James's Hospital Research Articles

Editorial: State of the Nation at EJEM

Correspondence to Patrick K. Plunkett, Department of Emergency Medicine, St James's Hospital, Dublin, Ireland E-mail: [email protected]

James Crawford Little of Morton Rig

James Crawford Little (“Johnnie”) trained in Newcastle upon Tyne under the highly formative influence of Professor (later Sir) Martin Roth. He was consultant psychiatrist at St James's Hospital, Leeds from...

Association of Hypoalbuminemia on the First Postoperative Day and Complications Following Esophagectomy

ObjectiveChanges in serum albumin may reflect systemic immunoinflammation and hypermetabolism in response to insults such as trauma and sepsis. Esophagectomy is associated with a major metabolic stress, and the aim of this study was to determine if the absolute albumin level on the first postoperative day was of value in predicting in-hospital complications. MethodsA retrospective study of 200 patients undergoing esophagectomy for malignant disease at St. James Hospital between 1999 and 2005 was performed. Patients who had pre and postoperative (days 1, 3, and 7) serum albumin levels measured were included in the study. Patients were subdivided into three postoperative albumin categories <20 g/l, 20–25 g/l, >25 g/l. Logistic regression analysis was performed to calculate the odds of morbidity and mortality according to the day 1 albumin level. ResultsPatients with an albumin of less than 20 g/l on the first postoperative day were twice as likely to develop postoperative complications than those with an albumin of greater than 20 g/l (54 vs 28% respectively, p < 0.011). Correspondingly, these patients also had a significantly higher rate of Adult Respiratory Distress Syndrome (22 vs 5%, p < 0.001), respiratory failure (27 vs 8%, p < 0.01) and in-hospital mortality (27 vs 6% (p < 0.001). On multivariate logistic regression analysis, day 1 albumin level was independently related to postoperative complications (odds ratios, 0.89: 95%; confidence intervals, 0.83–0.96; p < 0.005). In addition, albumin <20 g/l on the first postoperative day was associated with the need for further surgery and a return to ICU. ConclusionSerum albumin concentration on the first postoperative day is a better predictor of surgical outcome than many other preoperative risk factors. It is a low cost test that may be used as a prognostic tool to detect the risk of adverse surgical outcomes.

Early Termination Penalty

In Response: The general thrust of Dr. Wax's (1) comments is laudable, i.e., there is clearly a need for data from well-conducted clinical trials, which can be used to improve care and patient outcome. In theory, we would have liked to continue enrollment in our study (2), however, to optimize care of our patients, it was deemed prudent to stop enrollment. We take Dr. Wax's comments one step further. We believe that more large multicenter “clinical effectiveness” trials, with broad eligibility criteria, need to be conducted. Only these studies can generate conclusions that can be “generalized” to the broader medical community. A result from a single center study such as ours may be valid for that site, but cannot be strictly generalized to patients at other hospitals. Catherine M. O'Malley, FFARCSI Department of Anaesthesia St James's Hospital Dublin 8, Ireland [email protected] Elliott Bennett-Guerrero, MD Duke Clinical Research Institute Duke University Medical Center Durham, NC

Management of gastrointestinal stromal tumours: a single-centre experience

Gastrointestinal stromal tumours (GISTs), although rare, are increasingly recognized, characterized immuno-phenotypically in most cases by a mutation in C-Kit. The advent of imatinib, a tyrosine kinase inhibitor, has presented a novel and effective therapy in advanced disease. The aim of this study was to present the experience and outcomes of a single centre. Review of prospective GIST database at St James Hospital from 1997 to 2005. Survival data were analysed using Kaplan-Meier methods. A total of 32 patients (19 males/13 females) with a median age of 61 years (10-84) were treated. The stomach (n = 20) was the dominant site. Surgery was the first line of treatment for all these tumours, and in seven cases this was performed laparoscopically. C-Kit was positive in 81% of cases. The median survival was 78 months with a 5-year survival of 71%. GISTs are rare and surgical resection, increasingly with minimally invasive approaches, is associated with high cure rates, particularly in gastric tumours.

Baseline diagnostic imaging in early breast cancer—Five-year analysis of a large cohort

17059 Background: Many patients with newly diagnosed breast cancer undergo multiple investigations as part of baseline staging, although the evidence base for this is poor. To assess the use of baseline diagnostic imaging and its benefit a review of practice was carried out. Methods: A retrospective review of all patients diagnosed with breast cancer in St James's Hospital in Dublin, Ireland over a five-year period was carried out. Baseline demographics and the appropriateness of baseline diagnostic imaging were assessed. Results: Between 01/01/2001 and 12/31/2005 781 patients were diagnosed with breast cancer in St James's Hospital, of whom 776 were women and 5 were men, with a mean age of 56.7 years. At diagnosis 266 patients (34%) underwent a bone scan, which showed evidence of skeletal metastases in 42 (15.8%). Of the patients with positive bone scans 26 (61.9%) were symptomatic with bone pain, and 16 (38.1%) were not. In the 16 patients without bone pain a diagnostic workup for metastatic disease was undertaken in 5 patients because of clinical findings, in 4 patients because of abnormal liver blood tests and in 5 patients because of radiological findings. Only two patients out of 266 who underwent a bone scan were found to have an incidental finding of metastatic bone disease, of whom one had a bone scan as part of a clinical trial. At diagnosis 261 patients (33.4%) underwent a liver ultrasound, which showed evidence of metastases in 23 (8.8%). Of these, 19 patients had abnormal liver blood tests. Four patients had metastatic disease on liver ultrasound with normal liver blood tests and of these, one patient had a malignant pleural effusion and one patient had inflammatory breast cancer and was considered high risk for metastatic disease. Only two patients out of 261 who underwent a liver ultrasound had incidental findings of liver metastases. Conclusions: Over a five-year period, occult metastases were discovered in only two patients on bone scans and in two patients on liver ultrasounds. The routine use of these imaging modalities to detect metastases in early breast cancer is not justifiable. No significant financial relationships to disclose.

The Galasko report implemented: the role of emergency medicine in the management of head injuries

The objectives were to demonstrate the extra workload for emergency medicine of inpatient management of mild/moderate head injuries and to determine the effectiveness of current computed tomography guidelines. A retrospective study of head injuries presenting to St James's Hospital Dublin, where the Galasko report has been implemented since 2001. We studied injuries presented from January 2001 to January 2002. Length of stay, mechanism of injury, follow-up, indication for admission and computed tomography scan were identified. A total of 2281 patients presented with head injury as their first or second triage complaint. One hundred and twenty-three patients were admitted to the emergency ward, of which 34 had computed tomography investigation. Ten computed tomography scans demonstrated intracranial injury. Intracranial injury was associated with vomiting, Glasgow coma score 14 (confusion), deterioration of Glasgow coma score, clinical basilar skull fracture and alcohol-related falls. The average length of stay for patients admitted to observation ward was 2.3 days and 5 days for those who had a brain injury on computed tomography scan. Implementation of the Galasko report has resource, manpower and training implications for emergency medicine. The current computed tomography guidelines should be modified to include Glasgow coma score<15 and neurological symptoms for example, vomiting and alcohol-related falls.

Backyard burning

This study was undertaken to determine whether changes had occurred in the numbers of burns that could be related to backyard burning subsequent to the introduction of the council tax throughout Eire for the collection of household refuse. Numbers of patients admitted to our unit who had sustained burns by burning rubbish were recorded prospectively over a period of 12 months. A random control group was taken as three years prior to this and results found by retrospective chart review. Between January and November 2005, 168 patients were admitted to the National Burns Unit, St James's Hospital Dublin, Ireland. Nineteen of these patients sustained flame burns from backyard burning. One hundred and seventy patients were admitted in the comparative period of 2002; Seven of these from backyard burning. The total number of inpatient days for these patients in 2005 (255) was significantly more than in 2002 (68) (p=0.024). The numbers in our study show a marked increase in the number of patients sustaining burns in this manner, and appear to correlate with the introduction of bin charges by a number of county councils around the country last year. This study demonstrates that the introduction of legislation can have an unforeseen adverse affect on the population if not introduced in correlation with appropriate public education. While the introduction of waste charges represents a very necessary move forward in waste disposal in Ireland, public awareness campaigns should be implemented to prevent further such injuries from occurring.

Visceral Reactions: Visualising Health in History

Thackray Medical Museum. Beckett Street, Leeds, LS9 7LN, UK. Combination permanent and temporary galleries. Visited September 2006. Health& History• 9/1 • 2007 145 Visceral Reactions:Visualising Health in History Accessibility: Wheelchair accessible; induction hearing loops & text versions of audio material available. Furtherinformation:http://www.thackraymuseum.org The Thackray Museum can be found in Leeds (Yorkshire, UK) in the grounds of St James Hospital, reputedly Europe's largest teaching hospital. Since its opening in 1997 the museum has won a variety of awards, including the Interpret Britain Award, the UK Museum of the Year, and a Sandford Award for Excellence in Education. It was also nominated as European Museum of the Year.It is housed in the quite magnificent Leeds Union Workhouse, which constitutes an interesting if somewhat troubling historical intersection. The museum's origins lie in the Thackray Medical Supply Company, which was founded in 1902. The company established a collection of artefacts to illustrate its own historical development which Paul Thackray, grandson of the company's founder,ultimately donated as the basis of the ThackrayMuseum. Following the company's sale in 1990, he also established the trust fund which helps to support the museum. The Thackray is now also assisted by the Heritage LotteryFund, one of the main sources of funding for such activities in the UK. Nevertheless, the museum gives prominence in its publicity to its status as an independent, privately-funded institution. This sort of background information is often helpful for understanding the way a museum is laid out and the historical issues represented.But while its backgroundexplains some aspects of the Thackray,in other respects the museum has moved a good distance away from its origins with a medical instruments supply company. As an example, one particularly prominent theme is public health. Indeed, the first permanent exhibition that visitors encounter involves a 'tripback in time' to the streets of Leeds circa 1842. Peering through the windows of the city's poverty-stricken inhabitantswhile stepping around offal, and being bombarded by the sounds (and even the smells!) of a city reeling from the effects 146 EXHIBITION REVIEWS of the IndustrialRevolution, your reviewer noted that the gallery is well designed to appeal to the morbid sensibilities of the young. While the entire museum pays special attention to the demands of the junior and senior secondary school curricula (suggesting an enviable focus on medical history in schools), it nevertheless simultaneously maintains the interest of the youngsters' adult companions. Despite the unmistakable progressivism at the heart of the exhibition's message, its more subliminal insistence on the role of the state and public services in minimising the impact of private profit seeking mitigates any feeling that such progress was inevitable. The curators provide a link between this gallery and the next, which deals with disease treatments, by creating personas for various inhabitants of those 1842 streets. In the next gallery we find out what ails them in 'Health Choices.' This exhibition investigates the kinds of treatments that were available, and their comparative cost. Again, the positivist note is striking- quacks are uniformly condemned, even while the exhibits acknowledge the ineffectiveness of 'mainstream' cures at that time. Yet once more, the curatorsunderminethatmessage, in this case by anexamination of the many continuities between 'traditional'herbal remedies and contemporary pharmacopoeia. The next gallery's title 'Defeating Disease' continues the theme of cures andtreatmentsby physicians through a fairly standardnarrativeof the development of various vaccines and drug remedies. This is followed by the developments leading up to the 'golden age' of surgery in 'Pain, Pus and Blood.' One disquieting component of the surgical galleries (which by their nature are a test of a grown-up's mettle) is the 're-creation' of an operation endured by one of the street's residents of the earlier gallery: a badly fractured limb has to be amputated. The lead-up is effective and tension-building ... (It would probably spoil the ending to reveal more- but the exhibit is safe for most minors!) This by-way (visitors have the option of ducking it) does however provide a useful and informative background to the tools and techniques employed by nineteenth-century surgeons, and the likely outcomes for those unfortunateenough to need their...

Dr Robert Malcolm Mcfarlane: May 28, 1927 – February 27, 2006

Dr Robert Malcolm Mcfarlane: May 28, 1927 – February 27, 2006

Illness-related stigma, mood and adjustment to illness in persons with hepatitis C

We examined stigma in persons with hepatitis C and its relationship with mood and adjustment to illness. We studied 87 persons awaiting interferon treatment for hepatitis C at St James's Hospital, Dublin. Stigma was assessed using Fife's Experience of Illness scale. A structured clinical interview was used to establish DSM-IV diagnosis. The Hospital Anxiety and Depression Scale (HADS) and Beck Depression Inventory (BDI) were also used as measures of mood. Factor analysis and clustering around latent variables analysis were used to assess scale structure and reliability. The stigma scale had an overall reliability of 0.94. A strong dimension of fear of disclosure emerged, from item analysis, together with dimensions of social isolation and social rejection. Stigma was higher in those in manual occupations and the unemployed than in those in non-manual occupation. There were high levels in those with disease associated with injecting drug use and iatrogenic disease caused by transfusion or anti-D blood products, and low levels in those who had been treated for haemophilia with contaminated products or whose hepatitis was of unknown origin. Adjusted for confounders, a 1-decile increase in stigma score had an odds ratio of 1.4 for DSM-IV depression and similar associations with depression on the HADS and BDI. Stigma was also associated with poorer work and social adjustment, lower acceptance of illness, higher subjective levels of symptoms and greater subjective impairment of memory and concentration. These associations were replicated in the non-depressed subsample. The results underline the strong link between stigma and well-being in hepatitis C. However, they also suggest that stigma is a complex construct that will require further research to elucidate.

Shaping up to the future of shadows and spin

Department of Emergency Medicine, St James's Hospital, Dublin, Ireland Correspondence to Patrick K. Plunkett, Department of Emergency Medicine, St James's Hospital, Dublin 8, Ireland E-mail: [email protected]

Clinicopathologic factors predicting complete pathological response to neoadjuvant chemoradiotherapy in esophageal cancer

Multimodal therapy comprising neoadjuvant chemotherapy and radiation therapy prior to radical resection is increasingly utilized in gastroesophageal cancer. The achievement of a complete pathological response (pCR) or a major response is associated with an improved survival. However, up to 70% of patients show an incomplete or no response to the neoadjuvant regimen, and the identification of factors which predict a response would be of considerable clinical benefit. A retrospective analysis of a prospectively updated esophageal cancer database was performed. The predictive values of the following clinicopathological factors were investigated: age, sex, tobacco, alcohol, weight, clinical history, tumor type, site, length, width, morphology and differentiation. Statistical analysis was performed using Chi-square test with Pearson's test or Kruskal-Wallis test. One hundred and seventy-six patients were identified who had undergone neo-adjuvant chemoradiotherapy at St James's Hospital Dublin, between January 1990 and June 2003. A complete pathological response was seen in 40 cases (23%). There was a significant (P < 0.05) relationship between response to chemoradiotherapy and pretreatment tumor length. The median tumor length in the pCR group was 2 cm (1-5 cm) compared with 3 cm (2-7 cm) in non-responders (P < 0.05). Body weight, sex, tobacco or alcohol usage, tumor site, or differentiation were not predictive of response, although a trend (P = 0.08) was observed for squamous cell cancer compared with adenocarcinoma. Smaller tumor length was predictive of a greater response to chemotherapy and radiation therapy. This may reflect different tumor biology, perhaps with acquired resistance to treatment-induced apoptosis in the larger tumors. A simpler explanation is that the existing dose and treatment schedule for combination chemoradiotherapy is suboptimal in patients with larger tumors.

Smoking profile of non-consultant hospital doctors

In 1994 Doll and colleagues published smoking mortality figures for British doctors over 40 years. To assess smoking prevalence among junior doctors in a major Dublin teaching hospital. One hundred and fourteen non-consultant doctors (NCHDs) at St James's Hospital received a confidential smoking questionnaire. One hundred and six NCHDs responded (93%). Three refused, five were not available. Ninety per cent were aged 24-35 years. Twenty-six per cent of the doctors had smoked for 10 to 15 years. Seventy-five per cent were smoking more than 10 cigarettes daily. Ninety-seven per cent (20) of smokers wanted to stop smoking. Seventy-four per cent (17) had unsuccessfully attempted to quit. The smoking cessation method most commonly used was'cold turkey' in 60%. Others included nicotine replacement, bupropion and hypnotherapy. A significant per centage of NCHDs (22%) continue to smoke, despite overwhelming evidence that this causes health problems. The prevalence in our study is lower than the national figure of 29%.

First aid, fast track and the fertile fields of peer review

Department of Emergency Medicine, St James's Hospital, Dublin, Ireland Correspondence to Patrick K. Plunkett, Department of Emergency Medicine, St James' Hospital, Dublin 8, Ireland E-mail: [email protected]

Assisted conception and retinopathy of prematurity: 8-year follow-up study

To assess the effect of assisted conception (AC) on retinopathy of prematurity (ROP) and ROP screening. Follow-up to the study by McKibbin et al. Retrospective study utilising computerised databases of ROP screening, live births, AC and multiple births between 1st April 2000 and 31st August 2003 at St James's Hospital (SJUH) Leeds. chi(2) tests of significance were used. ROP screening was undertaken in 11/265 (4.2%) of AC births versus 1.6% of all SJUH births. This is significantly less than the 20.3% of AC babies screened in McKibbin et al study (P=<0.01). There was no ROP detected in the 11 AC babies. Of all AC births, 36.9% were one of twins and 1.5% from triplet births compared to 46.0% one of twins and 18.6% one of triplets in McKibbin's study. The percentage of AC babies requiring ROP screening has fallen since McKibbin et al study which was performed between August 1991 and December 1994. This appears to be at least partially due to the reduced multiple birth rates. This reduction in the multiple birth rates follows evidence that reducing the number of embryos transferred does not reduce the number of couples taking home a baby and Human Fertility and Embryology Association guidelines recommending 'no more than two embryos should be transferred in an IVF cycle'. Changes in clinical practice at SJUH have significantly reduced the likelihood of AC babies requiring ROP screening and developing ROP.

Synchronized, Interactive Teleconferencing with Digital Cardiac Images

St James's Hospital is a tertiary referral center for percutaneous intervention and cardiothoracic surgery for a number of referring hospitals. This article reports on the development and implementation of a synchronized, interactive teleconferencing system for cardiac images that links St. James's Hospital with a remote site (Sligo General Hospital) and overcomes the problems of transmission of large image files. Teleconferencing was achieved by setting up lossless auto transmission of patient files overnight and conferencing the next morning with linked control signals and databases. As a suitable product was not available, a commercially new software was developed. The system links the imaging databases, monitors and synchronizes progress through imaging sequences, and links a range of image processing and control functions. All parties to the conference are ensured that they are looking at the same images as they are played or at specific aspects of an image that the other party is highlighting. The system allows patient management decisions to be made at a weekly joint teleconference with cardiothoracic surgeons and interventional cardiologists from both sites. Rapid decision making was facilitated with 70% of decisions obtained within 24 h, and 88% within 1 week of their procedure. In urgent cases, data can be transmitted within 20 min of the diagnostic procedure. The system allows increased access to angiography for patients living in rural areas, and provides a more focused referral for revascularization. Participation of the referring cardiologist has improved the quality of decision making.

The use of chlorhexidine antisepsis in contaminated. Surgical wounds

Journal Article The use of chlorhexidine antisepsis in contaminated. Surgical wounds Get access M Crosfill, M Crosfill Bradford ‘A’ Hospitals and St. James's Hospital, Leeds Search for other works by this author on: Oxford Academic Google Scholar R Hall, R Hall Bradford ‘A’ Hospitals and St. James's Hospital, Leeds Search for other works by this author on: Oxford Academic Google Scholar D London D London Bradford ‘A’ Hospitals and St. James's Hospital, Leeds Search for other works by this author on: Oxford Academic Google Scholar British Journal of Surgery, Volume 56, Issue 12, December 1969, Pages 906–908, https://doi.org/10.1002/bjs.1800561209 Published: 07 December 2005

Carcinoma of the stomach following partial gastrectomy for benign gastroduodenal lesions.

Abstract Thirty-six patients presenting with a carcinoma in their gastric remnant following operation for benign lesions have been studied. The original pathology was found to be a gastric ulcer in 22 of 28 patients whose initial operation was undertaken at St James's Hospital. This represents an incidence of at least 1 carcinoma appearing for every 76 patients undergoing partial gastrectomy for gastric ulceration. Carcinoma is far more likely to develop in the stomach following partial gastrectomy when the original lesion is a gastric ulcer rather than a duodenal ulcer.

Acute necrotizing enterocolitis. Survival following perforation and resection in two postoperative patients.

Journal Article Acute necrotizing enterocolitis survival following perforation and resection in two postoperative patients Get access N C Tanner, N C Tanner St. James Hospital, Balham Search for other works by this author on: Oxford Academic Google Scholar K J Hardy K J Hardy St. James Hospital, Balham Search for other works by this author on: Oxford Academic Google Scholar British Journal of Surgery, Volume 55, Issue 5, May 1968, Pages 379–381, https://doi.org/10.1002/bjs.1800550512 Published: 06 December 2005