background: The combination of an aging population and their multiple morbidities is major driver of increased Emergency Department (ED) presentations. Acute Medical Assessment Units (AMAU) have been developed but there is little data on their utility for meeting the needs of the elderly. Methods: Both quantitative and qualitative methods were used to evaluate the AMAU as a pathway for elderly patients in one hospital. Data on all medical admissions for patients over 70 years old from January to September 2014 were extracted. AMAU was compared to ED on time to the decision to admit a patient; time from that decision to admission; and length of stay. Qualitative interviews with elderly patients admitted were conducted to compare their experiences of the two pathways. Results: 4769 patients over 70 presented to MUH ED between Jan 2014 and Sept 2014 of whom 2007 were admitted. 1576 were medical admissions of which 272 were admitted through AMAU. Mean age of AMAU group was 77.7 years compared to 79.8 years in the ED group. Time from presentation to admission was significantly shorter in the AMAU group with the biggest difference being time from decision to admit to admission which was \2 h in 76.4 % of AMAU patients compared to 16.2 % in the ED group. Mean length of stay was 4.3 days in AMAU group compared to 9.5 days in ED group. Patients in both groups expressed a positive opinion of hospital staff and an awareness of the pressures faced by them. They felt that the AMAU was a more appropriate setting to meet their needs. Conclusions: The AMAU functions as an efficient and preferred pathway into hospital for elderly medical admissions.

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A Twisted Tale Hyland SE1, Heneghan HM1, Prichard R1, Hanley A2 1 Department Breast/Endocrine/General Surgery, St Vincent’s University Hospital, Elm Park, Dublin, Ireland; 2Department of Colorectal and General Surgery, St Vincent’s University Hospital, Elm Park, Dublin, Ireland

Caecal volvulus is a rare cause of intestinal obstruction accounting for 1–3 % of intestinal obstrucions. [1–3]. It is caused by an axial twist of the caecum, ascending colon and terminal ileum around the mesenteric pedicle. It likely results from increased caecal mobility in individuals with inadequate right colon fixation during embryogenesis, and has a mortality of 10–40 % depending on the presence of intestinal gangrene and perforation. We present the case of a 30-year old male, with no past medical or surgical history, who presented to the Emergency Department with a 3-day history of worsening generalized abdominal pain, vomiting and constipation. Although vital signs were normal, his examination was concerning given the presence of abdominal distension and generalized tenderness. An abdominal radiograph demonstrated a significantly dilated loop of colon in mid-abdomen with the caput caecum directed towards the RIF. A CT abdomen confirmed a caecal volvulus, with no evidence then of ischaemia or perforation. Following resuscitation, urgent endoscopic decompression was undertaken. Visualizaton of ascending colon mucosa endoscopically identified patchy mucosal ischaemia, prompting the decision to proceed to surgical exploration. At laparotomy, a type 1 (organo-axial) caecal volvulus was identified, complicated by ischaemia of caecum and ascending colon. A right hemicolectomy with primary ileocolic anastomosis was performed. He made an uneventful recovery and was discharged home on Day 5 postoperatively. He remains well 6 months postoperatively and has no expected long-term sequelae. Although caecal volvulus is an infrequent clinical condition, it should be borne in mind when evaluating patients with an acute abdomen, regardless of age. A definitive diagnosis is difficult to make clinically and radiologically, therefore surgical intervention is often both diagnostic and therapeutic. Whilst endoscopic decompression is occasionally successful, high recurrence rates have deemed surgery the standard of care in the definitive treatment of caecal volvulus. References: 1. Rakinic J. Colonic volvulus. In: The ASCRS textbook of colon and rectal surgery, 2nd, Beck DE, Roberts PL, Saclarides TJ, et al. (Eds), Springer, New York 2011. p.395. 2. Lee SY, Bhaduri M. Cecal volvulus. CMAJ 2013; 185:684. 3. Baldarelli M, De Sanctis A, Sarnari J, et al. Laparoscopic cecopexy for cecal volvulus after laparoscopy. Case report and a review of the literature. Minerva Chir 2007; 62:201.

A Picture of Adrenal Crisis Spins into Non-Functioning Pituitary Macro-Adenoma Husain A1, Jafar A2, Crowley R3 1 UCD intern network, St Vincent’s University Hospital; 2Department of Surgical and interventional sciences, University College London; 3 Department of Endocrinology, St Vincent’s University Hospital

Background: Non-functioning pituitary adenomas (NFPA) are pituitary adenomas that are not hormonally active1. They account for

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S226 15–30 % of pituitary adenomas1. Diagnosis is usually made either from mass effect or during imaging for unrelated purpose or from hormonal deficiencies1. Case presentation: A 67-year-old lady was brought by ambulance to hospital with generalized weakness, fatigue, hypotension and hypothermia on a background of long-term prednisolone use, 20 mg daily, for temporal arteritis, she ran out of supplies 3-days prior to admission. Physical findings demonstrated blurry vision on right eye and long-standing complete blindness of left eye with no associated headaches or other neurological signs/symptoms. The clinical impression was Addison crisis; therefore, she was started on IV fluids and dexamethasone 4 mg IV BD. However, she remained hypotensive despite 3 L IVF and 8 mg dexamethasone over 24-h. A further 4 mg dexamethasone was administered; 2-days later she developed steroid-induced psychotic episodes along with agitation and confusion. CT brain was ordered for acute confusion, which revealed a sella turcica lesion; the differential for CT included meningioma, aneurysm or pituitary adenoma. The endocrine team was consulted and recommended switching dexamethasone to hydrocortisone, full pituitary function test and MRI pituitary. The MRI pituitary identified macroadenoma with supra-sellar extension and compression on right optic nerve. Laboratory findings confirmed secondary hypothyroidism, low gonadotropins, and mildly elevated prolactin (850 mu/ L). She subsequently, had visual field testing and retinal examination, which demonstrated complete blindness in left eye with nasal field defect and temporal pallor in right eye. She was transferred to Beaumont hospital for resection of pituitary macro-adenoma. Conclusion: Non-functioning pituitary macro-adenomas are associated with gonadotrophic, corticotrophic and thyrotrophic deficiencies. The mildly elevated prolactin in this case reflects ‘‘stalk effect’’, which is the compression of infundibular stalk produces a roadblock on the gland, therefore dopamine doesn’t reach lactotrophs, rather than an actually functioning pituitary prolactinoma. Reference: 1. Chanson P, Raverot G, Castinetti F, et al. Management of clinically non-functioning pituitary adenoma. Annals d’Endocrinologie. 2015; 76: 239–247.

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 showed multiple IPMNs; the dominant lesion found intra-ductally with size of 2.7 cm. Repeated EUS and biopsy suggested pancreatic adenocarcinoma, with poorly differentiated perineural invasion staged pT3 N0 M0. After a comprehensive pre-operative assessment, he underwent exploratory laparotomy with distal pancreatectomy and splenectomy with in situ drain left post-operatively. Post operatively the patient received all post splenectomy vaccinations and started on prophylactic Penicillin. Conclusion: Surgical treatment is the dominant choice for management of IPMN2. Furthermore, evidence of clonal progression are indicative that most if not all benign IPMNs may progress into invasive IPMNs, and the long-term follow up of resected patients showed excellent survival for benign and invasive lesions. The role of adjuvant therapy confers no survival benefit, although the choice of adjuvant therapy can be controversial in post-resection phase for malignant IPMN3. References: 1. Michaud DS. Epidemiology of pancreatic cancer. Minerva Chir. 2004; 59(2): 99–111. 2. Uehara H, Nakaizumi A, Ishikawa O, et al. Development of ductal carcinoma of the pancreas during follow-up of branch duct Intraductal papillary mucinous neoplasm of the pancreas. Ut. 2008; 57:1561 3. Turrini O, Waters J, Schnelldorfer T, et al. Invasive intraductal papillary mucinous neoplasm: predictors of survival and role of adjuvant therapy. HPB.12(7):447–455.

Posterior Reversible Encepholapthy Syndrome ODriscoll E Senior Author: Dr Tom Lee, Consultant Physician

West Northwest Intern Training Network

A Case of Invasive Intraductal Papillary Mucinous Neoplasm Husain A1, Jafar A2, Conlon K3 UCD Intern Network, St Vincent’s University Hospital; 2Department of Surgical and interventional sciences, University College London;3Hepatobiliary Department, St Vincent’s University Hospital 1

Background: Intra-ductal papillary mucinous neoplasm (IPMN) is a mucinous producing epithelial tumor that carries a risk of progression to invasive pancreatic ductal adenocarcinoma. IPMNs are among the common cystic neoplasms of the pancreas, they represent about 1–3 % of all exocrine pancreas tumors1. Most patients with IPMN present asymptomatically, and neoplasm becomes detected incidentally. Case presentation: A 79-year-old male patient with multiple comorbidities was admitted to the hospital for follow-up CT of his NonSmall Cell Lung Cancer (NSCLC). Since 2014, incidental finding on follow-up abdominal CT scan showed 2 9 2 cm unilocular pancreatic tail cyst with solid component composing 60 % of the entire lesion. Further diagnostic work-up included Endoscopic ultrasound (EUS) and biopsy of the lesion showed atypical cells, considered worrisome for pre-malignant mucinous neoplasm. MRI pancreas

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Mrs C, a 65 y/o lady visiting Ireland from Manchester presented to MGH ED on 25/7/15. She was BIBA, with loss of consciousness and a generalized tonic–clonic seizures, as witnessed by her husband. The patient experienced a second seizure in the ambulance. She was agitated and confused in ED, requiring IV sedation. The only other symptoms patient had experienced were nausea and vomiting for 3/7. PMHx of relevance includes hypertension and PE 21 y/o. The patient was diagnosed with nephrotic syndrome (membranous nephropathy) earlier in the month and had been commenced on Azathioprine, and is currently requiring weekly bloods (kidney disease profile) until she is seen in the renal clinic again. On examination in ED, CNS was intact with no focal neurological deficits. Bloods showed elevated d-dimers (4.05), elevated lactate (12.7), and decreased albumin (21). A differential at this time included vascular cause (Posterior circulation stroke/TIA), classic migraine, meningitis or possibly metabolic conditions (severe Hypoglycemia). Patient was commenced on Aciclovir, admitted to ICU, reviewed by anaesthetics and had an urgent CT Brain. CT Brain showed hypoattenuation in the bilateral occipital lobes most in keeping with P.R.E.S. MRI was then indicated. Team liased w/neuro reg in Beaumont who guided management which included holding azathioprine. Patient continued to be confused for the next week, also tearful with some visual disturbances and experiencing paranoid delusions. A severe headache also developed, warranting an LP, which was NAD. MRI appearances consistent with PRES.

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 During admission patient’s BP was treated aggressively, anticonvulsants given and US KUB to rule out renal event. Patient symptoms resolved completely over the following 10 days with patient having complete insight when psychological symptoms resolved. In conclusion, patient suffered a transient episode of neurotoxicity (Posterior Reversible Encephalopathy Syndrome) in the setting of nephrotic syndrome due to HTN and recent addition of oral Azathioprine. Patient advised on discharge to return home immediately and present to her renal unit.

Audit on B12 Screening/Supplementation in Metformin Treated Patients Casey M1, O Loughlin A2 1

NUIG Intern Network, Roscommon General Hospital; Endocrinology, Roscommon General Hospital

2

Objectives: Metformin is recognised as the standard initial medication for type 2 diabetes mellitus. The deleterious effect of metformin on vitamin B12 levels has been reported since the 1970’s,[1] whereas modern day studies find the incidence of B12 deficiency amongst metformin patients to be as high as 30 %.[2] Although no definitive guideline on frequency of screening for B12 deficiency in metformin patients exists, numerous studies corroborate that an annual check of B12 levels is recommended. Are metformin patients in Roscommon hospital screened for vitamin B12 deficiency and, if deficient, are they receiving supplementation? Design/methods: The patient lists of diabetic outpatient clinics in Roscommon GH over the space of 8 months were chosen at random. Each patient ID number was entered into DIAMOND diabetes database to determine which patients were on metformin and, if receiving the drug, their dose and B12 supplementation status. Those identified as metformin patients had their patient ID numbers entered into iLaboratory system to investigate whether their serum B12 level had been checked within the previous year. Clinic dates used in the audit were saved, to allow for re-audit. Results: The audit revealed 52 patients on metformin therapy, the spectrum of dosage ranging from 500 mg twice daily to 1000 mg three times daily. 33 patients (63 %) had a serum B12 level checked in the previous year. Out of those checked, 4 patients (12 %) were found to be B12 deficient. Just two patients were recorded as receiving B12 supplementation. Conclusions: Out of a total of 52 patients, a significant proportion (37 %) had not been screened for B12 deficiency within the recommended timeframe. Of those that were screened, B12 deficiency rates were quite low (12 %,) reflecting the low rate of B12 supplementation amongst the cohort. A re-audit would look for an increased percentage of metformin patients undergoing B12 workup as part of their ongoing diabetic care. References: 1. Tomkin, G., Hadden, D., Weaver, J. and Montgomery, D. (1971). Vitamin-B12 Status of Patients on Long-term Metformin Therapy. BMJ, 2(5763), pp. 685–687. 2. Liu, Q., Li, S., Quan, H. and Li, J. (2014). Vitamin B12 Status in Metformin Treated Patients: Systematic Review. PLoS ONE, 9(6), p.e100379.

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A Case of PR3 ANCA Vasculitis Keane S1, Magee C1 1

Department of Nephrology, Beaumont Hospital

Presenting complaint and background: 84-year-old lady transferred from OLOL Drogheda with a 1-week history of, nausea, vomiting and 3 episodes of haemoptysis along with abnormal U&E. She had reduced urine output of around 300 mls per day. She had a background of recurrent pulmonary embolus, atrial fibrillation and 1 previous CVA (deficits largely resolved). She had no renal history. She lives at home alone and is independent of all of her ADLs and has good family support around her. No smoking or significant alcohol history. Investigations: On presentation her creatinine was 347 and urea was 18.2. On further blood tests she was found to be ANCA Positive with a PR3 of 36 (0–2), MPO 1.4 (0–3.5). Chest x-ray showed nodular density in the right lower lobe. A renal biopsy was performed, which showed cresentric glomerulonephritis with moderate activity and severe chronicity features (fibrosis). She was subsequently given a working diagnosis of glomeluronephritis secondary to ANCA (PR3) vasculitis complicated by pulmonary haemorrhages. Of note, after the renal biopsy it was noted that her Hb had dropped to 7.4 from a baseline of 10. She was given 2 units of RBC and 20 mg of desmopressin. Her Hb subsequently resolved. Treatment: Given the low output (negative fluid balance) she was advised to fluid restrict. A central line was inserted into the right internal jugular vein and plasmapheresis was started. Cyclophosphamide was commenced 100 mg OD. White cells and fibrinogen levels were monitored daily. After day 3 of cyclophosphamide her WBC was 0.92. It was held for 2 days until the WBC resolved. The final diagnosis was an acute on chronic kidney disease due to a flare-up of ANCA vasculitis. Based on the fact that plasmapheresis was discontinued and the patient was feeling much better she was discharged home after an 11-day hospital admission. She was discharged on PO cyclophosphamide with regular blood monitoring.

Calling BS: A Case of Brugada Syndrome Carolan A1, Gorecka M2, Crowley J3 West Northwest Intern Training Network Introduction: Brugada syndrome (BS) is a rare autosomal dominant disorder of variable penetrance caused by a mutation in the cardiac calcium channel gene. The archetypal ECG shows right bundle branch block and ST segment elevation in the right precordial leads, V1 to V3. It is associated with an increased risk of ventricular tachyarrythmias and sudden cardiac death in a structurally normal heart. Description: A healthy 41-year-old Belarusian man with no significant past medical history presented to the emergency department following three syncopal episodes. Each episode was associated with a loss of consciousness for 3–5 min. The patient reported no associated symptoms such as chest pain or shortness of breath. Physical

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S228 examination was normal. ECG showed a right bundle branch block and a ‘RSR’ pattern. Other investigations were normal. It wasn’t until the patient returned for further investigation as an outpatient and an ajmaline test was performed that the diagnosis of Brugada became apparent. Discussion: Studies have shown that approximately 28 % of those with BS present with syncope at the time of diagnosis. A history of syncope conferred a 3.4 times greater risk of arrhythmogenic events versus asymptomatic patients in the FINGER registry study. Weighing up the benefits and the risks, it is important to consider the appropriateness of ICD insertion in each individual case of BS. As this case highlights, the ajmaline test is an important diagnostic tool to consider when faced with cases of unexplained syncope particularly if ECG changes are suggestive of the diagnosis of BS. Sacher F, Arsac F, Wilton SB, et al. Syncope in Brugada syndrome patients: prevalence, characteristics, and outcome. Heart Rhythm 2012; 9:1272. Probst V, Veltmann C, Eckardt L, et al. Long-term prognosis of patients diagnosed with Brugada syndrome: Results from the FINGER Brugada Syndrome Registry. Circulation 2010; 121:635.

What’s All the HIPE About? Cronin M, Hensey M, Galvin J Cardiology department–Connolly Hospital Blanchardstown In March 2015 The Department of Health published the first annual report of the ‘‘National Healthcare Quality Reporting System’’, designed to report the quality of healthcare provided across all sectors of our system. The indicator used as a measure of acute cardiac care was in-hospital mortality within 30 days of admission for acute myocardial infarction (AMI). Data was collected via Hospital Inpatient Enquiry (HIPE) information. It was found that Connolly Hospital Blanchardstown (CHB) had an above average in-hospital mortality post AMI over the period 2011–2013. We performed a retrospective chart review of patients who died in CHB between 2011 and 2013. We determined if there was in fact AMI during their admission, and cause of death from the clinical notes. From February 2011 to December 2013, we identified around 42 patients (confirmation pending with HIPE office) classified as having died due to AMI. Average age was 79.3 Years. Baseline characteristics and comorbidities were collated also. Based on our preliminary data only 59.5 % of these patients were confirmed as having had an MI during the course of their admission. AMI was the cause of death in only 26.2 %. Other common causes of death were sepsis (23.8 %) and VF arrest (21.4 %). Those who died from AMI within 30 days of admission had a lower pre-admission functional status on average. Around 25 % had not been seen by the cardiology service during their inpatient stay. We believe the use of in-patient mortality following admission for AMI is a valid and useful indicator of acute cardiac care. Our audit showed however, that many of the patients included from our institution had not suffered AMI and many had not been seen by the cardiology team during their stay. The findings of our audit underline the need to ensure that the data collected accurately represents outcomes.

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Clot in the Lung You Say? Diagnosis of Pulmonary Embolism and Incidential Findings on CTPA: A Review of Current Practice at Portiuncula Hospital Ballinasloe Rooney S1, TjinATon ER2, Gough N2, Baj M2 WNW Intern Network, Portiuncula Hospital Ballinasloe Consultant Radiologist, Portiuncula Hospital Ballinasloe West Nortwest Intern Training Network Objective: The study aimed to compare our current diagnostic rate of Pulin Portiuncula Hospital Ballinasloe (PHB) against international studies. Design/methods: We retrospectively reviewed the NIMIS e-charts and reports of 65 patients admitted on acute take with suspected PE over a 90 day period. Clinical Data provided on NIMIS order form was analysed and an modified wells Score was retrospectively calculated. Results: The reported findings for the 65 CTPA scans were PE in 8 (12.3 %) scan, 57 (87.7 %) were negative for PE. Alternate diagnoses in 22 (33.8 %) of CTPA and no abnormality idenified in 25 (38 %) of scans, Infective processes indentified in 12 (18.5 %) of scans. The Royal college of Radiologitst UK suggest an alternative diagonosis in up to 56 %, The results of this audit indicate than in 52.3 % of CTPA preformed provided an alternative diagnosis. Conclusion: The positive rate of CTPA in Portiuncula Hospital is 12.3 %. Positive rates of CTPA can vary according to setting, it may range from 7 % in small regional hospitals to as high as 30 % in one particular Emergency Department in Christchurch, New Zealand [11]. The rate of positive CTPA findings in Portiuncula is similar to other small local hospitals, however is it much lower than the pick up rates in larger tertiary hospitals. There are multiple factors which impact on positive CTPA reports, in particular patient cohort and hospital logistics which I will address. The current trend in CTPA positive studies exceeds that of other similar international small regional hospitals. However there is room for improvement, in particular regarding NIMIS request forms. Encouraging NCHDs and Consultants to provide concise and accurate clinical information, documenting a clinical probability score and D-Dimer titer where appropriate.

Penetrating Perineal Trauma in a Construction Worker Browne A1, Corry P1, Condon E2 1 Mid-West Intern Network, University Hospital, Limerick; 2Dept of Colorectal Surgery, University Hospital, Limerick

Introduction: A penetrating perineal trauma presents a difficult challenge to surgeons. The injury can affect soft tissue, vascular

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 structures, the genitourinary tract, the pelvis and the intra-abdominal viscera (Cleary et al., 2006). We describe the case of a construction worker who suffered a penetrating injury to his perineum and who underwent emergency laparotomy to repair two perforations to his bowel. Case presentation: A 32 year old male presented following a fall from a height of 10–15 feet onto a metal bar that pierced his perineum in the lumbrosacral region. On initial examination, he was hypotensive and tachycardic. He demonstrated tenderness and guarding in the lower abdomen and had a large bleeding perineal wound. Distal pulses were palpable. Neurological examination was normal except for sensory loss at L4-L5. A CT scan demonstrated the entry wound in the perineum with the exit wound posteriorly in the left para-lumbar region. The patient underwent emergency laparatomy with loop colostomy formation following repair of two rectal perforations. The perineal wound was debrided and sutured. Shirley drains were inserted intra-operatively. The patient was discharged 2 weeks post surgery following successful pain management, recovery from surgery and removal of drains. The plan is to reverse the loop colostomy 6 months following the initial surgery. It is anticipated that he will make a full recovery. Discussion: Controversy exists concerning the standard treatment for management of colorectal trauma. The treatment method should be selected based on considerations of risk factors, such as the injury mechanism and severity, the interval from injury to surgery, whether or not vital signs are stable and associated organ injuries (Jun Choi, 2011). Fortunately in this instance, most intra-pelvic structures were avoided and the injury was safely managed by means of primary repair and colostomy formation. References: 1. Cameron, J., & Cameron, A. (2011). Current Surgical Therapy, 10th ed. Management of Rectal Injuries. USA: Elsevier Saunders. 2. Cleary, R.K., Pomerantz, R.A., & Lampman, R.M. (2006). ‘Colon and Rectal Injuries’. Diseases of Colon and Rectum, 49: 1203–1222. 3. Corman, M.L. (2013). Corman’s Colon and Rectal Surgery, 10th ed. USA; Lippincott, Williams and Wilkins. 4. Jun Choi, W. (2011). ‘Management of Colorectal Trauma’. Korean Journal of Coloproctology, 27(4): 166–172.

Unresolving Osteomyelitis; Difficulties in Management McDonald L, Curran A Department of Otolaryngology, SVUH A 56 year old gentleman presented to ENT services with a tracheooesophageal-cutaneous fistula discharging large amounts of purulent fluid. Two years earlier he was diagnosed with Squamous Cell Carcinoma of the Larynx which was initially treated with chemotherapy and radiotherapy, followed by total laryngectomy. Some months later he presented with acute quadriplegia due to spinal cord compression. He underwent emergency cervical spine corpectomy and laminectomy, with insertion of a stabilising plate from C3-C6. A diagnosis of polymicrobial osteomyelitis of the C-spine was made. It was felt that the osteomyelitis was likely caused by local spread of infection from the site of his laryngectomy. Postlaminectomy he developed a trachea-oesophageal-cutaneous fistula. He was treated with a 6 week course of intravenous antibiotics as per

S229 protocol and was discharged to the National Rehabilitation Hospital. Four weeks later he was admitted to St Vincent’s University Hospital (SVUH) with a purulent discharge from the fistula. Radiological investigations in SVUH showed recurrence of his osteomyelitis and fracture of the spinal plate, with a direct connection between the infected c-spine vertebrae and pharynx. CT also demonstrated a soft tissue mass adjacent to the right common carotid artery, suspicious for local recurrence of malignancy. This case highlights both a rare post-operative complication of laryngectomy, tracheo-oesophageal-cutaneous fistula, and the difficulties in treatment of spinal osteoarthritis. The discharging fistula presented diagnostic and management dilemmas. The presence of a foreign body and the likelihood of active underlying carcinoma undoubtedly contributed to persistence of infection despite intensive antibiotic therapy. It may also be that he would have benefited from a more prolonged course of antibiotics, due to his complicated history and the presence of a foreign body.

Clostridium Difficile Bacteraemia in an 85-Year-Old Male with a Colovesical Fistula O Meara S, Daly T Mater Misericordiae University Hospital Introduction: Clostridium Difficile is most commonly associated with pseudomembranous colitis, and is frequently linked to prior antibiotic exposure. Extracolonic manifestations of Clostridium Difficile are rare, and include intra-abdominal abscesses, osteomyelitis, empyema, reactive arthritis and rarely bacteraemia. There is a high mortality rate amongst patients with Clostridium Difficile bacteraemia. The majority of these manifestations are preceded by gastrointestinal disease, either colitis or an anatomical or surgical disruption to the colon. Case history: We present a case of Clostridium Difficile bacteraemia in an 85-year-old gentleman. He presented with a urinary tract infection on a background of chronic urinary obstruction requiring long-term catheterisation. He was found to have Clostridium Difficile bacteraemia and imaging showed a colovesical fistula. He declined surgical treatment and passed away in hospital despite appropriate medical treatment. Discussion and conclusion: This is a unique case of Clostridium Difficile bacteraemia in a patient with a colovesical fistula. Although rare, extracolonic manifestations can have a poor prognosis and prompt recognition and treatment is essential.

A Comparison in Outcomes in Patients Diagnosed with Gestational Diabetes Mellitus (GDM), Between Those Treated with Metformin and Those Treated with Insulin: A Single Centre Experience Ludgate S1, Gannon M2, Hoashi S2 Midland regional Hospital Mullingar (MRHM), Co Westmeath, Ireland Background: The use of metformin in patients with gestational diabetes is a relatively new treatment in Ireland. The safety of metformin use in pregnancy has been established by various groups (1–5). It has been used in practice in MRHM since late 2014.

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S230 Method: This retrospective study compared the outcomes of women diagnosed with GDM, who were treated with metformin to those who were treated with insulin. 56 women were eligible for this study, of which 30 were treated with insulin only, 18 were treated with metformin only, and 8 were treated with a combination of the two. Results: The results of this study showed similar results between metformin and insulin in all fields compared (metformin vs insulin vs combination). The average BMI (kg/m2) at booking of all women in the study was 30.2 with similar values between the three groups (31.0 vs 28.9 vs 32.2). The average birth weight (KG) showed no statistical significance between the three groups (3.3 ± 0.46 vs 3.33 ± 0.54 vs 3.27 ± 0.53) and the overall mean birth weight was 3.31 kg. The caesarean section rate between the three groups also showed similar results (33 vs 38 vs 42 %). The overall LSCS rate in MRHM was 37 % in 2015. The average gestation (weeks + days) at delivery between the groups was (39 + 1 vs 39 vs 38 + 3). Tear rate was also similar between the groups. The average HbA1c (IFCC mmol/mol) at diagnosis was slightly lower in the group treated with metformin only compared to the other two groups (34.1 vs 35.2 vs 35.9). The average change in HbA1c (mmol/mol) over the course of the pregnancy also showed the greatest reduction in the group treated with metformin only (-0.61 vs -0.21 vs 0). Conclusion: In women diagnosed with GDM, metformin treatment alone appears effective in treating hyperglycaemia, and is not associated with an increased birth weight, LSCS rate, HbA1c or perineal tear rate compared to those treated with insulin. There is also no increase in pre-term delivery. References: 1. Metformin versus Insulin for the Treatment of Gestational Diabetes Janet AR, William MH, Wanzhen G, Malcolm RB, Moore P. N Engl J Med. 2008 Jul 3;359(1):106 2. Gutzin SJ, Kozer E, Magee LA, Feig DS, Koren G. The safety of oral hypoglycemic agents in the first trimester of pregnancy: a meta-analysis. Can J Clin Pharmacol 2003;10:179–183 3. Hellmuth E, Damm P, Mølsted-Pedersen L. Oral hypoglycaemic agents in 118 diabetic pregnancies. Diabet Med 2000;17:507–511 4. Hughes RCT, Rowan JA. Pregnancy in women with type 2 diabetes: who takes metformin and what is the outcome? Diabet Med 2006;23:318–322 5. Ekpebegh CO, Coetzee EJ, van der Merwe L, Levitt NS. A 10-year retrospective analysis of pregnancy outcome in pregestational type 2 diabetes: comparison of insulin and oral glucoselowering agents. Diabet Med 2007;24:253–258

A Retrospective Audit of Overdose Patients Admitted to the Intensive Care Unit of an Irish University Hospital Horan A1, Nolan TJ1, O Brien B1 1

Department of Anaesthesia and Intensive Care, Cork University Hospital It is estimated that approximately 3 % of patients with acute overdose require intensive care unit (ICU) admission1. The aim of this study was to assess the percentage of patients admitted to the ICU with acute overdose at Cork University Hospital over the past 3 years (2012–2014) and to record their demographics based on information recorded in the ICU registry. 29 patients were eligible for inclusion over the 3 year period. This represented 1.8 % of the population admitted to the ICU over the

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 study period (1599). 44.82 % of the overdose population were female and 55.17 % were male. The average age of patients admitted to the ICU with overdose was 41.34 years, 95 % confidence interval between 35.01 and 47.68 years. The average age of the control group was 61.58 years, 95 % confidence interval between 56.68 and 66.48 years. The mean length of stay in the ICU in the overdose group was 4.672 days, 95 % confidence interval 2.552 and 6.793 days with no statistically significant difference compared to the control group. 96.55 % of the overdose group required mechanical ventilation while only 75 % of the control group did. 10.34 % of patients died whilst in the ICU versus 25 % for the control group. Over the study period we found that the average age of overdose patients to be lower than the average ICU patient, while they had a decreased mortality rate and an increased rate of mechanical ventilation compared to the control group. Mokhlesi, B., Leiken, J. B., Murray, P. & Corbridge, T. C. Adult toxicology in critical care*: Part i: general approach to the intoxicated patient. Chest 123, 577–592 (2003).

Audit Examining the Completeness of Documentation and the False Positive Rate, of all Blood Cultures Taken Over a 1 Week Period in Midlands Regional Hospital Mullingar (MRHM) Ludgate S1, O Sullivan C2, Glynn S2 Midlands Regional Hospital Mullingar, Mullingar, Co. Westmeath Background: Blood cultures are used to detect the presence of bacteria or fungi in the blood, to identify the type present, and to guide treatment. They have a high clinical importance as they can help treat many life threatening conditions (1). It is important that cultures are taken aseptically so as to avoid false contamination of the sample (false positives) which may misguide treatment. The international target rate for false positives is between 2 and 3 % (2, 3), however MRHM has a current false positive rate of 4.5 % which has been reduced from previous rates of 7 %. Aim: The aim of this audit was to examine all blood cultures taken between 1st and 7th December 2015 at MRHM and to establish the false positive rate in this period. It also examined if the cultures had been fully documented in the patient charts and if the request forms had been correctly completed. Results: 44 blood cultures were taken in this time period on 35 patients. Of these 44 samples, 40 showed no growth and 4 were positive (9.09 %). Of these four, it was found that three were false positives (6.81 %) while one was a true positive (2.27 %). In terms of documentation in the patient chart it was found that 20 of the 44 were not documented at all (45.45 %), 20 were partially documented (45.45 %) and 4 were fully documented (9.09 %). On examination of the test request forms, it was found that 22 of 44 (50 %) had not been fully completed while 19 of the 44 (43.18 %) had either no clinical info recorded or had insufficient clinical data recorded. Conclusion: The false positive rate in MRHM is above acceptable limits (2, 3). Education and instruction in the taking of blood cultures is required. The importance of providing good clinical information to the microbiology team must also be highlighted to help improve patient care. References: 1. Coburn B, Morris AM, Tomlinson G, Detsky AS. Does this adult patient with suspected bacteraemia require blood cultures? JAMA 2012; 308:502

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 2. Kim JY, Rosenburg ES. The sum of the parts is greater than the whole: reducing blood culture contamination. Ann Intern Med 2011; 154:202–203 3. Chandrasekar PH, Brown WJ. Clinical issues of blood cultures. Ann Intern Med 1994; 154:841–849

A Turn for the Worst Hayden J, Crealey M, Ryan E West Northwest Intern Training Network Introduction: Vomiting in children is an extremely common presentation to the emergency department. In CB’s case however it evolved into an unexpected diagnosis. Case report: CB is a 14 year old boy with a 4 month history of intermittent nausea and vomiting. During this time he had one hospital admission where gastritis was the working diagnosis. In October 2015, he arrived to the accident and emergency department with persistent vomiting for 1 week. This was the worst episode to date. He had associated anorexia and weight loss. He had an open appendectomy in 2008 but no past medical history. His initial bloods were markedly abnormal demonstrating an acute kidney injury and metabolic alkalosis. He was hyponatremic (133), hypokalemic (2.9), hypochloremic (79) and had a rising urea (19.2) and creatinine (144). An abdominal ultrasound demonstrated a reversed relationship between the uppermost superior mesenteric artery and vein which is highly suggestive of small bowel malrotation. A barium swallow confirmed the diagnosis by showing a markedly abnormal duodeno-jejunal flexure lying anterior to L4/L5 lumbar vertebrae. CB underwent an open Ladd reparative surgery. Discussion: Malrotation is a rare congenital anomaly and is commonly a condition of infants with 90 % diagnosed in the first year of life1. CB presented unusually late in life and the incidence in adults is as low as 0.2–0.5 % 2. However malrotation should be considered in the differential diagnosis in a vomiting patient. Intestinal malrotation produces an abnormally placed right sided small intestine, a left sided colon and an abnormal relationship between the superior mesenteric vein and artery. This abnormal anatomy renders the patient at risk of intestinal volvulus. During the reparative laparotomy multiple adhesions and an associated para-vesical hernia were identified. The Ladd procedure has evolved to ensure the lowest risk of relapse therefore securing the gut and making it less likely to twist again3. This case highlights the importance of considering an alternative diagnosis when symptoms persist or recur. References: 1. Torres AM, Ziegler MM: Malrotation of the intestine. World J Surg 1993, 17:326–331. 2. Singh S, Das A, Chawla AS, Arya SV, Chaggar J. A rare presentation of midgut malrotation as an acute intestinal obstruction in an adult: Two case reports and literature review. Int J Surg Case Rep. 2013;4:72–75. 3. World J Gastrointest Surg. 2013 Mar 27; 5(3): 43–46. Published online 2013 Mar 27. doi:10.4240/wjgs.v5.i3.43

Attitudes of Patients with Type 1 Diabetes Towards Hypoglycaemia and Safe Driving Bradley C Department: General Practice

S231 Introduction: Patients with type 1 diabetes treated with insulin, with the potential for hypoglycaemia, must inform the Driving Licensing Authority and adhere to precautions set out in the Medical Fitness to Drive Guidelines, February 2013. Aim 1) To assess awareness of and adherence to these guidelines, to promote safe driving in Ireland 2) To see if certain groups of people have a higher compliance rate than others to the guidelines 3) To see if patients are receiving advice from their GP’s regarding safe driving practices Method: A cross-sectional, quantitative, survey based study was conducted using a survey monkey link to the self-designed questionnaire. Questionnaires were distributed via Diabetic clinics in CUH GP surgery Diabetic support groups Data were in-putted into excel and analysed using SPSS software. Results: In total 107 patients were surveyed. 36 were aware of the licensing authority guidelines. 1) Of the 36 people who appeared to be aware of the licensing authority guidelines only 41.7 % (15) reported that they always check their blood glucose level before driving. 25.3 % (21/83) of people over 40 years reported that they always carry their blood glucose monitor with them whilst driving compared to 74.7 % (62/83) of people under 40 years. 2) 27.1 % (29/107) were aware of the appropriate management of hypoglycaemia whilst driving according to the guidelines. 3) 15.9 % (17/107) of patients reported that they had received advice about safe driving from their GP. Conclusion: There appears to be a lack in patient knowledge of the Medical Fitness to Drive Guidelines. Education should be provided to all patients by their GP, with particular emphasis on certain higher risk groups.

Case Report: Liver Cirrhosis in the Setting of Retrospectively Diagnosed Autoimmune Pancreatitis Lynch F1, Kelleher B

2

1 Gastroenterology intern, Mater Misericordiae University Hospital, Eccles St, Dublin 7; 2Consultant Gastroenterologist, Mater Misericordiae University Hospital, Eccles St, Dublin 7

Abstract: A 55 year old female presented with painless jaundice. Imaging revealed a mass in the head of the pancreas. Following multidisciplinary review, a radiological diagnosis of pancreatic cancer was made. Biopsies were unsuccessful and tissue was never obtained. Despite this, she was treated with endoscopic biliary stenting, chemotherapy and radiotherapy. Follow-up imaging 1 year later showed a marked regression of her disease. No discrete pancreatic mass was visualised. Ten years later she presented with deranged LFTs. At this point her history and prior imaging were reviewed. Doubt was cast over the legitimacy of her original diagnosis. CT now showed a burnt out, atrophic pancreas. In retrospect, her initial presentation was likely autoimmune pancreatitis which responded to the steroids in her chemotherapy regimen. Interestingly, over the next few years she developed a distal biliary stricture as well as clinical and radiological features of cirrhosis and portal hypertension. There is some debate as to whether the aetiology of her cirrhosis is either primary sclerosing cholangitis (PSC) or IgG-4 associated

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autoimmune cholangiopathy (IAC). Differentiating these two entities can be challenging. They share similar radiological features. Unfortunately, histology was unhelpful in this case. PSC is characterised by chronic inflammation and stricturing of the biliary tree, seen as beading, pruning and diverticulae on imaging. It is strongly associated with IBD and carries an increased risk of cholangiocarcinoma. IAC is a known extrapancreatic manifestation of autoimmune pancreatitis. It is characterised by segmental bile duct narrowing and pre-stenotic dilatation. Unlike PSC, IAC is strongly steroid-responsive and generally has a better prognosis. Despite close radiological surveillance and frequent multidisciplinary discussion, a diagnosis has not been agreed upon. She was recently commenced on a steroid trial. Her response to this may ultimately establish or rule out a diagnosis of IAC.

virus-negative patients. International Journal of Infectious Diseases. 2006;10(1):72–8. 2. Perfect JR, Dismukes WE, Dromer F, Goldman DL, Graybill JR, Hamill RJ, et al. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of America. Clinical Infectious Diseases. 2010;50(3):291–322.

When Alcohol Withdrawal is not the Full Picture: A Sporadic Case of Cryptococcal Meningitis in an HIV-negative Patient

Department of Gynaecology Oncology, Mater Misericordiae University hospital, Dublin

Cronin C1, Fleming C1 Department of Infectious Diseases, University College Hospital Galway Introduction: Cryptococcal meningitis is an infrequently encountered condition in medically developed countries, where cases are comprised mainly of newly diagnosed HIV patients and patients receiving immunosuppressant therapies. The 3-month mortality rate during management of acute cryptococcal meningitis in all patient groups is approximately 20 %. (1) Case presentation: We report the case of a 57 year old homeless gentleman with chronic alcohol dependence who presented with a witnessed tonic–clonic seizure. The patient denied any alcohol consumption in the preceding 3 days. His GCS was 14/15 and he was agitated on review. He was orientated to person but not time or place. He denied any symptoms or past medical history of note. On examination the patient was tachypnoeic and pyrexial, with fine crackles noted at the left lung base on auscultation. Inflammatory markers were elevated and his chest x ray was unremarkable. The patient was treated for alcohol withdrawal (as the presumed aetiology of his seizure) and was commenced on antimicrobial treatment to cover for suspected aspiration pneumonia. The patient continued to deteriorate clinically despite escalation of antimicrobial treatment. Day 4 post admission blood cultures reported the growth of a fungus to be identified as cryptococcus neoformans. Cerebrospinal fluid culture following lumbar puncture confirmed cryptococcal meningitis. The patient underwent induction therapy with intravenous amphotericin and flucytosine and subsequently maintenance therapy with high dose oral fluconazole. Discussion: This case highlights the importance considering central nervous system infection in patients with altered mental status–particularly those with pyrexia or elevated inflammatory markers. The patient’s viral serology (including Human Immunodeficiency Virus) was negative, and subsequent laboratory and imaging investigations did not identify any evidence of an immunodeficient state. The patient was managed with reference to the American Society of Infectious Diseases guidelines for the management of cryptococcal disease. (2) 1. Kiertiburanakul S, Wirojtananugoon S, Pracharktam R, Sungkanuparph S. Cryptococcosis in human immunodeficiency

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Laparoscopic Resection of a Rudimentary Uterine Horn in a Patient with Multiple Congenital Anomalies Nevin-Maguire D1, O Leary B2,, Tadesse W3, Brennan D4, Walsh T5, Connolly G6

Mullerian anomalies occur in 2–4 % of women with normal reproductive outcomes [1, 2], and up to 25 % in patients with recurrent second trimester miscarriages [2]. Many functional non-communicating horns present with acute obstetric uterine rupture [3] and approximately half present with dysmenorrhoea [3]. A 17-year-old female presented with right lower quadrant pain and tenderness. Computed tomography suggested uterus didelphis with haemometra in the right horn. The patient had a complex background of bilateral absence of the femur, cleft lip and palate, hypoplastic pelvis, shortened upper limbs, scoliosis and a history of maternal type 1 diabetes (T1DM). At laparoscopy she was found to have a right rudimentary horn and fallopian tube. The left fallopian tube was normal as were both ovaries and the left hemiuterus was larger than the right. The right hemiuterus was resected laparoscopically using ligasure and the defect closed with a V-lock suture. The patient was discharged day one post-operatively and her abdominal pain had resolved at 4 week post-operative review. Diagnosis of a uterine anomaly can be made by hysterosalpingography, ultrasound, or magnetic resonance imagery (MRI) [4]. Ultrasound has become the mainstay of diagnostic imaging, however MRI remains the gold standard for diagnosing anomalies of the reproductive tract [5]. Obstructed hemi-uteri can be difficult to diagnose due to the presence of both patent and non-patent tracts. Once identified, an obstructed rudimentary uterine horn can be resected laparoscopically which is well tolerated and can prevent the development of endometriosis or pregnancy in the obstructed horn [6, 7]. Treatment is not warranted in asymptomatic women or those with primary infertility. ‘‘Femoral hypoplasia—unusual facies syndrome’’ (FH-UFS) is a described syndrome comprising many of the same congenital anomalies as this patient with some cases exhibiting genitourinary abnormalities [8]. An association between FH-UFS and maternal T1DM also exists.

First Presentation of Coeliac Disease in an Elderly Patient Dillon J1, Lyons D2 1 Mid-West Intern Network, University of Limerick Group of Hospitals; 2Geriatric Department, University Hospital Limerick

University Hospital Limerick; UL Intern Training Network

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Introduction: Coeliac Disease is common in Ireland with a prevalence of 1:100. Due to the rising age of our population it is unsurprising that over 30 % of patients above 60 years of age are newly diagnosed. However the atypical presentation in the elderly population may lead to exacerbations and complications of coeliac disease which could be easily prevented. Case presentation: An 80 year old man was admitted for investigation of ongoing weight loss (approximately 25 kg) for the previous 2 years but had accelerated over the past 8 months. The patient was noticeably cachectic at a weight of 66 kg and a BMI of 18. Other than a complaint of hoarseness, there were no other clinical signs or symptoms extracted from the history or clinical examination. This patient underwent extensive investigations. His routine bloods, thyroid function tests, haematinics and iron studies were all within normal limits. Viral and autoimmune serology including coeliac serology was sent off. He underwent an oesophago-gastroduodenoscopy and colonoscopy, both of which showed no abnormalities. A CT thorax, abdomen and pelvis indicated right-sided bronchial and lower lobe thickening in keeping with passive smoking exposure. Finally a nasendoscopy and thyroid ultrasound were both normal. Dietetics were involved and nutritional supplements were recommended. After his discharge, the patient’s coeliac serology returned markedly positive with a tissue transglutaminase of 174 RU/ml. The patient was advised to commence a gluten free diet with further follow up to confirm his diagnosis. Discussion: This case highlights the subtle presentation and delay in diagnosis of coeliac disease in elderly patients. More awareness of atypical presentations and early management with a simple gluten free diet can prevent complications and debilitation of this disease in the elderly. Johnson, M.W., Ellis, H.J., Asante, M.A., Ciclitira, P.J. (2008) Celiac Disease in the Elderly Nature Reviews Gastroenterology and Hepatology, 5, 697–706

A Complete Audit on Initial Vancomycin Dosing Lee C1, Kidd P2, Bray E3, Hickey P4 Department of Pharmacology, West North West, Galway University Hospital Background: Correct vancomycin dosing is necessary due to its narrow therapeutic index. Dosing is calculated using actual body weight and renal function. Initial loading dosing is an effective method of attaining early serum concentrations in critically ill, oncology or haematology patients and overall improving clinical outcomes.(1) Objectives: To determine if initial vancomycin prescribing is adhering to the recommended dosing. Methods: Data was collected on a single day using patient drug prescribing and medical charts, electronic lab system, and G.U.H. GAPP application. The parameters included patient age, height, weight, serum creatinine, loading and maintenance dose prescribed. Results: Of 64 % (9/14) of patients who received a loading dose, 67 % received the recommended dose. 54 % received an appropriate initial maintenance dose. 31 % of patients had below recommended dosing regimens and 3/14 received half or less than the recommended dose. Demonstrations were carried out after the original audit to increase awareness of dosing calculations to hospital interns and pharmacists. A re-audit 1 month later revealed 71 % (10/14) of patients received an initial loading dose all of which were appropriately prescribed. 64 % of patients were given an appropriate initial maintenance dose.

S233 The re-audit included first serum vancomycin concentration levels and whether these levels were measured correctly (within an hour before the 3rd/4th dose). 73 % of concentration levels were measured correctly; 40 % were within therapeutic range. Conclusion: This completed audit cycle shows an improvement of initial dosing regimens for Vancomycin in particular loading dose prescribing. Further evaluation is needed to address whether clinical outcomes are effected by suboptimal vancomycin dosing. In particular, to identify a correlation between serum concentration levels not in therapeutic range and deviation from best standard of care. 1. Rybak M, Lomaestro B, Rotschafer JC, Moellering R, Craig W, Billeter M, et al. Therapeutic monitoring of vancomycin in adult patients: A consensus review of the American Society of HealthSystem Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. American Journal of Health-System Pharmacy. 2009;66(1):82–98.

Bone Age Assessment in General Paediatric Practice O Rahelly M, Bussmann N, Jamal B, Murphy AM Introduction: Bone age in children is evaluated by examining an X-ray of the left wrist. This is assessed and compared to the chronological age of the child for discrepancy. The Greulich and Pyle method was used throughout our reports. Bone age is used to determine whether growth is appropriate and can be used to monitor the therapeutic effect of growth hormone treatment. Aims: To review requests for assessment of bone age and appropriateness of orders in our Paediatric practice. Methods: A list of requests of left wrist X-rays over the 12 month period between the 1st of July 2013 and the 30th of June 2014 in children less than 16 years was obtained from the radiological database. Excluded from our study were X-rays of the left wrist lacking a comment on bone age. A final number of 22 patients had a left wrist x-ray for which a bone age was calculated. Information recorded included gender, indication for the order, inpatient or outpatient status, discrepancies between bone age and chronological age and whether subsequent imaging was performed. Results: Of the 22 bone age examinations, 13 were female, 9 male, 7 were performed as inpatients and 15 as outpatients. Indications were in order of frequency as follows: short stature (8), precocious puberty (5), Congenital Adrenal Hyperpalsia (2), premature menarche (2), and others (5). Regarding results, there were 10 reports indicating delayed bone age, 10 indicating advanced bone age and 2 were concordant. Repeat images were performed in 9 cases. Conclusion: Bone age assessment is an uncommon radiological request in our Paediatric practice and when requested indications are in line with general recommendations.

The Role of Pre-Analytical Sample Handling in Diagnosis of Gestational Diabetes Mellitus C Carroll1; I Flynn2; N Daly2; M Farren2; A McKeating2; MJ Turner2 1

Gynaecology Department, Mater Misericordiae University Hospital, Dublin 7; 2UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Dublin 8

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S234 Gestational diabetes mellitus (GDM) is a common condition associated with increased maternal and fetal risk. Detection and appropriate management of GDM reduces adverse outcomes. Pre-analytical sample handling affects the accuracy of glucose measurements. We set out to determine the effect of implementing the American Diabetes Association (ADA) pre-analytical guidelines compared with normal hospital conditions on glucose concentration and the incidence of GDM. This was a prospective observational study. Women undergoing selective screening for GDM at 24–32 weeks were invited to take part when attending for 75 g Oral Glucose Tolerance Test (OGTT). Two blood samples were obtained at 0-, 1- and 2-h. One set of samples was handled as per ADA recommendations and was transferred to the laboratory on ice for immediate analysis (research conditions). The second set of samples remained at room temperature and was handled under normal hospital conditions (usual conditions). 155 women took part in the study. The mean 0-, 1- and 2-h blood glucose measurements were 5.0 ± 0.7, 7.9 ± 2.4, and 5.7 ± 1.8 mmol/L under research conditions and 4.5 ± 0.7, 7.4 ± 2.3 and 5.5 ± 1.8 mmol/L under usual conditions, respectively (all P \ 0.0001). The rate of GDM under research conditions was 38.1 % (n = 59) compared with 14.2 % (n = 22) under usual conditions (P \ 0.0001). All cases of GDM were picked up on the 0- and/ or 1-h samples. No additional cases were picked up at 2-h. Implementation of ADA pre-analytical handling recommendations was associated with significantly higher glucose concentrations and a 2.7-fold increase in detection of GDM. This will have resource implications, but the 2-h test may not be necessary for the diagnosis.

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 prevention. Varied rates of GDM previously reported between units may be partly explained by this. (4) The resultant under-diagnosis of GDM misses the opportunity to prevent fetal and maternal complications of this disease. 1. Guidelines for the Management of Pre-gestational and Gestational Diabetes Mellitus from Pre-conception to the Postnatal period. Health Service Executive. Available from: http://www. hse.ie/eng/about/Who/clinical/natclinprog/obsandgynaeprogramme/ guide11.pdf. Accessed 27 October 2015. 2. Daly N, Stapleton M, O’Kelly R, Kinsley B, Daly S, Turner MJ. The role of preanalytical glycolysis in the diagnosis of gestational diabetes mellitus in obese women. Am J Obstet Gynecol. 2015; 213:84.e1–5. 3. Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Kirkman MS et al. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Diabetes Care 2011; 34:e61–e99. 4. O’Higgins A, Dunne F, Lee B, Smith D, Turner MJ. A national survey of implementation of guidelines for gestational diabetes mellitus. Ir Med J. 2014;107:231–3.

Uterine Arteriovenous Malformations: A Comparison Between Pre- and Post-Menopausal Cases Carroll C1, Tadesse W1, Walsh T1, Boyd W1, Geoghegan T2

Diagnosis of Gestational Diabetes Mellitus in Ireland: A Clinical Audit of Adherence to National and International Guidelines in Maternity Units

Gynaecology Department, Mater Misericordiae University Hospital, Dublin; 2Radiology Department, Mater Misericordiae University Hospital, Dublin 7

Carroll C1, Flynn I2, Daly N2, FarrenM2, McKeating A2, Turner MJ2

Uterine arteriovenous malformation (UAVM) is an uncommon but potentially lethal condition. Here we compare two cases, one premenopausal and one post-menopausal, likely congenital and acquired UAVMs respectively, in terms of presentation and management. Although rare, UAVMs may cause significant vaginal bleeding, haemodynamic instability and even death. (1) We present these cases to highlight the different management approaches in women before and after menopause. Case one was a 23 year old female with several presentations of heavy vaginal bleeding including one massive haemorrhage with associated haemodynamic instability. Transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) pelvis findings were consistent with UAVM. Transcatheter embolization has been performed on four occasions but she continues to have occasional heavy vaginal bleeding. As further attempts at embolization are unlikely to be successful, she will probably require hysterectomy. Case two was a 59 year old lady with heavy post-menopausal bleeding following dilation and curettage. MRI suggested UAVM. She underwent hysterectomy and has been well since. UAVMs typically present as vaginal bleeding in pre-menopausal women but can present after menopause as illustrated above. They may be categorised as congenital or acquired. (1) Acquired UAVMs are usually associated with uterine surgery. TVUS with colour Doppler is the first-line investigation with pelvic MRI or computed tomography then used to confirm the diagnosis. (2) Management initially depends on haemodynamic status. Stable patients may be monitored and treated medically. In women requiring a more invasive approach who wish to conserve fertility, transcatheter embolization is commonly performed, both electively and emergently. For postmenopausal women and intractable bleeding, hysterectomy remains the treatment of choice. (3)

1 Gynaecology Department, Mater Misericordiae University Hospital, Dublin 7; 2UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Dublin 8

The oral glucose tolerance test (OGTT) is used in pregnancy to diagnose Gestational Diabetes Mellitus (GDM). National guidelines do not include recommendations for the pre-analytical handling of OGTT blood samples, therefore interpretation of the OGTT does not account for pre-analytical glycolysis of blood glucose samples. (1) Glycolysis has been shown to result in under-diagnosis of GDM. (2) This audit included all maternity units in the Republic of Ireland, and aimed to survey the procedure for the OGTT, particularly preanalytical handling of the glucose samples taken. The survey, conducted in January 2015, was based on the American Diabetes Association (ADA) recommendations for the preanalytical management of blood samples for the OGTT, and national guidelines on GDM. (1, 3) Clinical and laboratory staff in each unit were surveyed. All 19 maternity units participated. Pre-OGTT fasting times ranged from 6 to 12.5 h. Two units used 100 g OGTT rather than 75 g as recommended by national guidelines. All units used fluoride as a glycolysis inhibitor; none followed ADA recommendations of placing fluoride samples on iced-slurry with separation and analysis within 30 min. All units waited until completion of OGTT to send the blood to the laboratory for analysis. One unit transferred samples to another hospital for analysis the following day. Wide variations in the OGTT and pre-analytical handling of samples were evident, with little consideration for glycolysis

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Uterine AVMs should be considered in the differential diagnosis for unexplained vaginal bleeding. The priority in treatment is patient stabilisation. Beyond this, management varies depending on the patient’s desire to conceive. 1. Grivell RM, Reid KM, Mellor A. Uterine arteriovenous malformations: a review of the current literature. Obstet Gynecol Surv. 2005 Nov;60(11):761–7. 2. Cura M, Martinez N, Cura a, Dalsaso TJ, Elmerhi F. Arteriovenous malformations of the uterus. Acta Radiol. 2009 Sep;50(7):823–9. 3. Hashim H, Nawawi O. Uterine Arteriovenous Malformation. Malays J Med Sci. Penerbit Universiti Sains Malaysia; 2013 Mar 15;20(2):76–80.

Antibiotic Prescribing; Duration

S235 cough. He had no previous respiratory history however he admitted to keeping pigeons at home for the last 18 months. Case report: Mr DB underwent a number of investigations while an inpatient including chest x-rays, CT thorax, autoimmune screens, immunodeficiency screening and bronchoscopy. His CT thorax showed diffuse interstitial changes and his budgie and pigeon IgG were [200. Mr DB was diagnosed with an acute hypersensitivity pneumonia caused by a reaction to bird dander or ‘pigeon fancier’s lung.’ His breathing improved substantially with a 5 day course of IV steroids and was discharged home on a 6 month tapering course of oral prednisolone. He was counseled against keeping birds and not to use feather pillows and duvets. Conclusion: This case highlights the importance for a detailed history including pet and social circumstances in aiding diagnosis and effective treatment.

Hegazy A, O Mara G

Ear Reconstruction Using Autologous Cartilage Following Trauma in a 22 Year Old Male

Roscommon County Hospital

Cooney A, Cullen S, O Donovan D

West Northwest Intern Training Network

Department of Plastic Surgery, St James Hospital, Dublin 8

Objectives: The topic of antibiotic resistance is a major issue facing modern medicine. One of the main actions that can combat this emerging problem is by correct use of antibiotics. This audit looks at antibiotic prescribing, namely whether the correct duration for a course of antibiotics is clearly indicated and whether this is then executed accordingly. Incorrect use of antibiotics has many side effects, such as infections, and the emergence of antibiotic resistant strains of bacteria. Design/methods: All medical patients in the hospital, who were receiving antibiotic treatment, at one point in time, were included in data collection. Data including whether the treatment was clearly specified, and whether this was then executed was recorded. Results: Of the patients receiving antibiotic treatment, in only 22 %, was the duration of treatment specified. In 78 % of cases, the commencement date was specified, which would add to the difficulty of calculating a reasonable duration and stop date in the future when deemed necessary. Out of the cases in which the duration was specified, none had stopped treatment at this date, with no indication why this occurred. Conclusions: There is a clear lack of emphasis on accurate antibiotic prescribing in practice. In my opinion, it is not deemed necessary by medical professionals, as antibiotic resistance is not seen as an imminent threat and does not weigh on the minds of most physicians. In most cases it is stopped when there is a clinical improvement seen and not according to local anti-microbial guidelines. This maybe influenced by a lack of confidence in clinical practice as physicians may incorrectly prescribe antibiotics for fear of litigation in the future. One method which maybe effective in improving antibiotic prescribing is the inclusion of local anti-microbial guidelines for common conditions in drug cards as researching correct guidelines can be time consuming.

Introduction: This is a case of a 22-year-old male, AD, who suffered a partial amputation of the external pinna of his right ear following a human bite injury in 2014. The area affected by the injury included the helical fold, antihelix and scaphoid fossa. The main objectives in managing Mr. AD’s case was firstly to stabilize him in the emergency setting before planning a two stage pinna reconstructive operation with the aim of achieving a satisfactory aesthetic outcome and preventing any impairment to future hearing ability. Methods: The first stage involved creating a template for the deficit by comparing it to the unaffected side. Autologous costal cartilage was harvested and moulded using the template and placed beneath the skin behind the right ear as first described by Ortiz–Monasterio and Molina. The second stage involves raising the cartilage and fascial flap through a temporal incision and insetting it into the deficit creating a posterior auricular sulcus as described by Antonyshyn et al. Results: Both the patient and the surgical team report a successful aesthetic outcome with no residual loss of hearing ability. Both stages were completed without any complications Conclusion: Ear reconstruction is a complex operation given the detailed anatomy of the external pinna. However, creating a new whole or partial pinna using autologous costal cartilage is an effective reconstructive option and should be explored with patients following trauma as it can lead to favorable cosmetic outcomes.

Development Steps of a Protocol App Designed to Match the Training Needs of Interns Alsaffar A1, Wong C1, O Connor P2, Lydon S2, Byrne D1,2

Acute Hypersensitivity Pneumonitis in a 40 Year Old Male Cooney A, Lynott F, McLaughlin AM Department of Respiratory Medicine, St James Hospital, Dublin 8 Introduction: Mr DB, a 40-year-old male, presented to the ED with a 3-month history of increasing shortness of breath on exertion and dry

1 West Northwest Intern Training Network; 2National University of Ireland, Galway

Background: Research has consistently found that high percentages of newly graduated doctors report feeling under-prepared to begin working in a hospital and lack the skills necessary to perform their job1. This is most common in the acute care situation2. Protocols and check lists can be useful tools that facilitate teamworking and decision making in acute care.

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299

Aims: To identify the acute conditions that interns are commonly called to manage; identify the level of ease in managing these conditions; so as to inform the development of a set of protocols available as an app to support interns’ training needs. Methods: Pilot research carried out with non-consultant hospital doctors (n = 19) and hospital consultants (n = 15) identified a list of 21 acute conditions that interns are commonly called to manage. A questionnaire to identify how frequently interns are called to manage these 21 conditions from (1) ‘never’ to (5) ‘very often’, and their level of ease in the management of each of these conditions from (1) ‘very easy’ to (5) ‘very difficult.’ was distributed online to one intern network. Results: A total of 46 interns (response rate of 35 %) completed the survey. Fourteen acute conditions were identified as commonly seen by interns. Five of these, more than a quarter of participants indicated occurred ‘often’ or ‘very often’ and they found ‘difficult’ or ‘very difficult.’ These conditions were desaturating patient (29.1 % of participants), shortness of breath (29.1 %), acute confusion (29.1 %), severe pain (30.9 %), and electrolyte imbalance (30.9 %). Conclusions: The development of a protocol app as an intern support tool is an important innovation. The pilot research informing the content of this app is a critical step when resources are limited and in ensuring the app addresses intern training needs. The sourcing and development of protocols and check lists for each of these 14 conditions is the next step in the development process. 1. Medical Council Your Training Counts Report, 2015 2. The Shape of Training Report, D Greenaway, 2013 Background data:

Condition

Frequency encountered

Ease of management

Modal IQR Modal response response

% often/ very often AND IQR difficult/ very difficult

Tachycardia

Often

1

Bradycardia Hypotension

21.8

1

Neither difficult nor easy

Rarely

1

Difficult

1

0

Often

1

Easy

1

14.5

Hypertension

Often

1

Difficult

2

14.5

Desaturating patient

Often

1

Difficult

1

29.1

Pyrexia

Often

1

Easy

1

9.1

Shortness of breath

Often

1

Difficult

1

29.1

Atrial fibrillation

Sometimes 2

Difficult

1

12.7

Chest pain

Often

Easy

2

12.7

Acute confusion

Sometimes 1

Difficult

0

29.1

Severe pain

Sometimes 1

Difficult

1

30.9

Nausea and vomiting

Often

Easy

1

5.5

2

1

Hematemesis

Never

1

Difficult

1

0

Stroke

Never

1

Difficult

1

1.8

Diabetic ketoacidosis

Never

1

Difficult

2

0

Hypoglycaemia

Never

2

Difficult

2

0

Low urine output

Rarely

2

Difficult

1

10.9

Fluid overload

Often

2

Easy

2

10.9

Anaphylaxis

Never

1

Sepsis

Sometimes 1

Electrolyte disturbance Often

123

2

Very difficult 2

0

Difficult

2

14.5

Difficult

1

30.9

Attitudes Towards Professionalism Among Irish Medical Students and Relation to Academic Performance Christopher W1, Alsaffar A1, Tandan M2, Lydon S2, O Connor P2, Byrne D1,2 West Northwest Intern Training Network; 2National University of Ireland, Galway 1

Background: Among doctors, professionalism has been found to be associated with the quality of clinical care provided, patient outcomes and academic performance. Papadakis et al. (2005) demonstrated that disciplinary action by a medical board was strongly associated with prior unprofessional behaviour in medical school. Aims: To examine attitudes towards professionalism among Irish medical students and to assess the relationship between attitudes to professionalism and final academic medical school award. Methods: A total of 254 medical students participated in this research. Participants completed a validated questionnaire on professionalism—the Penn State College of Medicine Professionalism Questionnaire, provided demographic information, and gave permission for their final medical school award score to be extracted. Results: Mean final medical school academic score was 63.8 (SD = 4.9). Participants’ attitudes concerning the importance of the key elements of medical professionalism (i.e., accountability, altruism, duty, excellence, honesty and integrity, and respect) varied; with some considering these elements of little relevance to professionalism and others considering them to be highly important indicators of professionalism among doctors. There was no association observed between participants’ attitudes towards any of the elements of professionalism and their final medical school score. Conclusions: Although other studies have linked professionalism to academic performance, such a relationship was not evident in our data. However, a majority of Irish medical students appear to appreciate the importance of the key indicators of medical professionalism. Good professional practice is as important as academic achievement but can be difficult to measure in undergraduate medical students. The use of attitudinal measures such as that employed in the current study may aid with the identification of students with a poor understanding of professionalism, allow for remediation and decrease the likelihood of future negative outcomes such as impaired clinical care or disciplinary action.

Dieulafoy’s Lesion Ryan G, Iqbal A, McAnena O Upper GI Surgery, University Hospital Galway West Northwest Intern Training Network Introduction: A Dieulafoy’s lesion is a tortuous, dilated submucosal arteriole in the upper GI tract that erodes and bleeds intermittently in the absence of a primary ulcer. The aetiology of these lesions and triggers of bleeding are not well understood. Episodes of bleeding are often self-limiting. Description/case report: 78 year old male admitted for investigation of collapse on a background of recent left carotid endarterectomy, hypertension, ischaemic heart disease and COPD. He collapsed again

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 in the ED. Initial investigations showed no cardiac or vascular cause. During a further episode of hypotension and tachycardia with melaena his haemoglobin dropped from 9.7 to 5.2. He was brought to theatre for emergency OGD. He was found to have clotted blood in his stomach, originating in the fundus, with a visible spurting vessela Dieulafoy lesion. It was controlled satisfactorily with adrenaline injection, clipping and EndoClot spray. 2 days later he had a repeat bleed, with a haemoglobin drop to 4.8 and further melaena. He was brought for another emergency OGD where the bleeding was not controllable so a laparoscopic partial gastrectomy was performed. He recovered well in ICU and was discharged 7 days later. Discussion/conclusion: Dieulafoy’s lesions are a less common cause of Upper GI Haemorrhage. Bleeding is usually recurrent. Laparoscopic treatment should be considered if bleeding is difficult to control endoscopically.

Internal Audit of ‘Did Not Attend’ (DNA) Rates in a Community Psychiatric Out-Patient Setting Bolton M1, Njoku C1, Burns R.A1 1

North Cork Mental Health Services, St. Stephen’s Hospital, Sarsfields Court, Glanmire, Co. Cork Internationally Did Not Attend (DNA) rates for mental health services average between 13.9 and 20 % with same being two-fold greater than their medical equivalent (20.9 % psychiatry versus 9.1 % all specialties). DNA rates are concerning as non attendance has been associated with deterioration in mental state, functional impairment, poor compliance with medication and increased risk of relapse. This audit aimed to quantify the percentage of non-attendees and also identify patient groups who are at greatest risk of non-attendance, with the future possibility of targeting said patients. Non-attendance at two outpatient clinics (Charleville and Mallow) in the North Cork Mental Health Services were audited over a 6 month period (January–June 2015). Attending and non-attending service users were stratified by clinic location, new patients (NP), routine patients (RP) and total attendees. Patients were also stratified by previous history of admission or having been strictly community based patients. DNA rates were then calculated for the 6 month period. A total of 984 patients were registered over the 6 month period, of which 664 attended and 320 DNA (32.52 %). Of the 320 DNAs, 129 (40.31 %) had previously had at least one hospital admission versus 191 (59.69 %) who had not. With regards to patients status of the DNA’s, the vast majority 266 (83.31 %) were RP while 50 (15.63 %) were NP. DNA rates within the RP and NP cohorts were 33.76 and 27.47 %, respectively. DNA rates between clinics were not significantly different between each other or total patient cohort. The overall DNA rate (32.52 %) is higher than published median rates, however rates of 30 % have been noted. We identified community based patients and RP as the principle source of DNA. Furthermore, this effect was noted within both clinics. These individuals may benefit from targeted communication (call, orientation letter, text messages) to improve attendance.

Smelling a Rat: A Rare Case of Acute Kidney Failure Nolan C, Kumar R, Kelly F, Abernethy E Department of Nephrology, University Hospital Waterford

S237 A 65 year old Irish male referred to the ED of University Hospital Waterford presented with a 1 week history of headache and flu-like illness. He was a deep shade of jaundice and was also noted to be anuric for 24 h. He reported no medical history and was not taking regular medications. He also reported no recent travel or illness. With a bilirubin of 636 and no obstructive cause of his symptoms confirmed by ultrasound of abdomen, a suspicion was raised for an atypical cause. A detailed history taken by an NCHD regarding his occupation as a farmer revealed that the patient had recently received a shallow laceration from hoofing animals. With no history of having received tetanus immunoglobulin, bacterial and viral serology was sent. Leptospirosis serology subsequently returned positive. At hour 36 of admission and continuing anuria, his AKI had progressed to Acute Renal Failure (CR = 700) and he was dialysed. After 14 days treatment with IV Cefuroxime and Ciprofloxacin he was discharged at baseline functioning and asymptomatic stage 3 Chronic Kidney Disease. Leptospirosis is a bacterial disease caused by spirochetes of the genus Leptospira. It can manifest itself classically as a mild, anicteric, self-limiting illness or as an icteric disease with associated fever and variable organ involvement. It affects both humans and animals with rodents, particularly rats, being common carriers. The illness is usually contracted either through occupation particularly farming or recreational activities. Leptospirosis is a disease rarely found in temperate climates with the most recent published data reporting 14 cases in Ireland for 2013. Fewer of these again required hospitalization. Acute renal failure represents a rare but not unrecognised manifestation of leptospirosis.

Plasmapheresis Proves an Effective Intervention in a Case of Cerebellitis Madden M, O’Rourke K, Lynch T Department of Neurology, Mater Misericordiae University Hospital; University College Dublin Training Network A 29 year old Irish female presented to another hospital with a 1 day history of severe bilateral headache, with associated neck stiffness, nausea and vomiting. There was no history of prodromal illness or rash. Temperature was 37.2 C, other vital signs within normal limits and no focal neurology reported. CT brain was normal. Cerebrospinal fluid analysis showed lymphocytic pleocytosis and elevated protein, negative for organisms. A presumptive diagnosis of viral meningitis was made and she was discharged following a partial empiric antimicrobial course. She re-presented 4 days later with intractable vomiting, impaired standing and gait and new onset of ‘‘jumpy eyes’’ for 24 h preceding admission. Examination revealed downbeat nystagmus in primary position and all directions of gaze, globally reduced tone and pronounced finger-nose dysmetria. A gadolinium-enhanced MRI brain confirmed cerebellitis and was repeated at intervals to ensure no impending tonsillar herniation requiring neurosurgical intervention. Investigations to look for an underlying cause were negative; routine labwork was notable only for transient lymphopenia on admission, which may point to a viral agent causing subclinical infection and a parainfectious cerebellitis.

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S238 Initial therapy was with intravenous methylprednisolone and acyclovir but when symptoms persisted, the patient was transferred to our hospital and plasmapheresis implemented which produced rapid clinical improvement. This trajectory continued and she was discharged to a rehabilitation unit with goal to regain complete independence in mobility. A follow-up appointment with repeat MRI was arranged for 3 months post discharge. Cerebellitis is a severe manifestation of a spectrum of acute cerebellar ataxia considered a relatively common neurological condition of childhood, but seen less often in adults. The majority of cases are associated with infective agents, but other aetiologies must be ruled out1. Plasmapheresis for severe cases of cerebellitis has been studied infrequently in the literature but proved highly effective in our patient’s case2,3. References: 1. Sonneville R, Klein I, De Broucker T, Wolff M. Post-infectious encephalitis in adults: diagnosis and management. Journal of Infection. 2009 May 31;58(5):321–8. 2. Schmahmann JD. Plasmapheresis improves outcome in postinfectious cerebellitis induced by Epstein–Barr virus. Neurology. 2004 Apr 27;62(8):1443. 3. Widdess-Walsh P, Tavee JO, Schuele S, Stevens GH. Response to intravenous immunoglobulin in anti-Yo associated paraneoplastic cerebellar degeneration: case report and review of the literature. Journal of neuro-oncology. 2003 Jun 1;63(2):187–90.

Case Series of Two Patients Presenting with Granulomatosis with Polyangiitis Russell R, McWeeney M, Ali S West Northwest Intern Training Network Introduction: This is a case series of two patients who presented with Granulomatosis with polyangiitis (GPA) during my 3-month rotation in Respiratory Medicine. They have differing initial presentations, however the same diagnosis was reached in both cases, with similar inflammatory marker elevations and radiological findings. As GPA is a rare multisystem autoimmune disease of relatively unknown etiology, it is interesting to examine the effect which this widespread vasculitis had on the following patients. Description/case report: Patient A is a 75-year-old female who presented with persistent hemoptysis and 6-week history of dry cough and sinusitis. She had no cutaneous signs, no hematuria or evidence of arthritis but did have a previous history of GPA, presenting in 2011 with pulmonary hemorrhage and deafness, complicated by renal failure and bowel infarction. Patient B, a 54-year-old female had been unwell for 3 months with sinusitis and epistaxis, subsequently developing swinging fevers, arthritic symptoms and hemoptysis. This, in contrast, was her first presentation of GPA. Both patients had elevated ESR as well as positive PR3 ANCA, very specific to the disease. On radiological investigations, both were shown on CT to have cavitating pulmonary nodules, again consistent with GPA. Both were treated initially with high dose steroids switching to the monoclonal antibody Rituximab for maintenance. Discussion/conclusion: GPA is a rare condition with an incidence in the UK of 10.2 cases per million population.1 It is therefore unusual to have exposure to two such patients in a medical rotation. Throughout an intern year, common presentations reoccur, however it is important to be aware of the rarer conditions and the diagnostic complexities they present. This case study will serve to tie together the broad and often vague signs and symptoms which patients with GPA present

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 with and may offer interns the chance to consider rarer diagnoses when patients present. Reference: 1. Watts RA, Lane SE, Scott DG, Koldingses W, Nossent H, Gonzalez Gay MA, et al.: Epidemiology of vasculitis in Europe. Ann Rheum Dis 2001; 60:1156–115

Diagnostic Approach of Suspected Pulmonary Embolism in Oncology Patients at Sligo Regional Hospital with CT Pulmonary Angiography: Current Practice and Standard Guidelines Goggins M1, Ahmed Y1, Martin M1 1

West Northwest Intern Training Network

Objective: To investigate the current diagnostic approach towards suspected pulmonary embolism (PE) in the oncology department of Sligo Regional Hospital. Compare the use of pretest probability scoring and use of D-dimer with the current recommendations (NICE clinical guideline on venous thromboembolic diseases, 2012) regarding the assessment of a suspected PE. Develop an appropriate investigations pathway in patients with suspected PE, based on the outcomes. Design/methods: This is a retrospective analysis of 42 patients suspected of having PE who were admitted under the oncology service and underwent computed tomography pulmonary angiography (CTPA) between 1 April and 1 October 2015. The study was carried out according to a standard protocol (NICE clinical guideline on venous thromboembolic diseases, 2012). Clinical notes, CTPA requests/reports and laboratory investigations were accessed for the oncology patients who presented with suspicion of PE. Results: All patients (42) underwent CTPA and 7 patients (16 %) had PE. CTPA was undertaken in 30 % of patients with negative D-dimer. D-dimer was performed in 100 % of patients and was inappropriate in 12 % of patients. No patients with a negative D-dimer had a PE. Wells score was calculated in only 7 patients (16 %) prior to their scan. Wells score calculated by researchers revealed 37 (82 %) had PE unlikely, 10 % of which had positive scans. 5 (12 %) patients had PE likely probabilities and 60 % of these patients had positive scans. CTPA was positive for PE in 10 % of patients with PE unlikely and a positive D-dimer. Conclusion: Risk stratification using Wells’ score is underutilised. Inappropriate use of D-Dimer when PE likely. Inappropriate use of CTPA in patient with negative D-Dimer and PE unlikely. Through risk stratification via Wells’ Criteria, appropriate use of D-dimer and utilization of the NICE guidelines, we can avoid unnecessary CTPA scans while safely investigating a significant complication amongst oncology patients.

Adherence with a Post-Fall Medical Review: Proforma in an Acute Setting O Reilly M1,2, Greaney R1,2, Clifford GT1 1

Department of Elderly Medicine, St. Vincent’s University Hospital, Dublin 4; 2UCD Intern Training Network Introduction: Falls and fall-related injuries are a common and serious problem within hospitals. NICE guidelines (NICE 2015)

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 recommend that all patients who fall in hospital should have a medical review. SVUH has introduced a Post-Fall Medical Review: Proforma which guides the management of a patient in the immediate post-fall period and prompts falls prevention interventions, such as medication rationalisation and bone protection. The aim of this study is to determine adherence with the Post-Fall Medical Review: Proforma. Methods: A convenience sample of 55 fall events (by 33 patients) in hospital was selected from the adverse incident reporting system and compared to the patient’s healthcare record. The data collection tool comprised the following themes: history and clinical examination, injury management, and preventing further falls. This is the second audit since the introduction of the proforma. Data analysis is by simple descriptive statistics. Results: Forty-one fall events (75 %) had a medical review that used the proforma. There was overall improvement of 30–65 % in documenting mechanism of fall, hip trauma, and considering the presence of sepsis, delirium and dementia. High falls risk medications were identified in 25 % of falls but rationalisation, including continuation, was only considered in 5 % of cases. Three patients were considered for bone protection (e.g. bisphosphonate and/or supplements) after their fall. Implications: A medical review post-fall is an opportunity to identify and manage injuries, and, importantly, prevent further falls. Identification and management of injury continues to improve. Adherence to rationalising medications and considering bone protection remains low in the immediate post-fall period. An education programme for medical staff should be developed aimed at improving knowledge of high falls risk medications and bone health in the immediate post-fall period.

Doctors Attitudes towards Clinical Operation of Do Not Resuscitate Orders (DNRs) and Views on Introduction of Irish Guidelines for DNRs O Reilly M1,2, Doran K1 Medicolegal department of UCC; 2UCD Intern Training Network

1

Introduction: Do Not Resuscitate orders (DNRs) are documents which state that should a patient suffer from cardiopulmonary failure, resuscitation should not be attempted. No Irish guidelines exist to clarify the implementation of DNRs. Internationally, DNRs are misunderstood and used inappropriately. DNR use in Ireland has never been investigated. Aim: This study aims to investigate Doctors’ understanding of DNRs and to establish if they believe that Irish guidelines should be introduced. Methods: This study was a cross-sectional, quantitative study involving doctors of Cork University Hospital, Mercy University Hospital and Marymount Hospice. The specialities which participated in the study were palliative care, oncology, neonatology, geriatrics, neurology, renal medicine and emergency medicine. Understanding of DNRs and opinions on the introduction of Irish guidelines were examined. Data was collected and analysed using SPSS version 20. Results: 93.2 % (96/103) believed that there is a need for introduction of Irish guidelines. 57.6 % (59) would draft more DNRs were there guidelines in place. 45.9 % (47) believed that their knowledge was sufficient to draft a DNR but 48.7 % (23) of these chose the incorrect definition of a DNR when given three options. 35 % (36) of all doctors questioned have an incorrect understanding of a DNR. There was no significant difference in understanding of DNRs with increased experience.

S239 Conclusion: A substantial proportion of physicians do not understand the correct meaning of a DNR. The overwhelming majority believe that Irish guidelines are needed on the matter.

STEMI Patients with Ejection Fraction 35 % or Less; Percent Improvement, Average Time to Improvement and Outcomes Blake, N, Lobo, R, Kiernan, T Introduction: O’Gara et al. (2013) state that ‘‘those with initially reduced left ventricular ejection fraction (LVEF)’’ in the post STEMI period ‘‘should have repeat measurements 40 or more days’’ post myocardial infarction to address whether they are candidates for intervention in order to assess risk (p.13). Various sources set ejection fraction values in attempts to categorise patients into cohorts in attempts to determine greater risk of adverse cardiac complications with a given LVEF. Vakili et al. (2012) focus on LVEF 50 %, Daneault et al. (2013) and Ottervanger et al. (2001) set levels of LVEF at \40 % whilst Altmann et al. (2013) set levels of LVEF at 35 %. This study sets LVEF 35 % or less as an arbitrary cut off value. STEMI patients at University Hospital Limerick return to PCI clinic 6 weeks post discharge for repeat assessment clinically in order to guide care. This project attempts to assess the levels of post STEMI patients having repeat transthoracic echo (TTE) assessments while capturing basic demographics, culprit lesion as well as percentage improvement as a primary outcome. Aims and methods: This retrospective project aims to assess data which was extrapolated from UHL’s existing STEMI database which contributes to the national ‘Heartbeat STEMI Database’ in Ireland. A non-randomised stratified sample selected patients with ejection fraction of 35 % or less. Basic patient demographics were collected from this database as well as information regarding culprit lesion, time to follow up TTE as well as assessing percentage improvement Results and conclusions: A sample of 35 patients was drawn from existing data from 2014 to 2015 with LVEF of 35 % or less. A total of 24 patients had repeat TTE in the weeks post STEMI representing 68 % of the population cohort. Of these patients the average age was 63 ± 11.7 years. 79 % were male and 21 % female. Average LVEF at baseline was 29.5 ± 4.6 percent. Average time to repeat measurement was 58.7 ± 48.3 days. There was an average improvement of 33.85 ± 11.6 percent. 17 patients culprit lesion was LAD, 6 patients RCA and 1 patient Lcx. References: 1. Altmann, D, Marcus M, Ehlb, N, Kollerb, M, Schaera, B, Jo¨rgc, Ammannc, L.P, Ku¨hnea, M, Ricklic, H, S, Osswalda, S, Sticherlinga, C, 2013, Prevalence of severely impaired left ventricular ejection fraction after reperfused ST-elevation myocardial infarction, Swiss Med Wkly. 2013;143:1386–9 2. Daneault, B, Ge´ne´reux, P Kirtane, AJ, Witzenbichler, B, Guagliumi, G, Paradis, JM, Fahy, M, P, Mehran, R, & Stone, G, W, 2013, Comparison of 3-Year Outcomes After Primary Percutaneous Coronary Intervention in Patients With Left Ventricular Ejection Fraction \40 % Versus 40 % (from the HORIZONS-AMI Trial), The American Journal of Cardiology, Coronary Artery Disease/LV Dysfunction and MVD in STEMI 3. O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial

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S240 infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61:e78–140, doi:10.1016/ j.jacc.2012.11.019. 4. Ottervanger, J, P, van’t Hof1, AWJ, Reiffers, S, Hoorntje, JCA, Suryapranata1, H, de Boer, M, J, and Zijlstra1, F, 2001 Longterm recovery of left ventricular function after primary angioplasty for acute myocardial infarction, European Heart Journal, 22, pp.785–790 doi:10.1053/euhj.2000.2316, available online at http://www.idealibrary.com 5. Vakili, H, Sadeghi R, Rezapoor, P, Gachkar, L, 2012, In-hospital outcomes after primary percutaneous coronary intervention according to left ventricular ejection fraction, available at: http://www.ncbi.nlm.nih.gov/pubmed/25258637 (accessed 25/11/ 2014).

An Audit of Cardiac Troponin Orders in Naas General Hospital Blake, N, McCarrick, C, Quadri, T Naas General Hospital, Trinity College Training Network Introduction: Cardiac troponins are biochemical markers used in a clinician’s assessment for the presentation of acute coronary syndrome (ACS). Cardiac troponin is an indicator of damage to the cardiac myocyte. It is only a component of a clinical diagnosis comprising clinical acumen, the use of an ECG and a cardiac troponin. The highly sensitive Troponin T hs assay as utilised in Naas General Hospital (NGH) is sensitive in the acute window as early as 3 h. As highlighted by NICE (2014), high sensitivity troponins are useful as an early rule out method. However as research studies show (NICE 2014) many clinicians use troponin as a rule in strategy. With a poor specificity and a plethora of reasons for having a high troponin the ability for detecting an actual ACS is therefore potentially further diminished by inappropriate requests. Aims: To assess the appropriateness of cardiac troponin requests in NGH ED. To assess the potential cost of inappropriate requests. To utilise this information to guide hospital protocol in relation to criteria for troponin testing. Results: 289 patients had available data (n-322). Demographics: average age 61.2 ± 13 SD, female 44 % (n- 129) 56 % male (n-166). 56 % of requests were deemed appropriate. 44 % of requests were deemed inappropriate. Inappropriate requests were placed for a variety of presenting complaints including psychiatric admissions, cellulitis and simple mechanical falls.

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Estimated costs in spending in ED was between €172,500 and €261,600 due to inappropriate requests. The audit was presented in Naas General Hospital in front of a Consultant led audience where there was an open discussion of the findings and potential strategies that would lead to greater appropriateness in troponin testing whilst maximising cost efficiency. Consensus was that staff were ordering troponins in the ED as a routine test without awareness of when a troponin test was appropriate. It was recommended that perhaps an ED awareness poster and staff information session may be useful. There was discussion regarding the possibility of a change to blood order forms removing troponin as a regular blood order. It was suggested that perhaps it should be an add on request only. Discussion centred around about improving NCHD ECG reading skills possibly via ECG teaching opportunities or via the introduction of an ECG of the week at Grand Rounds. There is a plan for re-audit in 6 months time. References: 1. Abusalma Y, Yela R, McCreery CJ, Appropriateness of Troponin test requests from cost efficacy and safety prospective, Cardiology department Loughlinstown Hospital Dublin. E-Journal of Cardiology 2014; 3 (1):pp. 32–37 2. Gardezi, A, S, 2015, Troponin: think before you request one, BMJ, Royal Gwent Hospital, NHS Wales, United Kingdom 3. Jaffe et al., 2015, Troponins as Biomarkers of Cardiac Injury, http://www.uptodate.com 4. NICE Guidelines, Myocardial infarction (acute): Early rule out using high-sensitivity troponin tests (Elecsys Troponin T highsensitive, ARCHITECT STAT High Sensitive Troponin-I and AccuTnI + 3 assays)

Pneumocystis jirovecii Pneumonia in a Patient with HER2-Positive Breast Cancer Treated with Trastuzumab (Herceptin) Van der Putten S, Blazkova S Department of Medical Oncology, Galway University Hospital; NUI Galway Intern Training Network Between 2004 and 2009, 65 % of new cases of breast cancer in Ireland presented symptomatically and 7 % presented at stage IV[1]. Pneumocystis jirovecii pneumonia remains a risk in those patients receiving high dose steroids and/or are severely immunocompromised. A 55-year-old woman presented to Galway University Hospital with a 3 week history of a productive cough, nausea, vomiting and abdominal pain. A CT-Abdomen/Pelvis showed multiple areas of attenuation in the liver, multiple nodules in both lung bases and multiple sclerotic lesions in the lumbar spine all of which were suspicious for metastatic disease. A CT-Thorax was suggestive of lymphangitis carcinomatosis and extensive lymphadenopathy. On examination, the right nipple was inverted and crusted and there was a palpable lump in the right breast. A core biopsy confirmed ductal type invasive carcinoma. Immunohistochemistry demonstrated ER-, PR-, HER2 +++. Persistent respiratory distress on the ward eventually led to a transfer to ICU where she was intubated for 17 days. She was commenced on steroids and had her 1st cycle of Pertuzumab/Trastuzumab/Docetaxel as per the CLEOPATRA study. Eventually she was discharged home but represented to ED a month later in respiratory failure. A BAL was performed which confirmed pneumocystis jirovecii pneumonia and she was treated with co-trimoxazole.

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 A recent restaging CT-TAP has shown no lymphadenopathy, significant improvement in the pulmonary lymphangitis and almost complete resolution of the liver metastases after 5 cycles of Docetaxel. She remains on maintenance Trastuzumab/Pertuzumab and prophylactic co-trimoxazole. The incidence of PCP in the oncology patient cohort continues to rise and should be high on a differential for those patients who develop respiratory distress. The development of Herceptin has changed the natural history of breast cancer, with a 15.7 month increase in the median values of overall survival in those with metastatic HER2-positive breast cancer[2]. References: 1. Breast Cancer Incidence, Mortality, Treatment and Survival in Ireland: 1994–2009. A report of the National Cancer Registry of Ireland; 2012. 2. Baselga J, et al. Pertuzumab plus trastuzumab plus docetaxel for metastatic breast cancer. N Engl J Med. 2012;366:109–119.

‘‘Listen to Your Patient, He is Telling You the Diagnosis’’; a Case of Cannabinoid Hyperemesis Syndrome Deane C, Egan B WNW Introduction: Mr X a 21 year old gentleman presented to a general hospital with abdominal pain, nausea and vomiting. This was his 8th presentation with the same symptoms over a 2 year period. Description: Multiple investigations were done over this period of time including; AXR, US abdomen, CT and MRI abdomen, OGD and colonoscopy, synacthen test, celiac screen, urinary amylase, porphyria screen. An MRI abdomen showed luminal narrowing suggested to be consistent with terminal ileitis. Follow on investigations were found to be normal and there was no conclusive abnormality detected that could account for his symptoms. On his 8th admission a more thorough discussion regarding Mr X’s social history occurred. Mr X reported frequent cannabis use as a form of recreational activity. He admitted that his brother also smoked cannabis with him and was now reporting similar symptoms. Mr X was diagnosed with cyclical vomiting secondary to chronic cannabis use. He was informed about his diagnosis and the importance of cessation in symptom relief. Addiction counselling services were involved. Following his cessation of smoking cannabis Mr X had no further presentations. Discussion: Cannabinoid hyperemesis syndrome is an under recognised condition. This condition tends to be over investigated, with the delay of diagnosis averaging 8 years. (1) It is characterised by severe nausea, vomiting, abdominal pain, chronic cannabis use and relief with hot showers or bathing. (2) A recent study by the Eurobarometer survey revealed the use of cannabis to be higher by Irish youths then the EU average (28 %) emphasising the importance of awareness of this syndrome and enquiring about drug use. (3) Typically, cannabis has an antiemetic effect when used short term. The most popular theory as to what causes these symptoms is; D9tetrahydrocannabinol builds up in adipose tissue, when released it actions on the CB receptors in the enteric nervous system overriding the anti-emetic effect produced by CB receptors in the hypothalamus. (4)

S241 Learning points: • •

History taking as a pertinent diagnostic tool—asking about drug use in rural hospitals. Awareness of cannabinoid hyperemesis syndrome.

References: 1. Soriano-Mo, M. (2010) ‘The cannabis hyperemesis syndrome characterized by persistent nausea and vomiting, abdominal pain, and compulsive bathing associated with chronic marijuana use: a report of eight cases in the United States.’, Digestive diseases and sciences, 55(11), pp. 3113–9. 2. Simonetto, D. A. (2012) ‘Cannabinoid Hyperemesis: A Case Series of 98 Patients’, Mayo Clinic Proceedings, 87(2), pp. 114–119. 3. European Commision. (2014). Young people and drugs. Available: http://ec.europa.eu/public_opinion/flash/fl_401_en.pdf. Last accessed 21st December 2015. 4. Galli, J. A. (2011) ‘Cannabinoid Hyperemesis Syndrome’, Current drug abuse reviews, 4(4), pp. 241–249.

Unusual for the common or usual for the rare?: Coeliac Disease vs Systemic Mastocytosis Hyland N, McLoughlin R West Northwest Intern Training Network Coeliac disease is one of the commonest presentations to clinics throughout Ireland. Systemic mastocytosis is much rarer, with incidence of 1/150,000. It, therefore, needs consideration of other conditions for any diagnosis and considerable investigations, as in the case here: the case of a 62 year old lady, SB. SB presented to a gastroenterology clinic for coeliac follow up, diagnosed 2 years previously based on features of villous atrophy from OGD biopsy and negative TTG-IgA. She presented with diarrhoea, beginning 4 months previously, with 14 bowel motions daily at presentation. She had abdominal pain and had lost 10 kg over the previous 6 months. Her history was relevant for microscopic colitis and urticaria. Her regular medications included olmesartan. On examination, she was dehydrated and tender abdominally. Her bloods showed hypoalbuminemia and this time her upper oesophageal/duodenal/gastric endoscopy was suggestive of olmesartan induced duodenitis, while her colonoscopy was normal. On cessation of olmesartan, her diarrhoea dramatically improved, but appetite remained poor. Two days after admission an erythematous plaque was noted on her knees, arms and abdomen, and she complained of urticaria. Further investigations included a tryptase level, which was 24.4ug/ L. Punch biopsy of the right leg was done also as review of duodenal biopsy with Giemsa stain, both showing mast cells. A unifying diagnosis of systemic mastocytosis was made and the patient regained 10 kg once antihistamines began, with only minor urticaria. Seldom would a case such as this present at an outpatient clinic and it is unusual for diagnosis of both olmesartan induced duodenitis and systemic mastocytosis. It also highlights the importance of consideration of other causes of villous atrophy aside from coeliac, and the value of genotyping.

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Quality of Life following Wide Mesenteric Excision in Patients with Crohn’s Disease Murphy DJ1, Coffey JC 1

Department of Surgery, Limerick University Hospital, Limerick

Introduction: Traditionally, a conservative mesenterectomy has been performed for Crohn’s resections. However this is associated with a high recurrence rate. Extensive mesenterectomy is the gold standard for oncological resections. Since 2011 the surgical unit in UHL has performed wide mesenterectomies for Crohns resections. The aim of this study was to assess the impact of this approach on patient Quality of Life (QoL). Methods: We used the Crohn’s Life Impact Questionnaire (CLIQ), a fully validated Patient-Reported Outcome Measure (1), to assess QoL. It is a 27-point questionnaire which measures the physical and emotional effects of Crohn’s Disease. A higher score indicates a lower QoL. We performed non-parametric statistical analysis on patients’ scores to identify predictors of QoL following surgery. Results: Eighteen patients from a group of 30 returned the questionnaire. The mean duration of time from operation to survey completion was 27 months (±18.4). The mean score was 12.1 (± 7.4). Statistical analysis identified laparoscopic surgery as a significant predictor of a higher CLIQ score (p \ 0.035). Other factors such as age, family history, disease phenotype, pre-op medications, disease activity before surgery, age at diagnosis, and CRP were not significant predictors of QoL. Smoking status approached significance (p = .052) Conclusion: Overall, patients who have undergone a wide mesenterectomy have a reasonable QoL. Patients who have undergone open surgery have a better QoL than those who underwent laparoscopic surgery. Reference: 1. Wilburn J., McKenna S.P., Twiss J., Kemp K., Campbell S. The Crohn’s Life Impact Questionnaire (CLIQ): The first PatientReported Outcome Measure (PROM) Specific to Crohn’s Disease (CD) Quality of Life Research 2015, 24 (9): pp 2279–2288.

Detection and Management of Delirium in New Medicine for the Elderly Admissions Breathnach C1, Farrell A1, Mello S1 St. James’s Hospital, James’s Street, Dublin 8 Aims: This audit was conducted to assess the detection and management of delirium in Medicine for the Elderly admissions to St James’s Hospital and compared to current NICE guidelines. The audit cycle was completed with changes for improvement implemented and re-audit carried out. Methods: Data was collected on 50 consecutive patients admitted through Medicine for the Elderly. Patients were screened for delirium by being asked to say the months of the year backwards. Risk factors and subsequent diagnosis or treatment were established from admission notes in patient charts and the percentage of patients with delirium going undetected was calculated. Intervention for improvement was implemented in the form of an information session where the new delirium screening tool 4AT was introduced to clinical practice. The audit was repeated.

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Results: The results of the first audit showed poor screening for and detection of delirium, with only 12 % being screened on admission. The audit revealed 60 % of patients with delirium were going undiagnosed on admission. Following implementation of the 4AT screening tool re-audit results showed a significant increase, to 52 %, in the number of patients being screened. The number of cases of delirium undiagnosed at admission also dropped to 36 %. All cases of diagnosed delirium were treated appropriately. Conclusions: This audit showed that delirium was going largely under-diagnosed in the Medicine for the Elderly population in St. James Hospital. Following implementation of the new screening tool 4AT, significant improvements were made. This audit concluded that the 4AT was an effective tool, in combination with regular education sessions raising awareness, in improving the detection of delirium in the elderly. It will be re-audited in 6 months.

Ultrasound and Its Use as Diagnostic Tool for Appendicitis in Children Mc Loughlin L, Khan SA Department of General Surgery, Wexford General Hospital, Wexford Introduction: Appendicitis in children frequently poses a diagnostic challenge to physicians. Ultrasound is one of the most frequently used radiological investigations to diagnose appendicitis. The primary aim of this study is to evaluate the role of ultrasound in diagnosing appendicitis in children. Materials and methods: A retrospective study of 178 children, admitted surgically between June 2012 and June 2015 to our unit with suspected appendicitis, was undertaken. Children were compared for clinical presentation, radiological findings, operative findings and histopathology. Results: Of this patient cohort, 163, who underwent appendicectomy were included in the final analysis. The mean age was 11.43 ± 3.12. Male to Female ratio was 1.47:1. 34 of 163 children (20.85 %) had diagnostic ultrasound performed, with only 10 (29.41 %) showing radiological evidence of appendicitis. This was confirmed operatively in each, giving a specificity and positive predictive value of 100 % (95 % CI 69.15 to 100.00 %), despite the relatively low sensitivity of ultrasound in the diagnosis of appendicitis (31.25 %, 95 % CI 16.12 to 50.01 %). The appendix was not visualized in 24 children (70.59 %). Of the 34 who underwent appendicectomy, 2 were found to have normal appendix at time of operation. 129 children went for appendicectomy based on clinical findings alone, and 9 were found to have normal appendix. Overall, the negative appendicectomy rate in the group who did not have ultrasound was 6.98 %, and who had ultrasound was 5.9 %. Conclusion: In summary, when appendicitis could be confirmed radiologically, this was consistent with operative findings. While ultrasound appears useful for confirming a diagnosis of appendicitis, due to low sensitivity, radiological findings must be correlated with clinical findings to minimize the risk of a missed diagnosis.

Management of Chronic Disease in General Practice: Coeliac Disease in a Rural Practice O Donnell K, Mee D West/North West Intern Network Carrigart Health Centre, Co Donegal

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Objectives: Coeliac disease is a chronic condition which has a particularly high prevalence rate in Western Ireland, estimated at 1:300 to as high as 1:100 in the general population (1). The disease often presents in primary care and when managed effectively with regular follow up and adherence to a gluten free diet many of the possible complications can be prevented. These avoidable complications include anaemia, nutritional deficiencies, infertility, osteoporosis and rarely malignancy. The objective of this audit was to assess our follow up of these patients in reference to best practice, as recommended by the recently updated 2015 NICE guidelines and 2015 Irish College of General Practitioners guidelines (2, 3). We also make reference to the UK Primary Care Society for Gastroenterology guideline (4). Design/methods: Using the practice Health-ONE system and database, 17 patients with confirmed coeliac disease were identified. The patient’s charts were consulted to accomplish our aims. Aims to assess • • •

referral rate of our patients to a dietician (2, 3, 4) rate of annual review with investigation of haemoglobin and vitamin D levels (2, 3, 4) rate of investigation of B12/folate deficiencies (3, 4)

Results: Dietician referral was carried out in 82 % (n = 14) of the patients. A follow up review of each patient within the past year, with investigation of haemoglobin and vitamin D levels was carried out in 70 % (n = 12) and 58 % (n = 10), respectively. Investigation of vitamin B12 and folate deficiency had been performed in 58 % (n = 10) of the patients. Conclusions: A relatively high rate of dietician referral has been achieved, which is important as it has been shown to improve adherence to a gluten free diet (4). The audit has demonstrated a need for greater investigation of nutritional deficiencies. This has led us to add reminders to the practice electronic patient database and contact individual patients. Our goal is to achieve 100 % compliance throughout and we will determine our progress through re-audit in a years time. References: 1. Coeliac disease: A review. Issue: BCMJ, Vol. 43, No. 7, September 2001, page(s) 390–395 Articles, Hugh Freeman, MD, FRCPC, FACP, FACG 2. Coeliac disease: recognition, assessment and management NICE guidelines [NG20] Published date: September 2015 3. ICGP—Diagnosis and Management of Adult Coeliac Disease 2015, Dr. Audrey Russell, Dr. Eamonn Shanahan, Professor Eamonn Quigley 4. Primary Care Society for Gastroenterology. The management of adults with coeliac disease in primary care. Updated September 2012

Ankylosing Spondylitis Presenting with Vertebral Fractures Gnanasekaran R, Olupitan O, Silke C West Northwest Intern Training Network Introduction: A 31-year-old man presented to his GP with acute back pain. A subsequent AP and Lateral Lumbar and Thoracic X-Ray showed multiple wedge fractures at T3, T5, T7 and T9. He was referred to the Rheumatology Osteoporosis Clinic. Description/case report: At the Clinic, a DEXA with Vertebral Fracture Assessment showed he had a Z score of -2.5 at the Right Hip. He was Celiac antibody negative with normal testosterone, Vitamin D, protein electrophoresis and Parathyroid hormone levels.

S243 When he was reviewed, he complained of significant back pain rated 10/10 with 30 min back stiffness that would improve with activity and analgesia. He had experienced both height and weight loss over the past year. On examination, he was noted to be kyphotic with a positive Schobers and an increased occiput to wall distance. Further tests showed he was HLA Positive with a raised ESR and CRP. His initial Lumbar and Thoracic X-Ray was reviewed and an incidental finding of complete Sacroiliac joint fusion was noted. A diagnosis of Ankylosing Spondylitis was made and he was subsequently started on Biological therapy. Even though this patient was young, the severity of his presentation suggests that he had an undiagnosed inflammatory arthritis for many years that ultimately led to bone demineralization and multiple fractures. Discussion/conclusion: This case highlights the need for thorough investigation of atypical fractures in younger patients and the consequences of undiagnosed ankylosing spondylitis.

Adherence to Anti Tuberculosis Screening Protocols Before Starting a Patient on Biological Therapy for Inflammatory Arthritis Gnanasekaran R, Olupitan O, Silke C West Northwest Intern Training Network Objectives: To check whether patients had a Chest X-Ray and Quantiferon test prior to starting a Biological therapy for inflammatory arthritis as per local anti-tuberculosis guidelines and whether the results changed their treatment Design/methods: 39 randomly chosen patients that were started on Biologics in 2014 and 2015 had their charts pulled. The radiology and lab systems were checked for Chest X Rays and Quantiferons. Results: 37 Patients had their Chest X-Rays and Quantiferons recorded prior to starting Biological Therapy. Of these patients, 2 had indeterminate Quantiferons, 2 had positive Quantiferons and 2 had abnormal Chest X Rays (Pleural effusion, Calcific density). Neither of the patients with abnormal Chest X Rays had their results attributed to Tuberculosis. Of the 2 patients with indeterminate Quantiferons, neither had their treatment changed. Both of the patients with positive Quantiferons were given Rifinah for 3 months. Two patients were found not to have a Chest X Ray or Quantiferon result recorded in their charts and they were both initially private patients when their Biological treatment was commenced. These patients were found to have had Chest X Rays and Quantiferons once the electronic systems were checked. Conclusions: This audit has shown that we are screening our patients as per local guidelines. However, there are issues with documenting screening results in patients seen in other healthcare settings initially.

Electrochemotherapy for the Treatment of Cutaneous Metastasis: A Single-Centre Experience of 237 Lesions in 87 Patients Coutts CA1, Bourke MG2, Salwa SP2, Kelly EJ1, Soden DM2, Clover AJP1,2 1

Department of Plastic and Reconstructive Surgery, Cork University Hospital, Cork, Irelan; 2 Cork Cancer Research Centre, Mercy University Hospital and Leslie C. Quick Jr. Laboratory University College Cork, Ireland

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S244 Background: Cutaneous metastasis can develop in up to 10 % of all cancer patients, severely impacting on quality of life. Electrochemotherapy can be a treatment option for these lesions especially when conventional treatment options are limited. This treatment modality combines electroporation with administration of the chemotherapeutic agent bleomycin. Electroporation induces a transient cell membrane porosity which enhances intracellular drug delivery and the induction of apoptotic cell death within targeted lesions. Aim: To evaluate the effectiveness of electrochemotherapy for the treatment of cutaneous metastasis in a single institution and assess for response according to route of administration. Methods: Patients treated by electrochemotherapy were retrospectively audited for type of tumour, number of lesions treated, method of chemotherapy administration and response to treatment. Results: 97 patients were referred for assessment, of which 87 patients were treated for a variety of tumours with a total of 237 lesions. The overall response rate was 83 % (complete response 53 % and partial response 30 %) and 16 % had no response. Lesions less than 3 cm2 were found to respond significantly better than larger lesions (OR 96 % vs OR 69 %; p \ 0.005). A combination of intratumoral and intravenous injection of bleomycin was the most effective route of administration (OR 92 % vs OR 71 % for IT/IV vs IV only; p \ 0.001). Conclusions: Electrochemotherapy provides an effective treatment option for the treatment of cutaneous metastasis from a wide range of primaries with a high objective response rate. A combination of intravenous and intratumoral bleomycin can improve objective response rates.

Mental Health Issues among Undergraduate Students: Do Education Students Suffer More Than Medical Students? Klaus S1, Stewart B2, Lydon S2, Howard S3, Byrne D1,2, Fitzgerald J3, Gardiner-Hyland F3, Ring E3, O Connor P2 West Northwest Intern Training Network, 2National University of Ireland, Galway; 3Mary Immaculate College 1

Background: Research has consistently reported high levels of mental health issues such as anxiety, depression, and burnout among medical students, interns and junior doctors. Although mental health issues among teachers have been noted, mental health among education students has received limited research attention. Aims: To investigate and compare the prevalence of mental ill-health among education students and medical students. The comparison between education students and medical students will allow the levels of mental ill-health reported by education students to be ‘benchmarked’ against a population of medical students, known to report high levels of mental ill-health. Methods: 297 students pursuing a degree in education and 419 students pursuing a degree in medicine participated. Participants completed the 12-item General Health Questionnaire (GHQ-12), both paper based and on-line, which screens for the possible presence of a psychiatric disorder. Results: A total of 37.6 % of participants had GHQ-12 scores indicative of a potential psychiatric disorder. Education students had significantly higher levels of stress than medical students. Stress increased from junior to senior cycle among education students while the opposite pattern was observed among medical students. Conclusions: Research shows that University students have become increasingly vulnerable to experiencing psychiatric problems, are at high-risk of suicide, and frequently do not receive adequate support

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 services. Our findings are therefore troubling and have important implications—particularly for those who teach and support all students and in particular, medical and education students. Universities must seek to consider curricular changes that may better prepare students for work and to improve support programmes that will educate all students about mental health and the services available in times of need.

USA-300 Pattern Panton-Valentine Leucocidin Producing MRSA in Galway University Hospital Klaus S, Hevican C, Chaudhary A, Quill D Intern network: West Northwest Intern Training Network Introduction: USA-300 pattern Panton-Valentine Leucocidin is a virulent toxin released from community acquired (CA) methicillinresistant Staphylococcus aureus (MRSA) and is found primarily in the United States. CA-MRSA is implicated in up to 51 % of S. aureus hospitalizations in children and should be considered in any child presenting with an infection where S. aureus colonisation is possible1. Description: An 11-year-old boy presented to Galway University Hospital A&E department with a painful, swollen left knee with purulent discharge. History included a recent holiday in the USA and a bug bite. He had initially been prescribed oral flucloxacillin, which was ineffective. On examination, he was systemically well. The left knee was grossly swollen, tender to palpation and painful. He displayed reduced range of movement and had difficulty weight bearing on the left leg. Initially plain film radiograph showed dramatic soft tissue swelling over the anterior aspect of the joint extending inferiorly to the tibial tuberosity. Culture and sensitivity from the wound site was positive for MRSA susceptible to non-beta-lactam antibiotics. He was commenced on IV Vancomycin and incision and drainage was performed. Clinically, symptoms completely resolved during an uneventful 2-week admission and he was discharged. Subsequent X-rays showed no bony abnormality. However, further microbiological analysis of the wound swab using Pulsed Field Gel Electrophoresis (PFGE) displayed the characteristics of USA-300 pattern Panton-Valentine Leucocidin (PVL). All samples as an out-patient were negative for MRSA. Conclusion: The majority of CA-MRSA strains are susceptible to non beta-lactam antibiotics and should be identified and treated promptly. The history of trauma (bug bite) and recent travel was particularly pertinent in this patient and further highlights the necessity of elucidating travel history. USA-300 is rarely seen in the Irish community however in an increasingly globalised world its presence should not be dismissed without proper isolation and culture. 1. Gerber J, Coffin S, Smathers S, Zaoutis T. Trends in the Incidence of Methicillin-Resistant Staphylococcus aureus Infection in Children’s Hospitals in the United States. Clinical Infections Diseases. 2009;49(1):65–71.

Bone Protection in Patients with Polymyalgia Rheumatica (PMR) Receiving Glucocorticoid Therapy Miley C, O Mara G Roscommon County Hospital

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Introduction/Objectives: PMR is a condition that often requires long-term glucocorticoid therapy. These patients are at risk of steroidinduced osteoporosis/fracture and require prophylactic bone protection. This audit aims to quantify risk of fracture in a cohort of patients with PMR and to assess if these patients are receiving appropriate bone protection medication when compared to guidelines. It also aims to implement appropriate bone protection use in this hospital setting in the future. Method: Cohort: 27 (12 male and 15 female) rheumatology outpatients taking C3 months oral steroids for PMR. Using patient charts and GP calls, current dosage of steroid and bone protection was noted. Risk factors outlined in the *FRAX scoring system were combined to assess whether the patient was at low (\10 %), medium (10–20 %) or high ([20 %) 10-year fracture risk. Using the FRAX score, an *algorithm outlined by the ACR was used to determine the appropriate standard bone protection for each patient. Finally, actual bone protection within the cohort was compared to the guidelines provided. Results: Low risk group (5 patients); 1 patient was not receiving appropriate pharmacologic treatment (alendronate). All were receiving nonpharmacological vitamin D (800 IU/day) and calcium (1200 mg/day) supplementation. Medium risk group (7 patients); 2 were not receiving suggested pharmacological treatment. All were receiving non-pharmacological treatment. High-risk group (15 patients); 6 were not receiving the suggested pharmacological treatment and only 2 of those were receiving nonpharmacological treatment. Summary: 9/27 (33 %) of patients were not receiving appropriate pharmacological treatment as suggested by the ACR. 4/27 (15 %) patients were not protected by either treatment. Conclusion: Although, this is a small study, it highlights the need for extra vigilance when prescribing steroids. FRAX is a useful tool in assessing fracture risk in the clinical setting. Clinicians must ensure these vulnerable patients are receiving the appropriate prophylactic bone protection to reduce the risk of life-threatening fractures. References: 1. http://www.uptodate.com/contents/prevention-and-treatment-ofglucocorticoid-induced-osteoporosis 2. http://www.uptodate.com/contents/pathogenesis-clinical-featuresand-evaluation-of-glucocorticoid-induced-osteoporosis 3. http://www.shef.ac.uk/FRAX/tool.jsp?locationValue=9 4. American College of Rheumatology 2010 Recommendations for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis

Drug Associated Homicidal Deaths Greaney RM1,2, Curtis M1, Cassidy M1, Bolster M1,2 1. Department of State Pathology, Dublin 2. Department of Forensic Pathology UCC, Cork There is significant morbidity and mortality associated with drug and substance abuse. Previous research has not studied an Irish population for their drug behaviours in a homicidal setting. This study aimed to ascertain the proportion of victims who had substances in their system at the time of death.

S245 Case reports in the Department of State Pathology were reviewed. All homicidal deaths with a positive post mortem toxicology screen, between 2008 and 2012, were included. Exclusion criteria were accidental deaths, misadventures, suicides or negative toxicology. Of the total homicidal deaths (n = 288), 38 % (n = 109) were positive on toxicology screening. There was a significant male dominance, with males representing over 87 % (n = 95). There was a wide range of substances identified across the positive study sample, the most commonly abused drugs being Benzodiazepines and Barbiturates. Gunshot wounds were the predominant cause of death for close to 50 % (n = 52) of the cohort. The majority were within the age range 41 years and over, while other studies highlight a younger population at risk. This study suggests, but does not confirm, the correlation of drug abuse with violent crime.

Doing Our Breast? Breastfeeding Rates at 6-Week Check-Up in a Large Urban General Practice and Re-Audit 6 Months Later Post Intervention Curran D, Carberry C, Curran T Coombe Family Practice West Northwest Intern Training Network Objectives: Breastfeeding has immense health benefits yet Ireland has extraordinarily low rates (42 % ever breastfed vs. 98 % in Norway) (1). These rates vary with education level and socioeconomic status (2). The WHO recommends exclusive breastfeeding to 6 months. The aim of this study was to increase breastfeeding rates in this large urban practice, which serves a socially deprived catchment, through undertaking the following objectives: • • •

Quantify rates at 6-week check-up. Intervention. Re-audit 6 months later.

Design/methods: A retrospective audit was undertaken of all mothers/ babies who presented for 6 week check-up during the previous 6 months. The breastfeeding status and various demographics were recorded. Data was then presented to the GPs at the practice. Overall rates as well as for sub-groups were highlighted to demonstrate areas for improvement. GPs were asked to engage, encourage and educate expectant mothers during all ante-natal visits in an effort to increase rates (3). Information sheets with local and online breastfeeding groups and resources were distributed and posters were hung in the waiting room. The rates for the subsequent 6 months were then quantified and compiled. Results: 73 6-week check-ups were analyzed during the two 6 month periods (40 and 33). Overall breastfeeding rates were 32 and 30 %, respectively. Amongst Irish born mothers: 19 and 16 %. Amongst non-Irish born mothers: 78 and 75 %. Amongst medical card holders: 16 and 37 %. Amongst private patients: 48 and 21 %. Amongst Irishborn medical card holders: 0 and 14 %. Interestingly there was not one Irish-born mother with a medical card breastfeeding initially (0/16). Following the intervention, 14 % of this group were breastfeeding (2/14). Conclusions: Ireland continues to breastfeed its newborns at a suboptimal rate with education, socio-economics and origin of mother all being contributory factors. All healthcare workers in contact with pregnant and new mothers should educate, encourage and facilitate breastfeeding.

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S246 References: 1. OECD Family Database (2009). OECD-Social Policy DivisionDirectorate of Employment, Labour and Social Affairs. 2. Gallagher L, Begley C, Clarke M (2015) Determinants of breastfeeding initiation in Ireland. Irish Journal of Medical Science. July 2015 pp 1–6. 3. Lin–Lin Su, Yap-Seng Chong, Yiong-Huak Chan, Yah-Shih Chan, Doris Fok, Kay-Thwe Tun, Faith S. P. Ng, Mary Rauff and Qiugley (2007). Antenatal education and postnatal support strategies for improving rates of exclusive breast feeding: randomised controlled trial. BMJ. Vol. 335, No. 7620 (Sep. 22, 2007), pp. 596–599.

Management of Spontaneous Pneumothorax: An Audit of Local Adherence to Evidence Based Guidelines Coulter J1, Quin G1 Accident and Emergency Dept., University Hospital Limerick, Ireland Background: In 2010 the British Thoracic Society established guidelines for the treatment of spontaneous pneumothorax. These evidence-based guidelines suggest that first line treatment is usually needle aspiration followed by chest drainage for unsuccessful needle aspirations and symptomatic secondary pneumothoraxes. In this audit we looked to examine our practice surrounding spontaneous pneumothorax and our adherence to the evidence based recommendations. Methods: A retrospective audit was performed looking at all patients that attended Accident and Emergency at University Hospital Limerick with a primary complaint coded as a pneumothorax. Data was examined from a 5 month period in 2015. Results: 19 cases were recorded in the 5 month time frame. 12 were primary spontaneous, 3 were secondary spontaneous, and 4 were traumatic pneumothoraces. The median age of patient was 38 and 68 % of the patients were male. Only 2 cases deviated from treatment guidelines and these deviations were to more conservative treatment plans. This included not intervening in pneumothoraces greater than 2 cm. Conclusions: Conservative management was the most common form of treatment for pneumothoraces attending our institution. The data demonstrates that there were only two deviations from the guidelines and this leads the authors to believe that the clinicians at our institution are well versed in treating pneumothoraces. While the trends in the data are clear this 5-month period yielded a low sample size and increasing this would benefit the analysis and the auditing procedure.

A descriptive Study of the Burden of Animal-Related Trauma at Cork University Hospital Sheehan M1, Pao N2, Deasy C2 South Intern Network; 2Emergency Department, Cork University Hospital

1

Introduction: Farming is the most dangerous occupation in Ireland. Despite farm safety campaigns from several bodies, the incidence of farm accidents is rising. A recent Irish study found that animal attacks were the leading cause of injury on Irish farms.

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Aims: The aim of this study is to examine major farm animal-related trauma treated at Cork University Hospital over a 5 year period. Methods: Patients who were treated for animal-related trauma in CUH over a 5 year period (2009–2013) were found using Hospital Inpatients Enquiry Scheme. Those with farm animal trauma, with major trauma as defined by Trauma Audit and Research Network (TARN), were selected. These patients’ records were reviewed using a data collection template. Results: 54 Patients were admitted to Cork University Hospital from 2009 to 2013 with major farm animal-related trauma. There was 46 males and 8 females, with an average age at presentation of 56 and a median of 55 (range 2–83) years. One injury was fatal. The majority of patients were farmers. The mean length of stay was 10 days, with the range between 3 and 90 days. Tibia and fibula fractures from kicks from cows were the most common injury, followed by hip fracture, blunt chest trauma, head injury, forearm and humerus fracture. There was an association between patient age and length of hospital stay. 59 % of patients required surgery, and almost 80 % of these were under an orthopaedics team. Conclusions: Irish farmers are getting older, and this appears to be the single biggest factor driving increasing injuries on Irish farms. Common injuries, as well as high-risk activities and times of year are identified in an effort to alert farmers to risky behaviour. A change in attitude among Irish farmers is required to reduce farm fatalities and injuries.

A Study of Predictors for Admission Rates of Geriatric Patients Presenting to Kerry General Hospital Emergency Department Sheehan M1, Boyd M2 1

South Intern Network; 2Emergency Department, University Hospital Kerry Background: Irish Emergency Departments are full of patients awaiting inpatient beds. Early identification of patients who require admission would aid Bed Management in reducing the numbers of patients on trolleys. Objectives: To identify or outrule simple predictors of whether a geriatric patient will require admission, namely: Age bracket from 65 to 74, 75 to 84 or 85 years and over GP/South Doc referral, or self-referral Arrival mode-ambulance or non-ambulance arrival to hospital Methods: Kerry General Hospital IT department agreed to provide reports documenting all presentations to the Emergency Department over 7 days. Reports were compiled into one data set and analysed using Microsoft Excel. Data analysis: 139 patients over 65 years of age presented to the KGH ED in the 1 week time period studied. 55 were 65 to 74 years old, 54 were 75 to 84 years old and 30 were over the age of 85. 50 arrived by ambulance, while 89 used their own method of transport. 69 were referred to the ED by their General Practitioner, 7 by South Doc and the remaining 63 came directly to the Emergency Department. Results: Overall, 77 of 139 patients were admitted (55.4 %). Admission rates were similar across age brackets. The admission rate for patients referred by a General Practitioner was 57.89 %. The admission rate for patients who arrived to hospital by ambulance was 72 %.

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Patients who had both GP referral and arrived by ambulance were not significantly more likely to be admitted (75 %) than those who called the ambulance themselves, with no GP input (71.05 %). Older age of patients was not a predictor of likelihood of admission if they arrived by ambulance. Conclusion: This study shows that of the three possible predictors examined, only mode of arrival (by ambulance or not) is a predictor of likelihood of admission.

Audit of Recording BMI in Patient Prescribed COCP in a GP Practice Alsaffar A1, McDonagh S2 1 West Northwest Intern Training Network; 2Propesct Hill Health Centre

Introduction: Recording a BMI prior to prescribing COCP is common practice and recommended in RCOG guidelines. Women with a BMI [25 are at increased risk of venous thromboembolism, acute coronary syndrome and cerebrovascular accidents. Taking COCP compounds these risks and therefore BMI should be continually monitored in patients prescribed COCP. Objective criteria: To assess if women prescribed a COCP at the Prospect Health Centre, Galway, over the course of 1 year have had their BMI measured within 365 days of their prescription. Subsequently, practical changes will be implemented to the practice and will be re-audited in 6 months’ time. Method: Using Socrates Patient Management Systems, every patient prescribed COCP between 1/11/14 and 1/11/15 and their most recent BMI measurement was compiled. Those who met the objective criteria were identified. The reason BMI measurement did not meet the objective criteria was also recorded i.e. BMI recorded over a year ago, no weight and/or weight recorded, measurements never taken. Results: 113 patients were audited, 36 did not meet objective BMI recording criteria. 4 patients either had no height (3) or weight (1) recorded within a year, 15 patients never had measurements and 19 patients had not had their BMI measured in over a year. Amongst those 19 patients there was a range of 391–2114 days since BMI was recorded and a median of 599 days. Conclusion/discussion: The main issues are taking the initial BMI and remembering to retake the BMI after a year has passed. To solve this issue, the prescriber, through Socrates, will manually add a medication note when COCP is prescribed. This is a reminder designed to pop up if the patient returns after 365 days. Re-audit will be conducted in a year to see if compliance is feasible in a multiphysician practice and if there have been improvements.

Development Steps of a Protocol App Designed to Match the Training Needs of Interns Alsaffar A1, Wong C1, O Connor P2, Lydon S2, Byrne D1,2 1 West Northwest Intern Training Network; 2National University of Ireland, Galway

Background: Research has consistently found that high percentages of newly graduated doctors report feeling under-prepared to begin working in a hospital and lack the skills necessary to perform their job1. This is most common in the acute care situation2. Protocols and

S247 check lists can be useful tools that facilitate teamworking and decision making in acute care. Aims: To identify the acute conditions that interns are commonly called to manage; identify the level of ease in managing these conditions; so as to inform the development of a set of protocols available as an app to support interns’ training needs. Methods: Pilot research carried out with non-consultant hospital doctors (n = 19) and hospital consultants (n = 15) identified a list of 21 acute conditions that interns are commonly called to manage. A questionnaire to identify how frequently interns are called to manage these 21 conditions from (1) ‘never’ to (5) ‘very often’, and their level of ease in the management of each of these conditions from (1) ‘very easy’ to (5) ‘very difficult.’ was distributed online to one intern network. Results: A total of 46 interns (response rate of 35 %) completed the survey. Fourteen acute conditions were identified as commonly seen by interns. Five of these, more than a quarter of participants indicated occurred ‘often’ or ‘very often’ and they found ‘difficult’ or ‘very difficult.’ These conditions were desaturating patient (29.1 % of participants), shortness of breath (29.1 %), acute confusion (29.1 %), severe pain (30.9 %), and electrolyte imbalance (30.9 %). Conclusions: The development of a protocol app as an intern support tool is an important innovation. The pilot research informing the content of this app is a critical step when resources are limited and in ensuring the app addresses intern training needs. The sourcing and development of protocols and check lists for each of these 14 conditions is the next step in the development process. 1. Medical Council Your Training Counts Report, 2015 2. The Shape of Training Report, D Greenaway, 2013

Attitudes towards Professionalism among Irish Medical Students and Relation to Academic Performance Wong C1, Alsaffar A1, Tandan m2, Lydon S2, O Connor P2, Byrne D1,2 West Northwest Intern Training Network; 2National University of Ireland, Galway 1

Background: Among doctors, professionalism has been found to be associated with the quality of clinical care provided, patient outcomes and academic performance. Papadakis et al. (2005) demonstrated that disciplinary action by a medical board was strongly associated with prior unprofessional behaviour in medical school. Aims: To examine attitudes towards professionalism among Irish medical students and to assess the relationship between attitudes to professionalism and final academic medical school award. Methods: A total of 254 medical students participated in this research. Participants completed a validated questionnaire on professionalism—the Penn State College of Medicine Professionalism Questionnaire, provided demographic information, and gave permission for their final medical school award score to be extracted. Results: Mean final medical school academic score was 63.8 (SD = 4.9). Participants’ attitudes concerning the importance of the key elements of medical professionalism (i.e., accountability, altruism, duty, excellence, honesty and integrity, and respect) varied; with some considering these elements of little relevance to professionalism and others considering them to be highly important indicators of professionalism among doctors. There was no association observed between participants’ attitudes towards any of the elements of professionalism and their final medical school score.

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S248 Conclusions: Although other studies have linked professionalism to academic performance, such a relationship was not evident in our data. However, a majority of Irish medical students appear to appreciate the importance of the key indicators of medical professionalism. Good professional practice is as important as academic achievement but can be difficult to measure in undergraduate medical students. The use of attitudinal measures such as that employed in the current study may aid with the identification of students with poor understanding of professionalism, allow for remediation and decrease the likelihood of future negative outcomes such as impaired clinical care or disciplinary action.

Hepatitis E, Now a Notifiable Disease in Ireland Keane A, Naimimohasses S, Crowley B, Norris S St. James Hospital Dublin Southeast Network The case is that of a 58 year old Caucasian gentleman with a background history of cirrhosis who presented to the emergency department with an 8 day history of jaundice. Past medical history is significant for alcohol excess and recent commencement of an SSRI. HEV 3a was isolated from the serum and faeces of MR X. There was no significant history of foreign travel however interestingly the likely aetiology was thought to be due to undercooked pork. Conservative management was effective in resolving this gentleman’s jaundice with a decrease in bilirubin from 294 on admission to 59 at follow up appointment 2 weeks post discharge. This case highlights that a thorough history and examination to include all possible causes of acute on chronic liver disease is necessary. It is important to note HEV as a cause of liver derangement. More and more cases of HEV 3 and 4 are being seen in patients without a history of foreign travel.

Diabetic Ketoacidosis as a First presentation of Diabetes Mellitus in a 54 Year Old Lady Fennell DJ1, Hatunic M2 Department of Endocrinology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland; UCD Intern Training Network Introduction: Diabetic ketoacidosis (DKA) is a serious complication of diabetes mellitus; predominantly occurring in type 1 diabetes.1 This case is notable for its occurrence in a previously undiagnosed older patient. Case: A 54 year old lady was referred to the Mater Emergency Department by her GP with a 3 month history of lethargy and feeling generally unwell. She had no significant past medical history. She reported persistent vomiting and substantial weight loss over a 3 month period, also reporting polyuria, polydipsia and nocturia. Examination was unremarkable. Bloods on admission revealed a severe metabolic acidosis. PH was 7.02, bicarbonate was 8.7. Blood glucose was 27 and serum ketones were 6.7. HbA1c was 96 mmol/mol. She was admitted to the special care unit and treated as per the DKA protocol with intravenous fluids and an Actrapid infusion. The patient responded well, both clinically and biochemically. She

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 received education about insulin use and diabetes diet from the MDT and was discharged home on Novorapid and Lantus, with follow up in the Diabetes Day Centre and diabetes OPD. Blood sugar readings upon discharge were excellent. GAD antibody later proved positive. This case highlights the rare example of diabetic ketoacidosis as a first presentation of diabetes mellitus in an older adult. DKA is most commonly associated with type 1 diabetes mellitus, however case reports have shown it as a first presentation of LADA (latent autoimmune diabetes in adults). Although its incidence is less common in adults, type 1 DM can develop at any age.2,3 This case is an atypical first presentation of diabetes. It should be borne in mind for patients of any age who present with classical symptoms. References: 1. Barone B, Rodacki M, Cenci MC, Zajdenverg L, Milech A, Oliveira JE. [Diabetic ketoacidosis in adults—update of an old complication]. Arg Bras Endocrinol Metabol. 2007 Dec;51(9): 1434–47. 2. Nadhem O, Nakhla E, Smalligan RD. Diabetic Ketoacidosis as First Presentation of Latent Autoimmune Diabetes in Adult. Case Reports in Medicine, vol. 2015, Article ID 821397, 3 pages, 2015. 3. Maahs DM, West NA, Lawrence JM, Mayer-Davis EJ. Chapter 1: Epidemiology of Type 1 Diabetes. Endocrinology and metabolism clinics of North America. 2010;39(3):481–497.

Pneumonia: It’s Not All About The Bugs O Brien H1, Costello R2; Morgan R2 1 Intern, Beaumont Hospital; 2Consultant in Respiratory Medicine, Beaumont Hospital

Introduction: Chronic Eosinophilic Pneumonia is an idiopathic, noninfective eosinophilic lung condition with a typically insidious onset, characterised by accumulation of eosinophils in the lung parenchyma, coupled with an elevated peripheral blood eosinophilia and typical radiographical features. The case: JON, a 32-year-old gentleman, first presented to A&E in December 2013, with a 2-week history of generalised malaise and myalgia. He reported some dyspnoea in the days prior to his admission but denied any other associated respiratory symptoms. On admission, he was noted to be desaturating to 87 % with associated type 1 respiratory failure on ABG. This was associated with elevated white cells (27) and CRP (261), coupled with bilateral pulmonary infiltrates on chest x-ray. He was commenced on IV Tazocin for treatment of severe community acquired pneumonia. Unfortunately, he continued to deteriorate with worsening hypoxic respiratory failure, eventually requiring intubation and transfer to ICU. It was during review in ICU that it was noted his peripheral eosinophil count was elevated at 13.8. He was commenced on IV steroids and showed immediate improvement. He recovered well and required no maintenance steroids on discharge home. He had three further normal chest x-rays during the following year. He remained well until recently when he was re-admitted with a similar presentation. He was once again admitted with hypoxic respiratory failure and ICU admission was avoided with the early introduction of steroids. He admitted to taking cocaine recreationally, which is thought to be the trigger for these episodes. Unfortunately, his condition has become increasingly difficult to control, requiring maintenance dose of steroids to prevent any relapses. Learning points: This case illustrates the importance of considering atypical causes of pneumonia. It highlights the significance of white cell count differentiation, particularly in the acute setting.

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Recognition of this condition and early intervention are important for preventing significant morbidity and mortality.

Are We Providing the Correct Thromboprophylaxis Care to our Post-Partum Caesarean Section Patients? Heverin A, Imcha M Department of Obstetrics and Gynaecology, University Maternity Hospital, Limerick Introduction: Venous Thromboembolism (VTE) remains a leading cause of maternal mortality and morbidity. RCPI guidelines recommend low molecular weight heparins (LMWH) as the prophylactic agents of choice with weight adjusted dosing 1. As per guidelines LMWH may be commenced 6 h post caesarean section. We set out to determine if patients received the correct prophylactic treatment and dose in the recommended timeframe. We also wanted to ascertain if a VTE risk assessment was documented at the booking antenatal visit as recommended by the guidelines. Methods: Chart numbers were obtained for all patients who underwent elective or emergency caesarean sections over a randomly selected 2 week period. Data was collected on weight, VTE risk assessment performed, classification of caesarean section, medication and dose prescribed and the number of hours post caesarean section first dose was administered. Excel Microsoft was used to analyse the data. Results: A total of 51 patients underwent caesarean section. 64.7 % of patients underwent elective caesarean section while 35.2 % underwent emergency caesarean section. 0 % of patients had a VTE risk assessment documented. 100 % of patients received Tinzaparin. 92.2 % of patients received the correct dose based on their weight. Of the 7.2 % of patients who received an incorrect dose 75 % received a lower dose than that recommended for their weight. The length of time the first dose was administered post caesarean section ranged from 3.25 to 24.5 h. The average length of time for first dose post caesarean section was 9.5 h. Discussion: The results showed that all patients received the correct prophylactic treatment however the VTE risk assessment was not carried out at the antenatal booking visit. Our recommendation is the addition of a VTE risk assessment proforma to the antenatal booking information. Also we suggest all patients should receive prophylactic LMWH 6 h post caesarean section. Reference: 1. Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland and HSE Clinical Care Programme in Obstetrics and Gynaecology and Irish Haematology Society. Clinical Practice Guideline Venous Thromboprophylaxis in Pregnancy. Guideline No.20, Nov 2013.

Etanercept Induced Acute Panlobular Hepatitis Larkin M, Lynch B Department of Rheumatology, University Hospital Galway; NUI Galway Intern Training Network West Northwest Intern Training Network

S249 Introduction: Etanercept is a biologic drug which acts as a tumour necrosis factor alpha (TNFa) antagonist. It is a fusion protein, acting as a decoy receptor for naturally occurring TNF, thus leading to its anti-inflammatory properties. Etanercept is licensed for rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, polyarticular idiopathic juvenile arthritis and plaque psoriasis. (1) Case report: This is a case of a 17 year old female diagnosed with Ankylosing Spondylitis in September 2015 according to the 2013 Assessment of SpondyloArthritis International Society (ASAS) modified Berlin algorithm. Her Ankylosing Spondylitis was initially treated with Sulfasalazine which was ceased due to swollen eyelids on day three of use. She subsequently commenced on weekly Etanercept 50 mg subcutaneously. Three months after starting Etanercept she developed pruritis and malaise. On examination there was no scleraicterus, abdominal pain or stigmata of chronic liver disease. Laboratory results revealed abnormal liver blood tests; ALP 113 U/L (35–104), ALT 1114 U/L (0–40), GGT 148 U/L (6–42), Bilirubin 31 mg/dl (1–21) and INR 1.3. The metabolic and autoimmune liver screen was negative and virology screening for Hepatitis A, B, C, Epstein Barr virus, adenovirus and CMV was also negative. Abdominal Ultrasound was normal. A liver biopsy was consistent with acute panlobular hepatitis. Liver function tests began improving once Etanercept was stopped. Discussion: Hepatotoxicity is a less frequent adverse reaction in antiTNF-a drugs with fewer reported cases with Etanercept than other anti-TNFs. Drug induced hepatitis is one of the main causes of elevation in liver function tests observed with Etanercept, the other being reactivation of viral hepatitis. At present, this patient has not been restarted on an anti-TNF-a drug although it continues to be unclear in the literature whether previous hepatotoxicity to one anti-TNF-a drug predisposes to hepatotoxicity in another. (1) References: 1. Clinical and Research Information on Drug-Induced Liver Injury. http://livertox.nih.gov/Etanercept.htm

Interns as Medical Educators: Student experience from an Intern Delivered-Teaching Programme at University Hospital Limerick Burke G, Kaballo M, Stack A Department of Medicine, University Hospital Limerick, Graduate Entry Medical School, Health Research Institute, Limerick Background: Acquisition of skills in history taking, physical examination, diagnostic evaluation and professional competencies are fundamental in medical training. Interns, ‘‘fresh from medical school’’, and with experience in the clinical environment are wellplaced to assume the role of medical educator. The aim of this study was to evaluate student feedback on an intern-delivered teaching programme at University Hospital Limerick (UHL). Methods: Thirty five interns volunteered to participate in UHLs newly established intern-delivered student teaching programme. Each intern volunteered to deliver one 40-minute tutorial per week for 8 weeks during the academic year. A list of core clinical topics was identified and a flexible teaching schedule was created with oversight by Lead Intern, Professor of Medicine and administrative support. Student feedback of the programme and its perceived benefits was collected using an anonymous questionnaire. Results: Overall feedback on the performance of intern tutors was very positive. The response rate was 56 %. The average number of

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S250 tutorials received was 2. Clinical Examination was the most commonly used tutorial method (59 %). Tutorials on history taking, clinical investigations and management were cited as the most valuable. Students rated small group tutorials as the most preferred method of teaching. Importantly, 77 % of students indicated a desire to participate as intern tutors following graduation. Discussion: Feedback is an important aspect of the learning and teaching process for the administrators, interns and students. This report suggests that the intern-delivered teaching programme at UHL was beneficial and well received. A final review of the programme student with combined feedback from both students and interns is due at the end of the academic year. This positive feedback to-date bodes well for its continuation in 2016.

An Uncommon Complication of Ehlers-Danlos Syndrome Haugh C, O Connor M Mid-Western Intern Training Network; Institution: University Hospital Limerick Introduction: This is the case of a 56-year old man with EhlersDanlos syndrome (EDS), who was admitted to our institution with chest pain and dyspnoea. The purpose of this presentation is to discuss this rare disease, and also to address the twin dangers of both under investigating and over investigating patients with an established diagnosis of EDS, who present to hospital with common symptoms. Case description: A 56-year old Caucasian man with an established diagnosis of EDS was admitted to our hospital with chest pain and dyspnoea. His chest x-ray, ECG, troponins, and d-dimers were all normal. An echocardiogram performed 6 years previously showed mild dilation of the thoracic aorta. A CT of the thoracic aorta on this admission showed a thoracic aortic aneurysm. Discussion/conclusion: EDS is the term used for a group of relatively rare genetic disorders of connective tissue which are characterized by one or another of several features, including skin hyperextensibility, joint hypermobility, and tissue fragility1, as well as rarer, potentially life threatening complications as seen in our patient. In patients with known EDS who present to hospital with common symptoms such as chest pain and dyspnoea, it is important that common causes of these symptoms are excluded. However, as seen in our patient, life-threatening complications of EDS can present in a manner mimicking more common ailments, and these complications must also be ruled out where more common causes for the patient’s symptoms cannot be found. Reference: 1. Pauker S, Stoler J. Clinical manifestations and diagnosis of Ehlers-Danlos syndromes http://www.uptodate.com

An Unusual Cause of Abdominal Swelling in a Teenage Girl Lambe J1, Nally D1, Agnew G2, Hanly A1 1 Department of Surgery; Saint Michael’s Hospital, Dun Laoghaire, Co. Dublin; 2Department of Gynaecology, Saint Vincent’s University Hospital, Dublin 4; UCD Intern Training Network

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Introduction: Congenital uterine anomalies occur in 5 % of females [1]. However, they present a considerable diagnostic challenge, particularly when manifesting with atypical symptomatology. Case description: We present the case of a 17 year-old female who was admitted to Saint Michael’s Hospital with a 4-month history of abdominopelvic swelling associated with a 3-week history of persistent abdominal pain, half a stone in weight loss and decreased appetite. The pain was unrelated to menses, and the patient had no previous medical or gynaecological history. Physical examination revealed a firm, palpable 12 9 10 cm mass in the suprapubic region. Beta-hCG was negative, with CA-125 elevated at 230 IU/ml. Ultrasound showed a large cystic mass of unclear origin, believed to be arising from the ovary. Laparoscopy was perfomed, during which she was found to have normal ovaries and fallopian tubes bilaterally, with a bicornuate uterus, and a large, swollen rudimentary horn. Haemorrhagic fluid was drained from the cavity and peritoneal washings were sent for laboratory analysis, which were entirely benign. Discussion: This was an interesting case of a bicornuate uterus with unilateral menstruation, hence leading to the accumulation of haemorrhagic, clotted content within a rudimentary uterine horn. While the incidence of bicornuate uterus is believed to be approximately 0.5 %, cases of a noncommunicating uterine horn are extremely rare. Initial symptoms often occur in young women presenting with unilateral dysmennorhoea in the years following menarche [1]. Laparoscopy and excision is the gold standard for diagnosis and treatment [2]. This case highlights the importance of consideration of uterine anomalies among young females with an atypical presentation. References: 1. Borah T, Das A, Panda S, Singh S. A Case of Unilateral Dysmenorrhea. J Hum Reprod Sci. 2010; 3(3):158–159 2. Chakravarti S, Chin K. Rudimentary Uterine Horn: Management of a Diagnostic Enigma. Acta Obstet Gynecol Scand. 2003; 82(12):1153–54

‘Compression of the Median Nerve By Giant Lipoma Of The Hand: A Case Report’ Clesham K1, Ramasamy A2, Karkuri A2 1

West North West Intern Training Network; 2Department of Orthopaedics, Sligo Regional Hospital Introduction: Lipomas are benign neoplasms derived from adipose tissue, and are composed of mature adipocytes. They usually present as asymptomatic solitary mobile lumps found most commonly on the neck, upper back, proximal limbs and chest. Rarely they can be found on the distal extremities with 1 % of cases presenting this way. Case report: A 65 year-old retired civil engineer presented to us with a 2-year history of a swelling on his left palm. He also complained of pins and needles as well as decreased power affecting the lateral 4 fingers of the left hand. On examination a large lobulated mass on the volar aspect of the left hand was noted. It was soft on palpation, nontender with well-defined edges. Examination revealed decreased sensation and power found in the distribution of the median nerve. MRI suggested a large lobulated well-defined fatty mass measuring 5 9 4 9 2.7 cm in size found to be lying between the metacarpals and volar tendons, with a small component extending into the distal carpal tunnel. An excisional biopsy confirmed the diagnosis of lipoma. Discussion: This case involves a lipoma compressing the median nerve at the distal aspect of the carpal tunnel. The lipoma slowly

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 increased in size and the symptoms of median nerve compression manifested over a year after initial detection of the lump. Giant lipomas (greater than 5 cm) can present anywhere on the body but are exceedingly rare in the hands, with very few cases reported. There are also few case reports of median nerve compression caused by lipomas, and interestingly these cases report symptoms coinciding with first manifestation of the lump. This shows that although benign lesions, lipomas can progress to become symptomatic so patients should be investigated further if new symptoms develop.

The investigation and management of patients with suspected Venous Thromboembolism (VTE) in pregnancy between St Vincent’s University Hospital (SVUH) and the National Maternity Hospital (NMH)-audit Caul L Sponsor: Dr Nigel Salter, ED Consultant, St Vincent’s University Hospital (SVUH) Background: ED were asked to create a protocol for pregnant patients with suspected VTE based on Green—top Guideline recommendations1. In SVUH these patients are commonly referred from NMH creating unique problems in management between the two sites. Often NMH go directly to Radiology, bypassing ED. Audit was undertaken to examine the situation. Method: HYPE and PRP data (SVUH) was used to identify all pregnant patients with suspected PE or DVT in 2014 (N = 112). A questionnaire was created using SPHINX and completed for each patient using MAXIMS, SYNGOS and PALS records (SVUH). Data analysis was carried out using SPHINX. Results: NMH referrals comprised 80.4 % of total presentations (n = 90): 67 % to Radiology (n = 75) and 13.4 % to ED (n = 15). The remainder were self/GP/other presentations to ED. Third-trimester presentation was commonest (n = 41). 100 % of dimer results recorded were positive (n = 20). Documentation of advice regarding radiation was seen in 7.3 % of those investigated with CTPA/VQ (n = 3). CXR was done in 9.5 % of those with suspected PE who went directly to Radiology compared with 90.5 % of ED referrals. CTPA was commoner than V/Q in direct Radiology referrals while V/Q was commoner in ED referrals. Of suspected PEs 4.8 % had both scans (n = 2). NMH referrals accounted for 80 % of the positive diagnoses (n = 8) and 70 % had gone to Radiology directly (n = 7). 5 patients were admitted to SVUH. 30 % of confirmed diagnoses were referred for follow up with SVUH Haematology (n = 3). Conclusions: Multiple pathways of referral have resulted in inconsistent strategies. An agreed protocol between Obstetricians (NMH) and Physicians/Radiologists (SVUH) is recommended to standardise care and improve safety. CXR for suspected PE, increased documentation of advice regarding CTPA and V/Q risk and exclusion of D-Dimer are further recommendations. Additionally we suggest that pregnancy status be recorded on systems such as HYPE to facilitate future audit. Reference: 1. Royal College of Obstetricians and Gynaecologists. Thrombosis and embolism during pregnancy and the puerperium, the acute management of (Green-top Guidelines No. 37b. Published 2015 Apr. Available from: https://www.rcog.org.uk/en/guidelinesresearch-services/guidelines/gtg37b/

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An Incidental Finding of Gastric Adenocarcinoma in a 58 year old gentleman Grealis A1, Johnston S2 1 Dublin Mid Leinster Intern Training Network; 2Surgical Department, Midland Regional Hospital Tullamore

Introduction: In Ireland, gastric carcinoma accounts for 3.4 and 2.2 % of all non-melanoma skin cancers in men and women, respectively.3 Histologically, adenocarcinoma accounts for almost 80 % of all gastric cancers4. Description: Our case describes a previously healthy 58 year old gentleman who presented to the Midland Regional Hosptial, Tullamore for elective patch repair of an umbilical hernia. At the time of presentation for this procedure he reported no symptoms of abdominal pain, weight loss, dysphagia or early saeity. Prior to his umbilical hernia repair, the patient developed sudden onset central chest pain. Due to a past medical history suggestive of angina, his surgery was postponed and he underwent further investigation of this chest pain. The work-up for his chest pain was unremarkable except for an elevated D-Dimer; at a value of [1000 ng/mL. CT Pulmonary Angiogram was carried out to rule out a pulmonary embolism which showed no evidence of PE but did reveal mesenteric and retroperitoneal lymphadenopathy with apparent thickening of the wall of the stomach. Further investigation included CT Adbomen/Pelvis, Gastroscopy and Staging Laparoscopy, which together confirmed pT4a N2 gastric adenocarcinoma with peritoneal metastasis. Repair of the umbilical hernia was undertaken at the point of staging laparoscopy which also revealed metastatic involvement of the hernial sac. Conclusion: This case was discussed by the Multidisciplinary Team and it was decided that he was not a suitable candidate for surgical intervention. He is for palliative intervention only. 3. National Cancer Registry Ireland (2013) Annual Report of the National Cancer Registry 4. National Cancer Registry Ireland (2011) Cancer of the Oesophagus and Stomach

An Unsuspected Cause of Right Iliac Fossa Pain O Callaghan D, Elkassaby M, Tubassam M Department of Vascular Surgery, Western Vascular Institute, University College Hospital Galway West Northwest Intern Training Network Introduction: A 65 year old gentleman presented to the emergency department (ED) of a general hospital with an acute-on-chronic exacerbation of right iliac fossa (RIF) pain and swelling. Description: Patient has a history of acromegaly and well known to the orthopaedic department because he required bilateral total hip arthroplasty, with both hips requiring further revision surgeries. On admission, the patient complained of sudden, stabbing, deep seated right hip pain. He had limited range of movement at the hip joint, with increased pain on movement. The severity of the pain was 7/10, relieved marginally by analgesics. Vital signs were stable, with a low grade temperature (37.2 C).

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S252 Two trials of arthrocentesis without radiological guidance was performed, both aspirated blood and were negative for bacterial growth. A CT angiogram displayed a large 10 cm pseudo-aneurysm of the right external iliac artery (EIA), partially obscured behind the hip prosthesis. He was transferred to UCHG for further management. On arrival, he had a pulsating mass in the RIF. An urgent endovascular procedure was performed that involved exclusion with stent graft of the right EIA pseudo-aneurysm. Patient stayed in for 1 week post-operatively. A CT angiogram showed satisfactory placement of right EIA stent graft with satisfactory distal perfusion. Discussion: Pseudo-aneurysm of the EIA is a rare but serious vascular complication of total hip arthroplasty. These injuries are reported to have 7 % mortality and 15 % incidence of limb loss. (1) Radiological guidance would have been helpful in diagnosing the pseudo-aneurysm before arthrocentesis was attempted and so is an area that could be improved upon. An endovascular approach was chosen as he had had 4 previous surgeries to the right hip, and open repair is also associated with higher morbidity and mortality post-operatively. One drawback of the endovascular covered stent graft repair is that infected pseudo-aneurysms are reported in the literature and so antibiotic cover is required for 3 months post-operatively. (2)(3) References: 1. Sjoenfeld S et al. The management of vascular injuries associated with total hip arthroplasty. J Vasc Surg. 1990;11:549–55 2. Sanada J, et al. stent-grafting for infected iliac artery pseudoaneurysms. Cardiovasc Intervent Radiol. 2005;28:83–6. 3. Clarke MG, et alMRSA-infected external iliac artery pseudoaneurysm treated with endovascular stenting. Cardiovasc Int Radiol. 2005;28:365–6.

Etiological Profile and Treatment Outcomes of Epistaxis at a Major Teaching Hospital; a Review of 721 Cases Carey B1, Sheahan P2, O’Sullivan P3 1

South Intern Training Network; 2ENT Surgery Department, South Infirmary Victoria University Hospital, Cork Background: Epistaxis is the most prevalent ENT emergency and a significant burden on ENT services. Our objective was to study the incidence and outcomes of patients presenting with epistaxis at a major teaching hospital. Methods: Retrospective descriptive study of 721 patients who presented with epistaxis was conducted over a 1 year period. Data collected was analysed using SPSS software version 20. Results: Of 721 patients, initial treatment was by nasal cautery (298), nasal packing (200), or no treatment (223). 59 patients were admitted. The mean age of admitted patients was 66.8 years and the male to female ratio was 2:1. 69.5 % had hypertension and 78 % used antiplatelet/anticoagulation medication. The majority of admitted and return patients were out of hours referrals from ED and the mean admission duration was 5 nights. Surgical treatment for intractable epistaxis included arterial ligation or endovascular embolization. Successful treatment was defined as no recurrent epistaxis following pack removal or no readmission with epistaxis within 24 h of hospital discharge. 644 patients had successful treatment. Conclusion: More return and admitted patients presented at out-ofhours times with less clinical staff on site. Most non-admitted patients

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 receive no treatment. These factors possibly lead to increased stress on the ENT casualty service. Cautery and nasal packing are the most common treatment modalities in first-time and admitted patients yet result in higher rate of representation.

FRAX: The Relationship Between Web-Based and Paper-Based Scores McKenna-Barry M1, Clifford GT1, Van der Kamp S1, Hurson C1, McKenna MJ1 1

Bone AND Joint Unit, St. Vincent’s University Hospital, Dublin 4

Background: The National Osteoporosis Guidelines Group (NOGG, 2014) recommends that fracture risk is assessed in post-menopausal women and men aged 50 years or more using FRAX web-based algorithm incorporating clinical risk factors to determine the 10-year probability of a major osteoporotic fracture (MOF) as a percentage, and is specific to Ireland. In the absence of computer access, NOGG recommends a paper-based FRAX algorithm based on UK data. The aim of this study was to determine the relationship between the FRAXWEB score with the FRAXPAPER score. Methodology: A convenience sample of 150 subjects with a fracture was selected from six orthopaedic trauma clinics over 2 weeks in January 2015. Patients were excluded if they had a diagnosis of osteoporosis (n = 37), had no clinical risk factors for osteoporosis as per FRAX (n = 52), or a history of fragility fracture if female (n = 14). Results: Of the 101 subjects included, FRAXWEB median score was 7.4 % (IQR 10.4 %) and FRAXPAPER median score was 9.5 % (IQR 7.95 %). Both the FRAXWEB score and FRAXPAPER score identified 17 subjects at high risk of osteoporosis (MOF C 20 %). Data was normally distributed. A strong correlation was established between both scores [Pearson’s r = 0.87, Student’s t-test (paired, two tail) p = 0.72]. Discussion: The FRAXWEB and FRAXPAPER correlate with one another. The FRAXPAPER may be a suitable alternative in the absence of computer access. However, 52 subjects who would normally be included in FRAXWEB could not be as they had no clinical risk factors as per FRAXPAPER. The median FRAXPAPER risk of these patients was 5.85 % (IQR 6.85). This may underestimate the risk of osteoporosis in this population. Documentation in Irish hospitals remains largely paper based. A paper score drawing from Irish, as opposed to UK data may be more useful to quickly identify those at a high risk of MOF in a clinical setting.

Fat Can be Fatal, a Case of Fat Embolism Syndrome Following a Road Traffic Accident Akamnonu J Senior supervisor: Dr. C, Motherway University Hospital Limerick, Mid-West-Limerick, Clare and Tipperary North Fat embolism can arise following trauma such as fracture of long bones, soft tissue trauma, and burns. These emboli can travel through the bloodstream and lead to a rare, but potentially lethal complication known as fat embolism syndrome (FES). FES encompasses a triad of

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 systemic dysfunction and manifests clinically as cerebral and respiratory dysfunction with an associated petechial rash. The neurological symptoms are varied making clinical diagnosis difficult however imaging studies can be used to aid diagnosis. The purpose of this case report is to highlight FES and its associated symptoms/imaging to aid in diagnosis. 22 year old male admitted to A&E following a car vs. car collision in which he suffered multiple fractures including bilateral femoral fractures, tibia/fibula fractures, right clavicular fracture and fractured ribs. GCS 15/15 on arrival with no loss of consciousness and no evidence/history of head trauma. Patient was stable and admitted for repair of femoral fractures, however he subsequently became difficult to rouse with a reduced GCS. CT brain revealed a right cerebellar infarct and subsequent MRI brain revealed multifocal emboli with the largest in the R cerebellum. Patient was admitted to ICU for further treatment with an uncertain prognosis. However he improved over the coming weeks and was ultimately discharged to the ward for further rehabilitation. Diagnosis of cerebral FES can be aided by remembering the triad of systemic dysfunction. Neurological dysfunction varies from mild confusion to encephalopathy with coma and seizures. Neuroradiological diagnosis of cerebral FES is equally problematic, CT brain scans are usually negative with MRI being more sensitive and consistently showing multiple small, scattered, non-confluent hyperintense intracerebral lesions in the so called ‘’Starfield pattern’’. Any trauma patient admitted with no head injury who is initially alert and later develops an acute neurological status deterioration should undergo urgent investigation for possible FES.

Catching Out the CHA2DS2-VASc?: Apical Hypertrophic Cardiomyopathy in a Patient with Atrial Fibrillation Kitt K 1, O Donnell M

1

Department of Geriatric and Stroke medicine, University Hospital Galway 1 West North West Intern Training Network Description/case presentation: 67-year-old male who presented to A&E in UHG with sudden onset left hemiparesis, on the background of known atrial fibrillation. Excellent pre-morbid functioning, physically fit, CHA2DS2-VASc score = 1, on no long-term anti-coagulation. No other pertinent medical history. On examination the patient had a complete left hemiparesis, left sided facial droop, left sided sensory loss, dysarthria and positive left sided Babinski reflex, consistent with an right sided anterior circulation stroke. NIHSS score = 16. A large M1 infarct was confirmed on neuroimaging, ASPECTS score = 9. IV t-PA was administered, and the patient was transferred to Beaumont hospital for thrombectomy. The procedure established reperfusion in the MCA, and on return to UHG he had regained some power in left arm, with an MRC score of 3/5 after the first 48 h. Although some impairment remained over the following 4 week inpatient stay, he had an extremely successful recovery with physiotherapy and occupational therapy input. He has regained functional power to all limbs, and is now independent in ADL’s. An ECHO taken during his routine stroke work-up reported a hyperdynamic and hypertrophied left ventricle, with an ejection fraction of 60–70 %, and a dilated right ventricle. A Cardiac MRI confirmed the diagnosis of Apical HCM. Discussion/conclusion: The apical variant of HCM is relatively uncommon, responsible for 7 % of patients with HCM in the Europe

S253 and North America, and 25 % of cases in Asia. (1) While the risk of ischaemic stroke in patients with non-valvular atrial fibrillation has been quantified in large epidemiological studies, the risk with concomitant HCM is less certain. Some studies have reported a high incidence of stroke in those with atrial fibrillation and HCM. (2) It poses the question should cardiomyopathies be included in our current formulas for calculating stroke risk? 1. T. Chikamori, Y. L. Doi, M. Akizawa, Y. Yonezawa, T. Ozawa, and W. J. McKenna, ‘‘Comparison of clinical, morphological, and prognostic features in hypertrophic cardiomyopathy between Japanese and Western patients,’’ Clinical Cardiology, vol. 15, no. 11, pp. 833–837, 1992. 2. Higashikawa M, Nakamura Y, Yoshida M, Kinoshita M. Incidence of ischemic strokes in hypertrophic cardiomyopathy is markedly increased if complicated by atrial fibrillation. Jpn Circ J 1997; 61:673.

Management of Muscle Invasive Bladder Cancer Khan C, Kelly N University Hospital Limerick Introduction: Bladder carcinoma is the one most common malignancy of the urinary tract and management is based on the depth of invasion. Non-invasive bladder carcinoma is disease that is confined to the mucosa or sub mucosa. The initial treatment of choice for noninvasive bladder cancer is transurethral resection of the bladder tumor and BCG intravesical therapy. However, many patients experience disease recurrence and increase risk of progression, which may result in radical cystectomy. Presentation of case: Mr. X is a 70-year-old gentleman who initially presented in 2014 with painless, frank hematuria. He underwent a rigid cystoscopy and primary transurethral resection of his bladder followed by BCG induction and maintenance treatment. It was noted that there was multiple solid and papillary lesions in his bladder. Histology demonstrated a high-grade transitional cell carcinoma (pT1) with query muscle invasion (pT2). He subsequently had a follow up cystoscopy in 2015 and required further resection due to reoccurrence. Histology did not reveal any evidence of muscle invasion however CT imaging suggested the possibility of muscle invasion. Following multiple multi disciplinary discussions, the decision to perform a radical cystectomy and ileal conduit was made. Discussion/conclusion: The management of pT1G3 transitional cell bladder carcinoma remains a clinical challenge to urologists. Majority of bladder cancer cases present with non-muscle invasive disease. The management for these patients includes transurethral resection with or without adjuvant intravesical chemotherapy. Unfortunately, many patients present with reoccurrence and 10–20 % progress to muscle invasive disease, requiring a radical cystectomy. The main challenge is to correctly identify patients likely to develop progression of disease initially so that they can be treated aggressively from first presentation.

Reasons Why an Out Of Hours GP Service is Called to a Post-Acute Care Unit Cadogan S1, Power D2 1

Dublin Mid-Leinster Intern Network; 2Department of Medicine for the Elderly, Mater Misericordiae University Hospital

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S254 Introduction: Recent years have seen the development of ‘PostAcute Care’ units in response to the issues of hospital and A&E overcrowding. These facilities relieve acute hospital beds by providing care to patients who are medically discharged from the acute setting but are unable to return home. They follow a nurse-led model with minimal medical cover, which often relies on an out of hours (OoH) GP service to review medical issues. Aims: This study aims to assess reasons why an OoH GP service is called to a post-acute care unit based in north Dublin, and what effect the employment of an intern had on the frequency of consultations. Methods: Details of OoH GP consultations to Fairview Community Unit were obtained by examining invoices received over 24 month period from ‘D-Doc’, north Dublin’s OoH GP service. Each invoice was reviewed and details recorded of patient’s age, presenting complaint, and management including referral to MMUH ED. Results: From October 2013 to September 2015 there were 224 OoH reviews. In the first 12 month period, there were 152 call outs. This number fell to 72 in the second 12 month period, coinciding with the placement of a full time intern beginning October 2014. The most common reason for D-Doc review was post fall assessment, accounting for 34.4 % (n = 77) of all reviews. Only four of these falls required admission to MMUH ED for further investigation, with the remainder being managed conservatively. Confirmation of death accounted for 14.7 % of all GP call outs (n = 33), with respiratory tract infections responsible for 9 % (n = 20). Other less common reasons included pyrexia (4 %), catheter related issues (4 %), end of life care (3 %) nausea/vomiting (3 %), and electrolyte abnormalities (3 %). Conclusions: This study found a fall in OoH reviews to this unit following placement of an intern. Despite this, D-Doc and other OoH services remain an invaluable resource to the growing area of postacute care services.

Reasons Why Women Accept or Decline Prenatal Screening for Aneuploidy Cadogan S1, Russell N2, O Donoghue K2 1

Dublin Mid-Leinster Intern Network; 2Cork University Maternity Hospital Introduction: There is no state-funded national screening programme for aneuploidy in Ireland, therefore women pay for any chosen screening tests. This makes Ireland an ideal location to assess attitudes to new tests and techniques. Aims: The aims of this study were to describe the acceptability of screening in our population and to determine reasons for accepting or refusing a screening test. Methods: A study-specific questionnaire was distributed to women attending the antenatal clinics in CUMH from September- November 2014. Data was analysed using SPSS v20.0. Results: Six hundred and twenty questionnaires were distributed. The response rate was 74 % (n = 459). Ninety-three percent of respondents believe that all women should be offered prenatal screening. If offered, 74.2 % of women would accept, 19.8 % were undecided and 6 % would decline. The most common reason for having prenatal screening was ‘to be prepared for an affected baby’(63 %), followed by ‘gaining knowledge’(66 %), and ‘reassurance’(54 %). Reasons for declining a prenatal screening test included ‘not wanting to consider termination of pregnancy’(48 %), ‘anxiety’(30 %), and ‘diagnostic test has too high a risk of miscarriage’(28 %). Non-invasive prenatal testing was the most popular screening test with 39 % of women

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 selecting it as their first choice, followed by integrated testing (35 %), combined test (17 %) and quadruple screen (9 %). Conclusion: This study demonstrates a high acceptance of prenatal screening in our population. It also provides valuable information regarding women’s reasons for accepting or declining testing. This allows us to integrate new screening techniques and establish a service suited to the needs of our population.

An Audit of the Management of Patients with Community-Acquired Pneumonia in a Private Hospital Emergency Department Glynn D1, Cummings B1, O Carroll D1, Burke D1 1

Beacon Hospital, Sandyford, Dublin 18

UCD Intern Training Network Background: Community-acquired pneumonia (CAP) is defined as a lower respiratory tract infection acquired in the community or within the first 48 h of admission to hospital. The aim of this study was to evaluate the management of patients presenting with CAP in an emergency department and compare this management to the British Thoracic Society (BTS) 2009 guidelines for the management of CAP in adult patients. Methods: A retrospective review of medical records of all patients admitted to Beacon Hospital with CAP between July and September 2015 was performed. Data was recorded via Excel spreadsheets and included the following: patient demographics, presence of a documented CURB-65 Score, laboratory investigations, chest x-ray and antibiotic treatment prescribed. Results: The medical records of 25 patients with CAP were reviewed (n = 25). Only 1 patient (4 %) had a documented CURB-65 severity score. Only 8 % of patients (n = 2) were treated in line with BTS guidelines and five different antibiotic regimens were used on admission. The majority of antibiotic regimens used were delivered intravenously. Conclusion: While our findings suggest that a CURB-65 severity rating was not routinely documented in the medical records it must be noted that there was strong documentary evidence of the core variables that constitute the CURB-65 score within the medical records. The variability of antibiotic selection is also not unique to this emergency department, with previous studies reporting similar results (Nadarjan P. 2008). Focused training for our non-consultant hospital doctors on the need to document CURB-65 severity scores will be instrumental to ensure best practice and a standardised approach to the management of patients with CAP. A future audit would be recommended to track the success of an education and training intervention.

Regrets of Older Adults entering Residential Care Fennelly L1, O Toole R2, Ogbebor E2, Power D2 Dublin Mid-Leinster Intern Network; 2Department of Medicine for the Elderly, Mater Misericordiae University Hospital, University College Dublin Introduction: It is commonly assumed that an older adult and their family almost always meet admission to long-term care with sadness. However, there is currently a dearth of literature surrounding the

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 emotions experienced by elderly people when they reach this point in their lives. The purpose of this qualitative study was to gain an insight into the regrets reported by a group of elderly Irish people on the cusp of entering long-term care and some of the factors influencing this emotion. Methods: Qualitative, semi-structured interviews were undertaken with 12 elderly patients in a step-down or intermediate care unit of a Dublin teaching hospital. An MMSE, Geriatric Depression Scale (GDS) and Barthel Index score supported each of these interviews. Participants were included if their MMSE score was [20. Interviews gathered details of participants’ early lives, careers and relationships, their present regrets, greatest achievements and happiest memories. Detailed reports of participants’ responses were recorded and this data was subsequently analysed for recurrent themes. Results: The mean age of participants was 82 years. Their mean MMSE was 27. The key themes that emerged were relationship and family life regrets (not marrying, not having more children, losing touch with children) and career-related regret. Career-related regret was more common amongst the men interviewed. Conclusions: Patterns emerged in terms of the regrets experienced among this cohort. The interviews conducted revealed links between stability in childhood, happiness in marriage and later contentment. Only 4 participants scored highly on the GDS. The same number of participants (n = 4) reported no major life regrets. A strong theme emerged of an acceptance of increasing needs and diminishing independence, and this change was not necessarily correlated with sadness for the older person.

S255 Patients were managed by supportive care along with medications (66.3 %), counselling (53.7 %), and psychiatric referral (3.2 % via ED, 7.4 % to outpatients). Conclusions/discussion: This study finds a significantly higher prevalence of mental health problems than previously thought, with a worryingly high incidence of suicidal ideation. Further study is needed to assess whether there are sufficient resources and time for GPs to manage this safely with increasing prevalence. References: 1. Tedstone Doherty D, Moran R and Kartalova-O’Doherty Y (2008) Psychological distress, mental health problems and use of health services in Ireland. HRB Research Series 5. Dublin: Health Research Board 2. Cannon M, Coughlan H, Clarke M, Harley M & Kelleher I (2013) The Mental Health of Young People in Ireland: a report of the Psychiatric Epidemiology Research across the Lifespan (PERL) Group Dublin: Royal College of Surgeons in Ireland

Communicating Abscess of the Pubic Symphysis Kelly M, Shafquat A, Byrne F Trauma and Orthopaedics Department, University Hospital Galway

Assessing the Prevalence and Management of Mental Health Problems and Suicidality in General Practice 1

Nicholson L , Murphy S

2

West Northwest Intern Training Network; 2Galway Bay Medical Centre, Dock Road, Galway 1

Background/introduction: The majority of mental health problems in Ireland are managed by General Practitioners. There is very little data about their prevalence and management, but it appears to be increasing. Previous figures suggest almost 10 % of people have a current problem1. High levels of self-harm and suicidality amongst Irish youth has also been highlighted2. This study aimed to quantify what proportion of an urban General Practitioner’s caseload present with or have a background of mental health problems, specifically suicidal ideation, and gather further information about the demographics and management of these patients. Methods: An observational cross-sectional study of one GP’s consultations was conducted over a 1-month period in Spring 2015 in an urban General Practice. Data was compiled on patient demographics, reasons for attending, presence of current or past mental health problems including suicidality and management of same. Results: Of 273 patient consultations, 24.2 % (n = 66) had current mental health problems, with a slight female preponderance. 34.8 % (n = 95) had ever had mental health problems, and 8 % had current or previous suicidal ideation or passive death wish (23.2 % of those with mental health problems). Of these 95, 23.2 % had predominantly depression; 38.9 % anxiety conditions; 37.9 % combination of both. Of the 66 patients with current mental health problems, 83.3 % attended because of mental health problems and 16.7 % for unrelated problems. 68.2 % had 2 or more problems to discuss in that consult.

West North West Introduction: a 68 year old male presented via the emergency department with an 8 week history of right sided groin pain. Case: Mr. BM describes the gradual onset of right sided groin pain exacerbated by movement with erythema overlying. He was otherwise systemically well. Significantly, Mr. BM had undergone a circumcision immediately preceding the onset of his pain. His pain increased in the 5 days prior to his admission, extending to his lower abdomen and pelvis and he was no longer able to weight bear. Examination revealed erythematous swelling of the right groin area extending to the mid thigh. His CRP was 403 mg/l, with a white cell count of 22.8 9 109/L. Blood cultures were positive for Staphylococcus Aureus. An MRI of the pelvis was arranged which showed a large fluid collection in the intermuscular planes of the upper right anterior thigh compartment extending into the pubic region with surrounding soft tissue oedema in the adductor and pectineus tendon insertions. High dose flucloxacillin was commenced. Drains were also inserted under CT guidance draining purulent fluid which also grew Staphylococcus Aureus. Mr. BM improved both clinically and symptomatically with drains left in situ for 21 days. MRI on discharge showed near complete resolution of the collection. He was discharged with a PICC line in situ for outpatient antibiotic therapy under the guidance if the infectious disease service. Conclusion: Infective pubic collections associated with the use of dorsal penile nerve blocks during circumcision have been reported previously by Soh et al. This is the most likely aetiology in this particular case given the timeline of the onset of symptoms and the organism isolated. Yoshida et al. previously described a single case and the anatomical basis for infection in the prevesical space communicating with the thigh muscles as seen in this case.

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DVT: an Atypical Presentation of Abdominal Aortic Aneurysm Quigley N Supervisor: Medani M

University Hospital Limerick, Dooradoyle, Co Limerick Introduction: A 79 y/o gentleman presented to his GP with a unilateral swollen right lower limb of unknown aetiology and was referred to vascular surgery with a?DVT Case presentation: JF is a 79 year old gentleman, with a 65 pack year hx of smoking. He would consider himself well, having played rugby up to the age of 68. His past medical hx includes a previous CVA in 2013, with carotid dopplers at the time showing 50–69 % stenosis on the right and 20–29 % stenosis on the left. He has rehabilitated well from this and has no residual symptoms. He also suffers with hypercholesterolemia. On presentation to UHL he had an obvious swelling in the right leg compared to the left and his wells score was 4. He was put on bedrest, analgesia, antibiotics, heparin infusion and leg elevation. He was already on a statin and aspirin. Management and outcome: On bedside examination peripheral pulses were absent. Bedside ultrasound showed a large 8 cm AAA. CT of his abdominal aorta showed a 7.8 cm, infrarenal abdominal aortic aneurysm extending to the right common iliac with no evidence of rupture. The left common and internal iliac measured 19 and 16 mm, respectively. The management plan was theatre for an open AAA repair. Intraoperatively anaesthetics were unable to maintain appropriate blood pressure control on maximum inotropes. With a maximum dosage of noradrenaline JF still was not maintaining BP above 90/40 and surgery was abandoned. He had no postoperative issues and is awaiting a full cardiac review ± angiogram to see if he can be optimised for a further attempt at surgery. Discussion: This case demonstrates the unusual presentation of an AAA through the aneurysmal compression of the iliac vessels causing stasis and the development of a DVT. It also shows the complex anaesthetic decisions and management that are required during complex surgeries.

A Case of Hepatopulmonary Syndrome Causing Platypnoea-Orthodeoxia Syndrome O Ceallaigh E1, O Callaghan D2 1 Dublin Mid-Leinster Intern Network; 2Department Respiratory Medicine, Mater Misericordiae University Hospital, Dublin 7

The hepatopulmonary syndrome (HPS) is an uncommon condition characterized as a triad of liver disease, gas exchange abnormalities causing hypoxemia and intrapulmonary shunting. Currently, liver transplantation is the only curative intervention for HPS. (1) Platypnoea-orthodeoxia syndrome is a rare syndrome of dyspnea and deoxygenation when changing from a recumbent to upright position. Most commonly caused by right-to-left intracardiac shunting, it can also be caused by a variety of other cardiac, pulmonary, hepatic and autonomic conditions. (2) Here we present a case of HPS-associated platypnoea-orthodeoxia.

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 A 42-year-old male with prior intravenous drug use presented to the Emergency Department with worsening dyspnea. Past medical history was notable for hepatitis C and a hypoxic brain injury secondary to heroin overdose. Oxygen saturations were 82 % on room air but improved with administration of supplementary oxygen. Initial assessment excluded common causes of hypoxia. Because of the unexplained hypoxemia, the patient’s A-a gradient was calculated. This was increased indicating either a V/Q mismatch or a right-to-left shunt problem. On repeat examination, it was noted that his oxygen saturations decreased when he moved from a recumbent to an upright position. He also reported dyspnea on sitting up that was relieved by lying flat. These findings were pathognomic of platypnoea-orthodeoxia syndrome. To exclude an intracardiac shunt, a contrastenhanced ‘‘bubble’’ echocardiogram was performed. This confirmed a structurally normal heart however delayed visualization of microbubbles (after 3 cardiac cycles) in the left heart chambers was noted suggestive of an intrapulmonary shunt. Given the chronic liver disease and intrapulmonary shunting, a diagnosis of hepatopulmonary syndrome was made. Our patient had been previously deemed unsuitable for liver transplantation but is due re-assessment for oxygen therapy for symptomatic relief. This unusual case highlights a rare clinical finding, platypnoeaorthodeoxia, and the importance of recognising that organ systems work not in isolation, but in tandem. References: 1. Rodriguez-Roisin R, Krowka MJ. Hepatopulmonary syndrome–a liver-induced lung vascular disorder. The New England journal of medicine. 2008;358(22):2378–87. 2. Cheng TO. Mechanisms of Platypnea-Orthodeoxia: What Causes Water to Flow Uphill? Circulation. 2002;105(6):e47.

Response of Stage IV Colon Cancer to Novel Immunotherapy Treatment with Nivolumab McNeill D, Greene J, McDermot R Department of Medical Oncology, St Vincent’s University Hospital, Dublin; UCD Intern Training Network Colorectal cancer is the second most commonly diagnosed cancer in Ireland and is responsible for the third highest mortality of all invasive cancers[1]. We describe a case of stage IV colorectal cancer and an exceptional response to novel immunotherapeutic treatment with the anti-PD-1 monoclonal antibody nivolumab. MP, a 71 year old woman, was originally diagnosed with stage III colon carcinoma in March 2012. Despite surgical resection and adjuvant treatment with three different chemotherapeutic regimes, MP’s disease continued to progress and further treatment options were limited. In August 2014, immunohistochemistry on her tumour identified micro satellite instability (MSI). This is a hypermutable phenotype caused by the loss of DNA mismatch repair activity. As a result of this, MP was deemed suitable for a clinical trial recently opened in Ireland with a new monoclonal antibody—nivolumab. Nivolumab acts as an inhibitory ligand by blocking the programmed cell death 1 (PD-1) receptor on activated T cells and therefore promotes an immune response to the tumour[2]. Prior to starting nivolumab, MP was suffering with significant gastro-intestinal symptoms. Since starting the treatment these have markedly improved and her Eastern Cooperative Oncology Group (ECOG) performance status has gone from 2 to 1. Radiologically there has also been a significant improvement, with a 67 % reduction

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 in size of the target mesenteric lesion and associated reduction in size of any non-target lesions. MP has tolerated all cycles of treatment very well and suffered only minimal side effects. She is alive and well after 16 months of treatment. This case highlights the importance of genetically subtyping different cancers and the continuing advances in cancer treatment in terms of genetic abnormality rather than organ affected. It also proposes exciting developments in terms of the targeted treatment of colorectal carcinoma and the addition of immunotherapy in patients with micro satellite instability. References: 1. McDevittt, Joe, Paul Walsh, and Harry Comber. ‘‘Colorectral cancer incidence, mortality, treatment and survival in Ireland 1994–2010.’’ (2013). 2. Patel, Sandip P., et al. ‘‘Modulation of immune system inhibitory checkpoints in colorectal cancer.’’ Current Colorectal Cancer Reports 9.4 (2013): 391–397.

An Audit on Surgical Antimicrobial Prophylaxis Prescribing Practices McGowan C1, McKenna C2, McDermott S3 1

Department of General Surgery, Our Lady of Lourdes (OLOL) Hospital Drogheda and RCSI Intern Training Network; 2Pharmacy Department, OLOL Hospital Drogheda; 3Department of Microbiology, OLOL Hospital Drogheda Introduction: The purpose of surgical prophylaxis is to prevent infection at surgical sites. The correct drug must be prescribed in anticipation of the likely pathogens, and must be fully administered within 60 min of the first incision. It is critically significant that a single dose is usually sufficient. Multiple doses are rarely required and indications for such are explicit.1 OLOL Hospital Drogheda has the highest consumption of antibiotics for its hospital category, and one of the highest of all hospitals nationally.2 It is hypothesised that incorrect agent prescribing and incorrect duration of therapy are significant contributors to the current inflated antimicrobial use in the hospital. Aim: The aim of this audit was to ascertain specifically, how the prescribing of surgical prophylactic antibiotics deviates from best practice guidelines in OLOL Hospital Drogheda. Method: A retrospective audit of 60 patients who had surgery during 1 week in December 2015 was conducted. Relevant data from these charts were extracted to answer a quantitative questionnaire. Variables included; indications for prophylactic antibiotics, appropriateness of agent used, timing of administration, number of doses administered and details of the surgical procedure were also recorded. Data were analysed using SPSS and qualitative variables were individually appraised. Results: Results will be discussed in relation to the aforementioned variables aiming to reveal target areas for antimicrobial stewardship. Preliminary analysis has revealed significant deviation in surgical prophylactic prescribing from best practice guidelines, especially the duration of antibiotic use. Conclusion: Results of this audit are expected to show incorrect surgical prophylaxis as a major contributor to inappropriate antimicrobial prescribing. The findings will be disseminated throughout relevant hospital teams via information posters in surgical wards. Best practice guidelines will also be distributed to all relevant health care practitioners, with the intention of reducing overall antimicrobial consumption.

S257 References 1. Scottish Intercollegiate Guidelines Network,. ‘‘Antibiotic Prophylaxis In Surgery A National Clinical Guideline’’. ScottishIntercollegiate-Guidelines-Network. November 2014. 2. OLOL Hospital Drogheda,. Individual Hospital Antimicrobial Consumption Report 2015.

Serious Cellulitis ´ 1, Barry K2 O Meara A 1 West North West Intern training group; 2Mayo University Hospital, Castlebar, Co. Mayo

Introduction: A 48-year-old gentleman with a 3 day history of swelling and redness of his left leg, on a background of a BMI of 64. Case report: He reported the swelling and redness started 3 days previously, becoming increasingly painful and had developed pyrexia. There was no history of trauma. There was extensive swelling and erythema of his leg. On examination he was unwell. He was tachycardiac, pyrexial, and hypotensive. His inflammatory markers were raised; WCC 15, CRP 372. He was diagnosed with sepsis secondary to cellulitis and was commenced on IV antibiotics. Despite being commenced on antimicrobials, his inflammatory markers continued to rise and he continued to have pyrexias. He was commenced on IV Vancomycin. His inflammatory markers begin to fall. However his renal function, which was already impaired, began to climb, and he was diagnosed with Acute Renal Failure secondary to sepsis. All nephrotoxic drugs were stopped. He required two rounds of dialysis. Discussion: The above case shows how a relatively easily treated condition can lead to serious morbidity. This case showed that a holistic approach is needed when treating all patients. This gentleman is categorised as super morbidly obese as his BMI is greater than 60. His cellulitis was very difficult to treat as a result. He had multiple co morbidities: obstructive sleep apnea, hypertension and type two diabetes mellitus. His co morbidities are most likely as a direct result of obesity. In the acute illness it was critical to treat his sepsis and cellulitis, and it was equally important to plan for treating his obesity when he had recovered from his illness. He was counseled regarding his obesity and he was keen to lose weight. As a result was referred to bariatric services.

Pneumocystis jirovecii Pneumonia in a Non-HIV Immunocompromised Patient Ong G1, M Keane1 1 Department of Medical Oncology, Galway University Hospital, West Northwest Intern Training Network

Introduction: Pneumocystis jirovecii Pneumonia (PJP) is a wellrecognised opportunistic infection in HIV-seropositive individuals. However it has been increasingly described in HIV-negative patients1, largely due to drug-induced immunosuppression with longterm steroids, biologics, chemotherapy or transplantation. Case report: A 51-year-old woman with invasive ductal carcinoma of the breast presented with dyspnea and fever. Four months previously, she commenced dose-dense chemotherapy, receiving 3 days of

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Dexamethasone with each 14-day cycle. Inflammatory markers were elevated and a CXR showed bilateral lower-zone infiltrates. She was commenced on antibiotics. Over 24 h, the patient deteriorated. She became hypoxic and tachypnoeic with increasing oxygen requirements and persistent pyrexia with tachycardia. ABG confirmed Type-1 respiratory failure. CTPA was negative for PE, but demonstrated extensive bilateral ground-glass opacity in the upper lobes and consolidation in the lower lobes. Given her immunocompromised status and radiological findings, PJP was suspected and high-dose Co-trimoxazole and corticosteroid were commenced. Subsequently she required ICU admission for respiratory support. She underwent bronchoscopy, and bronchoalveolar lavage was positive for Pneumocystis jirovecii. The patient made a complete recovery. Discussion: This case highlights a potentially different clinical pattern of PJP in non-HIV individuals. These patients tend to present more acutely with significant hypoxemia, and it is associated with increased mortality when compared to HIV-positive individuals2. In making the diagnosis, physicians need to maintain a high clinical suspicion in at-risk individuals. Vital investigations include CXR and HRCT. In cancer patients with LRTI symptoms, hypoxia and bilateral interstitial infiltrates (seen as ground-glass opacities on CT), antiPneumocystis treatment with high-dose Co-trimoxazole should be started promptly before diagnostic investigations. PJP prophylaxis should be considered in patients with risk factors3 (e.g. long-term steroids and cancers especially lymphomas), hence knowledge of these risk factors is crucial. It should also be utilised in those with a personal history of PJP as recurrence may occur. References: 1. Fillatre P, Revest M, Belaz S, Robert-Gangneux F, Zahar JR, Roblot F, Tattevin P (2014) Incidence of pneumocystis jirovecii pneumonia among groups at risk in HIV-negative patients. Am J Med. 2014 Dec;127(12):1242.e11–7. doi:10.1016/j.amjmed.2014. 07.010. Epub 2014 Jul 21. 2. Bollee G, Sarfati C, Thiery G, Bergeron A, de Miranda S, Menotti J, de Castro N, Tazi A, Schlemmer B, Azoulay E (2007) Clinical picture of pneumocystis jiroveci pneumonia in cancer patients Chest. 2007 Oct;132(4):1305–10. 3. Stern A, Green H, Paul M, Vidal L, Leibovici L (2014) Prophylaxis for pneumocystis pneumonia (PCP) in non-HIV immunocompromised patients. Cochrane Database Syst Rev. 2014 Oct 1;10:CD005590. doi:10.1002/14651858.CD005590.pub3.

Iron Deficiency Anaemia and the Unseen Bowel Waldron J 1, Magzoub A1 Department of Gastroenterology, University of Limerick

1

Case report Introduction: Iron deficiency anaemia (IDA) can present due to a variety of conditions falling broadly under the headings 1) occult GI blood loss, 2) malabsorption, and 3) non-GI blood loss. Along with a detailed history and examination the work-up involves coeliac serology, and imaging of the bowel. This case presents a lady with repeated episodes of symptomatic IDA of unknown cause before eventual diagnosis of Crohn’s disease using novel method of small bowel capsule endoscopy (SBCE). Case presentation: Over a 2-year period this 49-year-old lady presented with IDA requiring hospitalisation on 3 occasions. The diagnosis of non-GI blood loss due to menorrhagia was made initially

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due to lack of conclusive evidence for bowel pathology from coeliac serology, an OGD, and colonoscopy. Her history had not indicated menorrhagia, however a hysteroscopy and D&C was recommended. It is after her second presentation that her faecal calprotectin is tested which is found to be raised and she then underwent a SBCE which showed multiple non-stenotic strictures with ulceration, one of which oozed blood. A diagnosis of Crohn’s disease was made and she has initially responded well to a course of steroids and biologics. Discussion: Our case is a lesson in how care should be taken in strict adherence to guidelines for investigation of IDA. Clinicians should be aware of the lab test faecal calprotectin and the availability of carrying out SBCE. A clinical suspicion of IBD without conclusive evidence after initial imaging with CT, OGD or colonoscopy should warrant consideration for both.

A Retrospective Database Review of Cholesterol Profiles in Irish Children Aged Under 16 Years in the Mid-West Region of Ireland King K, O Gorman C Dept of Paediatrics, University Hospital Limerick, University Hospital Limerick Background: Atherosclerosis is a disease that begins in childhood. Dyslipidemia is increasing in the paediatric population. Dyslipidemia may be primary (e.g. familial hypercholesterolemias), secondary (e.g. childhood obesity related) or idiopathic (polygenetic, multi-factorial or risk factor associated). The United States National Institutes of Health (NIH) National Heart, Lung and Blood Institue (NHBLI) Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescent released guidelines regarding childhood dyslipidemia in 2012 (NHBLI guidelines). The aim of this study was to assess the degree of dyslipidemia in a paediatric population in the MidWest region and to analyse the results based on the ranges for dyslipidemia outlined in the NHBLI guidelines. Methods: A retrospective biochemistry database review was performed to find all lipid profiles for children aged 0–16 years between January 2012 and June 2014. This database data did not include clinical details and reasons for blood tests. Results: 2490 lipid tests (1241 female, 1249 male) were performed on 1844 children. Mean age at time of the test was 9.47 ± 6.05 years (range 0.02–16.91 years). 1108 tests (44.5 %) were requested by hospital doctors, and 1382 (55.5 %) by general practitioners. Mean cholesterol results (mmol/L) for ages 0-16 years were: total 4.19 ± 1.02; LDL-c 2.49 ± 0.99; HDL-c 1.30 ± 0.34; non-HDL-c 2.95 ± 0.91; triglycerides 1.07 ± 0.99. Borderline/high results according to the NHBLI guidelines were: total cholesterol 748 (38 %); LDL-c 331 (27 %); HDL-c 444 (36 %); non-HDL-c 503 (40 %); triglycerides in the age group 0–9 years 449 (56 %); and triglycerides in the age group 10–16 years 340 (31 %). Conclusions: 14 % of total cholesterol results were elevated in the 0–16 years group. 36 % of triglyceride results in the 0–9 years population were elevated. 2490 lipid tests (1241 female, 1249 male) were performed on 1844 children. Mean age at time of the test was 9.47 ± 6.05 years (range 0.02–16.91 years). 1108 tests (44.5 %) were requested by hospital doctors, and 1382 (55.5 %) by general practitioners. Mean cholesterol results (mmol/L) for ages 0–16 years were: total 4.19 ± 1.02; LDL-c 2.49 ± 0.99; HDL-c 1.30 ± 0.34; non-HDL-c 2.95 ± 0.91; triglycerides 1.07 ± 0.99. Borderline/high results according to the NHBLI guidelines were: total cholesterol 748 (38 %); LDL-c 331 (27 %); HDL-c 444 (36 %);

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 non-HDL-c 503 (40 %); triglycerides in the age group 0–9 years 449 (56 %); and triglycerides in the age group 10–16 years 340 (31 %). Conclusions: 14 % of total cholesterol results were elevated in the 0–16 years group. 36 % of triglyceride results in the 0–9 years population were elevated..

The Iron Lady: a Curious Cause of Ataxia in a 69-Year Old Woman Doyle AE1, Bredin R2, Murphy S3 Mater Misericordiae Hospital, Dublin Introduction: A previously healthy 69-year old woman presented to clinic complaining of worsening unsteadiness for 3 years. She described herself as ‘wobbly and unsteady’. She had no other symptoms. Her neurological exam was positive for globally brisk reflexes, bilateral up-going planters and Romberg’s positive. Her gait was ataxic with poor coordination of both lower limbs. The rest of the exam and bloods were normal. Audiometry showed a mild highfrequency loss consistent with presbyacusis. A lumbar puncture showed excessive red blood cells in all 3 samples. MRI of brain and spine showed significant low signal within the cerebellum. This appearance is characteristic of Superficial Siderosis [SS] of the central nervous system. Management and outcome: Treatment of SS can be medical or surgical. Our patient was commenced on Deferriprone, an oral, lipophilic, iron chelator that crosses the blood–brain barrier. Deferriprone requires prolonged a treatment course and weekly bloods to monitor for agranulocytosis. MRI of the spine demonstrated a herniation of the dural sac as a possible source of bleeding. On this basis the patient has been referred for neurosurgical opinion regarding a definitive surgical resolution of her SS. Discussion: SS is a rare neurodegenerative condition caused by haemosiderin deposition along the leptomeninges. The cerebellum, particularly the folia and vermis, are often affected. Symptoms vary depending on the pattern of deposition. Typical symptoms are sensori-neural hearing loss, cerebellar and upper motor neuron signs, incontinence, dementia and sensory loss. The source of the haemosiderin is thought to be occult subarachnoid bleeds, though it not always possible to identify the source. Without treatment the condition is slowly progressive.

Improving the Design of Ward Storage for Core Clinical Task Equipment: The Storage and Organisation of Core Clinical Intern Gear (STOCCinG) Pilot Study Corry P1, O Sullivan F1, O Rahelly M1, O Riordan N2, Shire W2, O Connor M2, A Browne1, J Coulter1, J Waldron1, A Gabr2 1

Mid-Western Intern Training Network; 2University Hospital Limerick Background: Core clinical tasks (CCTs) such as cannulation, phlebotomy, catheterization, blood cultures and ABG sampling are often performed with delays. The MidWest Network interns have highlighted poor availability and incoherent layout of equipment across wards1 as major factors delaying these five CCTs. NHS figures estimate junior doctors spend an h/day looking for correct clinical

S259 equipment1. Such delays are hazardous, an opportunity cost, a source of poor multidisciplinary teamwork and frustration. We undertook a single-ward pilot study to assess the potential healthcare quality improvements of a clinically-led alteration to CCT equipment layout Design: Following an audit of CCT equipment stocking, a crossdiscipline (nurse managers, interns, care attendant) task group was established. The group designed a layout, placing all CCT equipment in a single column of transparent shelving, and clustered according to individual task. Interns were randomly selected and time taken to perform the following instruction was measured: prepare a tray for putting in a cannula and taking an FBC, U/E and Coag using only one stab, both pre (n = 8) and post (n = 8) layout reconfiguration. Results: Mean time for collecting all equipment as per the instruction was 496[334–604] s pre layout change, compared to 81 [42–131] s post layout change, with an average saving of 415 s. Conclusion: Layout of CCT equipment in a typical Irish training hospital was haphazard and inefficient. When a clinically-led storage design was implemented, approximately 7 min was saved per task i.e. 1 h gained for every nine procedures required. Such changes to clinical micro-systems are: relatively simple to design, cost-effectively implemented, better for patient access to doctors, a potential positive influence on healthcare worker stress, and should not be overlooked. We are expanding this project across the hospital group by issuing a standardized stocking protocol, and focusing on sustainability by continued collaboration References: 1. Roueche A, Hewitt J. Wading through treacle: quality improvement lessons from the frontline. BMJ Quality and Safety 2012;21:179–83

Transitional Cell Bladder Carcinoma Associated with Catheterisation: an Unusual Presentation Tomkins, M1, Lonergan, P2, O’ Malley, K3 1

UCD Dublin Mid Leinster Intern Network, Urology Specialist Registrar Mater Misericordiae University Hospital, Dublin; 2 Consultant Urological Surgeon Mater Misericordiae University Hospital, Dublin Abstract: This is a case of a 34 year old gentleman, smoker, who developed transitional cell carcinoma of bladder on a complex urological background of posterior urethral valves, self-intermittent catheterisation, hydronephrosis and chronic kidney disease. In June 2015 deterioration in kidney function with a suspected urinary tract infection warranted further investigation. Renal ultrasonography 1 year previous showed diffuse bladder wall thickening with bilateral hydronephrosis and hydroureter. Repeat renal ultrasonography on this presentation showed a focal bladder wall thickening that was not apparent before, as well as marked deterioration of hydronephrosis and hydroureter. The bladder wall lesion was adjacent to the right ureteral orifice, with the right kidney and ureter showing most marked dilatation. Rigid cystoscopy confirmed a right sided bladder wall lesion that was incompletely resected via transurethral resection of bladder tumour. A histological diagnosis of high grade transitional cell carcinoma was made. Computed tomography imaging confirmed an infiltrative mass on the bladder wall intimately related to the anterior abdominal wall and adjacent loops of small bowel. Further to this, there was shotty retroperitoneal lymphadenopathy however no distant spread. Following extensive discussion at multidisciplinary team meetings he underwent cystoprostatectomy and ileal conduit formation in August 2015 with lymph node dissection followed by

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S260 adjuvant chemotherapy. This case report will explore the risks of self intermittent catheterisation, including the occurrence of transitional cell carcinoma in patients who self-catheterise, where squamous cell carcinoma is more likely. Screening proposals for bladder carcinomas in patients who self catheterise will also be discussed.

Synchronous Emergency Presentation of Extensive Bladder Cancer and Associated Thromboembolic Disease in a 29 Year Old Male Patient McCambridge J, Davis NF, Mulvin D Department of Urology, St. Vincent’s University Hospital Background: Bladder cancer is exceedingly rare in patients below the third decade. We describe the case of a young male patient presenting with a large bladder tumour and associated extensive thromboembolic disease. Case description: A previously healthy 29 year old male fisherman presented to the Emergency Department with a 4 week history of painless frank haematuria, symptomatic anaemia (Hb: 6.2 g/dL) and dry gangrene on his right toes. He was a non-smoker and had no relevant past medical or surgical history. His family history was also unremarkable. Following standard emergency resuscitation and blood transfusion, he underwent a diagnostic cystoscopy which demonstrated a large bladder tumour occupying the entire surface area of the urinary bladder. A transurethral resection of the bladder tumour (TURBT) was subsequently performed which demonstrated high grade invasive papillary urothelial carcinoma (T1G3). Staging computed tomography (CT) indicated no nodal or distant metastatic disease. A further TURBT was necessary to complete the resection due to the extent of the tumour burden within the urinary bladder. A CT angiogram was also performed to investigate the aetiology of his gangrenous toes and this demonstrated complete occlusion of the right common femoral, superficial femoral and popliteal arteries with no proximal embolic source. An echocardiogram showed no cardiac source for the extensive thromboembolic disease. His right lower limb ischaemia was treated conservatively with therapeutic tinzaparin, aspirin, iloprost infusions and analgesia after unsuccessful embolectomy. A biopsy of the thrombus demonstrated no malignant cells and this associated phenomenon was attributed as a paraneoplastic process secondary to high volume bladder cancer. Conclusion: The association of extensive arterial thromboembolic disease in young patients presenting with bladder cancer has not been previously described. Herein, we emphasise the need for a detailed clinical examination and the importance of multidisciplinary input and thought processes for managing this rare association.

Metastatic Basal Cell Carcinoma and Upper Limb Amputation: A Case Report Fennessy AM1, Kane G1, Hurley H1, Dowdall J1 Department of Vascular Surgery, St Vincent’s University Hospital, Dublin 4 Basal cell carcinoma (BCC) is very common. Metastatic disease is reported in 0.0028 % to 0.5 % of cases; most commonly to the skin, bones, lungs and lymph nodes1. Prognosis is poor with 10 % five-year survival1.

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 A 64-year old right-handed man presented post-ligation of his right axillary artery. He was diagnosed with BCC of the right clavicle 9 years ago which recurred 4 years ago. This became locally invasive; eroding his brachial plexus. He underwent emergency ligation after a large volume haemorrhage caused by BCC invasion into the axillary artery. At the time of recurrence, he was found to have metastatic disease. He was diagnosed with locally invasive, lymph node positive disease and pulmonary metastases. He underwent further surgical resection; axillary clearance, radiotherapy and chemotherapy. Despite this, he became increasingly symptomatic and his disease progressed. He was in extreme pain on presentation to the Vascular Service. His arm was lymphoedematous, pale and demonstrated complete loss of function and sensation. Cutaneous ulceration was evident at the right scapula. The axillary artery was proximally ligated; CT angiography demonstrated collateralisation which resulted in suboptimal opacification of the mid-right brachial artery extending to the distal arteries. Multiple bilateral pulmonary nodules, mediastinal and subcarinal lymphadenopathy were evident. Once his pain was controlled, he underwent disarticulation of the right shoulder and amputation of the right arm with flap formation. Surgical management was necessary due to loss of function and the resultant adverse effects on his quality of life. The patient noted a significant improvement in quality of life post-amputation and he is currently undergoing rehabilitation. Upper limb amputation is an established treatment for bone and soft tissue sarcomas, and less commonly for locally-invasive breast cancer2. It is an established palliative measure for tumour-induced pain, lymphoedema, ulceration, and loss of function in metastatic disease2, as demonstrated in this case. References: 1. Soleymani D, Scheinfeld N, Vasil K, Bechtel MA. Metastatic Basal Cell Carcinoma presenting with unilateral upper extremity edema and lymphatic spread. J Am Acad Dermatol. 2008; 59(2): S1-S3. 2. Goodman MD, Mcintyre B, Shaughnessy EA, Lowry AM, Ahmed SA. Forequarter Amputation for Recurrent Breast Cancer: A Case Report and Review of the Literature. J Surg Oncology. 2005; 92:134–141.

Amyands Hernia: A Case Series Keenan M*, Hogan N, Ahmed I, Caldwell M, O Hanrahan T, Salah Ahmed A Department of Surgery, Sligo Regional Hospital, Sligo, Ireland Introduction: The Amyand’s hernia is a rare form of inguinal hernia first described by English surgeon Claudius Amyand in 1735. They occur in cases where an appendix (inflamed or non inflamed) is found in the hernial sac. They have an incidence of between 0.4 and 0.6 %. They are commonly mistaken for an incarcerated inguinal hernia and treated as a surgical emergency. Presentation: Over the past year Sligo University Hospital has seen three cases of the Amyand’s hernia. In one of the three cases reported, the Amyand’s hernia was discovered on the left side which is an extremely rare finding, given the normal anatomical location of the appendix. In the three cases reported from Sligo,, the patients were all males over the age of 75, who presented with irreducible inguinal swellings. One patient received an X-ray abdomen only, the Amyand’s hernia was discovered in theatre. The second patient received an Ultrasound Testes which detected a large inguinoscrotal

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 hernia containing bowel loops. The third and final case in the series received an X-Ray abdomen and a CT scan of the abdomen and pelvis. In this case the presence of the appendix in the inguinal hernia was detected by CT. All three of the cases in Sligo were repaired with a prosthetic mesh. In one case an appendicectomy was also performed. All three patients had an uncomplicated post op course and were discharged 2–3 days after repair. Discussion: There is much debate in the literature regarding the appropriate treatment of Amyand’s hernias. Some advocate a prophylactic appendicectomy, whereas others argue that this could predispose to septic complications and should only be carried out in cases of a coexisting appendicitis. Conclusion: This case series may increase awareness of this uncommon surgical presentation, particularly of a left sided Amyand’s hernia, and help surgeons prepare for management, should they encounter it.

Meigs’ Syndome Harbison M1, Daly T2 (Mater Misericordiae University Hospital) Meigs’ Syndrome is a rare condition characterised by pleural effusion and ascites in the presence of a benign ovarian tumour. These manifestations typically resolve upon excision of the tumour. We describe the case of a 79 year old Caucasian woman, who presented to the emergency department complaining of increasing abdominal distension, decreased appetite and weight loss over a period of 5 weeks. Her background history was notable for gastritis, diverticular disease and subtotal hysterectomy for uterine prolapse 10 years previously. Clinical examination revealed evidence of bilateral pleural effusions and ascites. The pleural effusions were confirmed on chest X-Ray. Further evaluation with computerised tomography of the thorax, abdomen and pelvis noted omental thickening. Serum ovarian tumour markers were normal. A diagnostic paracentesis and pleural tap were performed and fluid sent for cytological examination. This confirmed an exudative pleural effusion however cytology was negative. For symptomatic relief, both abdominal and pleural drains were inserted with good result. As there was evidence of omental thickening and positive cytology had not been retrieved, it was decided to progress to exploratory laparoscopy. This revealed bilateral papillary lesions and a right cystic ovarian lesion. Both ovaries were removed during surgery. Histological analysis of the tissue showed no evidence of malignancy. The patient recovered well postoperatively. Her pleural drain was removed day three post operatively without re-accumulation of pleural fluid. She was discharged within 5 days of surgery. Her symptoms have not returned. This case demonstrates that Meigs’ syndrome is somewhat a diagnosis of exclusion once screening for malignancy is negative. Following resection of a benign cyst, the effusions and ascites disappeared which is again supportive of Meigs’ syndrome. This case is notable for the fact that the underlying pathology is a cystic ovarian lesion which is rare but has been described.

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Should We Screen All Patients with Neck of Femur Fragility Fractures for Coeliac Disease? Nolan B.1, Tomkins M.1, Kennedy M T2 1 Dublin Mid-Leinster Intern Training Network; 2Department of Orthopaedics, Midlands Regional Hospital at Tullamore

Background: The prevalence of undiagnosed coeliac disease has increased in recent years1. The association of coeliac disease and osteoporosis in older patients is a much debated topic. It has been reported that the disease was found in 3.4 % of adults with low bone mass2 vs approximately 1 % of the general population3. It has also been suggested that low bone mass may be the only indication of coeliac disease in a large amount of patients4. Fragility fractures are a major complication of osteoporosis. Studies have shown that patients with coeliac disease may be at increased long term risk of hip fractures5. All patients attending the Emergency Department at Midlands Regional Hospital Tullamore with fragility neck of femur fracture are screened for coeliac disease. There is conflicting evidence relating to this practice6,1. This study aimed to investigate the appropriateness of this laboratory test in this patient cohort. Methods: 42 patients presenting to the Emergency Department with neck of femur fragility fracture over a 16 week period were chosen at random. None had a previous diagnosis of coeliac disease. There were no other exclusion criteria applied. They were screened for coeliac disease by testing serum IgA Tissue Transglutaminase levels (TTG IgA). Results: The mean age of the cohort was 79.9 years. 69 % (n = 29) of patients were female and 31 % (n = 13) of patients were male. Of the 42 patients screened, no patient had elevated levels of IgA TTG detected. Conclusion: The lack of previously undiagnosed coeliac disease demonstrated in this study, questions the appropriateness of the practice of IgA tTG testing in this patient population. However, the small sample size used in this study acts as a limitation. The results of this preliminary investigation provide a platform for subsequent studies to be conducted in this area. 1. Rubio–Tapia, Alberto et al. ‘‘ Increased Prevalence and Mortality in Undiagnosed Celiac Disease’’ Gastroenterology, Volume 137, Issue 1, 88–93 2. Murray, J.A. 2005, ‘‘Celiac disease in patients with an affected member, type 1 diabetes, iron-deficiency, or osteoporosis?’’, Gastroenterology, vol. 128, no. 4, pp. S52-S56. 3. Gujral, Naiyana, Hugh J Freeman, and Alan BR Thomson. ‘‘Celiac Disease: Prevalence, Diagnosis, Pathogenesis and Treatment.’’ World Journal of Gastroenterology: WJG 18.42 (2012): 6036–6059. PMC. Web. 3 Jan. 2016. 4. Fisher AA, Davis MW, Budge MM. Should we screen adults with osteoporotic fractures for coeliac disease? Gut. 2004;53(1):154–155. 5. Ludvigsson, J.F., Michaelsson, K., Ekbom, A., Montgomery, ¨ rebro universitet and Ha¨lsoakademin 2007, ‘‘Coeliac S.M., O disease and the risk of fractures—A general population-based cohort study’’, Alimentary Pharmacology and Therapeutics, vol. 25, no. 3, pp. 273–285. 6. Hjelle, A.M., Apalset, E., Mielnik, P., Bollerslev, J., Lundin, K.E.A. & Tell, G.S. 2014, ‘‘Celiac disease and risk of fracture in adults—a review’’, Osteoporosis International, vol. 25, no. 6, pp. 1667–1676.

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61 y/o Gentleman with Hepatopulmonary Syndrome on a Background of Alpha-1 Anti-Trypsin Deficiency Carron JM, O Neill S Beaumont Hospital Introduction: Alpha-1 Anti-trypsin (A1AT) deficiency is a codominant genetic disorder resulting in defective production of A1AT in affected individuals. While the liver and lung are two of the most commonly affected sites, recent research has illustrated that the complications associated with this condition are both multi-faceted and variable. Case presentation: WG is a 61 y/o gentleman with a background history of Alpha-1 anti-trypsin deficiency, ZZ phenotype, with decompensated liver cirrhosis secondary to same. He was admitted through the Alpha-1 Anti-Trypsin clinic following a 2/52 hx of progressive dyspnoea On review, Mr. WG’s dyspnoea was more pronounced in the upright position (platypnoea) and relieved while recumbent. He was demonstrating orthodeoxia and arterial blood gas showed severe hypoxia. High Resolution CT demonstrated a large, uncomplicated right sided pleural effusion, deemed to be an hepato-hydrothorax. Of note the patient underwent banding of oesophageal varices in July 2015 and abdominal paracentesis 2/52 prior to admission drained a 23 L transudate. Management and outcome: Due to his elevated INR, a complication of his cirrhosis, the patient required infusions of fresh frozen plasma prior to intervention to minimise bleeding risk. A diagnostic pleurodesis demonstrated a non-infective transudate, and subsequent drain insertion resulted in complete resolution of the effusion. A total of 7.65 L was drained. A contrast echocardiogram/bubble study, the gold standard in diagnostics, was then performed which confirmed the presence of hepatopulmonary syndrome. This diagnosis however, is an absolute contraindication to a TIPS procedure. Following review by gastroenterology and exclusion of other possible causes of his cirrhosis, the patient was referred to SVUH for transplant workup. Discussion: This case highlights the wide-ranging and extensive complications associated with one of the most under diagnosed conditions affecting the Irish population. It furthermore illustrates the importance of accurate interpretation of scans/studies as their results can impact hugely on the possible management of these patients going forward.

Sarcoidosis Presenting as Pulmonary Embolism: Case Report and Literature Review Hussain M1, Faisal M2, Siddiqi FS2, Shujaat A3 1 Royal College of Surgeons, Ireland; 2University of Florida at Jacksonville, USA; 3University at Buffalo, the State University of New York, USA

Introduction: This is case of a patient who presented with pulmonary embolism (PE) and was found to have sarcoidosis. Literature was reviewed to determine the typical presentation of sarcoidosis and its association with PE. Diseases characterized by chronic inflammation may predispose to venous thromboembolism (VTE) [1]. Case description: A 36-year-old African American gentleman presented to the ED with a 1 week history of right lower chest pain. He

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 reported a 2 month history of episodic fevers and fatigue and was otherwise asymptomatic. No risk factors for VTE were identified or exposure to tuberculosis or HIV. He had a one pack-year history of smoking. There was no family history of VTE or sarcoidosis. Physical examination was unremarkable. Labs revealed normocytic anemia but were otherwise unremarkable. Chest x-ray showed bilateral hilar lymphadenopathy. CT pulmonary angiography revealed sub-segmental pulmonary emboli in both lower lobes. Endobronchial ultrasound guided transbronchial needle aspiration of lymph nodes revealed non-caseating granulomas. Venous ultrasonography did not show deep vein thrombosis (DVT) and he did not attend for thrombophilia work up. Discussion: Neither DVT nor PE is a known presentation of sarcoidosis. There are four case reports of sarcoidosis associated with venous thrombosis [2–5]. Beside our case, there have only been 2 case reports of sarcoidosis presenting as PE [5, 6]. A meta-analysis to evaluate the risk of VTE among patients with sarcoidosis found that the risk ratio of VTE in patients with sarcoidosis was 1.42 (95 % CI, 1.12–1.79) [7]. Ina et al. found antiphospholipid antibodies in 38 % of 55 patients with sarcoidosis [8]. VTE and inflammation are closely associated; inflammation seems to drive thromboembolic events [9]. Abnormalities of coagulation and fibrinolysis have been described in the lungs [10] and blood [11] in patients with sarcoidosis. Nevertheless, the explanation for an association between sarcoidosis and PE remains speculative, and needs to be studied further. References: 1. Nicoletta Riva; Marco P. Donadini; Walter Ageno. Epidemiology and pathophysiology of venous thromboembolism: similarities with atherothrombosis and the role of inflammation. Thromb Haemost 2015; 113: 1176–1183 2. Rowland Payne CM, McGibbon DH. Sarcoidosis presenting as widespread thrombophlebitis. Clin Exp Dermatol 1985; 10:592–594 3. McLaughlin AM, McNicholas WT. Sarcoidosis presenting as upper extremity venous thrombosis. Thorax 2003; 58: 552 4. Vahid B, Wildemore B, Marik P. Multiple venous thromboses in a young man with sarcoidosis: is there a relation between sarcoidosis and venous thrombosis? South Med J 2006; 99(9): 998- 999 5. Rebeiz TJ1, Mahfouz R, Taher A, Charafeddine Kh, Kanj N. Unusual presentation of a sarcoid patient: multiple arterial and venous thrombosis with chest lymphadenopathy. J Thromb Thrombolysis 2009; 28(2):245–247 6. Birkenbach C, Schroder AS, Sperhake JP. Sudden death due to pulmonary embolism in a patient with cardiac sarcoidosis. Forensic Sci Med Pathol 2012; 8(4): 466–469 7. Ungprasert P, Srivali N, Wijarnpreecha K, Thongprayoon C.Sarcoidosis and risk of venous thromboembolism: a systematic review and meta-analysis. Sarcoidosis Vasc Diffuse Lung Dis 2015; 32(3):182–187 8. Ina Y, Takada K, Yamamoto M, Sato T, Ito S, Sato S. Antiphospholipid antibodies. A prognostic factor in sarcoidosis? Chest 1994;105(4):1179–1183 9. Sanjeevi CB. Autoimmune diseases and risk of pulmonary embolism. Lancet 2012; 379:200–201 10. Hasday JD, Bachwich PR, Lynch JP III, Sitrin RG. Procoagulant and plasminogen activator activities of bronchoalveolar fluid in patients with pulmonary sarcoidosis. Exp Lung Res 1988; 14(2): 261–278 11. Shorr AF, Hnatiuk OW. Circulating D Dimer in patients with sarcoidosis. Chest 2000; 117(4): 1012- 1016

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A Common Femoral Artery Pseudoaneurysm on a Background of Intravenous Drug Abuse: Complications and a Multidisciplinary Team Approach Mc Loughlin M1, Moloney T

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University Hospital Limerick The post-operative course is occasionally problematic and intravenous drug abuse causes new challenges to this process. This is a case of a 40-year-old male Mr. S. who presented to University Hospital Limerick with fever, vomiting and right groin pain. Mr. S. was found to have a right common femoral artery pseudoaneurysm on ultrasound scan, caused by injection of heroin into the right side of the groin. A methadone drug substitution program was initiated. He was also found to have elevated liver enzymes and tested positive for Hepatitis C. Blood cultures contained Methicillin Sensitive Staphylococcus Aureus and he required intravenous flucloxacillin. An ultrasound guided catheter was inserted into the right subclavian vein due to difficult venous access. After 5 days of intravenous antibiotics, the patient was brought to theatre, the pseudoaneurysm proved difficult to remove and the common femoral artery was ligated. Post-operative pain was challenging to control. Four days post-operatively Mr. S. complained of shortness of breath and chest tightness. Vital signs were normal. However, a CT Pulmonary Angiogram revealed a thrombus in the right lower lobe subsegmental pulmonary artery and anticoagulation was initiated. The ankle-brachial pressure index on the right lower limb remained stable at 0.5. Ten days post-operatively, the wound was swollen and erythematous. CT of the lower limb showed a large collection, which was positive for Vancomycin Resistant Enterococcus. Throughout the hospital stay the complications and treatment plans were explained to the patient. His General Practitioner and Addiction Counsellors were consulted. The consequences of further drug abuse were fervently illuminated. The discharge plan remains a work in progress as Mr. S. is of no fixed abode and is now on multiple medications, including opioid analgesics and an anticoagulant. Intravenous drug abuse is rising in incidence and causes a significant morbidity and mortality worldwide. The surgical, medical, social, financial, and psychological effects cannot be underestimated. This case is an example of the multidisciplinary team approach that is required for cases such as this.

Compliance with Vitamin D Supplementation in Infants Foley R, Diskin C, Curtis E AMNCH, Tallaght, Dublin 24 A significant proportion of children in Ireland are Vitamin D deficient and are therefore at greater risk of developing rickets, osteomalacia and osteoporosis. Vitamin D deficiency has also been linked to other chronic diseases. It is a particular problem for children of non-european ethnic backgrounds. An infant’s diet does not provide enough Vitamin D (particularly when breastfed) and their skin is too sensitive to provide enough Vitamin D via sunlight. HSE guidelines recommend that five micrograms of Vitamin D be supplemented daily for the first year of life[1]. Compliance is poor among parents and it gets worse over the year[2]. We propose that

S263 parents’ interaction with hospital staff may be an opportunity to remind them of the guideline and encourage them to continue or restart supplementation. In order to investigate this we first need to know if we are asking parents about Vitamin D supplementation. On two occasions over a 2 week period we audited all children under the age of one on the paediatric wards in the NCH and checked if Vitamin D supplementation was documented. This included a total of 20 under ones (15 boys and 5 girls). Vitamin D was not documented in any of the 20 cases. Following this, we emailed all medical paediatric NCHDs encouraging them to ask parents about Vitamin D supplementation and to document compliance. We re-audited the charts 1, 2 and 3 weeks later in the same manner as described earlier. After our intervention we found that 22 out of 35 admission notes for under ones documented Vitamin D status. Of these, 11 (50 %) were compliant and 11 (50 %) were noncompliant with the recommended Vitamin D supplementation. We conclude from these results that interaction with Hospital staff may indeed be an opportunity for positive health promotion with regard to Vitamin D supplementation. 1. Health Service Executive. Policy on vitamin d supplementation for infants in Ireland, 2010. 2. McSwiney E, Moran P, Garvey A, Quet J, Kelly T, Watson M, Kiely M, Hourihane J. Compliance with the HSE policy on vitamin D supplementation for infants. Irish medical journal. 2013 Mar;106(3):93.

Optimizing Perioperative Investigations for Elective Surgical Patients in AMNCH O Sullivan J, Kumar L, Fitzpatrick G Adelaide and Meath incorporating the National Childrens Hospital Introduction: Local AMNCH guidelines in accordance with the Association of Anaesthetists of Great Britain and Ireland require a preoperative full blood count, urea, electrolytes, creatinine and coagulation screen for procedures of surgical severity C3. However, an interval period within which normal blood results are deemed relevant for the day of surgery is unspecified. Pre-surgical blood tests range from days to several months prior to elective surgery. Due to this uncertainty, tests are often repeated on the day of surgery despite recent normal results. This prolongs patient processing time and increases hospital costs. Aim: To assess the plausibility of eliminating the need for repeat preoperative bloods on the day of surgery if normal blood results were obtained within 3 months prior to surgery, thereby minimizing patient processing time and hospital expenditure. Methods: Consecutive elective orthopaedic patients admitted to AMNCH between October and December 2015 were reviewed. All normal blood results within 3 months of surgery were compared to those taken on the day of surgery and assessed for change with respect to patient demographic and type of surgery. We also calculated the cost of repeating normal blood results. Results: Of 137 elective orthopaedic patients, 56.93 % had a FBC, U&E and Coagulation screen within 3 months of surgery. 75 % of patients with normal blood results had repeat blood tests on the day of surgery. 91.67 % of these results remained normal. Subgroup analysis revealed 95.59, 95.83 and 100 % of FBC, U&E and Coagulation Screens, respectively remained normal. The total cost for repeat normal blood tests in this period was €2079.42.

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S264 Conclusion: Repeat pre-operative blood tests in the setting of previously normal results within 3 months of surgery may be unnecessary, provided patients’ clinical conditions remain unchanged. We propose a clarification of current guidelines to reduce unnecessary pre-operative blood tests.

Post Brain Injury Hyponatremia Gibbons C, Kerins M University Hospital, Gaway West Northwest Intern Training Network Introduction: The following is a case report about a young gentleman, Mr S, who presented with an unwitnessed fall on a background of alcohol abuse who went on to develop hyponatremia. Description: Mr S was a 36yo gentleman who was brought in by ambulance with an unwitnessed fall; GCS on admission was 8/15. There was no evidence of seizure activity and he was maintaining his own airway. Initial CT Brain showed multiple intraparenchymal frontal and subarachnoid haemorrhages but no midline shift. A repeat CT brain showed increasing intracranial haemorrhage and he was transferred to Beaumont for ICP monitoring. On transfer back to Galway, he was diagnosed with delirium secondary to traumatic brain injury (TBI). His sodium fell to 121 mmol/L, with no change in his GCS. Endocrine were consulted and gave a provisional diagnosis of SIADH secondary to TBI. His sodium fell further to 118 mmol/L and absolute fluid restriction and 2 hourly sodium checks was recommended. He was transferred to HDU where his sodium fell further to 114 mmol/L and he was started on hypertonic saline 3 %.He was fluid restricted to 500 ml/24 h for 6 days and was then transferred back to the ward. The remainder of his inpatient course involved episodes of confusion and agitation and he was managed by multidisciplinary team members. Mr S was discharged 7 weeks later and was linked in with local services with a plan to attend the NRH. Discussion/conclusion: Neuroendocrine disorders following traumatic brain injuries can be difficult to diagnose initially as many of the early symptoms can be masked by the patient’s altered cognitive function. However SIADH following a TBI is not a rare complication, with a rate of 32 % (1). This case aims to highlight the importance of early recognition and treatment of post TBI neuroendocrine conditions to improve rehabilitation and patient outcomes. References: 1. Hyponatremia in traumatic brain injury patients: Syndrome of Inappropriate Antidiuretic Hormone (SIADH) versus Cerebral Salt Wasting Syndrome (CSWS). 2016. Hyponatremia in traumatic brain injury patients: Syndrome of Inappropriate Antidiuretic Hormone (SIADH) versus Cerebral Salt Wasting Syndrome (CSWS). [ONLINE] Available at: http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3571543/. [Accessed 05 January 2016].

Parental Knowledge on HIV Transmission and Attitudes Towards Disclosure

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Introduction: While there have been great advances in the treatment of HIV, resulting in improved outcomes and preventing progression to Acquired Immunodeficiency Syndrome (AIDS), those with HIV encounter challenges regarding disclosure, and societal attitudes towards HIV (Mahajan AP 2008). This study was designed to evaluate knowledge of parents on the transmission risks of HIV and their attitudes towards disclosure of one’s HIV status in a childcare setting. Methods: A cross-sectional study was conducted in University Hospital Galway paediatric outpatient department in May 2014. A self-administered, paper-based, anonymous questionnaire was distributed to all parents of children attending a paediatric outpatient clinic. Results: There were 80 participants in the study; 4 % were male and 80.6 % were female, with a mean age of 36.3 years. 92.5 % felt that the parent of a child with HIV should disclose the diagnosis to the school. 56.6 % of respondents believed that disclosure of HIV status to a child would have a negative impact. All parents overestimated the risk of transmission of HIV in a childcare setting. Discussion/conclusion: Parents are not obliged to disclose their child’s HIV status to a child care centre (Committee on Infectious Diseases 2006). It has been shown that stigma related to disclosure of HIV positive status and the associated stigma which followed was negatively correlated with adherence to antiretroviral therapy (Li, Murray et al. 2014). For those who wish to disclose, most HIV associations recommend disclosure to two staff members only: the principal and the class teacher (Conway M 2005). Our sample group favoured a more open approach with 21.6 % feeling that all parents in the school should be informed. Our assessment of parental knowledge of HIV transmission demonstrated that parents over-estimate the risk of transmission. Our study highlights the on-going education needed by the general population on the subject of HIV. References: 1. Committee on Infectious Diseases, A. A. o. P. (2006). Red Book 2006: Report of the Committee on Infectious Diseases. B. C. Pickering LK, Long SS, McMillan JA. Elk Grove Village, Illinois, American Academy of Paediatrics: 130–144. 2. Conway M (2005). HIV in Schools: Good practice guide to supporting children infected or affected by HIV. Wakley Street, London, The Children’s HIV Association: 21–25. 3. Li, M. J., et al. (2014). ‘‘Stigma, social support, and treatment adherence among HIV-positive patients in Chiang Mai, Thailand ‘‘ AIDS education and prevention: official publication of the International Society for AIDS Education 26(5): 471–483. 4. Mahajan AP, S. J., Patel VA, Remien RH, Ortiz D, Szekeres G, Coates TJ (2008). ‘‘Stigma in the HIV/AIDS epidemic: A review of the literature and recommendations for the way forward.’’ AIDS education and prevention: official publication of the International Society for AIDS Education 22(Suppl 2): 67–69.

An Unusual Presentation of Non-Hodgkin Lymphoma G Ong1, M Keane1 1 Department of Meical Oncology, Galway University Hospital, West Northwest Intern Training Network

Gibbons C1, Lyons C, Moylett E National University of Ireland, Galway West Northwest Intern Training Network

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Introduction: Non-Hodgkin lymphoma (NHL) often presents as painless lymphadenopathy, but its clinical manifestations vary depending on the site and histologic subtype. Diffuse large B-cell lymphoma (DLBCL) is the commonest and most aggressive subtype1.

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Case report: An 84-year-old woman presented with a 3-week history of dyspnea, malaise and unintentional weight loss. She did not have other B symptoms (fever and night sweats). On examination, she was cachectic and in respiratory distress. She had a 1-year history of an irregular right breast mass measuring 14 cm x 12 cm, which she had not brought to medical attention. Bilateral non-tender axillary lymphadenopathy was noted. Blood tests revealed raised LDH and hypercalcaemia. ABG showed type-1 respiratory failure. CXR demonstrated bilateral pleural effusions. CTPA was negative for pulmonary embolism, but showed the large mass invading her ribs and sternum, with pericardial and pleural involvement. Following symptomatic thoracentesis, the breast surgery service was consulted. Core biopsy demonstrated DLBCL with a minor component of follicular lymphoma. She was commenced on immuno-chemotherapy using R-mini-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, Prednisolone). Currently, she is showing evidence of clinical response. Discussion: The key differential of a large breast mass is primary breast cancer. This case highlights that tissue biopsy is essential to confirm the diagnosis. This unusual first presentation of NHL with a rapidly enlarging mass causing respiratory compromise indicates aggressive disease. The patient’s disease had undergone histologic transformation from indolent follicular lymphoma to aggressive DLBCL. Rituximab, a monoclonal anti-CD20 antibody has revolutionised treatment of aggressive NHL2 and is core to this patient’s treatment. With continuously emerging targeted therapies, it is challenging for the field of oncology to integrate new compounds with traditional approaches. For physicians, it is imperative to be aware of their adverse effects especially immunosuppression3. Long-term survivors should be monitored for late complications of intensive therapy, including cardiovascular disease, secondary malignancies, and cognitive sequelae4,5. References: 1. Jonathan W Friedberg (2008) Diffuse large B-cell lymphoma. Hematol Oncol Clin North Am. 2008 Oct; 22(5): 941–ix 2. Bruce D Cheson, John P Leonard (2008) Monoclonal antibody therapy for B-cell Non-Hodgkin’s lymphoma. N Engl J Med 2008; 359:613–626 3. David G. Maloney (2012) Anti-CD20 antibody therapy for B-cell lymphomas. N Engl J Med 2012; 366:2008–2016 4. Moser EC, Noordijk EM, van Leeuwen FE, le Cessie S, Baars JW, Thomas J, Carde P, Meerwaldt JH, van Glabbeke M, KluinNelemans HC (2006) Long-term risk of cardiovascular disease after treatment for aggressive non-Hodgkin lymphoma. Blood. 2006 Apr 1;107(7):2912–9. Epub 2005 Dec 8. 5. Travis LB, Curtis RE, Glimelius B, Holowaty E, Van Leeuwen FE, Lynch CF, Adami J, Gospodarowicz M, Wacholder S, Inskip P, et al. (1993) Second cancers among long-term survivors of non-Hodgkin’s lymphoma.

Infection: the Biggest Enemy of Vascular Surgery Wynne M, Shaikh FM, Walsh SR Department of Vascular Surgery, National University of Ireland, Galway, Ireland Intern Network: West Northwest Intern Training Network Introduction: Infected aortic aneurysm is considered to be one of the most challenging problems faced by vascular surgeons(1). We

S265 describe an unusual presentation of an infected infra-renal abdominal aortic aneurysm (AAA) treated successfully with in situ prosthetic graft. Description: A 58-year-old man presented to the emergency department with bleeding per rectum for 6 months, sudden onset of dull abdominal pain and lower back pain for 5 days. His past medical history was unremarkable. On examination, he was ill but alert, tachycardic, hypertensive and febrile. His abdomen was mildly tender in the left iliac fossa with no mass, rebound or guarding. Bowel sounds were present. Initial investigations showed low haemoglobin with raised inflammatory markers and a positive faecal occult blood test. Computed tomography of the abdomen revealed a four-centimetre AAA with para-aortic stranding, suggesting an inflammatory process, associated with significant sigmoid diverticular disease. After initial resuscitation, emergency laparotomy showed a sigmoid diverticular phlegmon, adherent to the aortic bifurcation and loops of small bowel, and a AAA with necrosis of the aortic wall. A Hartmann’s procedure with extensive debridement of necrotic bowel and aortic wall was performed along with the repair of AAA with rifampicin-impregnated synthetic graft. Patient was continued on 8 weeks of intravenous antibiotics and discharged home on lifelong antibiotics. At 6 months post-operative follow-up, he remains well. Discussion/conclusion: This case highlights the importance of timely surgical intervention. Urgent repair is needed in the setting of an infected AAA(2), and should be considered in differentials in patients with the classic triad of fever, back pain and a pulsatile mass(1). Aneurysm resection, retro-peritoneal debridement and aortic reconstruction, along with systemic antibiotics are the mainstay of treatment in the management of infected aortic aneurysms(2). Moreover, in situ graft replacement with prolonged antibiotic cover provides an excellent outcome in selected group of patients with primary infected aortic aneurysms(3). References: 1. Oderich G, Panneton J, Bower T, Cherry K, Rowland C, Noel A et al. Infected aortic aneurysms: Aggressive presentation, complicated early outcome, but durable results. Journal of Vascular Surgery. 2001;34(5):900–908. 2. Mu¨ller B, Wegener O, Grabitz K, Pillny M, Thomas L, Sandmann W. Mycotic aneurysms of the thoracic and abdominal aorta an d iliac arteries: Experience with anatomic and extraanatomic repair in 33 cases. Journal ofVascular Surgery. 2001;33(1):106–113. 3. Kan C, Lee H, Yang Y. Outcome after endovascular stent graft treatment for mycotic aortic aneurysm: A systematic review. Journal of Vascular Surgery. 2007;46(5):906–912.

33yo Nigerian Male Diagnosed with Hypertrophic Cardiomyopathy (HCM) Receives Appropriate Shock 3 weeks Post ICD Placement Lynch JM1, Thornton JM2, Crinion D1, Gumbrielle1 1 Beaumont Hospital, Dublin, Connolly Hospital, Dublin; 2James Connolly Hospital, Blanchardstown, Dublin

Introduction: Hypertrophic cardiomyopathy is a potentially deadly disease associated with early heart failure and sudden death. The following case demonstrates the potential for mislabeling a patient as ‘‘not-cardiac’’ in the setting of serial negative troponins and a normal angiogram.

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S266 Case: In Oct 2013 EU a 31-year-old male presented to A&E with exertional chest pain. ECG changes included ST depression and arrowhead T wave inversion (TWI), troponins were negative and angiogram was normal. Echocardiography showed LV hypertrophy with EF [55 %. CMRI confirmed a diagnosis of HCM, also showing fibrotic scarring of the myocardium. This scarring put the patient at increased risk of arrhythmias and an implantable cardiac defibrillator (ICD) was indicated. The placement was uncomplicated and the patient was discharged the same day in July 2015. 3 weeks later the patient received an appropriate shock during sleep. Conclusion: This case highlights the need for careful interpretation of ECGs, not just the presence or absence of TWI but also the morphology. This case also demonstrates the correct management of HCM according to the most recent European Society of Cardiology’s guidelines.

Novel Glansplasty Design in a 25-year-old Male Born with Bladder Exstrophy Lynch JM1, O Meara SK2, Berli J3, Zelken J3, Redett R3 1. Beaumont Hospital, Dublin, Ireland 2. Mater Hospital, Dublin, Ireland 3. Johns Hopkins Hospital, Baltimore, Maryland, USA Presentation includes an animation created by the 1st Author demonstrating creation of flap Introduction: Bladder exstrophy is the most common disorder within the exstrophy- epispadias complex spectrum. Features at birth include an open abdominal wall, open everted bladder, pubic diastasis and genital deformity. This deformity of the genitalia typically involves intrinsically short corpora and a wide intercorporeal angle, the combination of which results in a severely shortened phallus. In such cases standard methods of penile lengthening cannot give the patient a phallus suitable for sexual intercourse. Aims: Phalloplasty aims to give the patient a neophallus suitable for urination, sexual intercourse and orgasm. In this case a classic radial forearm free flap phalloplasty, a method first described in 1982 has been modified in its pattern of folding to give a more realistic glans. The radial forearm is favoured for its subtle pliable skin and for its superior sensation when compared to alternatives flaps, while other surgeons would argue that it comes at too high a price in terms of donor site morbidity. Materials and methods: The Radial Forearm Flap was raised with the use of a pneumatic cuff. The corona of the neoglans was created by undermining a strip of tissue and underpinning it. The defect was filled with a full thickness skin graft. The flap was de-epithelialized, trimmed and rolled in accordance with the new design. The flap was divided and the arteries, veins and nerves attached to the inguinal region using microsurgical techniques. Conclusions: This new method of folding the glans offers a good aesthetic result in radial forearm free flap phalloplasty.

Spontaneous Perforation of a Gangrenous Gallbladder Presenting as Dyspnoea in a 75 year old Man with Multiple Sclerosis Cotter G, Quill D West Northwest Intern Training Network, Galway University Hospital, Department of General and Endocrine Surgery

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Introduction: Gallbladder perforation is a rare and potentially fatal condition. This case report offers the opportunity to highlight how a high index of suspicion is necessary in elderly patients and patients with neurologic conditions in which infections can be clinically silent or difficult to diagnose. Description/case report: Mr Y., diagnosed with MS in 1992, presented to the emergency department with a 1 week history of a dry cough, mild breathlessness, and loss of appetite. Respiratory examination showed right sided decreased air entry only. His abdomen was soft and non-tender and all other systems were unremarkable. A chest X-ray revealed right basal consolidation. He was admitted with an initial diagnosis of sepsis likely secondary to lower respiratory tract infection. His clinical condition deteriorated over the next 24 h. A CT thorax/abdomen was performed showing a right basal pleural effusion, bibasal atelectasis and a large perihepatic collection. On repeat examination tenderness in the right upper quadrant was identified. Murphy’s sign was negative. An abdominal drain was urgently inserted and a subsequent diagnostic laparoscopy was converted to open cholecystectomy when gangrenous perforation of the gallbladder was confirmed intra-operatively. Discussion/conclusion: This topic is remarkably interesting from both diagnostic and treatment points of view. Gangrenous gallbladder and perforation is usually due to infection or torsion of the gallbladder and commonly presents with right upper quadrant pain. However, in this case, it is possible that the degree of intra-abdominal peritoneal irritation was masked by the patient’s demyelinating disorder1, leading to a more subtle presentation than what may be expected. On the other hand, previous cases have described denervation due to tissue necrosis as the culprit2. It is clear that early diagnosis and immediate surgical intervention are crucial. To our knowledge, this is the first report of gangrenous perforated cholecystitis in a patient with MS. References: 1. Scolding N, The Differential Diagnosis of Multiple Sclerosis, J Neurol Neurosurg Psychiatry 2001;71(suppl II):ii9–ii15 2. Khan M. et al., Male gender and sonographic gall bladder wall thickness: important predictable factors for empyema and gangrene in acute cholecystitis, PubMed.com.

Patients with Chronic Liver Disease (CLD) O’ Brien J, Crosbie O Department of Gastroenterology, Cork University Hospital Introduction: Patients with Chronic Liver Disease (CLD) often present late and may have already developed cirrhosis. The aetiology of Chronic Liver Disease (CLD) is changing and patients are developing CLD at a younger age. Late presentation of CLD is associated with an increased risk of cirrhosis, hepatocellular carcinoma and increased mortality. Aims: To identify the causes of CLD in patients referred to a Tertiary Referral Hepatology Centre over a 12-month period and to relate this to demographic profile, clinical presentation, liver function tests, and the presence of cirrhosis. Methods: Retrospective chart review of patients referred to the Hepatology Service Cork University Hospital and subsequently diagnosed with CLD during 2013 (n = 122). Data included: sociodemographic details, identified cause of CLD, BMI, clinical presentation, cirrhosis and laboratory data. Data was coded and entered into Excel and transported to SPSS for analysis.

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Results: Causes of CLD: Alcohol Liver Disease (ALD): 27.5 %, Non-Alcoholic Fatty Liver Disease (NAFLD/NASH): 38.5 %, Haemochromatosis: 23 %, Primary Biliary Cirrhosis: 4 %, Hepatitis B: 2 % Hepatitis C: 4 %. The majority of patients were asymptomatic. Twenty patients (16.5 %) had cirrhosis. ALD was more common in patients over 50 years (p \ 0.02) and NAFLD/NASH in patients under 50 years (p = 0.006) and in females. Cirrhosis was more common in patients aged over 50 and in ALD. Conclusions: NAFDL/NASH is the main cause of CLD seen in an Irish Hepatology Outpatient setting, particularly in patients under 50 years and females. ALD occurs in all age groups. The late presentation of CLD needs to be addressed, along with more careful recording of BMI, measures to prevent obesity and hazardous drinking patterns, and screening for haemochromatosis and viral hepatitis in at-risk groups.

Development and use of a handbook for ‘‘Out of Hours’’ Cook J, Nicholson S, Ramphul M, Madrigal M, McMaster R, Dinneen B, O Connor C, McCarrick C, Ridge K, Higgins M UCD Obstetrics and Gynaecology, National Maternity Hospital, Dublin Out of hours service (OHS) can be stressful for new senior house officers (SHOs). The aims of this study were to establish common reasons for presentation to OHS in The National Maternity Hospital and develop a useful resource for management. Methods were 1. Establishing the most common ten reasons for presentation to OHS—by reviewing all presentations to OHS in January and February 2015 2. Developing a handbook reviewing management of these presentations, based on national and local policy and guidelines with the addition of practical ‘‘tips’’ 3. Presenting the handbook at Grand Rounds for multidisciplinary review 4. Launching the handbook for use by new doctors starting in July 2015 5. Evaluating its usefulness by questionnaire 3 months later The most common reasons for presentation to OHS included early pregnancy bleeding, reduced fetal movements, antepartum bleeding, postnatal issues and suspected rupture of membranes. A handbook was developed, presented at rounds and revised. A copy was given to each new SHO starting in the NMH in July 2015— each were subsequently invited to complete a questionnaire evaluating its usefulness. Five of the eight SHOs completed the questionnaire, giving a response rate of 62 %. All had used the handbook, mostly in the early stages of rotation. All rated it as very useful or useful, and wished that it be used again in subsequent rotations. Practical additions, such as ‘‘how to make up common antibiotics’’ were also suggested. In conclusion, the handbook proved to be very useful to new doctors and will be continued into the future.

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Carbimazole-Induced Late Onset Pancytopenia Doran S, McQuaid S Department of Endocrinology, MMUH Carbimazole is an anti-thyroid drug used to treat hyperthyroidism. Pancytopenia is a rare complication of carbimazole treatment occurring in 0.01 % of cases1. Previous large case studies have reported a time range of 32–97 days following treatment initiation to pancytopenia onset1. We report an unusual case of pancytopenia occurring significantly outside this time range. An 86 year old male underwent a pre-clinic routine FBC which showed Haemoglobin 8.1, RBC 2.71, Platelets 29, WCC 1.51 (Neutrophils 0.62), demonstrating a marked pancytopenia. His background included toxic multinodular goitre (diagnosed 2002, controlled on carbimazole 5 mg daily), treated prostate cancer, COPD, and prior subdural haematoma. On ED presentation, he complained of a 2 week history of general malaise and was mildly confused. He was pyrexial with upper limb petechiae bilaterally on exam. Carbimazole was held and the patient was treated for neutropenic sepsis and investigated for causes of pancytopenia. Bone marrow biopsy demonstrated an acellular marrow with no atypical signs and no signs of marrow infiltration, consistent with a diagnosis of medication-induced pancytopenia. He became profoundly hyperthyroid and agitated on the ward. Lithium was introduced to control his thyroid disease with moderate success. He received multiple red cell and platelet transfusions over a prolonged period with no recovery in bone marrow function. His medical condition deteriorated and in consultation with family members and the patient it was agreed to withdraw active management and the patient died of a presumed CVA. This case highlights the importance of recognising antithyroid medication as a potential cause of pancytopenia years into treatment. It demonstrates the potential use of lithium in hyperthyroid patients in whom antithyroid medication is contrainindicated. It also highlights the importance of routinely checking FBC in elderly patients on this drug, who may not recognise signs of neutropenia. References: 1. Watanabe N, Narimatsu H, Noh JY, et al. Antithyroid DrugInduced Hematopoietic Damage: A Retrospective Cohort Study of Agranulocytosis and Pancytopenia Involving 50,385 Patients with Graves’ Disease. J Clin Endocrinol Metab; 97(1): E49–53. 2012

Failed Left Testicular vein Embolization Due to a Variant Left Renal Vein: A Case Study Alamiri J1, Browne C1, Brophy DP2, Galvin D1 1

Department of Urology, St Vincent’s University Hospital, Dublin 4, Ireland; 2Department of Interventional Radiology, St Vincent’s University Hospital, Dublin 4, Ireland Introduction: Varicocele is caused by dilation of the internal spermatic vein and pampiniform venous plexus. It affects 15–20 % of

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S268 men. Patients with symptomatic varicocele or associated infertility are offered treatment. Varicocele embolization is a commonly performed minimally invasive treatment for varicocele. We present the first reported case of failed testicular vein embolization due to variant anatomy. Case presentation: A 48-year-old male presented with a 1 year history of left testicular pain exacerbated by walking. Scrotal ultrasound revealed a moderately large left varicocele. After discussion with the patient, he opted for percutaneous transcatheter embolization of the left testicular vein. During venography via right common femoral venous approach, the radiologist was unable to identify and cannulate the left renal vein. Computerised tomography (CT) scan of the abdomen and pelvis demonstrated variant venous anatomy. The left renal vein drained directly into a left lumbar vein with no direct communication with the inferior vena cava (IVC). There were also two tortuous collaterals, one arising from the origin of the left gonadal vein and one arising from the distal left gonadal vein, which passed posterior to the aorta to drain into the IVC. Three months later, the patient underwent a left orchiectomy due to large varicocele and worsening symptoms. Conclusion: Variations in left renal venous anatomy are frequently encountered during routine CT scan12. However, this type of left renal vein anomaly has not been reported in the literature. Knowledge of this variation has implications for both renal surgery and interventional procedures. References: 1. Zhu J, Zhang L, Yang Z, Zhou H, Tang G. Classification of the renal vein variations: a study with multidetector computed tomography. Surgical and Radiologic Anatomy. 2015 Jan 8:1–9. 2. Koc Z, Ulusan S, Oguzkurt L, Tokmak N. Venous variants and anomalies on routine abdominal multi-detector row CT. European journal of radiology. 2007 Feb 28;61(2):267–78.

Are We Assessing for Hypocalcemia in Patients COMMENCED on Denusemab for Osteoporosis? McKenna R1, Mhurchu C.2, O’Malley G1 1

Department of Geriatric Medicine, Sligo Regional Hospital ; Pharmacy Department

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Objectives: Denosumab is a fully human monoclonal antibody to the RANKL receptor that inhibits osteoclast activity and thus increases bone mineral density. However, hypocalcaemia is an adverse event known to occur in those on Denosumab therapy. Subsequently, guidelines on the monitoring of renal function and calcium levels during therapy have been published to minimise the risk hypocalcaemia. The aim of this audit was to determine whether doctors in SGH were compliant with the MHRA/CHM guidelines and to implement changes to improve compliance with the guidelines if necessary. Patients who are prescribed Prolia 60 mg should have baseline calcium and renal function tests carried out prior to commencement of therapy. Those who have impaired renal function should have repeat calcium levels checked within 2 weeks of the initial dose of Prolia 60 mg. Design/methods: To carry out the audit the laboratory results of patients who were prescribed Prolia 60 mg between 17/04/2015 and 24/07/2015 was reviewed to determine which patients were compliant with MHRA/CHM guidelines

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Results: The results showed that of the 28 patients identified, only half, 46 %, had baseline calcium levels checked prior to starting treatment. Only 76 % of patients had renal function tests prior to starting therapy. Of the patients who had follow up calcium levels performed, two were found to be hypocalcaemic. Conclusions: The results demonstrate that monitoring during Denosumab therapy is inadequate and improvements are necessary in order to better protect patients from the adverse event of hypocalcaemia. References: 1. Steven R. Cummings, M.D., et al. Denosumab for Prevention of Fractures in Postmenopausal Women with Osteoporosis. N Engl J Med 2009; 361:756–765 2. Anastasilakis AD, Toulis KA, Goulis DG, et al. Efficacy and safety of denosumab in postmenopausal women with osteopenia or osteoporosis: a systematic review and a meta-analysis. Horm Metab Res 2009; 41:721 3. Rosen N. H. M.D., Denosumab for osteoporosis. In Clifford J Rosen (ed) UpToDate. Retrieved from http://www.uptodate.com/ contents/denosumab-for-osteoporosis

Right Sided Constrictive Pericarditis as a Cause of Ascites Byrne A1, Farrelly C2, Steele C2 Corresponding Author: Dr Alanna Byrne

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West North West Intern Training Network, Letterkenny General Hospital, Co. Donegal; 2Gastroenterology Department, Letterkenny General Hospital, Co. Donegal A 47 year old male presented with increasing abdominal girth of 8 weeks duration. He had no past medical history but a weekly alcohol intake of 40–50 units. He had no stigmata of chronic liver disease and denied any chest pain or dyspnoea. Findings on clinical examination were only of large volume ascites with shifting dullness and mild lower limb oedema to the mid-calf. Hematological investigations including liver screen, Mantoux, TFTs and ESR were normal apart from deranged LFTs, a mild coagulopathy and an elevated pBNP. Ultrasound confirmed ascites and showed a homogenously hyperreflective liver and endoscopy showed no evidence of varices. Treatment of the ascites was undertaken with diuresis and two large volume paracentesis which showed a transudate (high serum-ascites albumin gradient). Further investigations were necessary as results so far were not in keeping with a diagnosis of ascites due to alcoholic cirrhosis. Liver biopsy was unhelpful showing non-specific inflammation. CT Thorax Abdomen and Pelvis was done to exclude malignancy and it revealed a heavily calcified pericardium. An echocardiogram showed a severely dilated right atrium, with normal right ventricular systolic pressures but no respiratory variation in the superior vena cava diameter. Angiogram showed normal coronary vessels. Cardiac MRI had findings consistent with right sided constrictive pericarditis. Paracentesis and diuresis brought his weight down from 116.8 to 83.2 kg, but it slowly began to creep back up after diuresis had to be stopped for profound hyponatremia. Definitive treatment with pericardial stripping was done and the patient is now 2 months post operation and doing well with a complete resolution of symptoms.

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Determining Expression of Zinc-Alpha-2Glycoprotein in Biochemical Recurrent Prostate Cancers Byrne A1, O Neill A1, Finn S2, Watson RW1 Corresponding Author: Dr Alanna Byrne

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Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4; 2Department of Histopathology, Trinity College Dublin and St. James’s Hospital, Dublin 8 Prostate cancer is the most common non-cutaneous cancer affecting men. Approximately 25 % of patients who undergo a curative radical prostatectomy for localised disease will unfortunately fail, with increased prostate specific antigen, indicating biochemical recurrence (BCR). The ability to predict BCR would inform appropriate treatment strategies for patients. The objective of this study was to determine if Zinc-alpha-2glycoprotein (AZGP1) is differentially expressed in both the tissue and serum of BCR patients. Serum levels were measured using an in house developed multiplex ELISA. A tissue-microarray (TMA) of 16 BCR patients, matched with 16 non-recurrent control patients was constructed. Antibodies were identified and optimised for immunohistochemical analysis of the TMA. The staining scores were evaluated using the parametric independent samples t-test and nonparametric Mann–Whitney U test. No significant differences in either serum expression (p = 0.685) or the epithelial expression (p = 0.16) of AZGP1 where shown between BCR and non-BCR groups. However, AZGP1 tissue expression was shown to be significantly decreased in cancer epithelial cells in comparison to normal epithelial cells (p \ 0.0001). There was also a significant decrease in AZGP1 tissue staining between Gleason grade 3 and 4 (p \ 0.01). Neither AZGP1 epithelial tissue expression levels nor serum levels are suitable as predictive biomarkers of BCR. Serum levels and tissue levels do not correlate with each other. Thus serum levels of AZGP1 cannot be used as a surrogate marker for tissue expression. Yet AZGP1 could be helpful in the pathological grading of prostate cancer as epithelial levels were seen to be significantly different in cancer versus non-cancerous tissues and also between Gleason grades.

Thyroid Lymphoma E Hegazy, K Barry Mayo University Hospital, Castlebar, Co. Mayo West Northwest Training Network Introduction: Goitres are a common surgical presentation whose aetiology is largely well described. This case presents a rare cause of goitre, which posed both diagnostic and therapeutic challenges. Description/case report: A 59-year-old female presented with a 4-month history of increasing dysphagia to solids. She has a background history of Hashimoto’s Thyroiditis for which she underwent a right thyroid lobectomy and isthmusectomy 9 years previously. On clinical examination, she had a thyroid mass. Biochemical investi-

S269 gations revealed a normal free T4 and an elevated TSH, consistent with subclinical hypothyroidism. Fine needle aspiration demonstrated a destructive infiltrate of lymphocytes, which was suspicious of malignant lymphoma. Extrinsic compression of the oesophagus was seen on oesophagogastroduodenoscopy. Computed Tomography confirmed a thyroid mass. She was initially managed with a left thyroid lobectomy. Subsequent histology confirmed a diffuse large b-cell lymphoma. Staging of thyroid Non-Hodgkin’s lymphoma was done according to the modified Ann-Arbor classification. She went on to successfully complete a regime of Rituximab-Cyclophosphamide, Doxorubicin, Vincristine and Prednisolone (R-CHOP), which is the recommended chemotherapeutic protocol. She is currently due to start 6 cycles of this and is due to have a follow-up Positron-Emission-Tomography Computed Tomography (PET-CT) after cycle 2 and follow-up CT after cycle 6 to assess for remission of the disease. Discussion/conclusion: Thyroid lymphoma is a rare entity representing only 2 % of thyroid malignancies. The only known risk factor is chronic autoimmune (Hashimoto’s) thyroiditis. This supports the theory of chronic inflammatory processes predisposing to cancer in the body. The 5-year survival of non-Hodgkin’s Lymphoma is 70 %90 %.

Weekend Blood Testing: Opening Times may Indicate Areas for Improvement? Klaus S, Mongan O, Byrne D Galway University Hospital West Northwest Intern Training Network Aims: The audit was undertaken to measure the number of requests made for weekend venepuncture in a major teaching hospital (650 beds) to identify any factors that indicated a request as being an ‘unnecessary’ one. Methods: Blood request forms completed over a weekend, in 2015 were collected retrospectively from Galway University Hospital phlebotomy service. The forms were analysed for details of the requested investigations, date and time of request and the reason for the request. The opening times (time at which the result was checked by a doctor) were accessed electronically. The number and cost of the weekend blood investigations were compared with the same data for a weekday and bank holiday in the same calendar month. Results: The average number of requests per weekend day is on average the same as those for a weekday. In contrast this number is halved on a bank holiday when the intern draws the sample. The commonest investigations requested were FBC (n = 277), CRP (n = 226), SMAC20 (n = 145), oncology profile (n = 79) and coagulation screen (n = 71) at an estimated laboratory cost for an average weekend of €7762. Approximately 50 % of the forms recorded ‘emergency’ as the only reason for the request; only 67 % of requested investigations were checked by 6 pm the same day; over 5 % were not reviewed until 48 h and 1 % of the results were never viewed. Conclusions: The data suggest that both the number and cost of weekend blood investigations performed is high when compared with weekday practice and bank holiday figures when no phlebotomy service exists in the hospital. The lack of clinical data on the request and low opening rates further supports the data and suggests that up to 30 % of requests may not be necessary. This audit identified areas for improvement in the requesting of investigations both to improve patient care and hospital spending.

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Interns’ Attitudes to Venepuncture and Requesting Laboratory Investigations Klaus S, Byrne D, Mongan O Correspondence: Stephen Klaus

Galway University Hospital West Northwest Intern Training Network Background: Research consistently shows that newly qualified interns are not prepared to perform procedural skills such as venepuncture. More recent research has shown that interns often struggle with decision making in requesting appropriate radiological investigations and often request inappropriately1. Making appropriate decisions around laboratory investigations is an important clinical skill. Aims: To evaluate interns’ attitudes to venepuncture and requesting laboratory investigations to understand the factors influencing their decisions. Methods: An anonymous paper-based questionnaire was circulated to interns during an intern teaching session in one major teaching hospital in November 2015. Interns were asked to record their adherence to standard operating procedures for venepuncture, their reasons for requesting blood tests, the frequency of those requests, and their follow up practice. Results: 47 interns completed the questionnaire (response rate of 60 %). The results of the survey show that 75 % of interns would like additional training in venepuncture prior to starting work. Only 9 % were following standard operating procedure for venepuncture. Regarding the frequency of blood requests; 15 % of interns request bloods every weekday, 26 % of interns request bloods every day including weekends. Furthermore, only 58 % of interns request bloods ‘‘only when indicated’’. When requesting phlebotomy 32 % will add in extra tests that are not indicated. Only 34 % of interns ask a colleague to check the result of bloods requested at the weekend. 49 % of interns have discovered a blood result on Monday that should have been addressed at the weekend by the on call doctor had the result been checked. Conclusions: The results indicate that in addition to interns reporting a need for further training, there is a need for further training in decision making around requesting appropriate investigations to both improve patient safety and system effectiveness. 1. B. Moloney, C McDonnell, D. Byrne, C. McCarthy, PA McCarthy. ‘‘A cross sectional analysis to evaluate the performance of doctors in identifying appropriate diagnostic imaging studies and appropriately prioritising imaging requests.’’ In Proceedings BIR Annual Congress, Novemeber 2015, London, UK.

RAMI Case report: Treatment of One Malignancy Leading to Another Angelov S, Boyle T Department: Breast Surgery Department, St James’s Hospital Introduction: An interesting yet not unusual case of a background history of Hodgkin’s Lymphoma in youth and the subsequent development of Breast Cancer.

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Description: The background begins with a diagnosis of Hodgkin’s Lymphoma in Ms AJ’s early twenties treated with interferon radiotherapy and ABVD chemotherapy regime with nil recurrence. In 2001, a self detected right breast cancer (invasive ductal carcinoma) was discovered and managed by wide local excision followed by right axillary clearance and radiotherapy. Current presentation occurred when Ms AJ (53) was admitted electively to St James’s Hospital after an MRI detected in breast recurrence. Of note she had no other risk factors for breast cancer development. Surgical management consisted of completion right mastectomy. In terms of nodal management a lymphoscintigraphy was performed pre-op which suggested nodes in right and left axilla, however, intra-op only left sided contralateral nodes were hot and, therefore, were excised as sentinel lymph node biopsy. Discussion: Firstly, Hodgkin’s Lymphoma in childhood is as high a risk factor for development of Breast Cancer as BRCA mutation carriers, much higher than the general population. The cumulative risk by age 50 is 35 versus 31 %, respectively (1). Secondly, the lymph node drainage was to the contralateral side which occurs in 25 % of all sentinel lymph node procedures in Breast Cancer, more common if there has been prior surgery on the ipsilateral axilla. Lastly, to make other NCHDs aware that there is a national screening programme in place which consists of annual breast MRI and mammogram from age 25 or 8 years after radiation treatment (2). References: 1. Chaya S. Moskowitz et al., Breast Cancer after Chest Radiation Therapy for Childhood Cancer, 2014 American Society of Clinical Oncology Journal 2. International Late Effects of Childhood Cancer Guideline Harmonisation Group

Audit of empiric antibiotic prescribing practices for acute general surgical admissions in the University Hospital Limerick Conway A, Bhatt N, Boland M, Merrigan A Breast Surgery Department, University Hospital Limerick, St. Nessan’s Road, Dooradoyle, Limerick Background: Antibiotic prescribing practices vary between hospital sites, as does the prevalence of local causative organisms and their resistance to antibiotics. Surgical teams must, therefore, remain vigilant to ensure prescribing practices align with local best practice. Aim: To audit adherence to the University Hospital Limerick (UHL) Antibiotic Prescribing Guidelines for empiric antibiotic prescribing in acute general surgical admissions. Methods: A retrospective snapshot audit was carried out over a period of 3 weeks. The prescribed antibiotic therapies were compared to the current UHL Antibiotic Prescribing Guidelines. Data was collected from clinical notes and medication charts of patients who fulfilled the following inclusion criteria: (1) admission through the ED only during the period 04/09/15–24/09/15 inclusive, (2) admitted for general surgical services only and (3) required the use of empiric antibiotic strategies. Any adaptation of antibiotic strategies, based on microbiological testing from patient samples was not recorded. Patient information was anonymised to protect patient confidentiality. The following exclusion criteria were also applied: (1) elective admissions, (2) post-operative antibiotic regimen prescribed and (3) causative organism already isolated. Results: The review of patient data spanned three surgical teams over the specified 3-week time period. A total of 32 patients satisfied the audit inclusion criteria. The following prescribing anomalies were

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 identified; incorrect dose of antibiotic: 4 patients (12.5 %), incorrect mode of delivery of antibiotic: 2 patients (6.3 %), inappropriate antibiotic for patient group: 1 patient (3 %), C1 antibiotic omitted from recommended regimen: 22 patients (68.8 %) and inclusion of C1 antibiotic not included in the guidelines: 18 patients (56.3 %). Conclusions: Overall, there was low adherence to the local antibiotic policy guidelines. The results of this audit are to be disseminated to all surgical teams at UHL, with proposed re-training on the current UHL Antibiotic Prescribing Guidelines. A subsequent re-audit is planned to evaluate the effectiveness of this training programme.

Impact of Adverse Weather on Attendances at University Hospital Galway Emergency Department Kirby A1, McNicholl B1 Emergency Department, University Hospital Galway Background/introduction: A number of models have been proposed to predict the volume of attendances at Emergency Departments, to match patient flow and staffing. Our experience in Galway is that bad weather, such as high winds and rain, reduces attendances. While extremes of heat have been studied, very little published data has examined the effects of stormy weather and no studied has reviewed the impact in the Irish context. Methods: Met Eireann, the Irish Meteorological Service records weather conditions in the Galway region. The Athenry station covers the Galway city and suburban region, which is the most immediate catchment area of University Hospital Galway (UHG). We analysed 1 year of data from the 1st of October 2014 to the 30th of September 2015 from this station and compared with volume of attendances for the Emergency Department for the same period. We identified the 60 worst days (based on wind gust strength) with average attendances for the year. In addition we looked at the overall highest volume of wind days and the highest rain volume days. Results: Over the year there was a total of 60,491 attendances to UHG Emergency Department. The average daily attendance of 166 ranges from 194 on Mondays to 130 on Sundays. The 60 windiest days recorded wind gust strengths of 32 to 49 knots with average attendances of 159 patients, compared to a day adjusted average of 173, T = -3.8 P = .03. Attendances are also below average for the high overall wind and rain levels. Conclusions/discussion: Volumes attending the emergency department on stormy days is significantly lower than average, supporting our hypothesis that patient volumes are reduced during adverse weather. Anecdotally General Practitioners tell us that their attendances also fall. Further data analysis and studies are required in order to develop a modeling tool for resource planning.

The Use of 3D Computer Modeling and Animation to Teach Neuroanatomy to Medical Students Subject: Neuroanatomy, Education Lynch J1, Asad M1, Flanagan T2 1

Beaumont Hospital, Dublin, Ireland; 2School of Medicine, University College Dublin

S271 Introduction: Neuroanatomy is one of the most challenging concepts taught in medical school. Traditional 2 dimensional static diagrams of complex pathways in textbooks can appear crowded and intimidating. Today it is possible to create 3D models of body parts, such as the brainstem using software and skills taught in leaving certificate Design and Communication Graphics. These images can then be used to create simple animations demonstrating the sequence of events in any of the cranial nerve (CN) pathways. Aim: Create an interactive computerised teaching tool that simplifies the neural pathways involving Cranial Nerves II, III, IV, and VI. Materials and methods: SolidWorks 3D software was used to construct a 3D model of the brainstem including the relevant nuclei in their correct anatomical locations. Still images of the brainstem model were imported into Macintosh Motion 5 and used to make short animations showing the sequence of events in the firing of various pathways. A voice over was added in time with the animations. Short clips were edited and published on University College Dublin’s Blackboard as an online educational tool called Axon II. Axon II was incorporated into UCD Medicine’s Neuroanatomy Module. Conclusions: Interactive anatomy modules can be built by medical students with basic computer skills taught in leaving certificate subjects. More investigation is necessary to prove the benefit of these modules over traditional methods of teaching.

An Unusual Case of Infertility Reddin C1, Bogdanet D2, Bell M2 1

NUI Galway intern training network; 2Department of Endocrinology, University Hospital Galway West North West intern network Introduction: The testicular disorder of sexual differentiation (DSD), previously known as the XX male syndrome, is a rare clinical condition with a reported incidence of 1:20 000 newborn males. It is characterized by a male phenotype with 46 XX karyotype. There are three clinical phenotypes: normal male phenotype, males with genital ambiguities and males who are true hermaphrodites. Clinical features include normal pubic hair, normal penile size, but with small testes, azoospermia, and sometimes gynecomastia Description/case presentation: This is the case of a 33 year old gentleman who was referred to Endocrinology from the Fertility Clinic. The patient and his wife had a 3 year history of primary infertility. The female’s clinical examination and biochemical investigations were normal. The patient had normal libido and erectile function. Clinical examination revealed a normal height of 1.80 m, bilateral gynecomastia, normal virilization, normal penis size but small testes, 10 ml on the right and 5 ml on the left. Significant past medical history included undescended testes in childhood. There was no significant family history. Biochemical investigations revealed hypergonadotropic hypogonadism. Semen analysis revealed azoospermia. Chromosomal analysis showed a 46XX karyotype. Fluorescence in situ hybridization (FISH) showed the SRY region translocated to the short arm of the X chromosome. The patient received genetic counseling and was started on testosterone replacement therapy. Discussion/conclusion: Current data suggests 15 % of couples are infertile, and among these couples, male factor infertility accounts for50 % of cases. 5–16 % of men with severe sperm abnormalities have some form of chromosome abnormality. 46 XX DSD can lead to a variety of different clinical presentations and as such may be diagnostically challenging with the patient presenting to various subspeciality clinics.

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Prevention, Detection and Management of Acute Kidney Injuries in Letterkenny University Hospital Hamza M1,2, Burke C1,2, Dorman R1,2, Birmingham C1,2, Moran A1 Corresponding Author: Mohammed Hamza

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Letterkenny University Hospital, Letterkenny; 2West Northwest Intern Training Network West Northwest Intern Training Network Objectives: Acute Kidney Injury (AKI) is a prevalent disorder, with no standardly accepted definition and very serious consequences if undetected or inadequetely managed. The aim of the audit was to examine the incidence of AKI in admissions to LUH over a 1 week period, as well as recognition of AKI, preventive measures taken and management once recognised. Design/methods: All elective and emergency admissions over a period of 1 week (1/9/15–7/9/15 inclusive) were eligible for this study if they had a serum creatinine rise by more than 1.5 times their baseline at any stage during their admission. Paediatric and maternity admissions were excluded. The resulting cohort’s medical notes and lab data were interrogated for risk factors for AKI, preventive/prophylactic measures that were undertaken, detection of AKI and subsequent investigations, monitoring and management. Results: 2 % of elective admissions (n = 1) and 4.21 % of emergency admissions (n = 12) fit the inclusion criteria. In terms of co-morbidities, 33 % had at least one of diabetes, chronic kidney disease (CKD), heart failure, neurological disorder/intellectual disability or sepsis. 33 % had received iodinated contrast for non-emergency procedures within the preceding week or had escalating EWS, and 44.4 % had signs/symptoms of urological obstruction. 22.2 % had a history of AKI or had taken nephrotoxic drugs within the preceding week. Creatinine was monitored daily in 77.8 % and urine output was monitored in 67 %. Risk of AKI was documented, and prophylactic measures taken in 22.2 %. The diagnosis of AKI was documented in 55.6 %, and in 78 % the cause was identified, most commonly heart failure exacerbations or sepsis at 22.2 % each. Urgent ultrasound was offered and obtained within 24 h in 11.1 % of cases. In 22.2 % the management was discussed with a nephrologist, and this happened within 24 h in 11.1 %. 88.9 % survived, and 22.2 % had an unplanned readmission within 30 days of discharge. Conclusions: From this sample we can see that there are issues in prevention, detection and management of AKI that need remediation in the context of LUH. An AKI pathway/guideline should be disseminated on site prior to re-audit.

Case Report of Papillary Thyroid Carcinoma in a 32 Year Clinically Well Female O Reilly S, Quill D Galway University Hospital West/North West Introduction: In August 2014 a 32 year old female was referred from her GP with palpable swelling in the left anterior triangle of her neck. This swelling was present for a few months and on examination it moved on swallowing. Otherwise the patient was clinically well and had recently given birth.

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Description/case presentation: A neck ultrasound (September 14) indicated a normal left lobe with a cystic elliptical cyst measuring around 3.5 cm on the right lobe. Thyroid function tests and other routine bloods were normal. The management plan was to observe and repeat the ultrasound in a few months’ time. A repeat ultrasound with fine need aspiration of right lobe was done in February 2015 and again indicated a cystic nodule with was unchanged in size. However this time it was also noted that there was a possible solid component in the inferior pole. Following discussion it was decided to proceed to surgery and in September 2015 a left sided lobectomy was undertaken, clinically the mass removed was cystic in nature. The patient was discharged home the next day. However follow up histology report of the right thyroid gland indicated that this was a case of papillary thyroid carcinoma– follicular variant with capsular invasion. A single Hurthle cell adenoma was also identified. While there was no evidence that disease had extended to the right lobe follow up surgery in January 2016 was undertaken to remove the left thyroid lobe and this has also been sent for histology. Discussion/conclusion: Radiological investigation and fine needle aspiration indicated that the lump was benign and cystic in nature. Given the patients young age and lack of other symptoms there was a low level of suspicion that this could be something more significant. However definitive diagnosis was only made on surgery which provided both definitive diagnosis and treatment for this patient.

Audit of PSA Testing, their Indications and Digital Rectal Examinations Performed in a Single General Practice Surgery Cullen S, O Kelly, O Callaghan M Department of General Practice, Trinity College Dublin Introduction: Prostate specific antigen (PSA) is a proteolytic enzyme used in the liquefaction of ejaculation. It is used as a marker for detecting pathology in the prostate gland including cancer. Large randomized control trials performed in Europe (ERSPC trial) and America (PLCO trial) has shown that PSA screening for prostate cancer has no survival benefit and is not recommended. Therefore its use should be preserved for those who have a clinical indication for performing it for example lower urinary tract symptoms. Furthermore, each PSA test should be accompanied by a digital rectal exam (DRE) according to guidelines issued by the HSE. This audit examines the amount of PSA tests performed, their indications and presence of a DRE in a single GP practice. Methods: Socrates Audit tool was used to search the practice database to identify all patients who received PSA testing over the last 2 years. Then by reviewing the files of each individual patient, it was noted what indication, if any, was documented for performing the test along with the performance of a DRE. Results: Socrates identified 147 patients who had PSA testing between 1/12/2013 and 1/12/2015. 11 were excluded due to surveillance. Of the remaining 136 patients, 66 % had a documented clinical indication for performing this test. The main indications included lower urinary tract symptoms (48 %), malignancy symptoms (9 %) and at risk populations (7 %). Only 33 % of patients undergoing PSA testing had an accompanied DRE. Conclusion: This audit clearly shows a shortfall in clinical practice within this surgery and highlights areas that require more vigilant care such as documenting indications for investigations and performing Digital rectal examinations with PSA testing.

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Minimum Unit Pricing: Will it have any effect on heavy drinkers and medical students? Fennessy S1, Dillon A1, McKenna-Barry M1, O Neill D1, Stewart S1 1

Centre for Liver Disease, Mater Misericordiae University Hospital

Introduction: Minimum per Unit Pricing (MUP) is a proven public health mechanism for reducing alcohol consumption, particularly amongst the heaviest drinkers. Aims: The aim of this study was to examine the effect of the proposed introduction of MUP in Ireland on patients who present to our service with alcohol related problems. Methods: Patients who presented with alcohol related medical problems were interviewed about their most recent typical week of drinking. A group of medical students were also surveyed. Results: 50 patients were interviewed. The average alcohol intake was 154 units per week (range 50–900 units). The majority of patients drank alcohol purchased off licence (80 %). The mean percentage spend on alcohol was 46 % of weekly income (range 2–90 %). 54 % described themselves as an alcoholic with 56 % having experienced withdrawal symptoms in the past. The overall mean price per unit spent was €1.34 (range €0.29–4). A significant proportion of patients would be affected by the introduction of a MUP policy as illustrated in Figure 1, with 38 % spending less than 90c, and 52 % spending less than 110c. 35 medical students were surveyed and had a mean intake of 19 units/week (range 2–40). The mean price per unit was €1.28 (range 0.5–4.50). 42 % of medical students spend 90c or less on their main alcoholic beverage. Conclusions: A minimum unit pricing policy would significantly impact on medical students and hazardous drinkers. It should therefore impact on their alcohol consumption.

A Colonic Conundrum: Profuse watery diarrhoea in a 48 Year Old Female Cronin S, O Callaghan M, Divilly P, Mulcahy H, Cullen G UCD, St. Vincent’s University Hospital, Department of Gastroenterology Introduction: A 48-year old Irish lady presented with a 10-week history of profuse watery diarrhoea, abdominal cramps, vomiting and weight loss. Case presentation: The patient was having 10–15 episodes of watery diarrhoea per day. Her GP had given a course of ciprofloxacin and metronidazole with no effect. She had weight loss of 8 kg over 4–6 weeks. Total parenteral nutrition was initiated. Her CRP was raised at 36, with an albumin of 18. The only other abnormality identified was a low serum immunoglobulin G level which was 50 % less than the lower limit of normal. The patient was not taking any regular medication, non-smoker and had no significant medical history. Infectious causes of diarrhoea were ruled out. Gastroscopy and colonoscopy were macroscopically normal, but biopsies identified submucosal collagen deposition in the duodenum and throughout the colon consistent with the diagnosis of collagenous enterocolitis. Microscopic colitis is characterised by a triad of watery diarrhoea, a macroscopically normal colon and typical microscopic findings1. Two distinct histological forms of microscopic colitis have been defined: lymphocytic colitis and collagenous colitis. The cause remains unknown and is likely to be multifactorial.

S273 Randomised controlled trials and a recent meta-analysis confirm that budesonide is an effective treatment for moderate to severe collagenous colitis2. Our patient did not respond to budesonide, perhaps because she had both small and large bowel involvement. She was commenced on intravenous hydrocortisone. She had a partial response to intravenous steroids and escalation to immunosuppressive therapy was considered. However due to the patients hypogammaglobulinemia she was treated with intravenous immunoglobulin and has an excellent clinical response. All symptoms settled after 3 weeks and the patient went home on tapering dose of steroids. Conclusion: This is an unusual case of collagenous entercolitis associated with hypogammaglobulinemia. Chronic diarrhoea is a well recognised manifestation of hypogammaglobulineamia but there are no reported associations with collagenous enteropathy. References: 1. W. R. Brown and S. Tayal, ‘‘Microscopic colitis. A review,’’ Journal of Digestive Diseases, 2013. 2. M. J. Stewart, C. H. Seow, and M. A. Storr, ‘‘Prednisolone and budesonide for short- and long-term treatment of microscopic colitis: systematic review and meta-analysis,’’ Clinical Gastroenterology and Hepatology, vol. 9, no. 10, pp. 881–890, 2011.

An Audit of Suitability for Six-Monthly Reviews of HIV Positive Patients on Anti-Retroviral Therapy Davey N, Jackson A Cork University Hospital Background: HIV is a disease with growing prevalence; approximately 400 patients on anti-retroviral therapy (ART) attend the onceweekly, public Cork University Hospital (CUH) HIV Clinic at present. This has risen from 166 patients on ART in 2008 demonstrating the growing number of clinic slots required annually. The purpose of this audit was to establish whether it would be feasible to reduce the visit frequency of virally suppressed patients on ART who are biopsychosocially well. Methods: Five consecutive clinics were audited retrospectively with an end point of 12th January 2013, 6 months prior to the start date. A cohort of 100 consecutive patients receiving ART from 5th December 2012 until 9th January 2013 was evaluated over the course of 12 months. Those patients with a CD4 count greater than 350 cells/lL and a Viral Load (VL) less than 50 copies/mL were deemed to be clinically well once these patients were considered entirely healthy under all auspices of the biopsychosocial model by the specialist HIV nurses, it was deemed that they could attend less frequently. Results: Of 100 patients receiving antiretroviral therapy, 50 were virally suppressed. Of those, it was established that 26 could safely be seen twice as opposed to three times a year. Following up these patients 9 months later, it was found that although various barriers to less frequent clinic attendances had arisen for seven of this group, no major complications had arisen that were in anyway related to progression of their HIV. Conclusion: HIV incidence is increasing and as treatment regimens improve, the lifespan of treatment compliant patients is lengthening. The average attendance at the CUH HIV clinic is three times per year and reducing this to twice a year for those who are deemed well will provide much needed spaces for both existing patients and new attendees.

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VTE Prophylaxis in Hospitalised Oncology Patients in Galway University Hospital: A Cross-Sectional Audit Ong G1, Blazkova S1 1 Department of Medical Oncology, Galway University Hospital, West Northwest Intern Training Network

Background/objectives: Cancer patients have a high risk of developing venous thromboembolism (VTE). This thrombotic risk is further heightened during hospitalization1. Thromboprophylaxis significantly reduces the risk for VTE. As such, the NCCN, ESMO and ASCO guidelines recommend pharmacologic VTE prophylaxis in all hospitalized cancer patients unless a contraindication to anticoagulation is present. In Galway University Hospital, low molecular weight heparin (LMWH) is recommended. However, VTE prophylaxis has been shown to be underutilised2. The aim is to determine the rate of VTE prophylaxis prescribed for patients admitted to medical oncology in GUH. Methods: The audit was carried out on 1 day. The prescription charts of 36 inpatients admitted to medical oncology were audited for the prescription of LMWH. The date of admission and date of LMWH prescription were recorded. For patients not currently receiving LMWH, their medical notes were analysed for contraindications. Results: 12 (33 %) patients were not prescribed VTE prophylaxis on the day of admission. 4 (11.1 %) had contraindications including a suspected stroke, low platelet count, a previous cerebral haemorrhage and awaiting surgery. 8 (22.2 %) were not prescribed prophylaxis on admission despite the lack of contraindications. 6 of them later received VTE prophylaxis within 7 days, while 2 did not. Conclusions: 22.2 % of patients had not received prompt VTE prophylaxis despite the lack of contraindications. Simple dissemination of expert guidelines appears insufficient to ensure adherence. As such, multi-faceted strategies are needed to raise awareness and ensure guideline adherence. The new hospital prescription chart VTE prophylaxis reminder on the first page of regular medications is now available on the oncology wards. The pharmacists have also implemented a verbal-call system to the oncology intern whenever VTE prophylaxis is not promptly prescribed for a patient. The audit will be re-assessed in 3 months’ time to assess the effectiveness of these changes. References: 1. Stein PD, Beemath A, Meyers FA et al. (2006) Incidence of venous thromboembolism in patients hospitalized with cancer. Am J Med 2006; 119:60–68 2. Burleigh E, Wang C, Foster D et al. (2006) Thromboprophylaxis in medically ill patients at risk for venous thromboemnolism. Am J Health Syst Pharm 2006; 63(suppl 6):S23-S29

An Audit of Prescribing Practices and Adverse Drug Reaction Reporting in Drug Kardexes at UCHG Buckley B1, Lydon S2, McDonagh M2, Concannon L2, Mulvihill D2, McDonnell A2, Kidd P3 NUIG Intern, Galway; 2Pharmacy Department, UCHG, Galway; Chief II, Clinical Officer Pharmacy Department, UCHG, Galway

1 3

West Northwest Intern Training Network

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Objectives: To assess accuracy and clarity of adverse drug reaction reporting and prescribing practices at UCHG and to identify areas around prescribing practices which could improve patient safety. Design/methods: Inpatient drug kardexes at UCHG were randomly selected and following the application of exclusion criteria, 155 were selcted for retrospective audit. Each kardex was analysed for the following parameters: Adverse drug reaction and corresponding nature, prescribing errors, omissions, duplications and ambiguous prescribing. Any errors, omissions or ambiguity noted by a reviewing pharmacist was collected on a specifically designed data collection sheet. Results: 22 % of Doctors did not complete the Adverse Drug Reactions (ADR) in the designated section of the kardex. 54 % (n = 27) of doctors that recorded an ADR failed to record a nature of reaction, whereas 100 % of pharmacists noted a nature of reaction along with an ADR. Of the 155 kardexes reviewed there were 23 incidences of incorrect drug being prescribed, 47 incidences of incorrect dose, 25 incidences of incorrect frequency and 5 incidences of incorrect route. In total 119 pre admission medications were omitted, 45 ambiguous medications prescribed and 1 duplicate were found across all 155 kardexes. Conclusions: A high number of doctors failed to document any ADR on the kardex at admission with the majority of those that did failing to document a nature of that reaction. The high incidences and nature of prescribing errors and medication omissions are broadly in line with the international experience1,2. Significant opportunity exists to improve patient safety through improved prescribing practices, better medication history taking and diligent adverse drug reaction reporting. References: 1. Dean B, Schachter M, Vincent C, Barber N (2002) Prescribing errors in hospital inpatients: their incidence and clinical significance. Quality and Safety in Health Care. 11(4):340–4. 2. Cornish PL, Knowles SR, Marchesano R, Tam V, Shadowitz S, Juurlink DN, Etchells EE (2005) Unintended medication discrepancies at the time of hospital admission. Archives of internal medicine. 165(4):424–9.

Bigger Isn’t Always Better: A Clinical Case of Gigantomastia Bollard SM, Byrne M, Lawlor C Department of Plastic and Reconstructive Surgery, St. Vincent’s University Hospital, Dublin, Ireland UCD Intern Training Network The definition of gigantomastia is varied throughout the literature, though is widely accepted as breast enlargement requiring reduction of over 1.5 kg of breast tissue per breast. Though the majority of cases are idiopathic, it can be also be related to endogenous hormone stimulation. We report a case of a 44 year old female with a past history of benign breast disease, referred to the Plastic Surgery Outpatient Department with a longstanding history of back pain, neck pain and intertrigo. The patient also reported she was embarrassed and selfconscious of her breasts. On examination she was found to have bilateral ptotic and pendulous breasts, which were significantly enlarged. She also had an increased Body Mass Index at 44.4. Management included numerous appointments to optimize the patient pre-operatively, encouraging weight loss and ensuring suitability for

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 surgery followed by a bilateral breast reduction, during which she had 4.2 kg of tissue resected from either breast. Her symptoms subsequently resolved. The bilateral breast reduction offers patients a great improvement in self-esteem and rates of depression and anxiety, and its impact on quality of life is has been demonstrated to be comparable to that of a Total Hip Replacement. This case serves to highlight the psychological aspects of gigantomastia, which are often overlooked in the context of severe physical symptoms, and the benefits of surgical intervention in the context of appropriate patient selection. References: 1. Klassen, Anne F et al. ‘Satisfaction And Quality Of Life In Women Who Undergo Breast Surgery: A Qualitative Study’. BMC Women’s Health 9.1 (2009) 2. Saariniemi, Kai M. et al. ‘Breast Reduction Alleviates Depression And Anxiety And Restores Self-Esteem: A Prospective Randomised Clinical Trial’. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery 43.6 (2009): 320–324. 3. 3. Saariniemi, Kai M., Harri Sintonen, and Hannu O. Kuokkanen. ‘The Improvement In Quality Of Life After Breast Reduction Is Comparable To That After Major Joint Replacement’. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery 42.4 (2008): 194–198.

An Atypical Presentation of A Salivary Gland Tumour: A Case Report Bollard SM, Fernando C, Curran A Professorial Department of Otorhinolaryngology/Head and Neck Surgery, St. Vincent’s University Hospital, Dublin, Ireland UCD Intern Training Network Adenoid Cystic Salivary Gland malignancies are uncommon, accounting for approximately 8.4 % of salivary gland tumours. The majority are benign, normally presenting as a slowly growing mass, with the parotid gland being the most commonly affected. We present a case report of a 74-year-old woman originally referred to neurology with a 5 month history of pain on the right side of her chin, associated with a sensation of sunburn and a ‘feeling of a clumsy tongue’. She had no history of radiation exposure and did not smoke. On examination she was found to have numbness on the right side of her chin, with associated right sided tongue deviation and right-sided tongue wasting and numbness. She was initially investigated for an underlying neurological cause. Her MRI demonstrated an abnormality affecting the mandibular branch of the trigeminal nerve. A subsequent CT Neck and Ultrasound demonstrated a lesion within the right sublingual space, which was biopsied and shown to be an adenoid cystic carcinoma. A radical resection of the lesion was performed, resecting from the floor of mouth and base of tongue, with a right-sided selective neck dissection, approached via mandibulotomy. The procedure also involved the formation of a tracheostomy and reconstruction with a free radial forearm flap to the floor of her mouth. The patient also received adjuvant radiotherapy, an additional intervention shown to increase the 5-year survival in advanced disease. This case demonstrates an abnormal presentation of a salivary gland tumour in a less commonly involved gland, and discusses the impact of surgical intervention in the management of invasive salivary gland malignancies.

S275 References: 1. Jones, A.V. et al. ‘‘The Range And Demographics Of Salivary Gland Tumours Diagnosed In A UK Population’’. Oral Oncology 44.4 (2008): 407–417. 2. Armstrong, J. G. et al. ‘‘Malignant Tumors Of Major Salivary Gland Origin: A Matched-Pair Analysis Of The Role Of Combined Surgery And Postoperative Radiotherapy’’. Archives of Otolaryngology, Head and Neck Surgery 116.3 (1990): 290–293.

Endocolonic Ultrasound Mapping of the Mesocolon and Its Mesenteric Attachments: a Prospective Observational Study Byrnes KG1, O Leary DP1, Coffey JC1,2,3 1

Professorial Unit, Department of Surgery, University Hospital Limerick, Dooradoyle, Limerick, Ireland; 2Graduate Entry Medical School, University of Limerick, Limerick, Ireland; 3Centre for Interventions in Infection, Inflammation and Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland Recent advances in surgical and anatomic appraisals of the mesocolon have shown that the structure of the mesentery is different to what was previously thought, and that it is in fact a contiguous organ extending from the duodenojejunal flexure to level of the distal mesorectum[1]. No previous studies have characterized these advances in mesocolic anatomy using portable ultrasonography on ex vivo specimens. The aim of this study is to formally delineate and map the anatomical mesocolon and its mesenteric attachments using cadaveric specimens and ultrasonography. An ultrasound scan was performed postoperatively on 3 cadaveric specimens from patients undergoing colonic resections for either inflammatory bowel disease or cancer. A high-resolution portable ultrasound machine (SonoSite M-Turbo; SonoSite, Bothell, WA) with a curvilinear array transducer probe was used to perform the ultrasound scans. The specimens were suspended to simulate in vivo conformation of the mesentery. Orientation was achieved with needle insertion at macroscopic landmarks. Ultrasonography was performed on the endocolonic surface of the cadaveric specimens. The colonic wall and its structural architecture were visualized. The serosa was clearly represented by a hyperechogenic band orientated at the external surface of the colon. The mesentery and its interface with the colon was similarly identified by its hyperechogenicity and subsequently mapped by transducer manipulation along the endocolonic surface of the specimen in the distribution of the mesentery. We have demonstrated the feasibility of accurately delineating the anatomical mesocolon using portable ultrasonography. Moreover, the identification of the mesentery and its mesenteric attachments has scope for translation to the use of ultrasonography during colonoscopy. These findings hold potential for translation to novel diagnostic technologies in colorectal disease. Conflict of interest: None; Disclosures: None References: 1. Culligan K, Coffey JC, Kiran RP, et al. The mesocolon: a prospective observational study. Colorectal Dis. 2012; 14:421–30.

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What Lies Beneath Millar K, O Sullivan B Plastic Surgery department, Beaumont Hospital Basal Cell Carcinoma (BCC) is the most common type of skin cancer. In the vast majority of cases, BCCs are managed with simple surgical excision. They can, however be extremely invasive and cause devastating impact, which may require extensive reconstruction following excision. A 40-year-old gentleman was referred to the Plastic Surgery Department following a CT Brain, which revealed that a biopsy proven BCC at the vertex of his scalp had invaded the Dura mater of his brain. The patient also presented with 18 other scalp lesions, 8 of which were BCCs. The patient had a background history of Chronic Lymphocytic Leukemia with neurological spread at age 3 and relapse at age 13, requiring multiple cycles of chemotherapy and radiotherapy. Following Neurosurgical consultation, a plan was made to preform excision of BCC, frontoparietal craniotomy with antero-lateral thigh free flap (ALT flap) reconstruction. The ALT flap was raised form the patient’s right thigh. Three perforating vessels were harvested from the medial aspect of the flap. The long saphenous vein of the left lower limb was also harvested. These vessels were then microsurgically anastomosed with the marginal mandibular branch of the left facial artery and facial vein. The right lower limb defect was repaired with a split thickness skin graft harvested from the left thigh. On day 5 post-op, the patient’s flap was ischaemic and he underwent removal of ischaemic ALT flap with further left ALT free flap reconstruction. On day 9 post second reconstruction, the flap appeared ischaemic and the patient returned to theatre. Following anesthetic induction, the flap spontaneously reperfused and no operative management was required. The patient was discharged to the care of the neuro-radiation oncology. He is under consideration for the use of Vismodegib, a hedgehog inhibitor that is licensed for use in complex BCCs.

Central Nervous System Lymphoma Coady L, Gullo G Department of Oncology, St. Vincent’s University Hospital, Dublin 4 Introduction: Central nervous system involvement in indolent lymphomas is rare, occurring in an estimated 3 % of patients.1 Case: A 62-year-old man presented in August 2015 with a 2-week history of unsteady gait, decreasing mobility, impotence, constipation, saddle paraesthesia and lower back pain. He had previously been diagnosed with Stage IIIA Follicular NonHodgkin’s Lymphoma in December 2013, when he presented with a sore throat and palpable nodes in his neck. He had a background history of schizophrenia and lived in poor social circumstances. He was kept on active surveillance with 3-monthly CT scans until September 2014 when he developed symptomatic progression of disease (POD). He was treated with Rituximab, discontinued after first dose due to severe allergic reaction, and COP (Cyclophosphamide, Vincristine, Prednisolone) for 6 cycles. Post-treatment CT scan in April 2015 showed further POD and he was treated with Bendamustin for 3 cycles, together with a Rituximab re-challenge, which again resulted in allergic reaction.

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 MRI lumbar spine on admission revealed abnormal appearances of the cauda equina with diffuse malignant infiltration. MRI whole spine revealed lymphomatous involvement of the conus and cauda equina extending from the T11-T12 disk space to the lumbrosacral junction. He underwent treatment with high dose steroids and radiotherapy (RT) to the thoracic-lumbar spine. Shortly after completion of RT he developed intermittent diplopia, nausea, vomiting and was diagnosed with right lateral rectus palsy. He subsequently developed right lower motor neuron facial nerve palsy. MRI brain showed no abnormally enhancing intracranial lesions or leptomeningeal enhancement. Lumbar puncture confirmed leptomeningeal disease and he received whole brain RT. However, his symptoms deteriorated rapidly and he was transferred to the hospice for end of life care where he passed away about 10 days later. Conclusion: Although rare, CNS involvement in indolent lymphomas should always be considered in patients presenting with neurological symptoms. Reference: 1. Spectre G., Gural A., Amir G, Lossos A., Siegal T., Paltiel O. Central nervous system involvement in indolent lymphomas; Ann. Oncol 2005; 16(3):450–454

Audit to Determine the Incidence of Central Line Associated Bloodstream Infections in ICU Setting of Letterkenny University Hospital McGarrigle C, Ng K, Aremu M, Sugrue M Department of Surgery, Letterkenny University Hospital, Donegal West Northwest Objectives: Central line associated bloodstream infections (CLABSI) represent a serious issue for ICU patients. The aim of this audit was to determine incidence of CLABSI in this institution and to recommend any changes based on current guidelines to decrease infection rate. Design/methods: In this retrospective study, all ICU patients in Letterkenny University Hospital, who had a central line inserted during a 12 month period between December 2014 to December 2015 were included. Twenty-three patients who died within 48 h of insertion of their central line were excluded from the study as they were not eligible for inclusion criteria of a CLABSI (1). Data was collected using records from the ICU department and microbiology reports. Results: One hundred and seven patients were included in this study. 86 % (92) were internal jugular, 5 % (5) subclavian and 9 % (10) femoral insertion sites. Total parenteral nutrition was administered through the central line in 31 % (34) patients. 30 % (32) patients had a laboratory confirmed bloodstream infection while a central line was in situ, while 21 % (23) met the criteria for a CLABSI. Gram positive organisms accounted for 78 % (18).Gram negative and fungal infections accounted for 17 and 9 %, respectively. Of all central lines used for TPN, 44 % of these developed a CLABSI, whereas 12 % of the patients not administered TPN developed CLABSI. 30 day mortality occurred in 39 % (9) of patients with a CLABSI, compared to 12.5 % (9) of patients with no CLABSI.(p = .01) Conclusions: The high incidence of CLABSI in this institution requires intervention. Introduction of minocycline and rifampin-impregnated central lines have recently been shown to substantially decrease infection rates in ICU patients (2). A simple educational programme on central line care, primarily directed toward ICU and

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ward nursing staff have been shown to dramatically decrease the incidence of CLABSI, leading to a subsequent drop in cost, morbidity and mortality attributable to central line infections (3 and 4).

The Importance of Outruling Organic Pathology in Patients with Depression Who Report Weight Loss

References: 1. http://www.cdc.gov Bloodstream Infection Event (Central LineAssociated Bloodstream Infection and Non-central line-associated Bloodstream Infection) 2015 2. Effectiveness of minocycline and rifampin vs chlorhexidine and silver sulfadiazine-impregnated central venous catheters in preventing central line associated bloodstream infection in a high volume academic intensive care unit: A before and after trialStephanie Bonne et al. 2015 3. A Simple Educational Intervention to Decrease Incidence of Central Line Associated Bloodstream Infection in Intensive care units with low baseline incidence of CLABSI-Alfonso Perez Parra et al. 2010 4. The impact of bedside behaviour on catheter-related bacteremia in the intensive care unit—Craig M et al. 2004

Conroy J1, Kirca M1

Diagnostic accuracy of a clinical prediction rule (CPR) for identifying patients with recent-onset undifferentiated arthritis who are at a high risk of developing rheumatoid arthritis: A systematic review and meta-analysis McNally E, Keogh C, Galvin R, Fahy T Objectives: The Leiden clinical prediction rule (CPR) was developed in 2007 to predict disease progression in patients with recent-onset undifferentiated arthritis (UA). This systematic review and metaanalysis investigates the predictive ability of the rule at identifying patients who are at a high risk of developing rheumatoid arthritis (RA). Methods: A systematic review of the literature search was conducted from 2007 to May 2013 to identify studies that validated the rule. This study adhered to the PRISMA guidelines. The methodological quality of studies was assessed using the QUADAS-2 tool. Pooled sensitivity and specificity values for each of the cut points were generated using a bivariate random-effects model. Heterogeneity was assessed using the variance of logit-transformed sensitivity and specificity. Bayes’ theorem was used to calculate post-test probability of progression from UA to RA. Results: The search identified four relevant studies, resulting in six data sets (n = 1084). A cut point of C 9 was identified as the optimal cut point for determining progression to RA. It is associated with a greater pooled specificity (0.99, 95 % CI 0.95–1.00) than sensitivity (0.31, 95 % CI 0.24–0.37). Using Bayes’ theorem, a score of C 9 points increased the pre-test probability from 40.04 to 93.63 %. A less stringent cut-off of C 8 also identified a significant proportion of patients at risk of RA who have a high likelihood of progressing to RA (LR + 9.5, 95 % CI 6.21–14.54). Conclusion: A cut point of C9 offers an optimal estimate for identifying patients with UA who are at a high risk of developing RA and warrant intervention. However, a number of methodological limitations identified across studies suggest that the results should be interpreted cautiously and that further validation of the Leiden CPR is necessary.

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Department of Gastroenterology, Midlands Regional hospital Mullingar UCD Intern training Network Introduction: In 2014, 377 new cases of HIV were diagnosed in Ireland with a median age of diagnosis of 33 years. 38 (10.1 %) of those diagnosed had a concurrent AIDS diagnosis [1]. Description/case presentation: A 48 year old male was referred to MRHM with unintentional weight loss of 15–20 kg over the previous 12 months. He reported fatigue and reduced exercise capacity and had a generalised erythematous pruritic rash. The patient had a long history of depression and described his mood as being particularly low over the past year. A recent OGD and colonoscopy had found no pathology and it was thought that his mood was the cause of his weight loss. Routine bloods were performed and he was lymphopenic (0.22) with no other abnormality. On a 6-minute walk test he de-saturated to 79 % after 3 min and testing was stopped. A CXR showed no significant abnormality but a CT-TAP showed marked emphysematous changes and marked new cystic changes in both lungs, predominantly in the upper lobes. These changes were characteristic of atypical infections found in immunocompromised patients and the patient was screened for HIV. HIV testing was positive and his CD4 + T cell count was 48 giving a concurrent diagnosis of AIDS. He was counselled on the implications of the diagnosis. The only risk factor identified was a single unprotected sexual encounter 10 years previously. Based on the CT findings and his immunocompromised status he was treated for PCP and commenced on Septrin immediately. He was transferred to the Infectious Diseases unit at SJH where he has been commenced on anti-retroviral therapy. 1. HSE. Health Protection Surveillance Centre. HIV in Ireland, 2014. Dublin: Health Protection Surveillance Centre; 2015.

Effects of Magnesium Sulphate on Respiratory Function in the Preterm Infants Who Received Magnesium Sulphate Prophylaxis at Delivery O Reilly E, Rogers EL, Hayes B Department of neonatology, The Rotunda Hospital, Dublin Introduction: Magnesium sulfate [MgS04] is administered to expectant mothers prior to preterm delivery in order to minimize the risk of cerebral palsy in the neonate by 32 %.[i] However, there is concern surrounding its safety and the adverse effects it poses on the newborn infant. It has been hypothesized that magnesium sulphate neuroprophylaxis is associated with an increased need for respiratory support in the neonate, yet there is insufficient evidence based research to support this finding. The aim of this study was to audit the use of magnesium sulphate neuroprophylaxis treatment and to determine whether it adversely affects neonatal respiratory function post preterm delivery.

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S278 Methods: A retrospective study was conducted on 100 preterm infants born at the Rotunda Hospital, Dublin, during the time period July 2012-December 2012. Subjects were newborn infants delivered at 24–32 weeks of gestation whose mothers received MgS04 prophylaxis treatment prior to delivery. Control infants were infants also delivered at 24–32 weeks whose mothers were not recorded as having received MgS04 therapy prior to delivery. Measure of respiratory function was based on the following: Need for intubation, time after delivery of intubation, length of intubation, need for CPAP, BiPAP, Apgar scores, administration of antenatal steroids and grade of intraventricular haemorrhage. Results were analysed comparing two standard groups; those exposed to MgS04 and the non-exposed and measures of respiratory function were compared against administration and MgS04 and time before delivery of MgS04. Results: Out of these 100 infants, 55 received MgS04 infusion prior to delivery, while the remaining 45 did not receive any MgS04 prophylaxis. The results of the study showed that MgS04 administration had no significant effect on Apgar scores after birth compared to the Apgar scores of the control group. Mean Apgar scores at 1 min of the magnesium exposed group and control group were 6.45 and 6.67, respectively (p = 0.6295, 95 % confidence interval; student t-test). The same trend applied to Apgars at 5 min, [8.02 for both groups (p [ 0.05)] and 10 min [8.6 and 9.23, (p [ 0.05)]. With p [ 0.05, all differences between the two groups are considered to be ‘not statistically significant’. Babies born to mothers who had received MgS04 closest to time of delivery remained intubated for a longer median of hours compare to those born to mothers who received it the longest amount of time before delivery.Infants who had received MgS04 were intubated for a shorter period of time in comparison with those who did not receive MgS04. The data was controlled for gestational age and these findings were found to be statistically significant (p = 0.0011, 95 % confidence interval). There was a notably variation in the length of hours of intubation among the subgroups who received MgS04 at different time periods before delivery. Subgroups were divided into babies whose mothers received MgS04 \1, 0–4, [4 h prior to delivery. Conclusion: Infants born to mothers treated with MgS04 are at no increased risk of respiratory depression at birth. Post delivery, there is no increased need for intubation, however, infants of mothers who received MgS04 nearer to time of delivery may be associated with longer length of time of intubation than those who receive it further from time of delivery. There were no additional respiratory complications experienced by the neonate that could have been attributable to MgS04. MgS04 is an effective neurophylaxis that should be continued to be administering to mothers in preterm labour. However, we recommend further research be carried out in this area with larger sample size and statistically comparable controls. 1. Doyle LW, Crowther CA, Middleton P, Marret S, Rouse D.Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus Cochrane Database Syst Rev. 2009 Jan 21

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Introduction: Portal hypertension is defined as a chronic increase in portal pressure due to mechanical obstruction of the portal venous system. Most common causes include intrahepatic obstruction of portal venous flow from cirrhosis. Variceal formation is a common complication. A TIPS procedure is effective in the management of ectopic variceal bleeding. Case: 51 year old female who presented with a 2 day history of right upper abdominal pain, fever and syncope. Her past medical history included rheumatoid arthritis (on prednisolone 2 mg OD), 2 previous thoracotomies for rheumatoid lung disease in 2014, a Hartmann’s procedure for diverticular disease in 2014, a recent admission for biliary sepsis and was awaiting elective laparascopic cholecystectomy. Biliary sepsis was diagnosed and she responded well to antibiotic therapy. On Day 7 of admission two episodes of BRB per stoma (*150 ml) were noted. Subsequent further episodes of bleeding per stoma, requiring RCC transfusions and ICU admission, with two focal spouts of bleeding were identified. A TIPs procedure was performed with no further episodes of bleeding. Ultrasound guided liver biopsy confirmed liver cirrhosis. Discussion: Ectopic varices occur at various sites in the abdomen including small bowel, rectum, stomas, falciform ligament, umbilicus, retroperitoneum, biliary tract, vagina and bladder. \5 % of all varices occur from ectopic sources. Bleeding from these sources can be difficult to manage because of an initial difficulty in determining the source of bleeding and subsequent difficulty in application of therapy due to inaccessibility of varices in some locations. Transjugular intrahepatic portosystemic shunts (TIPS) involves the creation of a low-resistance channel between the hepatic vein and the intrahepatic portion of the portal vein (usually the right branch) using angiographic techniques. It is kept patent by deployment of an expandable metal stent across it, thereby allowing blood to return to the systemic circulation and reducing portal pressures. References: 1. Transjugular intrahepatic portosystemic shunt in the treatment of intermittently bleeding stomal varices. Bernstein D, Yrizarry J, Reddy KR, Russell E, Jeffers L, Schiff ER.Am J Gastroenterol. 1996;91(10):2237 2. The side-to-side portacaval shunt revisited. Grace ND N Engl J Med. 1994;330(3):208. 3. The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension: update 2009.Boyer TD, Haskal ZJ, American Association for the Study of Liver Diseases Hepatology. 2010;51(1):306.

A Pyrexia of Unknown Origin Brennan F1, O’Driscoll L1, Daly T1 1

Department of Medicine for the Elderly, Mater Misericordiae University Hospital, University College Dublin

Bleeding Stomal Varices managed by TIPS procedure: A Case Report Ahern D, Martin S Intern Network: UCD

Department of Colorectal Surgery, St. Vincent’s University Hospital, Dublin

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A 75 year old man presented with a 2 week history of general malaise with fevers, night sweats and myalgia. This was on a background of an excision of a malignant melanoma 4 months prior and aplastic anaemia treated by steroids 30 years before. This resulted in avascular necrosis at the time leading to a left total hip replacement 5 months prior to admission. On admission he was febrile, with raised inflammatory markers and a leucocytosis. He was treated empirically with IV vancomycin and meropenem. He was investigated for an infectious cause of his symptoms including 12 negative blood cultures, CT-TAP, trans-oesophageal echo, bone-scan, viral screen and a lumbar puncture among others with no likely cause identified. His

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 condition worsened over the following week, spiking fevers nightly and developing lower limb weakness. An infectious cause looking unlikely and with a ferritin greater than 3000, IV steroids were started resulting in a rapid improvement clinically and biochemically. Over the course of his admission he was fully investigated for an infectious, auto-immune and neoplastic/paraneoplastic cause of his symptoms. None were found beyond quadriceps oedema on MRI and PET-CT. Possible diagnoses had included adult-onset Still’s disease however this did not explain the oedema. A muscle biopsy then showed evidence of fasciitis. This and the history of aplastic anaemia suggested eosinophilic fasciitis however repeat fascial biopsy (after commencement of steroids) was non-diagnostic. Unfortunately there has been no definitive diagnosis to date though it is likely he has a fasciitis responsive to steroids. This case demonstrates a thorough work up of a pyrexia of unknown origin as well as the dilemma of when to start steroid treatment when an as yet undiagnosed systemic inflammatory process is ongoing.

Analysis of the Efficacy of a Selective Ultrasound Screening Programme for Developmental Dysplasia of the Hip McDonnell CM, Laffan E, Fenelon R, Roberts J, Donoghue V Department of Radiology, National Maternity Hospital, Holles Street, Dublin 2 Background: Early treatment provides the best outcome for infants diagnosed with developmental dysplasia of the hip (DDH). There is no uniform screening policy for this condition in Ireland. Selective hip ultrasound (US) screening is performed at the National Maternity Hospital (NMH). If there is clinical suspicion of frank hip dislocation or a dislocatable hip during neonatal examination the infant is referred for a hip US prior to discharge. Additionally, infants who fall into the following categories are referred for hip US at approximately 6 weeks of age: • • • •

Breech presentation Significant family history Hip ‘‘click’’ Congenital foot deformity

We assessed the efficacy of this screening programme in infants born in 2011 with follow-up for a minimum of 18 months. Methods: We reviewed the imaging reports of all infants referred to the orthopaedic team at Temple Street Children’s Hospital with an ultrasound diagnosis of DDH in 2011. All follow-up imaging studies of those referred were reviewed. Results: There were 10,302 infants born at NMH in 2011. Of those 1988 were referred for hip US. 154 (1.5 %) infants were diagnosed with DDH and were referred to orthopaedics. Of these, 8 had a clinically suspected dislocation at birth, which was confirmed on US examination with treatment initiated prior to discharge. 38 infants were breech, 48 had significant family history, 50 had a hip ‘‘click’’ and the remainder had other indications. At follow-up at 24 months, 7 infants (0.7 per 1000 births) had undergone Salter osteotomies, and 3 were lost to follow-up. All remaining infants had normal hips at 18–24 months. Conclusions: The selective screening programme is effective. The referral rate to orthopaedics compares well with rates in the limited published literature. Late Salter osteotomy rates (0.7 per 1000 births), while low, are higher than rates quoted in the limited literature (0.38 per 1000 births).

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Attitudes towards opting out of paper based reports for rapid turnover blood lab tests amongst hospital doctors in the departments of Geriatric Medicine and the Acute Medical Unit at the University Hospital of Limerick Bloch A, O Sullivan F South-West Objective: It is currently national HSE policy that all laboratories issue paper based reports for all lab test, including rapid turnover tests that are routinely reviewed electronically on acute inpatients. Some departments in UHL, such as the Heart Failure Clinic, have devised a policy (including recommendations around governance and audit) to opt out of issuing of such paper reports. The departments of Geriatric Medicine and the Acute Medical Unit at University Hospital Limerick are considering adopting such a protocol for rapid response lab results. I conducted a qualitative survey to assess attitudes towards changes in the current protocols. Design/method: A simple, qualitative survey was either sent electronically or via paper based copies to current and recent NCHD’s and consultants in the Acute Medical Unit and Geriatric Medicine departments at University Hospital Limerick. In total 13 doctors responded from both departments. The template for the survey was roughly borrowed form those used in other departments which have adopted a policy to opt of issuing paper based lab reports. Results: The views of the NCHDs and consultants surveyed largely agreed that the change would save clinically relevant time (92.31 %) without affecting quality of care or patient safety (92.31 %). 76.92 % of respondents strongly agreed with a change from the issuing of paper based reports. Conclusion: The change of practice from issuing paper based lab reports to electronic lab reports only for acute inpatients under the care of the Acute Medical Unit or Geriatric Medicine departments is largely accepted amongst all ranks within both departments. This project will lead on to a proposal, which we will then audit to assess the efficiency of the proposed change.

Use Your Head: Creating a Standardised Pathway For Head Injuries at Mayo University Hospital Murray M1, Reynolds I1, Hand F1, Coyle P1, Barry K1, Waldron R1 1

Mayo University Hospital

West Northwest Intern Training Network Introduction: Head injuries are a common presentation to the emergency department and account for a significant proportion of admissions, usually under the general surgical service. The aim of this study was to examine the incidence, mechanism and outcomes of head injuries admitted over a 3 month period at Mayo University hospital (MUH). Methods: Data was collected from electronic-handover, electronicdischarge, radiology and inpatient notes. Data collected included mechanism of injury, use of computed tomography (CT), the presence of acute intracranial pathology on CT and overall length of stay. Results: 68 patients with head injuries (mean age ± SD, 46 ± 28 years) were admitted to MUH over a 3 month period. 48 (70.6 %) of the head injuries admitted to MUH were classified as mechanical which included falls secondary to environmental causes and medical causes.

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S280 20 (29.4 %) of the patients admitted had alcohol consumption determined as the main causative factor of their admission. There was one fatality and 2 head injuries requiring acute transfer to a tertiary neurosurgical unit. 32 (47.0 %) of the patients admitted to MUH had a length of stay 24 h or less. 59 (86.8 %) patients admitted were investigated with CT with 23 (39.0 %) positive for intracranial pathology. The average length of stay was 2.65 days (mean stay ± SD, 2.65 ± 3.17). Conclusion: CT is performed in most patients admitted with head injuries and has positive findings in almost 40 %. The remainder have normal scans and hence may be suitable for early discharge. Our findings suggest that 24 h access to CT scans and prompt reporting for patients with head injuries has the potential to reduce surgical admissions and thus contribute positively towards the current bed crisis in Irish hospitals. Furthermore public health initiatives in the community may play a role in reducing admissions due to head injuries given that 29 % were secondary to alcohol consumption in our study.

Right Sided Weakness: A Presentation of Infective Endocarditis? More CC, O Sullivan F University Hospital Limerick Introduction: This is the case of a young male who presented with what was thought to be a simple transient ischaemic. His symptoms had resolved upon arrival but after a full work up the evidence pointed to an embolic event secondary to infective endocarditis. Case description: The patient is a 48 year-old male who was brought in by ambulance to the emergency department following sudden onset right sided weakness lasting approximately 45 min. The patient presented after being found collapsed in the bathroom by his daughter. He could not recall feeling ill in the days/weeks prior to this event, however, careful history taking revealed that he has been suffering from night sweats for the last year. Upon arrival, neurological symptoms had resolved but he was found to have a temperature of 38.1 degrees Celsius, white cell count of 13.75, neutrophils of 11.95 and a CRP of 202. Blood cultures came back positive for Staphylococcus Aureus x 1 bottle. Trans thoracic echo showed no abnormalities to the heart valves and there were no other clinical signs. MRI showed acute infarcts in the left frontal-parietal and basal ganglia regions without evidence of vasculitis. The clinical picture lead to a diagnosis of infective endocarditis with cerebral embolisation and the patient was commenced on high dose flucloxacillin. His symptoms resolved within 5 days and no embolic/infection source was ever found after multiple investigations. Discussion: This simple case demonstrates the strength that just one clinically significant neurological event coupled with careful history taking and a few blood test results can lead to a very important diagnosis of infective endocarditis. In essence it illustrates how subtle a severe and life-threatening disease can present and highlights the importance of having broad differentials.

Intranasal Fentanyl for Paediatric Orthopaedic Injuries in the Emergency Department Davey N, O Sullivan R Cork University Hospital

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Background: CUH has an annual census of 60,000 patients and is the largest ED in Munster. Acute pain is the most common presenting symptom amongst paediatric patients attending Cork University Hospital (CUH) Emergency Department (ED). A protocol for intranasal Fentanyl (INF) was introduced in CUH ED in August 2013 and this is the first known time that it has been studied in Ireland. Venepuncture is cited as one of the worst types of pain that hospitalised children experience; prior to the introduction of INF, intravenous (IV) Morphine was the sole agent used to treat severe pain. This project aimed to determine whether the introduction of INF increased the overall number of paediatric patients being treated appropriately for acute and severe pain. Methods: A retrospective chart review was conducted in a mixed adult and children ED following the introduction of Intranasal Fentanyl (INF). The population of this ‘before-and-after’, observational study consisted of all 1–15 year old children presenting with longbone injuries over a 10-month timeframe. Results: 1052 patients received an opioid medication over the 10 month timeframe; only 92 (8.75 %) of these patients were children. Children with long bone injuries constituted the majority (59.78 %) of paediatric patients receiving Morphine or INF. Following the introduction of INF, more children received opioid analgesia (n = 40) as opposed to when IV morphine was the sole analgesic in use (n = 15). Children receiving INF were younger than those receiving morphine (median = 7.9 vs. 8.59 years). The median time to analgesia was 63.56 min for Morphine and 81.76 min for INF. Conclusion: Opiophobia results in children being under-treated for obviously painful conditions as compared to their adult counterparts. Although, analgesia use continues to be sub-optimal, the introduction of an alternative opioid analgesic that avoids intravenous access increased the likelihood of children receiving appropriate opioid analgesia when clinically indicated.

Alpha-1 Antitrypsin Deficiency Associated Panniculitis Hevican C, Klaus S, Chaudhrey A, Quill D University College Hospital Galway West North West Introduction: Alpha one antitrypsin deficiency is an autosomal, codominant genetic disorder resulting in the polymerization of abnormal, misfolded proteins in hepatocytes. Mutations manifest primarily as pulmonary and hepatic conditions. Dermatological complications include vasculitis and panniculitis. The latter is quite rare, with less than 60 cases reported, mainly in homozygous individuals. Case presentation: A 23-year-old female presented to UCHG with multiple erythematous areas throughout her body and non-pitting oedema on the left leg, on a background of alpha 1 antitrypsin deficiency (PiZZ subtype). Initially, she was treated with doxycycline and co-amoxiclav, but failed to improve. Following this, she was commenced on a reducing regime of oral prednisolone, anti-inflammatory, anti-viral medications and hydroxychloroquine. Histological examination confirmed features consistent with septal panniculitis, with involvement of the deep reticular dermis suggestive of alpha-1 antitrypsin associated panniculitis. Clinical deterioration lead to readmission of the patient. As well as increasing serous discharge from the biopsy sites and worsening generalized oedema, she was also complaining of diffuse abdominal

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 pain. An exploratory laparoscopy revealed a collection in the right fallopian tube. What followed was a complex clinical course, necessitating admission to ICU, albumin infusions and ultimately, infusion of alpha one antitrypsin itself. Conclusion: Alpha one antitrypsin deficiency is characterized by a broad spectrum of disease. While much is known about the heterogeneity in phenotypic expression among the genetic variants of the condition, the clinical pictures of these patients do not always correlate with the patient’s level of alpha one antitrypsin. Patients who develop the rarer manifestation of panniculitis are at risk of developing pulmonary emboli, pericardial effusions and pancreatitis. Wound healing is also compromised further by steroid therapy and deficiency states (hypoalbuminemia). In light of this, it seems pertinent to consider the relevance of the current guidelines for augmentation therapy of alpha one antitrypsin deficient patients.

Treatmet Dilemmas in practice: A case of Clozapine induced Interstitial Nephritis O Connor T, Holian J St. Vincents University Hospital Case presentation: A 42 year old female presented to the Emergency Department with a 1 month history of elevated inflammatory markers and worsening renal function (Urea 7 mmol/L; Creatinine 193) since the commencement of Clozapine for treatment resistant Schizophrenia. In addition, she had recently been treated for a Urinary Tract Infection with Co-Amoxiclav. Original Clozapine dosing was 25 mg mane and 100 mg nocte and was switched to 25 mg BD, 2 weeks prior to presentation. Initially, there was no sign of hypotension and Renal Ultrasound showed no signs of obstruction. Urine dipstick was positive for blood and relevant blood results included CRP 61; Eosinophils 0.9; ANCA positive; Free Kappa Light Chains 209.10; Free Lambda Chains 97.01; Kappa Lambda Ratio 2.16 and Gamma moderate polyclonal increased. Over the following 3 days, renal function continued to deteriorate with CRP rising to 252. As a result, the patient was sent for renal biopsy which noted diffuse marked inflammatory infiltrate with greater than 90 % plasma cells. After excluding a plasma cell dyscrasia, a diagnosis of drug induced interstitial nephritis was noted. Treatment: Based on the biopsy results, Clozapine was stopped and the patient switched to alternative anti-psychotic medications. In addition, the patient was commenced on 60 mg Prednisolone. Discussion: The first case of Clozapine induced interstitial nephritis was reported in 1999 1 and to date, a total of ten cases of Clozapine attributed acute interstitial nephritis have been reported in the literature 2,3. This case highlights the detrimental side effects of medications. Interestingly, this case draws attention to the deterimental impact of medication side effects as well as highlighting the treatment dilemma between stopping Clozapine to allow AKI recovery and the risk of inducing acute psychosis in treatment resistant Schizophrenia. References: 1. Clozapine Induced Acute Interstitial Nephritis, Elias TJ, Bannister KM, Clarkson AR, Faull D; Lancet 1999, Oct 2;354 (9185): 1180–1 2. A case of Acute Renal Failure in a patient recently treated with clozapine and a review of previous cases; Kanofsky. JD,

S281 Woesner. ME, Harris. AZ, Kelleher JP. Prim Care Comparison CNS Disord 2011;13:PCC.10br01091 3. Clozapine Induced Acute Interstitial Nephritis; Chan. SY; Cheung CY; Chan PT; Hong Kong Med J. 21/4(2015)

A Retrospective Analysis of the Influence of PET CT on the Subsequent Management of Head and Neck Malignancy O Connor T, Curran A St. Vincent’s University Hospital Introduction: PET-CT scan is a commonly used imaging modality for the initial staging and surveillance of patients with head and neck malignancy. It has been suggested that diagnostic pre-operative PETCT could accurately predict the pathological staging of head and neck malignancies and thus contribute more effectively to the management. Method: Retrospective analysis of all pre-treatment PET CT scans carried out over a 14 month period for patients (n-46) with suspected head and neck malignancy. Results: Pre-treatment PET CT had a significant impact on the management of head and neck malignancy. In 52 % of cases, the PET CT led to a change in the TNM staging. In addition, PET CT led to a revision of the proposed treatment plan in 46 % of cases. As to the effect on the TNM staging of head and neck malignancy, 37 % of patients were upstaged, 15 % were downstaged and 48 % of cases remained unchanged following PET CT. On examination of the specific parameters of TNM staging, it was found that the pre-treatment PET CT scan resulted in the modification of the Primary Tumour Grade (T) in 39 % of cases, in the Regional Nodal status (N) in 20 % of cases and in the Metastatic status (M) in 26 % of cases. The influence of the PET CT scan on the initial treatment plan was also examined. In 46 % of patient cases, the PET CT resulted in the revision of the treatment plan. Discussion: We have found that PET CT upstaged the malignancy in 37 % of cases, downstaged in 15 % and influenced the treatment modality in a total of 46 % of patient cases. Despite the significant positive impact of diagnostic PET CT, our analysis identified one case where PET CT led to a false positive upstaging of malignancy on the background of multiple inconclusive biopsies and subsequently resulted in unnecessary surgery.

Extra-Testicular Leydig Cell Tumour: A Case Report Abstract Davey N, Looney A, Daly P, Cullen I University Hospital Waterford Introduction: Leydig Cell Tumour are unusual testicular tumours which are usually benign and rarely occur outside the gonad. They account for 1–3 % of all testicular neoplasms. Leydic Cell Tumours occur at all ages, but are most common between the second and sixth decades of life. Case description: A 50 year old gentleman presented with a year long history of fatigue, decreased libido and a right scrotal mass.

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S282 Physical examination revealed bilateral testes of normal consistency but a firm oval mass abutting the right epididymis. There were no extra-scrotal positive examination findings. Doppler ultrasonography was performed which demonstrated a hypervascular 2.9 cm solid lesion adherent to the head of the right epididymis. An early-morning serum testosterone revealed a lowerend of normal reading of 11.8 nmol/L (8.3–27.8). Further biochemical investigations and a staging Computed-Tomography of his Thorax, Abdomen and Pelvis were unremarkable. This gentleman underwent an urgent right inguinal radical orchidectomy. Histological analysis of the specimen demonstrated a benign encapsulated Leydig Cell Tumour (LCT) separate to the right epididymis and testis, with no dysplastic features, no lymphovascular invasion or tumour necrosis and less than one mitosis per high power field. Immunohistochemistry revealed the tumour was positive for a-Inhibin, Calretinin and Melan-A; this is consistent with a benign epididymal LCT. Discussion: This case highlights a rare type of extra-testicular LCT. LCT’s are a steroid secreting tumour which can present with testicular swelling, decreased libido (20 %) and gynecomastia (15 %). LCT’s can also be disovered incidentally. In the past few years, the incidence of LCT’s has increased which is possibly explained by the use of better ultrasound technology. The diagnostic immunopanel of LCT is diffuse cytoplasmic positivity for a-Inhibin, Calretinin, Melan-A, and vimentin and negative immunostaining with cytokeratin. The prognosis for benign LCT’s is excellent; however the mean survival in patients with a malignant variant is 2–3 years.

‘‘Supremely Well Hydrated Postoperative Patient Leaves Surgeons Stunned!’’: Case Report Extract Clancy K, McMahon G, Joyce M University College Hospital Galway Introduction: This is a submission regarding a very interesting case observed from our time at UCHG! It’s the story of NL, a 66 year old, self caring lady who underwent an electively planned and uncomplicated abdominoperineal resection with sacrectomy and subsequent flap construction for management of locally invasive rectal cancer. Case description: NL was first referred for an urgent outpatient appointment by her GP for investigation of recent unexplained weight loss and persistent iron deficiency anaemia. Of note; She was noted to have a longstanding history of bipolar disorder which was managed with regular lithium. She was also noted to have CKD stage 3a and was an ex smoker with a 20 pack year history. She underwent a colonoscopy with biopsy, imaging and histological investigations revealed a locally invasive, mid rectal adenocarcinoma involving meso-rectal fascia, anterior sacrum and multiple perirectal nodes. Her ICU stay was complicated by the formation of a left lower lobe collapse due to a mucus plug and was managed appropriately. Following her transfer to the ward she developed a massive diuresis of over 5 L/24 h. On consultation with the endocrinology and renal teams; the impression was that she had developed nephrogenic diabetes insipidus secondary to chronic lithium therapy. She was managed with strict control of her fluid balance, monitoring of urea and electrolyte and her lithium was substituted for a second generation antipsychotic medication. With continued input from medical teams she made a good recovery and arrangements were made for her to be followed up in the community regarding this issue. Discussion: Diabetes insipidus is a rare but possibly under-recognized phenomenon especially in those who are taking lithium therapy long term. A better understanding of this complication may benefit its appropriate management in the future.

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‘‘A Lucky Evacuation!’’: Case Report Extract McMahon G, Clancy K, Joyce M University College Hospital Galway Introduction: This is a submission regarding a very interesting case observed during our time at UCHG! It’s the story of PS; a 70 year old gentleman who was admitted for drainage of a left lower limb haematoma on a background of a 20 year history type 2 diabetes, atrial fibrillation on warfarin therapy, and hypertension. Case description: He was admitted to The Galway Clinic complaining of left hip pain radiating to his knee, a loss of sensation over the anterior left knee, and a loss of power in the left leg. He had required wheelchair assistance to mobilise for the previous 2 days and had no prior history of these symptoms. Of note; His INR was mildly elevated at 4.5 on admission. He was uncomfortable at rest and nonweight bearing on his left side. The power in his left leg was 3/5 (He couldn’t move his leg up; against gravity) and there was decreased sensation over the anterior knee joint. Imaging showed a only left iliopsoas haematoma anterior to iliac blade with surrounding oedema. Subsequently, he was transferred to UCHG for emergency surgery. Intraoperatively; following a blunt dissection down the left iliac wing—a large swelling was palpable in the iliacus body. The fascia of the muscle was released and two washout drains inserted. Following surgery he was weight bearing with a return of left anterior knee sensation. With the help of physiotherapy he was able to regain full strength in his left leg within a number of days. Discussion: Intramuscular haematomas are a rare but possibly underrecognized phenomenon especially in those who are on long term warfarin therapy. A better understanding of this complication may benefit its appropriate recognition and management in the future. Luckily, PS did not suffer any irreversible complications due to prompt access to imaging and surgical intervention.

Churg-Strauss Syndrome: the Unlikely Cause Arize C1, O’Loughlin A1 Department of Internal Medicine/Geriatrics, Roscommon County Hospital, Athlone road; WNW Intern Training Network Introduction: Churg-Strauss Syndrome is a rare systemic disease characterized by the triad of hyper-eosinophilia, asthma and necrotizing vasculitis. Although the cause is unknown, it can be triggered by hypersensitivity after inhaling an allergic agent or following a parasitic infection1. The lungs tend to be most commonly involved followed by the kidneys1. Case report: A 42-year-old female was referred by her GP for nonresolving LRTI refractory to oral antibiotics therapy. On presentation, a cough productive of yellow sputum was present with an associated pleuritic pain in the right subcostal region of the chest and weight loss. On physical examination, Her vitals were stable; RR 20, sats 97 %, BP 111/63, HR 65, temp 36.5. There were scattered crepitations on auscultation of both lung bases. She admitted to noticing subcutaneous nodular lesions mostly on the hands and the trunk. The relevant background includes mucosal sinusitis, asthma and nasal polyps. Imaging using a High-resolution computerized tomography (HRCT) revealed the presence of ground glass opacity throughout the left upper lobe. Full blood count showed moderate eosinophilia but vasculitic screen was negative. Biopsy of the subcutaneous lesions and nasal polyps were negative. An urgent review by a respiratory

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 specialist was requested. The diagnosis was made based on the presence of eosinophilia, findings on HRCT, sinus abnormalities, background history of asthma. She was started on high dose prednisolone and started to showed immediate improvement in symptoms. Discussion: Churg-strauss syndrome should be suspected in patients with a pattern or ground glass opacities and consolidation with an associated history of asthma and sinus problems1. These patients tend to respond well to high dose steroids. References: 1. Fernandes, G. (2014). Churg-Strauss syndrome: A case report. 47(4), 259–261.

Painless Weakness of an Upper Limb: An Unusual Presentation of a Surgical Problem Arize C1, O Mara G1 Department of Internal Medicine/Geriatrics, Roscommon County Hospital, Athlone road West North West Intern Training Network Introduction: Superior Labral anterior to Posterior (SLAP) lesion is a newly defined cause of shoulder disability. The incidence of SLAP lesions is about 3.9–11.8 %2. SLAP lesions can occur in association with paralabral cysts that extend into the joint space compressing regional nerves2. Knowledge about these lesions and a high index of suspicion are important in identifying this cause of shoulder weakness3. We describe the clinical findings, radiological findings, management and outcome in a patient who presents with a SLAP lesion associated with a spino-glenoid notch cyst. Description: A 49-year-old gentleman presented with a 6-month history of painless weakness of the right shoulder. On physical examination, weakness of external rotation and abduction above 90 degrees was reported. Ultrasound imaging showed the presence of a 3 cm spinoglenoid cyst encroaching on the suprascapular nerve. Further work up of the complaint with MRI arthrogram of the right shoulder reported a SLAP tear extending from approximately ten o’clock to one o’clock position. It also conveyed the presence of a paralabral cyst encroaching on the suprascapular neurovascular bundle. This was associated with atrophy of both the infraspinatus and teres minor muscle. The patient could not recall any significant shoulder trauma in the previous year. Arthroscopic decompression of the cyst was performed with associated SLAP repair and the arm was placed in a sling post-op. He received continuous physiotherapy and is now at his baseline with regards to movement Conclusion: There is a correlation between paralabral cysts and SLAP tears. These can be diagnosed effectively via Ultrasound or MRI and managed arthroscopically1. The majority of patients tend to report a favourable outcome following arthroscopic decompression and SLAP repair. References: 1. Rizzello, G. (2013). Bilateral Suprascapular Nerve Entrapment by Ganglion Cyst Associated with Superior Labral Lesion. The Open Orthopaedics Journal TOORTHJ, 129–132. 2. Lee, Y., Han, E., Choi, S., Kim, B., & Suh, M. (2015). Type 2 Superior Labral Anterior to Posterior Lesion-Related Paralabral Cyst Causing Isolated Infraspinatus Paralysis: Two Case Reports. Annals of Rehabilitation Medicine, 848–852. 3. Brockmeier, S. (2009). Outcomes After Arthroscopic Repair of Type-II SLAP Lesions. The Journal of Bone and Joint Surgery (American) J Bone Joint Surg Am, 91(7), 1595–1603.

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Venous Thromboembolism Prophylaxis in the Hospitalized elderly Patients: A Retrospective Audit Arize C1, O’Mara G1 Department of Internal Medicine/Geriatrics, Roscommon County Hospital, Athlone road WNW Intern Training Network Introduction: Venous thromboembolism (VTE) is prevalent in the elderly population (1). Hospital acquired thrombosis is defined as any episode occurring within 90 days of hospitalization (2). In the general population, the incidence of VTE is 1–2 per 1000 persons (2). This risk increases by 8 fold in hospitalized medical patients (2). A retrospective audit was performed to identify if elderly hospitalized patients at risk of VTE were receiving adequate pharmacological/mechanical prophylaxis. Method: A retrospective audit was conducted in which data was collected from 36 elderly inpatients (over 65 year old) on St. Coman’s ward on a single day. An audit proforma was constructed for efficient data collection. The proforma noted the patient gender, risk factors and risk stratification, pharmacological and/or mechanical prophylaxis. Results: The study comprised 36 patients all aged over 65 years with 19 (53 %) female and 17 (47 %) male. Following risk stratification using Caprini risk assessment model, 32 (88 %) patients were deemed to be at high risk of developing VTE.27 (75 %) of the patients were on pharmacological anticoagulation. Out of these, 33 % were receiving either warfarin or a NOAC for atrial fibrillation. 18 (50 %) were receiving VTE prophylaxis, which consisted of either enoxaparin, or tinzaparin. 9 (25 %) were not receiving pharmacological anticoagulation; out of these 3 were on mechanical prophylaxis (graduated compression stockings), 5 were mobilizing well and 1 patient did not receive anticoagulation. Conclusion: The majority of the patients (75 %) at risk of VTE were on appropriate prophylaxis. However, proper risk stratification strategies need to be implemented for appropriate prophylaxis to be administered unless contraindicated. This can be done by making a streamlined protocol for assessing patients on admission for risk of VTE. This will aid in administering the appropriate prophylaxis to the patients at risk. References: 1. Abdel-Raseq, H. (2010). Venous thromboembolism prophylaxis for hospitalized medical patients, current status and strategies to improve. Ann Thoracic Med, 5 (4), 195–200. 2. (2015). Thromboprophylaxis guidelines for Adult Patients in: Medicine, haematology and Oncology, Intensive Care Unit, Surgery, Orthopaedics, Major Trauma. Cork University Hospital, Hospital Thrombosis Group. Cork: Health Service Executive.

Application of National Guidelines to an Endoscopy Wating List O Mara N1, Young EA1, Devane LA1, Zeeshan S1, Cooke F1 1

Department of Colorectal Surgery, University Hospital Waterford, Waterford, Ireland Introduction: The introduction of national screening for colorectal cancer has placed great strain on the demands for gastrointestinal

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S284 endoscopy. The current endoscopy waiting time in our institution exceeds 10 months. We examined the repeat/surveillance colonoscopy waiting list to assess the appropriateness of these procedures compared to the national endoscopy guidelines. Method: The repeat/surveillance colonoscopy list contains 684 patients. A sample of 100 of these was selected. The hospital computer database of procedure notes, histology, radiology and clinic letters was reviewed and information on completeness of endoscopy, polyp histology, and other risk factors was compiled. The planned follow up interval was compared to the RCSI/RCPI endoscopy guidelines (2014). Results: Of the 100 cases, 41 were scheduled for a colonoscopy that was not required. A further 11 had the procedure scheduled sooner than recommended by a mean of 20 months and 9 were scheduled later than recommended by a mean of 33 months. Overall 61 % are listed inappropriately. Conclusion: We have identified that 41 % of patients in our surveillance waiting list sample can be removed from that list with a further 11 % postponed by an average of 20 months. We have also identified patients at risk due inappropriately long intervals. We expect that applying changes based on these findings will greatly benefit patients by reducing waiting list times, eliminating the risk of inappropriate procedures, and identifying those requiring earlier reexamination. Furthermore we expect significant cost savings to the institution and a more streamlined service.

‘What I Wish I Knew in Final Year’: Near Peer Teaching (NPT) in An Irish University Hospital O’Mara N, Davey N Department of Surgery, University Hospital Waterford Background: Near peer teaching (NPT) is a relatively new concept in education where a near peer tutor is a one or more years senior to another trainee (1, 2, 3) This teaching practice has been applied in many undergraduate medical education programs outside of Ireland (4). Recognizing the value of near peer teaching, the Royal College of Surgeons in Ireland (RCSI), has introduced a structured trainer the trainer (TTT) programme to provide medical interns with the tools required to deliver near peer teaching. NPT was launched in University Hospital Waterford in August 2015 with the brief ‘What I wish I knew in Final Year’. NPT at UHW is the only such programme in the country offered to two distinct university student groups. This pilot study seeks to determine the feasibility and value of NPT in an Irish university hospital. Methodology: Over 6 weeks, NPT sessions occurred once weekly in UHW. Sessions were designed to assist both UCC and RCSI students fulfill the principal clinical examination requirements of final year medicine. Feedback from students was elicited using minute papers, a validated classroom assessment technique. Results: An initial cohort of 54 students participated in NPT. Weekly teaching sessions had a 100 % attendance rate. Feedback from students revealed that: 54 (100 %) of students agreed teachers to be both approachable and helpful 51 (94 %) of students finding that teaching sessions helped better their understanding Conclusion: Initial results suggest participating students find NPT to be a valuable resource, and useful for exam preparation. NPT interns will be assessed to determine the perceived benefit of teaching, as the study progresses. It is anticipated NPT will become an increasingly useful tool as the teaching commitments burgeon in proportion rising student numbers.

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Mobile Devices in a Healthcare Setting: Fomite for pathogenic bacteria? O Mara N1, Ryan L2, Phelan E2, Doyle M2 1

Department Of Medicine, University Hospital Waterford; Department Of Microbiology, University Hospital Waterford

2

Background: Mobile phones are widely used by doctors throughout the course of clinical duties. The widespread use of these devices by doctors provide a new vector for the transmission of microbial pathogens (1, 2). Clear evidence exists that personal items, such as mobile phones, act as an ideal fomite (3). A recent meta-analysis revealed that up to 30 % of doctors mobile phones were contaminated with pathogenic bacteria, including antibiotic resistant organisms (4). In an Irish context, little data exists regarding the burden of potential microbial pathogens dwelling on doctors mobile devices. In this study we examine culture plates from swabs of mobile devices belonging to 100 non-consultant hospital doctors, looking specifically for the presence of multi-drug resistant organims (MRDO) i.e. meticillin resistant Staphylococcus aureus (MRSA), vancomycin resistant enterococci (VRE), carbapenem resistant Enterobacteriaceae (CRE) and extended spectrum beta-lactamase (ESBL). This is a pertinent venture considering the significant rise in antimicrobial resistance in Ireland. Ireland, for example, is the only country in Europe where the proportion of invasive E. faecium isolates which are VRE is greater than 25 %; in 2015 in Ireland 48 % were VRE. The proportion of invasive E. coli infection which were ESBLs increased from 6.1 % in 2010 to 10.8 % in 2015. The proportion of invasive K. pneumoniae infection which were ESBLs increased from 5.1 % in 2010 to 13.5 % in 2015. The proportion of invasive K. pneumoniae infections which were CRE increased from 0.0 % in 2010 to almost 3.0 % in 2015 The findings of the study will provide an ideal graphical means to construct educational interventions for healthcare workers and increase awareness of infection control practices, including ways of targetting this potential mode of MRDO transmission. References: 1. Ulger, Fatma, et al. ‘‘Are we aware how contaminated our mobile phones with nosocomial pathogens?.’’ Annals of clinical microbiology and antimicrobials 8.1 (2009): 7. 2. Tacconelli, E. ‘‘When did the doctors become fomites?.’’ Clinical Microbiology and Infection 17.6 (2011): 794–796. 3. Bhoonderowa, A., S. Gookool, and S. D. Biranjia-Hurdoyal. ‘‘The importance of mobile phones in the possible transmission of bacterial infections in the community.’’ Journal of community health 39.5 (2014): 965–967. 4. Brady, R. R. W., et al. ‘‘Review of mobile communication devices as potential reservoirs of nosocomial pathogens.’’ Journal of Hospital Infection 71.4 (2009): 295–300.

The Establishment of an Intern Junior Mentoring Programme (IJUMP): An Overview and Early Evaluative Data McVicker L1, Stankard A1, Goreka M1, Lydon S2, Byrne D1,2, Mongan O1, O Connor P2 1

West Northwest Intern Training Network; 2National University of Ireland, Galway

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Background: Lack of preparedness for clinical practice amongst newly graduated doctors has been identified by the Medical Council in the 2014 and 2015 Your Training Counts Reports. Mentoring programmes have been suggested as a promising strategy for improving medical students’ and doctors professional and social skills. Aims: To introduce and evaluate the newly established intern mentoring and teaching program (IJUMP) which provides Galway University Hospital interns with the opportunity to teach and mentor final year medical students. Methods: Thirty-five interns participated in the IJUMP programme. A total of 14 interns participated in pre-programme semi-structured interviews to talk about their reasons for getting involved and their perceptions of the programme. Results: Few of the interns had any formal teaching experience. Interns perceived a number of benefits of participation including the opportunity or incentive to improve their own knowledge, learning, and teaching skills. Interns also thought the programme had a number of advantages for students over traditional teaching methods including the less pressurised nature of teaching sessions with more junior doctors and getting a more ‘‘in touch’’ perspective than offered by senior doctors. However, challenges such as time management, selfdoubt, and a lack of knowledge were reported. Nonetheless, interns also described a number of rewarding aspects that encouraged their involvement. Conclusions: Early data suggest that the IJUMP programme may prove a valuable component of the intern education and training programme as well as the final year medical curriculum. Interns are eager to participate and perceive the programme to be of value for both interns and students. Further programme evaluations will be carried out with medical students and senior doctors.

Does Personality or Empathy predict Final Medical School Score among Irish Medical Students? Stankard A1, McVicker L1, Goreka M1, Tandan M2, Lydon S2, l O Connor P2, Mongan O1, Byrne D1,2 1

2

West Northwest Intern Training Network; National University of Ireland, Galway Background: There has been an increasing focus on the non-cognitive traits of physicians in recent years. Non-cognitive traits such as personality and empathy have been implicated in success in medical school, clinical performance, and physician coping and wellbeing. Aims: To examine whether there is an association between final medical school exit score and personality traits or empathy among a sample of Irish medical students. Methods: A total of 326 current or newly graduated medical students participated in this research study. Participants completed the Toronto Empathy Questionnaire, the NEO Five Factor Index, provided demographic information, and gave permission for their final medical school score to be extracted. Results: Mean final medical school score was 63.4 (SD = 4.96). There was no association between participants’ level of empathy and their final medical school score. The only personality trait found to be associated with final medical school score was conscientiousness, which is indicative of care, thoroughness, or vigilance in task performance. Conclusions: The current study identified little association between participants’ non-cognitive traits (i.e., personality and empathy) and their performance in medical school. These data indicate that suggestions that individuals should be selected for medical school on the

S285 basis of specific non-cognitive traits must thus be considered premature. However, the link between conscientiousness and final medical school score is of note. Previous research has indicated that conscientiousness can be learned and a focus on increasing conscientiousness among medical students may yield improved academic outcomes.

The Axillary Popliteal Bypass; A Case Study 1

Cody L, 1Elhosseiny M, 2Sultan S

1

Western Vascular Institute, Galway University Hospital; Department of Vascular and Endovascular Surgery, Galway Clinic

2

Abstract: We report a case featuring a rare surgical procedure, the axillary-below knee popliteal bypass (APB). The procedure was performed on a 77-year-old female who presented with unilateral critical limb ischemia on a background of extensive bilateral aortoilliac atheromatous disease to the level of the popliteal artery. A superior femoral artery bypass was first planned until surgical exploration revealed no arteries suitable for bypass proximal to the axillary artery. The end result was an APB using Dacron synthetic and Omiflow biosynthetic anastomosed grafts. Perfusion was successfully returned to the limb and despite the initial formation of an axillary haematoma and pleural oedema, the patient went on to make a full recovery. This case highlights the potential of APB grafts in patients with advanced peripheral artery disease and the technical challenges this procedure presents.

A Changing Landscape: Hepatocellular Carcinoma and Hepatitis B in Ireland Fox A, Dempsey S, Fleming University Hospital Galway, West Northwest Intern Training Network Introduction: The demographics of Ireland’s population are changing and along with it the healthcare landscape. Between 1996 and 2009 there was net immigration into Ireland. According to the 2011 Census there were 65,579 Asian and 41,642 African people living in Ireland, increasing by 39.7 and 17.9 %, respectively between 2006 and 2011. The crude rate of liver cancer has increased from 1.98 in 1994 to 5.32 in 2012 across both genders. Hepatocellular carcinoma (HCC) accounts for approximately 60 % of cases of liver cancer in Ireland. The incidence has increased by 10 and 8 % annually in women and men respectively in this period. Hepatitis B virus (HBV) is the leading risk factor for HCC. Description/case report: A 38-year-old man presented to the emergency department with increasing dyspnea, abdominal distension, early satiety and weight loss. He was of African origin but had lived in Europe for the last 23 years. He had no significant medical, social or sexual history. On examination large hepatosplenogmegaly, ascities and scleral icterus were noted. Investigations revealed deranged liver function tests (total bilirubin—55 mmol/l, ALP—558 mmol/l, ALT—47 mmol/l, GGT—497 mmol/l), a-fetoprotein level— [7000 mmol/l and positive HBV serology. CT imaging showed [50 hypoattenuating, non-enhancing lesions in the liver that were suggestive of malignancy. HCC caused by chronic HBV infection was diagnosed.

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S286 Discussion/conclusion: In Africa and East Asia, approximately 60 % of HCC is due to HBV compared to approximately 20 % in the developed western world. The change in make up of the Irish population brings new challenges for the healthcare system and practitioners alike. With the changing demographics physicians should have a higher index of suspicion for HBV. Liaw et al. demonstrated that antiviral therapy reduced incidence of HCC from 7.4 to 3.9 % in those with chronic HBV. Should viral screening be de rigor for at risk populations in the community and/or the Emergency Department?

The Value of Routine CXRs in Young Children with Cystic Fibrosis McHugh D1, Oketah N1, Power N1, Lynch C1, Linnane B1 1

CF Unit, The Ark, University Hospital Limerick

Introduction: There are 93 children with Cystic fibrosis treated in this unit. As part of their annual review they have a Chest X-ray (CXR) to screen for possible lung pathology and disease progression. The aim of this study was to review routine CXRs done on CF patients at the time of their diagnosis and subsequent annual reviews in the first 6 years of life from 1st January 2002 to 31st June 2015. We wanted to ascertain whether or not routine CXRs detect any abnormalities in individual patients and if they result in a change in patient management. Methods: The UHL CF database was used to identify patients who had annual reviews done between 1st January 2000 and 31st October 2015 and who were between birth and 6 years old at the time of the chest x-ray. The hospital NIMIS system was used to look at CXRs reported findings. Medical charts were reviewed to obtain clinical history. Information recorded included age at the time of diagnosis, sweat chloride value, mode of presentation, patient CF genotype, CXR abnormalities and the change to management. Results: A total of 31 patients met our criteria and a total of 186 CXRs were looked at. The average age of diagnosis was 11.5 months. 62 % of CXRs showed no abnormalities at annual assessment. Of the abnormal CXRs peribroncial thickening was the most common finding. 6 % of CXRs instituted a change to treatment (all for infective exacerbation). 26 % of CXRs changed from previous year. Conclusion: The majority of routine CXRs done in the first 6 years of life are normal, the most common abnormality being peribroncial thickening. This opens the discussion whether or not CXRs are of value or should another modality be used for annual assessment.

Is Organ Donation Following Circulatory Death Ethical… A Survey of Consultants and SpRs in Emergency Medicine? Doyle B1, McCabe A2, Deasy C1 1 Cork University Hospital, Wilton, Cork; 2Royal College of Surgeons, Dublin

Background: Organ Donation following Circulatory Death (DCD) consists of collecting organs from persons having suffered cardiac arrest, usually in the community, who could not be successfully resuscitated and are therefore considered to have died. This is called

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Maastricht Category II (uncontrolled) Organ Donation following Circulatory Death. Methods: All Consultants and SpRs in Emergency Medicine in Ireland were invited to participate in an online survey on ethical issues concerning a protocol for organ donation following circulatory death in use in a Scottish centre. Results: A total of 82 complete responses were received. There were 49 (60 %) responses from Consultants in Emergency Medicine and 33 (40 %) responses from SpRs in Emergency Medicine. There were 47 (95.9 %) consultants versus 26 (78.8 %) SpRs who said they would donate one of their organs after death (p \ 0.05). There were 75 (91.5 %) respondents who had heard of organ donation following circulatory death compared to 7 (8.5 %) who had not. Regarding the outlined protocol in use in other jurisdictions, 70 (85.4 %) respondents had no ethical concerns, 7 (8.54 %) had ethical concerns and 5 (6.1 %) selected ‘‘I can’t answer right now’’. There were 21 (25.6 %) respondents who felt cardiac death organ donation raised the same ethical problems as brain-dead organ donation, 46 (56.1 %) felt cardiac death raises more ethical problems, 9 (11 %) felt cardiac death raised fewer problems, and 6 (7.3 %) had no opinion. Conclusion: Although it is appreciated that there are increased ethical issues with Maastricht Category II (uncontrolled) DCD when compared to Donation following Brainstem Death (DBD), a majority of respondents had no ethical concerns with the protocol.

The Potential for Organ Donation After Circulatory Death in Ireland’s Emergency Departments Doyle B1, Masterson S2, Deasy C1 Cork University Hospital, Wilton, Cork; 2Royal College of Surgeons, Dublin

1

Background: The Maastricht criteria categorises organ donation following circulatory death in different scenarios. Maastricht Category II organ donation covers the collection of organs from persons having suffered cardiac arrest, usually in the community, who could not be successfully resuscitated and are therefore considered to have died. Methods: Using the National Out of Hospital Cardiac Arrest Register (OHCAR) and established criteria from a Scottish centre, we identified all patients who died in the Emergency Department (ED) at Cork University Hospital (CUH) following cardiac arrest, who were unsuccessfully resuscitated and who met the criteria for Maastricht Category II (uncontrolled) DCD. Potential donors must be aged between 16 and 60, have a witnessed collapse, paramedics must have arrived within 15 min and death must have occurred less than 2 h from the time of collapse. Exclusion criteria include a traumatic arrest, suspicious death, hypothermia a factor, drug ingestion, HIV, disseminated cancer, recent melanoma, or neuro infectious disease. Results: During a 2-year period from the 1 January 2012 to 31 December 2013, 160 patients were brought to the ED at CUH in cardiac arrest and subsequently died following unsuccessful resuscitation. There were 11 patients who met the criteria and may have been eligible for Maastricht Category II (uncontrolled) organ donation. Conclusions: The potential to harvest up to 22 kidneys over the 2-year period of our study at CUH highlights that DCD from emergency departments may make a contribution towards reducing the size of the Irish transplant waiting list. The long-term cost saving to the Irish health service for each additional organ transplant further supports the potential for Maastricht Category II (uncontrolled) organ donation.

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A Curious Presentation of a Spinal Arterio-Venous Malformation Gallen R, McNamara P, Kavanagh E, Looby S, O Hare A, Lynch T Neurology Department, Mater Hospital, Eccles St., Dublin 7 UCD/DML Training network Introduction: Spinal arterial-venous fistula is a rare entity that is difficult to diagnose. Case details: A 46 year-old man presented with total body numbness and 1 month of intractable hiccups and vomiting. He subsequently developed paraesthesia, quadriparesis, and dysphagia. MRI showed hyperintensities in medulla more than cervical cord. Lumbar puncture revealed elevated protein. We treated a presumptive diagnosis of Neuromyelitis Optica (NMO) with intravenous steroids and plasma exchange with some improvement. He deteriorated suddenly 3 weeks post admission whilst receiving intravenous immunoglobulin, becoming quadriparetic and hypercapnoic and requiring intubation. An alternative diagnosis was considered and imaging was re-reviewed at the MDT Neuroradiology conference. A second opinion was sought from a tertiary neuroradiology centre. NMO was still thought the likely diagnosis but spinal angiogram revealed a dural AV fistula (DAVF); the middle meningeal artery drained into a varicose anterior spinal vein. The DAVF was embolised and he made a steady recovery over the follwing number of weeks. Discussion: Neurological history and examination, based upon detailed neuroa-natomical knowledge, attempt to answer two questions; (1) where is the lesion? and (2) What is the lesion?. Investigations then confirm or refute the clinician’s diagnosis. Total body numbness localises to the high cervical cord and hiccups and vomiting localise to the medulla (area postrema at the floor of the 4th ventricle). Pontine venous drainage ascends rostrally, whilst the medulla drains caudally. Our patient’s MRI hyperintensities showed a sharp demarcation at the pontomedullary junction and provided the clue that his problem was related to venous hypertension and congestion rather than demyelination associated with NMO. This radiological clue was the key in unlocking the diagnosis and initiating potentially life-saving treatment. MDT radiology conferences are underestimated in their importance in providing clear diagnoses and guide to appropriate therapies that can be life-saving.

Hypertension and Headaches; a Complicated Surgical Case Cosgrave N, Casey C, McCarthy C, O Shea D, Crowley R Department of Endocrinology, St. Vincent’s University Hospital A 42 year old Lithuanian man was referred to ED by his GP with headaches and acute severe hypertension (226/175 mmHg), on a background of poorly controlled hypertension. He was investigated for renal artery stenosis, with CT angiography of the renal vessels revealing a 7.7 cm enhancing para-aortic mass. Analysis of urinary metabolites revealed a markedly raised urinary normetadrenaline (12827 nmol/24 h, ULN 213 nmol/24 h), raised urinary metadrenaline (224 nmol/24 h, ULN 228 nmol/24 h), and raised urinary 3-O-methyldopamine (682 nmol/24 h, ULN 320 nmol/ 24 h). Imaging with PET CT showed an FDG-avid mass, which further demonstrated metaiodobenzylguanidine tracer uptake. The mass was in close proximity to the left ureter and the distal abdominal aorta, but without radiological evidence of invasion.

S287 He was commenced on alpha-adrenergic blockade with phenoxybenzamine pre-operatively, and underwent open resection of the mass, with specialist endocrine, urology and vascular surgeons present due to the complex anatomy of the lesion. Histology showed an extra-adrenal paraganglioma, with a PASS of 5, Ki67 \1 % and a mitotic count \1/10 hpf. This is indicative of a low likelihood of malignancy, although this cannot be definitely excluded on pathology alone. Genetic testing for mutations in SDH genes, VHL, RET, NF1 TMEM and MAX were negative. Following resection, blood pressure had normalised on a single agent antihypertensive. This case report describes the successful management of an atypical case of a paraganglioma.

Straight to the Heart of the Matter: A Rare Case of Endocarditis Nolan C, Kumar R, Abernethy E Department of Nephrology, University Hospital Waterford A 72 year old Irish male was admitted from Chronic Dialysis with a high suspicion of septicaemia. He had a past medical history of End Stage Renal Disease, Diabetes Mellitus, Ischemic Heart Disease, Diverticular disease, Hypertension and Atrial fibrillation. Blood cultures on this occasion were positive for Escherichia Coli from peripheral lines. Cultures from his fistula were negative for organism growth on two attempts. This was the patient’s third admission for E. Coli septicaemia in the previous 3 months. During his second admission, GU and GI sources had been out ruled with multiple investigations including CT TAP, OGD, Colonoscopy, transthoracic ECHO and cystoscopy. Microbiology team were consulted for their advice on other possible sources of E. Coli bacteraemia. What emerged from the discussion was the potential for the source of this recurrent infection to be cardiac. After consultation with cardiology, a transoesophageal ECHO was performed which subsequently confirmed vegetations on the mitral valve. A diagnosis of E. Coli endocarditis was made and the patient was treated with 8 weeks of IV Meropenam with OPAT after PICC line insertion. Chronic haemodialysis patients are at significant risk for infective endocarditis with the incidence being estimated at 308 per 100,000 patient years. However, it’s reported that gram negative organisms adhere less readily to heart valves than their gram positive counterparts, hence native valve endocarditis due to gram negative bacilli such as E. Coli is profoundly rare.

‘Cytomegalovirus and Inflammatory Bowel Disease, a Case Report.’ McGarvey C, Stack R, Alakkari A Department of Gastroenterology, AMNCH Tallaght Introduction: This report addresses the importance of considering a diagnosis of cytomegalovirus in patients on immunomodulatory

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S288 treatment for IBD and also looks at how its prevalence ([90 % in some studies) should affect future practice. Case description: This case report presents the case of a 35 year old lady with Crohn’s Disease on Azathioprine, presenting with a 7 day history of fevers, rigors, myalgia and non-productive cough with a 14 day history of loose bowel motions. On examination the patient was febrile, tachycardic, normotensive, saturating well with a normal systemic exam. Investigations showed mild thrombocytopaenia, mild derangement of LFTs, raised CRP (114.7) and hypokalaemia (3.2). CXR and abdominal ultrasound were normal. The patient was started on IV Co-Amoxiclav with poor clinical response, spiking fevers to 40.4 Æ C. With profound leucopaenia (1.5) and severe respiratory distress, repeat imaging showed a subtle right upper lobe lesion, suggestive of pneumonitis, the patient was commenced on IV Ganciclovir on suspicion of CMV infection. CMV IgM and IgG were later positive and CMV viral load was 20,205 copies/ml. The patient went on to require intubation, admission to ICU and ventilation for 20 days. Discussion: ECCO guidelines 2014 for systemic CMV infection in IBD patients recommend 2–3 weeks of ganciclovir therapy and discontinuation of immunosuppressant agents. The guidelines also suggest that there is no benefit in screening for CMV, however screening for latent CMV infection is increasingly carried out in Irish Hospitals. Further clarification is needed. No vaccine is available, although nucleoside analogues exist, their adverse effects outrule their use as chemoprophylaxis. The prevalence of CMV infection indicates that there should be a higher index of suspicion for CMV infection in this cohort, particularly given its varying presentations. Cases of patients presenting with active CMV disease should be recorded to determine prevalence, risk factors and best management.

CT Brain and Lens Exclusion McGarvey C, Curran S Department of Radiology, St Columcilles’s Hospital, Loughlinstown Introduction: The exclusion of the lens of the eye in routine head CT reduces the radiation dose to the eye and thereby reduces the risk of lens damage and cataract formation. Aim: The aim of this audit is to allow for the development and implementation of protocol regarding lens exclusion from Head CT and therefore reduce the overall radiation exposure to the patient. Methods: The audit was retrospective in nature, looking at patients who had undergone routine CT brain on a 32 slice Toshiba scanner in St. Columcille’s Hospital, Loughlinstown between the dates of the 1st and 12th of January. 50 consecutive cases within these dates were included in the sample, 24 male and 26 female, with an average age of 60 years. These CT scans were reviewed retrospectively by a Consultant Radiologist and lens exposure was recorded as complete, partial or none, this data was then collated. Results: n = 50 Complete exposure = 17 (34 %) Partial exposure = 22 (44 %) No exposure = 11 (22 %) Conclusion: The department were not meeting the standard as set out by the Royal College of Radiologists in the UK, cases with lens excluded amounted to 22 % while the recommended standard is 100 %. The majority of cases had partial radiation exposure to the lens, at a value of 44 %. In 34 % or 17 cases the complete scan range included all of both lenses.

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 It was recommended that the Department protocol for head CT be adapted to include guidelines for radiographers on the positioning of patients in the gantry to avoid exposing the lenses to radiation. These positioning changes will be emphasised particularly in those under the age of 65 and a re audit should be carried out in 2016.

A rAIRE cause of Addison’s Disease Finnegan J, McQuaid S Department of Endocrinology, Mater Misericordiae University Hospital, Dublin A 28 year old Caucasian female presented to the Emergency Department with a 3-day history of epigastric pain and vomiting on a background of Addison’s disease. On examination, she was heavily pigmented, hypotensive and tachycardic. Laboratory investigations revealed hyponatraemia (Na 120 mmol/L), hypoglycaemia (BSL of 2.4 mmol/L) and mild metabolic acidosis. An Addisonian crisis was diagnosed secondary to persistent vomiting and failure to ingest oral hydrocortisone. She was immediately treated with IV steroids and fluids. Following clinical and biochemical improvement she was switched to PO hydrocortisone and tapered back to her maintenance dose (20 mg Mane/10 mg Tarde). Our patient initially presented with adrenal insufficiency and a history of recurrent vaginal candidiasis. Genetic testing confirmed homozygous c.967_979del frameshift mutations in exon 8 of the autoimmune regulator gene (AIRE) on chromosome 21, thus establishing a diagnosis of Autoimmune Polyendocrine Syndrome (APS) Type 1. APS Type 1 (also called Autoimmune Polyendocrine Candidiasis Ectodermal Dystrophy) is a rare potentially life threatening disorder with an estimated incidence of 1:130,000 in Ireland. Diagnosis requires the presence of at least 2 of the following; mucocutaneous candidiasis, hypoparathyroidism and adrenal insufficiency. Its importance lies in the association with other autoimmune conditions such as Type 1 Diabetes mellitus (our patient is GAD antibody positive) autoimmune thyroid disease and chronic atrophic gastritis. It is also associated with oesophageal cancer. The case that Thomas Addison described in 1855 was secondary to TB. This case is due to a mutation in the AIRE gene which codes for a nuclear transcription factor, thought to be involved in organ specific immune modulation.

Pregnancy Post Renal Transplantation, A Successful Caesarean Section Delivery Drumm C1, Gannon MJ1 1 Department of Obstetrics and Gynaecology, Midlands Regional Hospital Mullingar (MRHM)

Abstract: Pregnancy post renal transplantation is viable as approximately 70 % of pregnancies progress beyond the first trimester, with about half of the first trimester losses occurring spontaneously. After the first trimester, the majority (94 %) of pregnancies to allograft recipients end successfully in live births. However, complications during pregnancy are common and include late pregnancy hypertension with or without pre-eclampsia (30 %), pre-term delivery

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 (45–66 %), foetal growth restriction (*40 %), gestational diabetes (8 %) and caesarean section (60 %). Pregnancy appears to have minimal adverse effect on the long-term graft prognosis, provided that pre-pregnancy renal function is satisfactory (serum creatinine \125 micromol/L), and there is no graft rejection. To offer the best chance of a favourable outcome, pregnancy in renal transplant patients should be planned with multi-disciplinary input from an obstetrician, nephrologist, surgeon and paediatrician. We present the case of a 28 year old from Lithuania, G2 P0 + 1, who booked in MRHM at 18 weeks. She had a history of two renal transplants in Lithuania, the first in 2001, lasting for 8 years, and the second in 2012. This case highlights the complications in pregnancy post renal transplantation as she had three admissions during her pregnancy, first for headaches, secondly for decreased micturition and thirdly for hypertension which was later diagnosed as mild-moderate pre-eclampsia. She delivered a healthy male infant by elective caesarean section at 38 weeks and 2 days gestation.

Dilated azygous vein associated with congenital absence of inferior vena cava: a case report

S289 other co-morbidities such as congenital heart disease, asplenia, polysplenia and a higher risk of developing deep venous thrombosis due to lower limb venous insufficiency and the development of subsequent pulmonary embolism. In isolation, a diagnosis of azygous continuation of IVC requires no treatment. However, knowledge of the anatomy is particularly important pre-operatively in cardiothoracic surgery in order to avoid difficulties and complications relating to the altered anatomy. References: 1. Bass JE, Redwine MD, Kramer LA, et al. Spectrum of congenital anomalies of the inferior vena cava: cross-sectional imaging findings. Radiographics 2000; 20: 639–52 2. Ruggeri M, Tosetto A, Castaman G, et al. Congenital absence of the inferior vena cava: a rare risk factor for idiopathic deep-vein thrombosis. Lancet 2001; 357: 441

An Audit of the Prescription of Venous Thromboembolism Prophylaxis on Admission in General Surgical Patients in Letterkenny University Hospital

Heslin D, Hynes T, Casserly B Geraghty G, Aremu M Department of Respiratory Medicine, University Hospital Limerick Introduction: Azygous continuation of the inferior vena cava (IVC) is an uncommon vascular anomaly which has a prevalence of 1–1.5 %. It is usually found incidentally, with the patient being asymptomatic. Anatomically, there is an absence of the hepatic segment of the IVC, leading to a compensating dilated azygous vein. Case presentation: A 57 year old female presented to the respiratory clinic, via GP referral, complaining of a persisting cough of 6 months duration. Of note, she had a 30 pack year smoking history and had reported weight loss over the previous year. She underwent a bronchoscopy as part of a malignancy work up. Pre-bronchoscopy CT Thorax revealed a dilated azygous vein and an absence of the inferior vena cava. Interestingly, as seen in the below CT image, this patient also has a diagnosis of situs invertus.

Department of Surgery, Letterkenny University Hospital, Co. Donegal; West Northwest Intern Training Network Objectives: 1. To audit the use of Venous Thromboembolism (VTE) prophylaxis in general surgical patients on admission to Letterkenny University Hospital. 2. To formulate a local VTE risk assessment proforma for trial use on future surgical admissions. Design/methods: •

• • •

• •

An audit of the medical notes and drug kardexes of general surgical inpatients on two dates in November and December 2015 was carried out to determine the documented thromboprophylactic measures recorded at admission. Both emergency admissions and elective admissions were included in the audit. Patients were assigned to VTE risk categories of ‘low’, ‘moderate’ and ‘high’. As no formal local guidelines could be identified, NICE (N92), ACCP and manufacturer guidelines were employed to aid formulation of appropriate patient risk categories for VTE and the level of pharmacological thromboprophylaxis required for each patient category. They were also used to inform of contraindications to anticoagulation. Admission notes were assessed for documentation of VTE and bleeding risk factors to aid assignment of risk categories. We wish to introduce our proforma for future general surgical admissions to the hospital on a trial basis and re-audit our findings.

Results: • Management and outcome: Bronchoscopy was otherwise unremarkable, with no evidence of malignancy. There were no complications regarding the patient’s post-procedure recovery. Discussion: In this case, our patient presented with an isolated anomaly of azygous continuation of the IVC. However, it is important to note that the above condition has been associated with

• •

A total of 46 patients were included in the study. Patient age ranged from 16 to 90; with a median age of 57. 37 patients had been admitted through the emergency department and 9 patients were admitted on an elective basis. Of the 46 patients studied, 26 were considered to be in the ‘high risk’ category, 15 had a ‘moderate risk’ and 1 patient had a ‘low risk’ of VTE.

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S290 •

Within the high risk category, 6 (23 %) patients did not receive pharmacological prophylaxis on admission. A further 13 (50 %) did not receive an inappropriate dose on admission.

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299

Fistulising Fellows Smyth S, O Connell R

Conclusions: •

•

•

The rates of appropriate pharmacological VTE prophylaxis, determined by this study, suggest the need for formulation of a local VTE protocol which can be used by NCHDs when admitting surgical patients. We propose a proforma for introduction on a trial basis and which would address specific VTE and bleeding risk factors. These risk factors could be elicited from the patient and/or medical notes before prophylaxis is suitably prescribed. A re-audit following introduction of our proforma could then be performed to assess for improved rates of appropriate thromboprophylaxis prescription.

Multiple systemic embolisms after Gastric variceal obliteration with cyanoacrylate injection. Report of one case and review Granahan A Department of Gastroenterology, Our Lady Of Lourdes Hospital, Drogheda Introduction: A case report of complex unstable upper gastrointestinal bleed treated with endoscopic sclerotherapy complicated with systemic embolization is reported. Case description:A 57 year old gentleman presented with frank hematemesis and melena on a background history of decompensated alcoholic cirrhosis. On examination he was haemodynamically unstable, he was resuscitated and a massive transfusion protocol was activated. With a Glasgow-blatchford score of 6, he underwent an Emergency endoscopy which revealed a large non bleeding isolated fundal varices. The varices were treated with injection of 1:1 mixture of n-butyl cyanoacrylate and lipiodol. On day 4 post endoscopy, the patient became tachycardic, tachypneic, and hypoxemic, requiring intubation and mechanical ventilation and was transferred to ICU. Due to persistent hypoxemia requiring high fractions of inspired oxygen a CT Pulmonary Angiogram was performed. This revealed bilateral consolidation and pleural effusions with high density material within the pulmonary artery branches consistent with embolised glue particles. Subsequently a CT Abdomen, pelvis with contrast revealed embolized high density material consistent with fluid noted within the left renal artery extending into the IVC, with evidence of hepatic cirrhosis, portal hypertension, large perigastric varices and minimal ascites. A repeat CT Abdomen and Pelvis showed embolised glue particles within the bowel and portosystemic embolization from varices intervention. Following an extensive stay in ICU, he was transferred to the ward and was subsequently discharged with rehabilitation. Discussion: The Literature shows that the use of cyanoacrylate, when used to obliterate oesophageal or gastric varices, is assocaiteted with a 90–97 % rate of primary haemotstasis, and as such is becoming the treatment of choice. This unique case highlights the rare and potentially fatal complication of systemic glue embolization following endoscopic sclerotherapy.

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Introduction: Diverticular disease (DD) is a common condition affecting *60 % of those greater than 60 years old. Crohn’s disease (CD) has a bimodal presentation, predominantly between the ages of 20–40 and greater than 60 years old. Therefore 50 % of CD patients greater than 60 years old have concurrent DD (1). In the elderly, CD has a predilection for the distal colon, similar to DD, giving rise to similar clinical presentations (2). One of the common complications shared by DD and CD are fistulae. Description: This is the case of a 71 year old lady who presented to the OPD with faecaluria, ‘‘pilluria’’ (passing routine medication per urethra), intermittent urinary incontinence and a history of recurrent UTIs. This presentation is on a background history of DD and CD, diagnosed that same year. Upon investigation of these symptoms, a CT abdomen/pelvis revealed a colovesical fistula of the sigmoid colon and a cystoscopy confirmed its presence. She underwent a laparoscopic assisted panproctocolectomy with ileostomy formation and the colovesical fistula was taken down. From a urological point of view, her ureters were protected pre-operatively with bilateral JJ Stents and a suprapubic catheter was sited post-operatively. Once a cystogram confirmed healing, the catheter was removed and she was discharged with a follow-up appointment with urology for JJ stent removal via flexi cystoscopy. She is for routine follow-up with the colorectal department following her surgery. Conclusion: Co-existing CD at the same sight as diverticulosis carries a worse prognosis than either alone, especially if diverticulosis is complicated by diverticulitis (3). CD of the sigmoid colon may also induce diverticulitis in DD (4). However, CD in the older patient is generally less aggressive (less systemic evidence of disease and less incidence of peri-anal disease) (1). The most common fistula complicating DD is a colovesical fistula which accounts for 53 % of fistulae seen in DD. (5) In this case concurrent DD and CD likely increased her risk of the incidence of fistulae. References: 1. N A Shepherd Diverticular disease and chronic idiopathic IBD: associations and masquerades Gut 1996 38: 801–802 2. Carr N. Schofield PF: IBD in the older patient. Br J Surg 1982; 69: 223–5 3. A Gkedhill, M F Dixon. Crohn’s-like reaction in diverticular disease. Gut 1998; 42: 392–395 4. Meyers MA et al., Pathogenesis of diverticulitis complication granulomatous colitis. Gastroenterology 1978;74: 24–31 5. Colcock BP, Stahman FD. Fistulae complicating diverticular disease of the Sigmoid colon. Ann. Surg. June 1972 Vol. 175No6.

Complex Periprosthetic Infection following Total Knee Arthoplasty Cahill D, O Carmody, Hurson C Department of Trauma AND Orthopaedics, St. Vincents University Hospital, Dublin Introduction: Periprosthetic knee infection is a devastating complication of total knee replacement and is the leading cause of revision

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 knee arthroplasty, with an estimated prevalence of between 1 and 2 %. This case report demonstrates the management of a complex periprosthetic total knee infection. 1 Case: This is the case of a 47 year old male chef. In 1990, following an RTA, he suffered severe left knee injury. Four years later he underwent a left total knee replacement for post traumatic arthritis. For 16 years, he had no issues, but was under review in 2013 for aseptic loosening of his prosthesis. In March 2013 he attempted suicide, slipped from the chair suffering a distal femoral periprosthetic fracture. This was initially treated conservatively but after displacement, required a revision procedure using a distal femoral and proximal tibial replacement. In December 2014, he developed periprosthetic infection due to an embedded thumbtack in the knee. The infection developed a discharging sinus despite oral antibiotic treatment, necessitating a complex two stage revision. It involved the vascular team exploring popliteal artery and the plastics team to complete the case with a medial gastrocnemius flap, split thickness skin graft. He was discharged on IV antibiotics via OPAT. At OPD review in Oct 2015, he was mobilising with one crutch, and his ROM is 0–40 degrees. Discussion: Total knee arthroplasty is a common procedure, has excellent results in rehabilitation but also associated with morbidity. Periprosthetic infection can result devastating outcome for patients. Therapy should not be commenced in a suspected infection if the patient is systemically well until sterile aspirations obtained and a diagnosis confirmed. Management of periprosthetic infection depends on the presence/absence of sinus tract and length of time post op. A two-stage revision is the gold-standard management. However, its success rate is still only approximately 70 %. Reference: 1. Parvizi J, Cavanaugh PK, Diaz-Ledezma C. Periprosthetic Knee Infection: Ten Strategies That Work. Knee Surgery and Related Research. 2013;25(4):155–164. doi:10.5792/ksrr.2013.25.4.155.

An Audit of the Use of Bisphosphonate Drug Treatment and Calcium Supplementation in the Management of Osteoporosis Dr. D Cahill, Dr. N Breen, Dr. McAuliffe

S291 were randonly selected from the list for the audit. Random selection was assisted using online random selection software. 55 % of patients were on Alendronic acid, the recommended 1st line treatement for osteoporosis. 20 % were on Risendronate. 25 % were on Ibandronic acid. 25 % of patients on Alendronic acid were prescribed Fosavance, the recommended type for patients in Ireland where deficiency exists. 43 % of patients selected had an initial DEXA result recorded in the system. Of note, 23 % of patients selected were diagnosed outside the practice so no initial DEXA scan result was available. Therefore, by deduction 57 % of paitents prescribed a bisphosphonate first by the GP had an initial DEXA result recorded. 57 % of patients had a DEXA result at diagnosis. 35 % patients had a follow up scan to assess response therapy. Conclusion: GP practices require processes using in place existing IT systems to manage Bisphosphonate therapy initiated by various medical teams to ensure seamless management. References: 1. National Osteoporosis Guideline Group—Executive summary of Osteoporosis: Clinical guideline for prevention and treatment— http://www.shef.ac.uk/NOGG. 2009 2. Quandt SA, Thompson DE, Schneider DL, Nevitt MC, Black DM, Fracture Intervention Trial Research G. Effect of alendronate on vertebral fracture risk in women with bone mineral density T scores of -1.6 to -2.5 at the femoral neck: the Fracture Intervention Trial. Mayo Clinic proceedings. 2005;80(3):343–9. 3. Kanis JA et al. FRAX TM and the assessment of fracture probability in men and women from the UK. Osteoporosis international: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2008;19:385–97. 4. Black DM, Schwartz AV, Ensrud KE, Cauley JA, Levis S, Quandt SA, et al. Effects of continuing or stopping alendronate after 5 years of treatment: the Fracture Intervention Trial Longterm Extension (FLEX): a randomized trial. JAMA: the journal of the American Medical Association. 2006;296(24):2927–38. 5. Reid IR. Cardiovascular effects of calcium supplements. Nutrients. 2013;5(7):2522–9. 6. Bolland MJ, Leung W, Tai V, Bastin S, Gamble GD, Grey A, et al. Calcium intake and risk of fracture: systematic review. BMJ. 2015;351:h4580.

Greystones Harbour Medical Practice, Co. Wicklow Introduction: Guidelines exist for the use of bisphosphonates and calcium in the management of Osteoporosis. These guidelines include criteria for initiation, monitoring and cessation of bisphosphonate therapy. Aims and Objectives: An audit to assess the management of osteoporosis using bisphosphonate drug treatment and calcium supplementation under the following headings: Diagnosis of osteoporosis—intial DEXA/T-score Criteria for initiation of pharmacological therapy for Osteoporosis Response to therapy—2nd DEXA 1–2 years after initiation Stopping therapy—Bisphosphonate holiday Calcium and Vit D supplementation Methodology: A retrospective review was conducted of patients with Bisphosphonate as active drug therapy. Each patient medical record was reviewed to assess against standards set down by best practice guidelines. Results: 136 patients were identified on the HeathOne system as having a bisphosphonate as active therapy. Following an initial data cleanse, a total of 109 patients were deemed eligible for the audit. 40 patients

Analysis of Weight Gained by Children Whilst Awaiting Review at Temple St. Children’s Hospital Obesity Clinic Cahill D, Doyle S, Murphy S Weight2Go Programme, Community Paediatrics, Temple St. Children’s Hospital, Dublin Introduction: Obesity is both a national and an international problem.1 The causes are complex and multi- factorial and the pathophysiology is poorly understood. Childhood consequences of obesity include low physical fitness, hypertension, early signs of cardiovascular disease and metabolic disease. 2, 3, 4, 5. The management of obesity is challenging and requires multi- disciplinary input. Methods: We reviewed 111 children referred to a tertiary referral obesity clinic. We recorded the referral weight, height and BMI; the weight, height and BMI at assessment; and the time interval between the referral and the clinic appointment.

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S292 Results: Of the 111 cases reviewed, 56 % were female. 40 were referred by their GP (36 %), 55 (50 %) from a consultant in the hospital, 4 (4 %) from consultants in other hospitals, 3 from Mental health services, 1 from the physiotherapy department, 1 from the Dietetics department, 1 from community nurse, 1 from public health and 4 had no referral information. 19 (48 %) of GP letters contained weight, height and a calculated BMI. The average weight was 75 kg, heaviest 120 kg. 98 % of children had a BMI in the 99th centile. 71 (64 %) gained weight on the waiting list, 16 (14 %) lost weight on the waiting list and 24 (22 %) the weight gain/loss was not recorded. The average waiting time to clinic was 6.1 months and the average weight gain was 3.3 kg and the average weight loss was 2.7 kg. Weight gain during the waiting period ranged from 2.3 kg with 1 month wait to 14.8 kg weight gain with 26 month wait. Of those who lost weight on the waiting list 85 % had made changes to their diet. Conclusion: In general, children gain weight while waiting for review. It would be helpful for the referring doctor to have resources available to give to the families while waiting review. References: 1. Layte et al., 2011. Growing Up In Ireland Study. 2. O’ Malley G., High Normal fasting glucose level in Obese Youth: a marker for insulin resistance and beta cell dysregulation. Diabetologica 2010. 3. D’Adamo E., Cali AM., Weiss R., Santoro N., Pierpont B., Northrup V., Caprio S. Central role of fatty liver in the pathogenesis of insulin resistance in obese adolescents. Diabetes Care 2010 Aug;33(8):1817–22 4. Finucane FM., Pittock S., Fallon M., Hatunic M., Ong K., Costigan C., Murphy M., Nolan JJ. Elevated blood pressure in overweight and obese Irish children. Irish J Medical Sci. 2008 Dec:177(4):379–81 5. Tounian P., Aggoun Y., Dubern B., Varille V., Guy-Grand B., Sidi D., Girardet JP., Bonnet D. Presence of increased stiffness of the common carotid artery and endothelial dysfunction in severely obese children: a prospective study. Lancet 2001 Oct 27:358(9291):1400–4

Any Sick Contacts? Hayden J, Dempsey S, Fleming C West Northwest Intern Training Network Introduction: This case explores the investigation of a chronic cough in a young smoker with chest radiograph changes. Oral antibiotics yielded minimal response and further investigations revealed a direct film microscopy positive for acid fast bacilli with pan-sensitive mycobacterium tuberculosis (TB). This diagnosis was complicated with the fact that her six children also tested positive for TB. Case report: MC, a 32 year old lady from the Irish travelling community, presented with a productive cough with green sputum for 10 months and increasing fatigue and anorexia. Pertinent negatives were night sweats, weight loss, rigors, rashes, lymphadenopathy or myalgia. Her brother and niece had tuberculosis in 2013 and 2012, respectively. She has a fifteen pack year smoking history. Vital signs and physical examination on admission were unremarkable apart from an audible cough and mild coryzal symptoms. Her admission

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 bloods were normal except for an elevated c-reactive protein (20.6). On repeat imaging a cavitating opacity was reported. The six children underwent chest radiographs and Mantoux testing. Three children had chest radiographic findings and positive tuberculin tests and were started on active tuberculosis treatment. The remaining three had clear chest radiographs but positive skin testing and were commenced on latent TB treatment. Discussion: Tuberculosis is a global health concern in the developing and developed world and remains one of the most deadly communicable diseases1. It is pertinent not to overlook this diagnosis in a young smoker especially with radiographic changes and contacts. This case highlights the importance of early radiological imaging in patients with a chronic cough. The diagnosis is rather difficult in children as they are more likely to have tuberculosis caused by a smaller number of bacteria (paucibacillary disease) and sputum samples are difficult to retrieve. Therefore, the tuberculin skin testing is the most reliable investigation in children2. The risk of radiation should not be neglected in children. Diagnosis is crucial in infants, young or immunocompromised children as they are more likely to develop disseminated tuberculosis and tuberculosis meningits3. References: 1. Pai M, Schito M. Tuberculosis diagnostics in 2015: landscape, priorities, needs, and prospects. J Infect Dis. 2015 Apr 1;211 Suppl 2:S21–8. doi:10.1093/infdis/jiu803. 2. Julius P Kiwanuka. Interpretation of tuberculin skin-test results in the diagnosis of tuberculosis in children. Afr Health Sci. 2005 Jun; 5(2): 152–156. 3. Susanna Esposito, Claudia Tagliabue, Samantha Bosis. Tuberculosis in Children. Mediterr J Hematol Infect Dis. 2013; 5(1): e2013064.

Embolisation for the Control of Intractable Epistaxis in Adults; A Retrospective Review Carron JM, Walsh MA Beaumont Hospital Introduction: Epistaxis (nasal bleeding) is a common clinical concern, which affects up to 60 % of the general population at some point in their lifetime, approximately 6 % of whom will require medical attention. Intractable epistaxis is defined as sustained haemorrhage, despite employment of conservative methods. Embolisation of the vessels responsible has become an accepted means of managing those cases which remain refractory to these conservative interventions. Methods: The purpose of this investigation is to evaluate the success and complication rates of the embolisation procedure in a large tertiary hospital. Inclusion and exclusion criteria were applied to all those admitted to the ENT department between January 2002 and December 2012. A total of 58 procedures involving 52 different patients were retrospectively reviewed and analysed, the second largest study of its kind. Results: Of the 58 cases reviewed, 15 were female and 43 were male. In all cases but one the procedure was successful in achieving an immediate cessation of blood flow, with resultant initial success rate of 98.2 %. All patients benefited from an improvement in bleeding severity. The overall complication rate of 8.6 % was comparable to the reported literature average and all had been remedied prior to patient discharge. Conclusion: This retrospective review suggests that embolisation is a safe and effective means of controlling intractable epistaxis, reducing not only the severity of haemorrhage, but also the reoccurrence of

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 epistaxis. Furthermore, numerous reports advocate its efficacy, with results that rival, and in some cases surpass those associated with arterial ligation. Discussion: From the time it was first described in 1974, embolisation of the internal maxillary artery has become not only a viable alternative, but a prominent forerunner for the future management of intractable epistaxis. The results of this audit perhaps further illustrate the integral role the interventional radiology department is coming to play in our hospitals nationwide.

Familial Pancreatic Cancer: Is There a Role for Screening in Selected Populations? Windrim C, Horgan G St Vincent’s University Hospital, Donnybrook, Dublin UCD Introduction: Familial Pancreatic Cancer is an umbrella term for families with a predisposition for the condition. Research continues to look for the genetic basis and evaluate screening programs. Case presentation: On admission for elective colonoscopy, a 76 year old man was noted to be profoundly jaundiced. The patient had only noticed yellowing of the eyes and darkening of his urine the night before. He reported no fevers, pain, vomiting or purititis. He had been referred by his GP for a 2 week history of change in bowel habit on a background of colorectal cancer (Dukes C; curative anterior resection with adjuvant chemotherapy and radiotherapy in 2003). His brother had died from pancreatic adenocarcinoma just 3 months prior. The patient was admitted, investigated and diagnosed with a pancreatic adenocarcinoma confined to the head of the pancreas and deemed suitable for surgical resection. Discussion: The patient enquired whether there was merit for screening him at the time of his brother’s diagnosis. We reviewed that his family history was significant as 5–10 % of patients with pancreatic cancer have a first degree relative with the disease. Furthermore, case control and cohort studies suggest that the risk of developing the disease is 1.5–13 % higher for individuals with an affected family member with an 18 fold increase for those with 2 or more affect family members. The literature highlights that pancreatic cancer aggregates in some families either within defined syndromes (BRCA, STKII, HNPCC) or under the umbrella term of familial pancreatic cancer, which encompasses all those with an inherited predisposition. Research centers have an ongoing focus on the genetic basis for this predisposition and recognize that the best chance of long term survival is through early diagnosis. At present there is no proven screening program but current clinical trials are evaluating the use a combination of blood tests, imaging and molecular methods to screen families with a higher predisposition. Our patient had only one family member affected and would not have been eligible for these trials. There was no justification for early screening in his case.

The Acutely Confused Gentleman: How far must we cast the diagnostic net? Windrim C, Bourke R, Hughes G St Vincent’s University Hospital, Donnybrook, Dublin Intern Network: UCD

S293 Introduction: The presentation of an acutely confused patient in the non-geriatric population creates unique diagnostic and management challenges. Case presentation: A 56 year old man presented with acute confusion on a background of significant alcohol excess. At the time of admission, his blood alcohol level was not elevated, his GCS was 14/15 and he had marked rotational nystagmus. Throughout his admission, the patient had marked ataxia, paranoid psychotic delusions and violent agitation. The working diagnosis included encephalitis, encephalopathy (alcoholic, metabolic) and a vascular insult. Initial investigations were significant for a microcytic anemia (Hb 7.1), deranged liver function tests and diminished synthetic liver function with no raised inflammatory markers. His CT brain and MRI brain were normal. Abdominal ultrasound noted mild splenomegally. Liver autoantibodies, viral screen and ceruloplasmin were within normal limits but his ammonia level was markedly elevated. This prompted a fibronectin scan to confirm cirrhosis, however triphasic CT did not identify any portal hypertension or portosystemic shunt. Finally the patient was screened for ornithine transcarbamylase deficiency, the most common urea cycle disorder with a variable age of onset and presentation. Symptoms typically include lethargy and ataxia, however in patients that present later in life symptoms include headache, nausea and psychiatric symptoms (confusion, delirium, aggression or self injury). Treatment includes avoiding precipitants that lead to increased ammonia, low protein diets and liver transplant is considered curative. He did not have OTC deficiency or any other reversible cause and he was diagnosed with Korsakoff’s psychosis. Discussion: It was important that any reversible cause for this patient’s encephalopathy was outruled before we established a diagnosis of Korsakoff’s psychosis and the ramifications this diagnosis brings. This patient lacks capacity with no enacted power of attorney. This will result in ward of court proceedings and then difficulty finding an appropriate placement.

Treatment of Volume Overload and Acute Kidney Injury: A Balancing Act

Storan B, Casserly L Midwest Introduction: Treating volume overload while preserving kidney function is one of the most challenging and common scenarios we encounter. It is also one where clinicians and patients respond very differently. This case endeavours to highlight how an individual approach is necessary, as well as how to correlate test results with clinical impression. Description/case presentation: Morbidly obese (BMI [50) 56-yearold farmer, who didn’t routinely attend any medical services, presented to the Emergency Department with 6 weeks of dyspnea and general malaise with clinically evident volume overload. RR 24, SpO2 93 %, apyrexial. Tests: Type 2 Respiratory Failure pH 7.441, Hb 11.5 (normochromic normocytic), Na 129, Creatinine 86, Albumin 30, GGt 108, BNP 220, Trop normal, HbA1c 82, ECG: No ischaemic changes, CTPA-No pulmonary embolism although cardiomegaly, pericardial + basal pleural effusions noted. Treated for CCF (diuretics, ACEi), LRTI, new onset Type 2 Diabetes. Echocardiogram– EF 45–50 % (Difficult study due to body habitus)? Diastolic dysfunction. Although a cardiology consultant re-review was requested, and a possible septal bounce was noted. Coronary angiogram showed mild atheromatous disease with 10–30 % stenosis. Liver enzymes increased despite initial diuresis (ALP 209, GGT 149,

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S294 ALT 59)- hepatitis screen, autoimmune screen, ferritin, alpha-one antitrypsin, and SPEP negative. CT abdo/pelvis with contrast performed, which showed only fatty infiltration of the liver, however in the following days contrast-induced oligouric acute kidney injury developed. All nephrotoxic medications were stopped but his condition markedly deteriorated, progressing to anuria, nausea, hypotension, creatinine 814. He was started on hemodialysis and received 3 sessions. Thereafter, his kidneys started to recover and creatinine dropped to a baseline of 135. Cardiac MRI showed features of significant constriction: significant thickening of pericardium (7 mm, normal \3 mm), diastolic septal bounce consistent with equalisation of RV and LV EDP, dilated IVC, enlarged atria, and moderate pericardial effusion without evidence of tamponade. Right heart catheterization confirmed the diagnosis of constrictive pericarditis. Monteux test was negative (zero). Pericardectomy is scheduled although he is felt to be a high-risk surgical candidate. Discussion/conclusion: Key Learning Points: 1) The importance of pushing for a diagnosis and using the whole clinical picture rather than simple test results. 2) Aggressive treatment of heart failure can have devastating effects. 3) The occult nature of constrictive pericarditis.

Acquired Factor VIII Deficiency in an Elderly Gentleman McNicholas D, Soomro N Portincula General Hospital

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 been more thoroughly investigated on this gentleman’s initial presentation? Finally, we can discuss Acquired Factor VIII deficiency including its course, cause and treatment.

Marchiafava Bignami Disease Donnelly F Corresponding Author: Wan Lin Ng A 63 year old female care assistant was admitted with a history of sudden collapse without warning signs. She had no headache, no dizziness, no fits, no focal neurology, no chest pain and no palpitations. She had a similar episode in March 2015 while doing some gardening, although she attributed this to a fall, but had noticed some balance and gait issues since that event. On examination tone and power were normal, but she displayed some truncal ataxia and dysdiadokinesia. She felt quite well otherwise, and was largely unfazed by this sudden onset of ‘‘clumsiness’’. Our Differential Diagnosis began with posterior circulation TIA, or vascular event, then cerebellar syndrome, then paraneoplastic causes, as she had a history of breast and ovarian cancer. She was investigated with CT and MRI brain which showed a ‘‘diffuse white matter abnormality most in keeping with metabolic encephalopathy’’ Both her and her family were shocked, as though she was an alcoholic she was very highly functioning, and had maintained a job and a marriage right up until this admission to hospital. They also questioned why she had no impairment of her liver function, as had been the case with a sibling of hers who was also an alcoholic. We explained that this was unfortunately just her phenotype. She was treated with IV Pabrinex, Thiamine, and Physiotherapy, but has continued to deteriorate and display more signs of neurological degeneration and now of dementia.

West North West Intern Network Introduction: This case report displays both a number of common medical issues among the Geriatric population, such as Falls, Atrial Fibrillation, Stroke, as well as a quite rare medical condition, Acquired Factor VIII deficiency. These are interlinked in this Case Report in a fashion that is both interesting and offers valuable learning outcomes. Case description: A 92 year old gentleman presented to the Emergency Department with 3 day history of extensive bruising to the right hip, knee and abdomen after falling at home. He had a 6 week history of oral anti- coagulant use for newly diagnosed Atrial Fibrillation. A full falls work up was performed including a full blood work up, ECG, Geriatric screen and Echocardiogram all performed. His Apixaban was stopped. The only findings of note were Fast Atrial Fibrillation and an elevated APTT. The patient was diagnosed with a Fall secondary to Vasovagal syncope, and bruising secondary to oral anti-coagulants. This patient re-presented to the ED after a second fall, with new onset confusion and malaise. He deteriorated clinically, with increased confusion and drowsiness. His haemoglobin dropped to 7.9. He was transferred to ICU. CT Brain demonstrated a right temporal lobe haematoma, which a neurosurgical consult decided was for medical management. He had a haematology consult regarding his haemoglobin level, stroke, bruising, and elevated APTT. They immediately requested for a Factor VIII level to test for an Acquired Factor VIII deficiency. This level was 3 %, and he was transferred to the Haematology Department in St. James’ Hospital, Dublin for Factor Eight Inhibitor Bypass Activator (FEIBA) therapy. Discussion: This Case offers us many potential topics for discussion, including the common causes for a fall, and what comprises a full and thorough work up for someone who has had a fall? I’m interested to discuss what the causes of an elevated APTT are, and should this have

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A Subacute Presentation of Ischaemic Cardiomyopathy Murphy C, McDonald K Cardiology Department, St. Vincent’s University Hospital. UCD Intern Network Introduction: Ischaemic cardiomyopathy is the term used to describe significantly impaired left ventricular function that results from coronary artery disease. Case description: A 59 year old gentleman, with no cardiac history, presented to his GP following a single episode of chest heaviness while out cycling, succeeding which he experienced progressive dyspnoea. Over the following weeks he was treated by his GP with antibiotics and steroids for a presumed infective exacerbation of asthma. He subsequently re-presented to his GP with an episode of severe breathlessness, tachycardia and diaphoresis. An ECG taken revealed LBBB and the patient was taken to SJH by ambulance where he received PCI to his LAD which was 99 % occluded. During the procedure, he was also given a stat dose of IV Furosemide due to severe dyspnoea. Following this he was transferred to SVUH for ‘post-STEMI care’. On admission his JVP was elevated, he had bi-basal crepitations and his heart rate was in an intermittent gallop rhythm. CXR showed pulmonary oedema and ECHO revealed severely dilated internal cardiac dimensions with globally reduced systolic function (EF 22 %) and inferior-anterior-anteroseptal akinesia with thinned wall

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 appearance. BNP level was 516 pg/ml. Diagnosis of HFrEF secondary to ischaemic cardiomyopathy was made. Discussion: Based on the advanced internal dilation and thinned ventricular wall seen on Echocardiography this case is clinically suggestive of a subacute cardiac event, rather than an acute MI and it is likely that the patient had infarcted his anterior myocardial wall during the episode of chest pain experienced while cycling 1 month previously. The STEMI for which he underwent PCI was likely a coronary artery embolic event within the LAD. The patient is actively being followed up with the Heart Failure Unit, SMH.

Acute Pyelonephritis Requiring Haemodialysis: A Case Report Murphy C, O Connor T, Holian J Nephrology Department, St. Vincent’s University Hospital. UCD Intern Network Introduction: Bacterial invasion of the renal parenchyma, pyelonephritis, is rarely considered as a primary cause of acute renal failure, particularly in adults Case description: A 69 year old gentleman with a background of Waldenstrom’s Macroglobulinaemia, being treated with Lenalidomide, was referred to St. Vincent’s Emergency Department after presenting with non-resolving cough, decreased appetite, general malaise and a creatinine level of 792 found during work up by his GP. On admission he was oliguric with an eGFR of 6 ml/min/1.73 sq.m. A dipstick urine was positive for blood, protein and leukocytes. A urinary catheter was inserted and 50 mls of urine drained. Renal ultrasonography was carried out immediately and demonstrated normal size and echotexture of the kidneys bilaterally. A Vas Cath was inserted and the patient underwent ur-gent Haemodialysis. Contrastenhanced CT scanning showed no urinary tract abnormalities or collections. The patient was haematologically investigated considering his history of Waldenstrom’s Macroglobulinaemia, however there was no evidence of a paraproteinaemia and blood film reported only burr cells. Enterobacter Cloacae complex, sensitive to Ciproflxacin was isolated on MSU. Re-nal biopsy was carried out on day 5 of admission and revealed a heavy infiltrate of polymorphonu-clear leukocytes in the glomeruli, tubules and interstitium; histologically consistent with acute pye-lonephritis. Discussion: Acute pyelonephritis was a surprising biopsy result considering the marked degree of renal failure on presentation. The patient had no classical symptoms of pyelonephritis, nor radiolog-ical evidence of the infection. Albeit rare, acute pyelonephritis should be considered in the differen-tial diagnosis of acute renal failure. Nahar A, Akom M et al. (2004 Aug) Pyelonephritis and Acute Renal Failure. Americal Journal of Medical Science 328(2): 121–3

S295 seizures (managed with 1 AED) and 6-monthly botox injections to lower limbs for spasticity. This patient had noted global developmental delay during 1st year of life, epileptic seizures from 1 to 3 years, has no spoken words and is non-ambulant with lower limb dystonia. MRI Brain showed prominent brain iron in the basal ganglia, and cerebral atrophy, despite any evidence of this in earlier brain imaging. Genetic testing which followed showed a de novo mutation in WDR45, which encodes the NBIA subtype, BPAN (Beta propeller associated neurodegeneration). [first described in 2012]1 It is known that this form of NBIA results in childhood global development delay and seizures and progresses to parkinsonism and dementia. Currently there is no definitive cure for NBIA. Treatment is with a MDT approach aimed at alleviating symptoms, but awareness of the condition may, in the short term, allow earlier identification of progression resulting in timely alleviation of symptoms (e.g. Levodopa for movement disorders), with potential for reversal/stasis of the condition in the medium to long term. 2,3 NBIA is a rare progressive neurodegenerative condition with a number of different sub-types. Onset ranges from infancy to adulthood, and rate of progression and symptoms vary. In many of the subtypes the condition is heritable. While NBIA is a rare condition, awareness is important for diagnosis, prognosis, treatment strategies and genetic implications. It is also likely to be more commonly recognized in the future with improved MRI access and imaging, and more widespread genetic testing. It is therefore particularly important for paediatric and adult neurology units to have brain iron accumulation as a differential diagnosis in movement disorders and cognitive decline/global developmental delay. 1. Haack TB, Hogarth P, Kruer MC, et al. Exome Sequencing Reveals De NovoWDR45 Mutations Causing a Phenotypically Distinct, X-Linked Dominant Form of NBIA. American Journal of Human Genetics. 2012;91(6):1144–1149. doi:10.1016/j.ajhg. 2012.10.019. 2. Jankovic, J. Bradykinetic movement disorders in children. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2015 3. Schneider SA, Bhatia KP. Excess iron harms the brain: the syndromes of neurodegeneration with brain iron accumulation (NBIA). J Neural Transm (Vienna). 2013 Apr;120(4):695–703. doi:10.1007/s00702-012-0922-8. Epub 2012 Dec 2. Review. PubMed PMID: 23212724.

Surgical Resection of Richter’s Transformation (RT) in Chronic lymphocytic Leukaemia (CLL) Alani D, Nugent E, Joyce M Mr. Joyce, Galway University Hospital West North West (WNW)

Neurodegeneration with brain iron accumulation De Buitle´ir C, Lynch J Department of Neurology, University Hospital Galway, Galway West North West 17-year-old female with neurodegeneration with brain iron accumulation (NBIA) attends clinic for follow up treatment of epileptic

Introduction: The occurrence of Richter’s transformation (RT) in the Rectum is a rare condition which carries a poor prognosis. Mr RJ, a 72 year old man known to oncology with a 6 year background history of Chronic Lymphocytic Leukaemia (CLL) developed Richter’s transformation and subsequently went on to undergo a Hartmann’s procedure to resect this tumour. One year later, he was admitted for the reversal of this colostomy. Description/case presentation: After initial diagnosis, Mr RJ underwent Chemotherapy for CLL and had regular follow-up by the Haematology/Oncology specialists. He was in remission up until

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S296 1 year previously until he presented with a Lymphadenopathy and altered bowel habit. Investigations revealed progression of CLL and a large rectal mass. Systemic chemotherapy was initiated and on completion underwent a laparoscopic Hartmann’s procedure last year to remove the mass with the formation of an end colostomy. One year on, due to difficulty managing the stoma, Mr. RJ was well and deemed suitable for reversal of the colostomy. Allowing for a minor wound infection post operatively, Mr RJ made a good recovery and was discharged home some time later. Discussion/conclusion: Richter’s transformation is a rare Oncological occurance in a patient with Chronic Lymphocytic Leukaemia to the development of a diffuse large B cell Lymphoma. Incidence of this occurring in patients has been estimated at 2–9 %. RT is a rapidly progressive course with mean survival of 4–8 months. Clinical features associated with RT include a worsening of ‘‘B Symptoms’’ (fever, night sweats and weight loss), Lymphadenopathy and splenomegaly. Other key serum markers include Thrombocytopenia, elevated lactate dehydrogenase (LDH) and Anaemia. Treatment generally involves combination chemotherapy with surgical intervention considered if there is a resectable tumour as in Mr. RJ’s case. Although prognosis is poor, if left untreated RT is fatal.

An Audit of Paediatric Asthma Management in an Urban General Practice O Dwyer L1,2, O Shea E1 Claddagh Medical Centre, Galway; 2West Northwest Intern Training Network

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Objectives: Asthma is the most common chronic disease in childhood, affecting approximately 1 in 5 Irish children. Poor asthma control is associated with significant morbidity and mortality. Structured asthma management involving patient education and selfmonitoring supported by regular medical review and a written asthma action plan has been found to improve health outcomes in children with asthma. The aim of this audit was to investigate the standard of paediatric asthma management in our practice compared to current best practice guidelines, to identify areas for improvement and to implement changes to optimise asthma care. Design/methods: Eight criteria for best practice in asthma management were identified and standards set. Asthma patients \18 years were identified by using the Socrates patient management system to search for those with an asthma coded diagnosis or on asthma medication. Each patient file was then reviewed to determine if the criteria were met. Results: 99 patients \18 years were identified as having asthma, giving a 12 % prevalence. 46 were active asthmatics, defined as having asthma medication prescribed in the previous 12 months. 80 % of asthmatics were on the practice Asthma Register. Of the patients with active asthma, 37 (80 %) had an asthma review in the previous 12 months, the majority of whom presented with an exacerbation. Only 7 (15 %) had household smoking status documented, 8 (17 %) had inhaler technique checked at last review, 20 (43 %) had recent centiles recorded, and 22 (48 %) had asthma control assessed using the Royal College of Physicians ‘3 questions’ screening tool. 10 (22 %) patients received a written asthma action plan. Conclusions: All criteria measured fell below the standards set. Deficiencies in current asthma management in the target population

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 were identified and changes implemented. We plan to re-audit in 6 months to assess the effectiveness of these measures.

Communicating Abscess of the Pubic Symphysis Kelly M, Shafquat A, Byrne F Trauma and Orthopaedics Department, University Hospital Galway West North West Introduction: a 68 year old male presented via the emergency department with an 8 week history of right sided groin pain. Case: Mr. BM describes the gradual onset of right sided groin pain exacerbated by movement with erythema overlying. He was otherwise systemically well. Significantly, Mr. BM had undergone a circumcision immediately preceding the onset of his pain. His pain increased in the 5 days prior to his admission, extending to his lower abdomen and pelvis and he was no longer able to weight bear. Examination revealed erythematous swelling of the right groin area extending to the mid thigh. His CRP was 403 mg/l, with a white cell count of 22.8 9 109/L. Blood cultures were positive for Staphylococcus Aureus. An MRI of the pelvis was arranged which showed a large fluid collection in the intermuscular planes of the upper right anterior thigh compartment extending into the pubic region with surrounding soft tissue oedema in the adductor and pectineus tendon insertions. High dose flucloxacillin was commenced. Drains were also inserted under CT guidance draining purulent fluid which also grew Staphylococcus Aureus. Mr. BM improved both clinically and symptomatically with drains left in situ for 21 days. MRI on discharge showed near complete resolution of the collection. He was discharged with a PICC line in situ for outpatient antibiotic therapy under the guidance if the infectious disease service. Conclusion: Infective pubic collections associated with the use of dorsal penile nerve blocks during circumcision have been reported previously by Soh et al. This is the most likely aetiology in this particular case given the timeline of the onset of symptoms and the organism isolated. Yoshida et al. previously described a single case and the anatomical basis for infection in the prevesical space communicating with the thigh muscles as seen in this case.

An Audit of the St. James’s Hospital Bleep Policy Farrell A1, Kelly C1, Cooney J1, Mahon J1 St. James’s Hospital, James’s Street, Dublin 8 Introduction: The bleep policy in St. James’s Hospital was created in 2012 and reviewed and rewritten in July 2015. It aims to optimise efficient communication between healthcare professionals and thus improve patient care. It is a guideline for staff to follow when contacting NCHDs via their bleeps. The policy was audited to review staff awareness and compliance, and identify areas for improvement. Method: Two questionnaires (one for NCHDs and one for nursing staff) were compiled to assess staff experience of the bleep policy. Aims: To establish whether staff were aware of, educated on and compliant with the policy. To identify areas for improvement based on these results.

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 Results: 32 NCHDs and 8 nurses completed the survey. 85 % of NCHDs and 62.5 % nursing staff were previously aware of the policy. 20 and 25 % had read it respectively. 0 % of NCHDs and 50 % of nurses reported receiving policy education. The bleep list (detailing which pager number NCHDs carry) was reported to be inaccurate 25–30 % of the time. Over 80 % of NCHDs reported receiving non-emergency bleeps during ‘emergency bleep only’ periods. 62.5 % of NCHDs said non-emergency tasks were recorded on NCHD on-call workbooks ‘fairly often.’ 70 % of NCHDs reported receiving bleeps on call regarding chronic clinical issues already addressed by the day team. Conclusion: A number of key areas of the policy were identified for improvement. We held formal meetings with Nursing Administration and set targets for education sessions for staff. A corrected updated electronic version of the bleep list was established based on our results. It has been successfully published on the hospital intranet. Nursing administration will ensure increased availability of and compliance with NCHD on-call workbooks. It is hoped this will improve compliance with ‘emergency bleep only’ periods. We aim to re-audit after implementation of above changes in 6 months time.

Mater Misericordiae University Hospital Perioperative Oral Anticoagulation Management Audit Healy N, Monaghan R, Hanley C, Flood G Department Of Anaesthesia, Mater Misericordiae University Hospital Aim: This clinical audit examines the adherence to preoperative anticoagulation guidelines as suggested by Mater Misericordiae University Hospital over a 12 week period. In addition we looked at the percentage of patients who had attended pre operative assessment clinic and if a correlation between clinic attendance and compliance with anticoagulation guidelines exists. Methods: Over a period of 12 weeks, data was collected to a total of 46 patients who presented for elective surgery in Mater Misericordiae University Hospital. All patients included were receiving oral anticoagulation therapy preoperatively. Patients fitting criteria for the audit were identified in the day surgery unit on a daily basis and a proforma sheet was completed by the title authors following patient interview. Follow up data was collected post operatively to assess adverse bleeding outcomes. We assessed whether compliance with Mater Misericordiae University Hospital anticoagulation guidelines was achieved. In cases where compliance was not achieved we examined reasons as to why appropriate management was not followed and if adverse surgical outcomes occurred as a result. Results: At the end of a 12 week period, it was found that 65.2 % of patients were compliant with guidelines. Concerning the role of pre operative assessment clinic, 46.67 % of those managed correctly had been seen by an anaesthetist in clinic. Of 16 patients who were not managed as per guidelines, 81.25 % had not been referred to pre operative assessment clinic. Of note, 18.75 % of those incorrectly managed had attended POAC. There was no discrepancy in the compliance with guidelines between patients on Warfarin and those on a newer anticoagulation agent. Significance: The data supports the role of preoperative assessment in correctly managing anticoagulated patients in the perioperative period. The importance of adherence with recommended anticoagulation guidelines is recognised as is its role in reduction of surgical morbidity.

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Candid-eye-asis: A Case Study and Clinical Audit Doolan E, Khan R, FitzGerald S St. Vincent’s University Hospital Introduction: Ocular candidiasis is a major complication of Candida bloodstream infection. An estimated 16 % of patients with candidaemia have ocular complications of chorioretinitis and/or endophthalmitis. The Infectious Diseases Society of America’s 2009 guidelines recommend that all patients with candidaemia have a dilated fundus examination early in the course of therapy[1]. In 2012, The European Society of Clinical Microbiology and Infectious Diseases state that immunosuppression and repeatedly positive blood cultures are risk factors for ocular candidiasis and should prompt ophthalmological examination[2]. Aims: To audit current practice around positive candida blood cultures. To audit management practice where a diagnosis of ocular candidiasis is made. To discuss a relevant case study. Methods: Ophthalmological consultation requests for patients with positive candida blood cultures between January 2014 and November 2015 were analysed. Microbiology data on positive candida blood cultures for the same time period were accessed and cross referenced. Where a diagnosis of ocular candidiasis was made, medical notes were reviewed to determine the presence of risk factors and symptoms, and the management plan undertaken after diagnosis. Preliminary results: 61 relevant consultation requests were reviewed. 2 patients had confirmed chorioretinitis. 1 had a nonspecific finding (Roth’s Spots). 43 had no findings relevant to candida. 11 examination results are pending. 3 were not examined. Conclusion: Compliance with current guidelines pending. The advent of more potent antifungal agents combined with an early initiation of treatment of candidaemia has reduced the incidence of ocular disease. This may negate the need for ophthalmological examination of every patient with candidaemia. The presence of symptoms is a useful indicator. References: 1. Pappas P et al. (2009). Clinical Practice Guidelines for the Management of Candidiasis: 2009 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 48, 50–535. 2. Cornely O et al. (2012). ESCMID* guideline for the diagnosis and management of Candida diseases 2012: non-neutropenic adult patients. Clinical Microbiology and Infection 18, 19–37.

Refeeding Syndrome O Loughlin S, Boland K, Patchett S Department of Gastroenterology, Beaumont Hospital Introduction: Refeeding syndrome is a potentially fatal condition characterized by severe shifts in fluid and electrolyte balances in malnourished patients undergoing refeeding. Presenting complaint: Mr. GD is a 48-year old man presenting with jaundice and confusion on a background history of excess alcohol intake. He became jaundiced 3 weeks previously. He had intermittent confusion, anorexia, nausea and lethargy over the past 3 months. His abdomen had been distended for 1 year. He had been consuming 16–20 units of alcohol per day for 1–2 years and had very poor nutritional intake.

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S298 Investigations: Initial bloods showed hyponatraemia (121), hypokalaemia (2.8), hypomagnesaemia (0.73), hypophosphataemia (0.68) and hypoalbuminaemia (20). Liver enzymes were raised. There was megaloblastic anaemia, thrombocytopenia and prolonged INR. Viral, autoimmune and metabolic causes of liver disease were excluded. Diagnosis: On the basis of his clinical presentation and alcohol intake, Mr. GD was diagnosed with alcoholic hepatitis and decompensated liver disease. Management: Mr. GD was treated with IV electrolyte replacement, steroids, Pabrinex and chlordiazepoxide. Vancomycin was added for hospital-acquired pneumonia. His appetite returned and he had good nutritional intake. He quickly became fluid overloaded and required IV diuretics. Despite aggressive IV replacement his potassium, phosphate and magnesium continued to plummet (K+ 2.1, Mg/ PO4 \0.5). He developed a prolonged QT interval and required telemetry. His respiratory function deteriorated and he was placed on CPAP. After a week in hospital, Mr. GD’s prognosis was poor and ICU transfer was considered. A central line was placed. Potassium and magnesium were replaced in smaller 250 ml solutions, leading to an improvement in his fluid balance. His electrolytes and ECG normalized and his pneumonia resolved. He was discharged home after 3 weeks. Conclusion: This case reminds us to be vigilant of refeeding in chronic alcoholic patients and highlights the potential difficulties associated with electrolyte replacement in refeeding syndrome.

How Many Units?!: A Surgical Emergency of Severe Upper GI Bleed Flinn K, Naqi SA Beaumont Hospital Presentation: M.M, a 58 year old gentleman admitted via the Emergency Department with a two day history of coffee ground vomiting, malaena and epigastric pain. Background: alcohol [80 units/week, recent NSAID use, and previous oversewing of gastroduodenal artery. Management: Blood tests, PFA and CXR, PPI infusion, followed by emergency OGD. • •

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OGD showed a large duodenal ulcer that was not actively bleeding or covered in clot. Haemoglobin level returned at 3.2 and he was started on immediate RBC transfusion. M.M required a total of 14 units of RBCs, 4 units of FFP, 2 pools of platelets and 1 g of Tranxeamic Acid. A repeat OGD showed an actively bleeding duodenal ulcer. Injection with adrenaline was unsuccessful. CT Angiogram and embolisation was successful.

Outcome: M.M was discharged home on day 13 of admission on triple therapy, thiamine, and galfer. He was advised to avoid NSAIDs and alcohol use, and was for follow up OGD in 10 weeks. Despite in hospital measures to prevent future alcohol use, M.M continued with his excessive alcohol intake and was readmitted 2 weeks later with a similar episode. Learning point: Is there a sufficient way to discharge high-risk patients with a background of alcohol dependency home following a severe upper gastrointestinal bleed? It is a well-known fact that increased alcohol intake is an independent risk factor for upper gastrointestinal bleeding1. One study published in 1996 that looked at when to discharge patients following a bleeding ulcer excluded patients from the trial who had a known history of alcoholism. They

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Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 state that alcoholism alone is a confounding factor that influences discharge2. A 2015 study identified the need for a close follow up programme for patients with known increased alcohol intake following a bleeding ulcer3. Is it possible to create a structured programme for discharging these patients to avoid future rehospitalisation? References: 1. Kelly J, Kaufman D, Koff R, Laszio A, Wiholm B, Shapiro S. Alcohol consumption and the risk of major upper gastrointestinal bleeding. The American Journal of Gastroenterology. 2016;90(7): 1058–1064. 2. Hsu P, Lai K, Lin X, Yang Y, Lin M, Shin J et al. When to discharge patients with bleeding peptic ulcers: a prospective study of residual risk of rebleeding. Gastrointestinal Endoscopy. 1996;44(4):382–387. 3. Ka¨rkka¨inen J, Miilunpohja S, Rantanen T, Koskela J, Jyrkka¨ J, Hartikainen J et al. Alcohol Abuse Increases Rebleeding Risk and Mortality in Patients with Non-variceal Upper Gastrointestinal Bleeding. Dig Dis Sci. 2015;60(12):3707–3715.

Percutaneous Coronary Intervention vs. Coronary Artery Bypass Graft Surgery in Left Main Coronary Artery Disease: Clinical Outcomes at 2 Years in the Mid-West Region O Regan S, Yagoub H, McCarrol P., Kiernan T University Hospital Limerick Importance: Ischaemic heart disease is the leading cause of death worldwide. Traditionally coronary artery bypass graft (CABG) surgery was the primary treatment option for patients with left main disease. However as percutaneous coronary intervention (PCI) has become more refined with advent of drug-eluting stents—many physicians see it is a viable alternative to CABG. Objective: Since July 2013 PCI for unprotected LMCA stenosis has been performed in the cardiology department of the University Hospital Limerick (UHL). The primary aim of this study is to assess the clinical outcomes at 2 years of patients with unprotected significant LMCA stenosis ([50 %) who underwent PCI in the cardiology department of UHL in 2013 and 2014. The performance of this cohort was then compared to those who underwent CABG for unprotected left main disease within the same time frame. Methods: Patients with significant ULMCA disease were identified from the clinical registry. The primary end points of this study were major adverse cardiac and cerebrovascular events (MACCE) at 2 years post intervention. MACCE were defined as death, Q wave myocardial infarction, CVA, and the requirement for repeat revascularisation. In October 2015, 45 of 57 participants were followed up by telephone questionnaire where; the occurrence of MACCE was determined. Analysis was performed using SPSS for Windows Version 22. Categorical variables were compared across both groups using Fischer’s exact test or the Chi Square test where appropriate. Continuous variables were compared using the Independent Samples Median Testing. A p value of \0.05 was considered statistically significant. Results: While all patients treated with CABG were alive at 2 years, 9 % (n = 3) of patients in the PCI group had died. No patients from either group suffered an MI within 2 years of their procedure. However three patients were diagnosed with a CVA within 2 years

Ir J Med Sci (2016) 185 (Suppl 5):S187–S299 (PCI n = 1, CABG n = 2). Cardiac revascularisation was required in one of the patients initially treated with PCI, compared with none of the CABG group. Conclusions: This study has provided 2 year outcome data on patients at UHL with left main disease and subsequently treated with PCI or CABG. In our initial investigation in 2014, patients with mild to moderate coronary artery disease (SYNTAX 0-32) were most often treated with PCI. However, in the presence of severe disease (SYNTAX [33) tended to be referred to a tertiary centre for CABG.

S299 At 2 years, there was no significant differences in the occurrence of all MACCE, death, myocardial infarction, stroke or target vessel revascularisation (p \ 0.05). Consequently, both PCI and CABG can be viewed as reasonable options for treating left main coronary artery disease, as they share similiar 2 year outcome data with respect to the occurrence of MACCE. More data is need on the durability of PCI in the long term. Disclosure statement This supplement has received no external funding or sponsorship.

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