Mater Misericordiae University Hospital Research Articles

P02-03 Brain imaging in clinical psychiatry: Why?

Aims:To explore clinical indications for, and results of, brain imaging in a department of general adult psychiatry.Method:We reviewed the 100 most recent episodes of brain imaging at the Department of General Adult Psychiatry, Mater Misericordiae University Hospital, Dublin.Results:Patients had a mean age of 55.30 years. The most common indications for scans were cognitive impairment (33%) and other neurological concerns (e.g. seizures) (30%). Forty-seven per cent of scans were abnormal. The most common abnormalities were ischaemia (17%) and atrophy (10%). Patients with abnormal scans were older than those with normal scans (61.90 and 48.70 years, respectively; p< 0.001).Conclusion:Brain imaging contributes significantly to diagnosis in general adult psychiatry, especially for older patients.

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+ Affiliation: Mater Misericordiae University Hospital, Cappagh National Orthopaedic Hospital, Dublin, Ireland

Alice in Wonderland: The Psychiatric Perspective

Department of Adult Psychiatry University College Dublin Mater Misericordiae University Hospital Dublin 7, Ireland e-mail: [email protected] Conflict of interest statement: There is no conflict of interest. Address correspondence to: Brendan D Kelly, MD, MRCPsych, Department of Adult Psychiatry, University College Dublin, Mater Misericordiae University Hospital, 62/63 Eccles Street, Dublin 7 Ireland; e-mail: [email protected].

Community rehabilitation for severe enduring mental illness: a naturalistic, observational study

Dear Editor, The development of rehabilitation and recovery services forms a key element of national mental health policy in Ireland [1]. Over the past 10 years, mental health services in Monaghan and Cavan have developed Assertive Outreach Teams (AOT) as part of Community Rehabilitation Teams (CRT), with the aim of providing individualised care programmes for clients with severe and enduring mental illness and their carers, based on identified needs and implemented as much as possible in a non-institutional settings. The CRT provides specialised services for people disadvantaged by a range of problems that can develop with severe mental illness, and which cannot be adequately met by generic mental health services. This approach helps to optimise social inclusion, reduce the need for repeated admissions and increase patient satisfaction and quality of life. On 1 July 2006, 24 patients were selected from the case-load of the CRT in Cavan; these patients were receiving intensive community treatment for psychiatric symptoms at that time. This naturalistic, observational study aimed to determine the benefits of the CRT in terms of (1) the health and social needs that the CRT was addressing, and (2) the number and duration of hospital admissions before and after intervention by the CRT. The CRT reviewed the cases of each of the 24 patients being treated by the CRT on 1 July 2006 and used the Camberwell Assessment of Need (CAN) [2] to determine the areas of health and social need in which each patient was receiving assistance (see Table 1). Case notes were reviewed to determine the number and duration of hospital admissions before and after intervention by the CRT. Patients were receiving treatment and assistance from the CRT in all 16 areas of health and social need, most commonly psychotic symptoms, psychological distress and information about illness (Table 1). Prior to intervention by the CRT, these 24 patients had an average of 0.93 admissions per year (standard deviation [SD] 0.63); in the 3 years following intervention by the CRT, they had an average of 0.18 admissions per year (SD 0.39) (Z = -3.94; P \ 0.001). Prior to intervention by the CRT, these 24 patients spent an average of 49.53 days in hospital per year (SD 69.12); in the 3 years following intervention by the CRT, they spent an average of 3.37 days in hospital per year (SD 7.04) (Z = -4.17; P \ 0.001). The introduction of the CRT has resulted in (1) interventions aimed a broad range of medical and social needs and (2) a reduction in the number and duration of hospital admissions in patients with severe, enduring mental illness. This is an observational study without a comparison group and was primarily aimed at establishing the effects of the CRT in a ‘‘real life’’ setting. These naturalistic data support research findings [3] that community rehabilitation programmes are valuable in reducing need for admission, optimising provision of individualised care and improving quality of life for patients with enduring mental illness in community settings. A. Niazi B. D. Kelly (&) Department of Adult Psychiatry, University College Dublin, Mater Misericordiae University Hospital, 62/63 Eccles Street, Dublin 7, Ireland e-mail: brendankelly35@gmail.com

Intraoperative Harlequin Syndrome

To the Editor: Recently, Mashour et al. (1) described a patient who developed an intraoperative Harlequin syndrome after an asymmetric epidural anesthetic. We (2) reported a similar case of a patient who developed postoperative ipsilateral Horner’s syndrome with contralateral facial flushing and sweating after high thoracic paravertebral analgesia. We believe that upward migration of local anesthetic in the paravertebral space was followed by an interruption of the sympathetic outflow at the level of preganglionic fibers originating from T1–3 spinal segments which impaired the oculomotor, vasomotor, and sudomotor response to the face on to the blocked side. Consequently, the contralateral side appeared excessively flushed and sweaty in special environmental circumstances such as exposure to heat. A similar Harlequin appearance after low thoracic epidural analgesia was described recently by Crawley (3) and thought to be related to the rostral unilateral migration of the local anesthetic to the upper spinal segments after Trendelenburg’s positioning during surgery. The explanation for perioperative Harlequin syndrome (with or without Horner’s syndrome) after regional anesthesia in the vicinity of sympathetic outflow track appears, therefore, logical. The mystery resides in the rarity of this condition. Crina L. Burlacu, MSc, FCARCSI Donal J. Buggy, MD, MSc, FRCPI, FCARCSI, FRCA Department of Anaesthesia, Intensive Care and Pain Medicine Mater Misericordiae University Hospital Ireland [email protected]

Thalidomide and Dexamethasone in Newly Diagnosed Multiple Myeloma.

PURPOSE: The combination of thalidomide and dexamethasone has been shown to have excellent antimyeloma activity in both relapsed and newly diagnosed patients. This combination offers a potential oral, less toxic alternative to standard regimens. This single-centre retrospective study evaluates the activity of the combination of thalidomide and dexamethasone in patients with newly diagnosed multiple myeloma attending the haematology department of the Mater Misericordiae University Hospital, Dublin.METHODS: Forty-six patients with newly diagnosed multiple myeloma between April 2000 and April 2006 were treated with thalidomide and dexamethasone as first line treatment. The median age of the patients was 70 years (range 46 to 88 years). The median serum paraprotein level was 32g/l (range 2 to 99g/l). The median bone marrow plasma cell percentage was 40% (range 10% to 99%) The first twenty-two patients were commenced on thalidomide at 200mg od with the dose increased by 200mg every two weeks if tolerated to a maximum of 800mg od. The most recent twenty-four patients were commenced on thalidomide at 100mg od with the dose increased to a maximum of 200mg if tolerated. All patients received dexamethasone 40mg per day on days 1–4, 9–12 and 17–20 ot the first cycle and for a four day pulse every four weeks for subsequent cycles.RESULTS: The response rate was 67.4% when assessed by Blade criteria (50% reduction in serum myeloma protein and 90% reduction of urine myeloma protein on at least two occasions for a minimum of 6 weeks). A complete response was observed in 10.9% of patients. There was no significant difference in response rates between the higher thalidomide dose group and the lower thalidomide dose group. The main toxicities included constipation in 57.8%, hyperglycaemia in 33.3%, peripheral neuropathy in 22.2%, drowsiness in 15.6%, peripheral oedema in 15.6%, venous thromboembolism in 11.1%, rash in 11.1% and proximal myopathy in 8.9%. Routine anticoagulation was not used although patients with additional risk factors for venous thromboembolism received prophylactic dose low molecular weight heparin and in total 53.3% of patients were receiving either aspirin, warfarin or low molecular weight heparin at the time of treatment. There was no significant difference between the two thalidomide dose groups in terms of frequency of toxicities. However 27.3% of patients in the higher thalidomide dose group had their treatment stopped within one month due to toxicities compared to 4.2% in the lower dose group.CONCLUSION: The combination of thalidomide and dexamethasone is safe and effective in the treatment of newly diagnosed multiple myeloma. There is less treatment-limiting toxicity and no loss of efficacy with lower doses of thalidomide.

Letter To The Editor: An Unusual Complication of Radiofrequency Ablation Treatment of Osteoid Osteoma

Letter To The Editor: An Unusual Complication of Radiofrequency Ablation Treatment of Osteoid Osteoma

Efficacy and tolerability of fentanyl or clonidine in combination with diluted levobupivacaine in paravertebral analgesia

Department of Anaesthesia, Intensive Care and Pain Medicine, Mater Misericordiae University Hospital, Dublin, Ireland

The Future of Virtual Colonography

Dr Helen Fenlon is a Consultant Radiologist at the Mater Misericordiae University Hospital, Dublin, Ireland

Empowering nurses—Improving care: Nurses’ response to the new Health Services Reform Programme in Ireland

The Health Service Reform Programme in Ireland will be the biggest change ever seen in the health service. This programme will be dependent on information structures that provide appropriate and timely information. The Nursing Informatics Project Team in the Mater Misericordiae University Hospital, Dublin is in the process of implementing an Integrated Nursing Information System, which will facilitate participation in the new reforms.

Patient pain during stretching of small pupils in phacoemulsification performed using topical anesthesia

To assess the pain experienced by patients with small pupils during pupil stretching in phacoemulsification performed using topical anesthesia. Royal Victoria Eye & Ear Hospital and Mater Misericordiae University Hospital, Dublin, Ireland. This was a prospective study that included 26 eyes with small pupils requiring mechanical pupil stretching during phacoemulsification cataract surgery performed under topical anesthesia without sedation. The mean pain score for the instillation of anesthetic drops (2.02) was higher than the mean pain score for the pupil stretch (1.63), but this difference was not significant (signed rank test = -32; P = .2738). There was no significant correlation between the duration of surgery and the overall pain score (r = 0.345; P = .08). There was no significant correlation between change in pupil size and either the pupil stretch score (r = -0.069; P = .74) or the overall pain score (r = -0.032; P = .8739). Pupil stretching during phacoemulsification in patients with small pupils was performed with minimal patient-reported pain using topical anesthesia. Stretching small pupils with a mechanical device during phacoemulsification performed under topical anesthesia was a safe procedure and did not result in significant patient discomfort.

Ironing out the cryptic intestinal defect in hereditary hemochromatosis

Kelleher T, Ryan E, Barrett S, Sweeney M, Byrnes V, O’Keane C, Crowe J. (Centre for Liver Disease and Department of Pathology, Mater Misericordiae University Hospital, Dublin, Ireland). Increased DMT1 but not IREG1 or HFE mRNA following iron depletion therapy in hereditary haemochromatosis. Gut 2004;53:1174–1179. It is quite impossible to evolve a theory to cover the absorption and excretion of iron which does not conflict with some of the published findings.—R. A. McCance and E. M. Widdowson (Lancet 1937)