South Infirmary Victoria University Hospital Research Articles

Impact of the COVID-19 pandemic on the trauma and orthopaedic department at level one Major Trauma Centre in the republic of Ireland

The Coronavirus Disease (COVID-19) has been identified as the cause of a rapidly spreading respiratory illness in Wuhan, Hubei Province, China in early December 2019. Since then, the free movement of people has decreased. The trauma-related injuries and the demand on the trauma and orthopaedic service would be expected to fall. The aim of this study to examine the impact of the COVID-19 pandemic on a level 1 Trauma Centre in the Republic of Ireland (ROI). Patients admitted to the Trauma & Orthopaedic (T&O) Department at Cork University Hospital (CUH) and the South Infirmary Victoria University Hospital (SIVUH), and their associated fracture patterns and management, between 01/03/20 and the 15/04/20 were documented and compared to the patient admissions from the same time period one year earlier in 2019. The total number of T&O operations performed decreased by 10.15% (P= 0.03)between the two time periods. The number of paediatric procedures fell by 40.32% (P= 0.15). Adult Distal radius and paediatric elbow fractures (excluding supracondylar fracture) increased by 88% and 13% (P= 0.19), (P= 0.04) respectively. Hip fractures remained the most common fracture-type admitted for surgery. The COVID-19 crisis has to lead to a decrease in the total numbers of trauma surgeries in a major trauma centre in the ROI. This decline is most evident in the number of paediatric and male adult patients presenting with fractures requiring operative management. Interestingly, fractures directly related to solo outdoor activities, such as running or cycling, as well as simple mechanical falls like ankle, distal radius, elbow, and hand fractures all increased. Irish males were more compliant with outdoors restrictions than females.

Impact of the COVID-19 Pandemic on Trauma and Orthopaedic Service in the Republic of Ireland

Background: The novel coronavirus disease-2019 (COVID-19) has been identified as the cause of a rapidly spreading respiratory illness that is thought to have originated from Wuhan, China in early December 2019. Since then, the free movement of people has decreased, which has thus reduced the number of trauma-related casualties. The Irish governments initiated strict social distancing measures in response to the COVID-19 pandemic in late March 2020. It remains challenging to quantify the impact this had on reducing the spread of the virus. The viral outbreak has led to significant changes in the lifestyle of Irish citizens. The aim of this study was to examine the impact of the pandemic on activity, related to emergencies in trauma and orthopaedics departments. Methods: Patients admitted to the Trauma and Orthopaedic Department at Cork University Hospital (CUH), Cork, Ireland and South Infirmary Victoria University Hospital (SIVUH), Cork, Ireland between the 1st of March and the 15th of April 2020 were documented and compared to the patient admissions from the same time period in 2019. Results: The total numbers of lower limb trauma cases dropped by 20.44% from 137 (females: 87; males: 50) to 109 (females: 74; male: 35), (p=0.72). Of note, there was a 30.00% reduction in the number of male cases (from 50 to 35; p<0.05), in comparison to the 14.94% reduction observed in the female population (from 87 to 74; p<0.05). The total number of upper limb trauma cases increased by 0.14% from 90 (female: 44; men: 46) to 94 (female: 54; male: 40; p=0.14). The increase reported was only applicable to the female population; the number of male cases of upper limb trauma slightly decreased from 46 to 40 (p<0.005). Conclusion: The COVID-19 crisis has led to a decrease in the total numbers of lower limb trauma surgeries but an increase in the number of upper limb fractures. The main reduction was amongst the male patients, while the number of female cases increased.

The Role of the Clinical Pharmacist in an Irish University Teaching Hospital: A Mixed-Methods Study.

Medication review (MR) is a vital part of the pharmacist’s role in hospital. However, in the South Infirmary Victoria University Hospital (SIVUH), Cork, Ireland, this has not been fully implemented due to resource issues. In addition, the cost of providing this service has not been evaluated. Moreover, it is not clear how other members of the multidisciplinary team e.g., Nurses, value any interventions made as a result of the MR. This mixed methods study assessed the impact of MR in terms of (i) potential clinical harm, (ii) cost avoidance and (iii) the views of nursing staff on the role of the pharmacist. The setting is a 192-bed, voluntary, acute hospital, in the Munster region of Ireland. Study I: The pharmacist provided MR to patients conventionally once a week. Any interventions were then assessed for potential clinical harm and to calculate cost avoidance. Study II: Semi-structured interviews, guided by a topic guide were completed with 12 nurses (11 female). Thematic analysis was used to code the main themes. Main outcome measure: To estimate the cost, cost avoidance, and the net cost benefit ratio of MR provided by pharmacists. Study I: Of 128 patients who received the MR, 113 interventions were made. The estimated cost of providing the MR was €2559 (senior pharmacist). Using €1084 as the cost of an adverse drug event (ADE), the cost avoidance was calculated at €42,330. This led to a net cost benefit of €39,771 (senior pharmacist) which equated to a net cost benefit ratio of 16.5:1. Study II: The main themes were (i) perceptions of pharmacy services, (ii) the role of the pharmacist—past, present and future, and (iii) teamwork and communication. Nurses expressed a desire to have more pharmacists present on the wards.

Efficacy and tolerability of metronomic chemotherapy in patients with metastatic breast cancer – an international experience in West Sweden and in the South of Ireland.

IntroductionMetronomic chemotherapy (MCT) is the continuous administration of low dose chemotherapy. It has significant clinical efficacy with minimal toxicity as compared to conventional chemotherapy regimens. Thus represents an attractive treatment modality in selected patients with advanced breast cancer. MethodsPatients who received MCT in the form of Capecitabine/Cyclophosphamide for the treatment of advanced breast cancer between May 2014 and October 2018 in Sahlgrenska University Hospital in Sweden and in Cork University Hospital, University Hospital Kerry and the South Infirmary-Victoria University Hospital in Ireland were identified. Medical records were retrospectively reviewed to collect data. All survival analyses were described by Kaplan-Meier curves and analysed with log-rank tests. The primary end-point was time on treatment, used as a surrogate marker for efficacy. Results148 patients were identified (84 – Sweden, 64 – Ireland), with a median age of64.2 (range 31–89). The overall mean time on treatment for all patients in both countries is 9.05 months (range 0.36 – 67.21). In patients with bone only disease the mean time on treatment was 10.1 months (range 0.7 – 67.2), compared to patients with visceral disease of 8.91 months (range 0.36 – 39.77). Treatment was ended in the majority of patients because of progression of disease, representing 108 patients (72.9%). ConclusionThis is an observational, retrospective study demonstrating the real world effectiveness of MCT in the treatment of advanced breast cancer. In this cohort of unselected pre-treated patients, the efficacy of MCT was comparable with the survival outcomes of landmark clinical trials.

Ionizing Radiation Dose Exposure to the Ocular Region of Pain Physicians During C-arm Guided Pain Interventions

Background: The growth of interventional pain medicine in recent years has resulted in more procedures being carried out under fluoroscopic guidance. The proximity of the pain physician (PP) to ionization radiation (IR) potentially increases the risk of radiation exposure to the ocular region. A European directive has reduced the limits of occupational ocular dose 7.5-fold. Objectives: The objectives of this study are to quantify the typical IR exposure in the ocular region of PP and to compare it to recommended international guidelines. Study Design: Three consultants involved in the pain unit service were enrolled in the study to reflect the dose implications involved with different caseloads, training obligations, and procedure types. All 3 consultants were experienced primary operators. Setting: The study was undertaken at the pain management suite in the South Infirmary Victoria University Hospital (SIVUH). Annually, this unit performs 2,800 fluoroscopic guide pain procedures. Methods: Thermoluminescent dosimeters (TLDs) calibrated to measure eye lens doses [Hp (0.07)] and whole-body doses (WBDs) were fitted to 3 pain consultants while they undertook imaging-guided pain procedures using mobile C-arm fluoroscopy over a 3-month period. The duration of radiation exposure, screening time (seconds), and procedure type were recorded. Radiation dose was calculated to estimate the effective radiation dose to the ocular region using (i) dose-area product (DAP) in milliGray per centimeter squared (mGycm2 ) and (ii) Air Kerma (AK) values in mGy. Results: IR doses were effectively recorded in 682 cases over 3 months and the data extrapolated. The estimated annual lens dose experienced by pain physicians performing fluoroscopy-guided procedures is less than the recommended international guidelines. A significant linear relationship between screening time and IR exposure was estimated (rs = 0.93, P < 0.01) Limitations: In many centers, including our own, fluoroscopy procedures are undertaken by nonconsultant staff. Therefore, a small single-center cohort recruiting experienced consultant staff and not including pain fellows or registrars/residents with varying levels of experience is a limitation. Conclusion: While IR to the ocular region was significantly less than the recommended European safety guidelines, the annual dose needs to be confirmed in pain physicians with a lesser degree of clinical experience. Key words: Ionizing radiation, ocular, radiation protection, pain medicine, interventional

Outcomes of transoral laser microsurgery for oropharyngeal squamous cell carcinoma in Ireland and review of the literature on transoral approaches.

The optimal treatment for oropharyngeal squamous cell carcinoma (OPSCC) is controversial. There is increasing evidence that, in selected cases, minimally invasive transoral surgery can offer improved functional outcomes, with equivalent oncologic outcomes, compared to chemoradiotherapy. We report the outcomes of transoral laser microsurgery (TLM) for treatment of OPSCC at our institution. Patients with OPSCC undergoing TLM at the South Infirmary Victoria University Hospital, Cork, between 2010 and 2016, were identified from an institutional database. Human papillomavirus (HPV) status was determined by p16 immunohistochemistry. Survival outcomes were analysed using the Kaplan-Meier method. Complications following surgery and gastrostomy tube dependence were evaluated. The study cohort consisted of 26 patients, with mean age of 56years (range 29-71). Primary tumours were located in the tonsil (18), base of tongue (4) and other subsites (4). Seventeen cases were p16-positive. Complications included haemorrhage necessitating return to theatre (1) and aspiration pneumonia (1). Four patients underwent tracheostomy, all of whom were successfully decannulated. One patient underwent gastrostomy tube insertion during postoperative radiotherapy. No patient was gastrostomy dependent at latest follow-up. Twenty-two patients received adjuvant treatment, with radiation alone (21) or chemoradiotherapy (2). Mean follow-up was 27months. Five-year locoregional control was 92% and disease-specific survival was 81%. In selected patients with OPSCC, TLM offers excellent functional and survival outcomes, and as such offers an alternative approach to chemoradiotherapy as primary treatment. We compare TLM to other transoral approaches and discuss its potential use in the Irish healthcare system.

Experiences of lifestyle management and support during pregnancy: a qualitative study of the attitudes and experiences of pregnant women and healthcare professionals

Event Abstract Back to Event Experiences of lifestyle management and support during pregnancy: a qualitative study of the attitudes and experiences of pregnant women and healthcare professionals Caragh Flannery1*, Sheena McHugh2, Emma Clifford3, Louise Kenny4, Molly Byrne1 and Patricia Kearney2 1 NUIG, Health Behaviour change research group, School of Psychology, Ireland 2 University College Cork, Department of Public Health and Epidemiology, Ireland 3 South Infirmary Victoria University Hospital, Department of Nutrition & Dietetics, Ireland 4 University College Cork, Department of Obstetrics and Gynaecology, Ireland Background Overweight and obesity during pregnancy is associated with the risk of gestational diabetes mellitus (GDM) among other complications. Lifestyle interventions have been shown to be effective in this population however, studies often fail to identify the mechanisms by which the intervention is expected to be effective. Aims Our aim is to identify the barriers and enablers to behaviour change from the perspective of overweight and obese pregnant women and healthcare providers (HCP) in order to inform the development of a technology supported lifestyle intervention. Methods Semi-structured interviews are being conducted with a purposive sample of overweight or obese women at different stages of pregnancy, recruited from a public antenatal clinic in a large academic maternity hospital in Cork (CUMH) (n=15-20). A purposive sample of HCP will also be recruited (n=10-15). The Framework approach is being used for analysis, drawing on the Theoretical Domains Framework (TDF) and the COM-B model of behaviour change. Results Preliminary analysis of pilot interviews with HCPs suggests that pregnancy is ‘a wake-up call’ for some women as the risks of overweight and obesity are made explicit. Social influences were identified as a potential facilitator; HCP suggested behaviour change was easier for pregnant women when supported by their partners. HCPs identified the environmental context and resources within the health system as barriers, particularly the lack of dedicated obesity clinics. Conclusion HCPs believe pregnancy offers a window of opportunity to change behaviour. However, there are limited resources available to them to support women to make these changes. Keywords: Technology, lifestyle, Behaviour Change, Ireland, overweight and obese, Pregnancy Complications Conference: 2nd Behaviour Change Conference: Digital Health and Wellbeing, London, United Kingdom, 24 Feb - 25 Feb, 2016. Presentation Type: Poster presentation Topic: Academic Citation: Flannery C, McHugh S, Clifford E, Kenny L, Byrne M and Kearney P (2016). Experiences of lifestyle management and support during pregnancy: a qualitative study of the attitudes and experiences of pregnant women and healthcare professionals . Front. Public Health. Conference Abstract: 2nd Behaviour Change Conference: Digital Health and Wellbeing. doi: 10.3389/conf.FPUBH.2016.01.00093 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 30 Sep 2015; Published Online: 09 Jan 2016. * Correspondence: Ms. Caragh Flannery, NUIG, Health Behaviour change research group, School of Psychology, Galway, Ireland, cflannery@ucc.ie Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Caragh Flannery Sheena McHugh Emma Clifford Louise Kenny Molly Byrne Patricia Kearney Google Caragh Flannery Sheena McHugh Emma Clifford Louise Kenny Molly Byrne Patricia Kearney Google Scholar Caragh Flannery Sheena McHugh Emma Clifford Louise Kenny Molly Byrne Patricia Kearney PubMed Caragh Flannery Sheena McHugh Emma Clifford Louise Kenny Molly Byrne Patricia Kearney Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Primary urachal malignancy: case report and literature review

Dear Editor, We present the case of a 38-year-old nulliparous woman who presented with a 3 months history of lower abdominal pain, dysuria and frequency. She denied weight loss, altered bowel habit or PR bleeding. Examination revealed a pelvic mass palpable to the level of the umbilicus. It was firm, non-tender and immobile. Hb was 9.6 g/dl and CA 125 was 18 U/ml. Her liver function tests, urea and electrolytes were within normal limits. Past history included emergency surgery at 3 days of life for Meckels diverticulum, atrial septal defect repair at 7 years of age and an appendectomy at 8 years of age. She had no previous gynae history or family history of breast, ovarian or bowel carcinoma. An abdominal and pelvic CT scan revealed a 9.5 9 7.7 cm midline abdominal mass suspicious for ovarian malignancy (Figs. 1, 2). The mass appeared adherent to the anterior abdominal wall had irregular margins and fat stranding. It indented small bowel loops and possible invasion of the small bowel was suggested. A further multi-cystic lesion was seen in the left adnexa. No pleural effusion or ascites were present. Multiple mesenteric nodes of 1 cm in diameter were present. She was referred to a tertiary gynaecology oncology centre where a laparotomy was performed with a colorectal surgeon present. She was found to have situs inversus of the abdominal organs, an absent right ovary and fallopian tube and normal left ovary and fallopian tube. The tumour was adherent to the anterior abdominal wall and to the bladder posteriorly. A frozen section confirmed metastatic mucinous adenocarcinoma consistent with an ovarian primary. Also present was a healthy appendix although situated in the left iliac fossa. The mass was resected en bloc (Fig. 3) including much of the rectus muscle, the dome of the bladder, two loops of small bowel and a right hemicolectomy was performed. A simple cystic left paraovarian mass was also removed. Histology showed a signet-ring mucinous adenocarcinoma of the urachus (10 cm) extending from the dome of the bladder with full thickness invasion of the small bowel and inflammatory adhesions to large bowel. All bowel, bladder and soft tissue margins were free of tumour. A normal appendix was noted. 31 lymph nodes isolated were free of tumour. The para-ovarian mass showed signet-ring mucinous adenocarcinoma also consistent with metastasis from urachal malignancy. Peritoneal washings were negative. She recovered well postoperatively and was referred to urology for discussion re-adjuvant chemotherapy. The urachus is a midline vestigial remnant located between the dome of the bladder and the umbilicus (Fig. 4). In the foetus the urachus connects the bladder to the allantois. In normal development the allantois is gradually reduced and obliterated with the urachus becoming a fibrous band extending from the anterior bladder dome to the umbilicus. Primary adenocarcinoma of the bladder accounts for less than 1 % of all bladder malignancies, of these 20–39 % are urachal in origin. Urachal adenocarcinoma is more common in men and tends to present in the fifth and sixth decade of life. The common presenting symptoms are haematuria, pain, irritative voiding symptoms and mucosuria. Most urachal malignancies (70 %) are mucin-producing adenocarcinomas, more rarely it is a non-mucin producing adenocarcinoma (15 %). Consistent with other enteric type adenocarcinomas, urachal cancers may express detectable D. Hayes Ryan (&) P. Paramanathan N. Russell J. Coulter South Infirmary Victoria University Hospital, Cork, Ireland e-mail: dee_hayes_ryan@hotmail.com

Osteoporosis and HIV

Osteoporosis poses a significant public health issue, causing significant morbidity and mortality. It is a disease of bone that leads to an increased fracture risk through a reduction in the bone mineral density (BMD), disruption of bone microarchitecture, and alteration of the amount and variety of non-collagenous proteins in bone. The treatment aims of this condition are to prevent fractures and maintain the quality of life of the aging adult. Approximately three million people in the UK have osteoporosis, and every year more than 230,000 fractures occur because of it. One in two women and one in five men over the age of 50 will have a fracture mainly as a result of the condition, and therefore, osteoporotic fractures are of great importance to patient and clinician. As the HIV-infected population continues to live longer, due to the advent of highly active anti-retroviral therapy (HAART), osteopenia and osteoporosis are becoming more common metabolic complications in the aging adult with HIV [1]. Certain lifestyle and hormonal factors, which increase the risk of disordered bone metabolism, are prevalent in HIV-infected patients. These include physical inactivity, suboptimal intake of calcium and Vitamin D, cigarette smoking, alcohol and opiate use, depression, and low testosterone levels. HAART itself may be associated with decreased BMD [2–5]. Although prevalence estimates of low BMD vary considerably, most studies indicate an increased risk in HIVinfected individuals. In a meta-analysis by Brown et al. [2], 20 cross-sectional studies were reviewed and it was demonstrated that 67 % of 884 HIV patients had reduced BMD and 15 % fulfilled the diagnostic criteria for osteoporosis. Similar findings were noted by Cazanave et al. [3] in a cross-sectional survey of 492 HIV patients within the Aquitaine cohort, which involved analysis of BMD of total body, lumbar spine, and femoral neck regions. Cazanave et al. reported osteopenia in 55 % of men and 51 % of women, along with osteoporosis in 34 and 8 %, respectively. Variations between sexes are being explained by age differences and cigarette use. More recent publications by Mallon [4] and Calmy et al. [5] report similar correlations between low BMD and HIV positive status among Irish and Australian patients, respectively. Low BMD among patients with HIV infection is usually multifactorial, since weight loss, malnutrition, malabsorption (leading to vitamin D deficiency), and hypogonadism may be present. HIV infection itself may cause chronic T cell activation and increased production of proinflammatory cytokines that enhance osteoclast activity [6]. Traditional risk factors for bone loss such as female gender, low body mass index (BMI), physical inactivity, steroid use, advanced age, duration of menopause, smoking, and injection drug use may act in concert with HIV-associated risk factors. In addition, the importance of the status of reproductive function was highlighted by a study of 84 normal-weight, HIV-infected women, which reported reduced bone density among women with oligomenorrhea or elevated follicle-stimulating hormone (FSH) levels compared to women with normal menses. Studies have been conducted to determine the effects of HAART and individual anti-retroviral agents or medication classes on bone loss in HIV-infected patients. In a metaanalysis of ten studies comparing HAART-naive (n = 202) with HAART-treated (n = 824) patients, there was a 2.5M. B. O’Connor (&) Department of Rheumatology, South Infirmary Victoria University Hospital, Old Blackrock Road, Cork, Ireland e-mail: mortimeroconnor@gmail.com

A re-audit of prevention of venous thromboembolic disease in medical and surgical hospital patients in a single university teaching hospital

The importance of the prevention of venous thromboembolic events (VTEs) among medical and surgical hospital patients is coming more and more to the fore with the ongoing development of initiatives and recommendations across the globe. As readers of this journal will note, we have previously carried out an audit of the level of VTE prophylaxis among patients at our hospital in October 2009 [1]. This led to the development of on the ward reminder notices highlighting VTE prophylaxis. As a follow-up to our previous work we reaudited in October 2010 to assess the impact of on the ward VTE reminders. On a designated day during October 2010, all medical and surgical in-patients at the South Infirmary Victoria University Hospital, Cork were assessed regarding VTE prophylaxis. A proforma, identical to our previous proforma, was used to assess patients, with data collection being from patient case notes and medication prescription charts. Proforma preparation was as per current European VTE prophylaxis guidelines. Medical and surgical teams were not aware that the audit was taking place to avoid bias changes in management behavior, while audit approval was prospectively received from the hospitals Drugs & Therapeutics committee. Eighty percent (97/122) of in-patients were included in the study, with the remaining 20% (n = 25) being either inaccessible for inclusion (n = 10), had a contraindication to VTE prophylaxis (n = 4: active bleeding disorder) or already receiving therapeutic anticoagulation (n = 11). Fifty percent (n = 49) were female and 50% (n = 48) male, with a mean age of 67.9 years. The modal length of hospital stay at review was 3–7 days. Forty percent (n = 39) of patients received VTE prophylaxis and 25% (n = 24) were using TEDS. Among those on VTE prophylaxis medication, 41% (n = 16) received Tinzaparin Sodium 3,500 units, 38% (n = 15) enoxaparin 20 mg and 21% (n = 8) enoxaparin 40 mg. Four patient received VTE prophylaxis at 08.00 hours, 3 at 13.00 hours and the remaining 32 at 22.00 hours. Among the patients included in this audit 50 had a medical indication for VTE prophylaxis and 23 had a surgical indication. No patient had both medical and surgical VTE prophylaxis indications. Fifty-three percent (39/ 73) of patients with a clear indication for VTE prophylaxis were appropriately receiving such. Sixty-five percent (15/ 23) of surgical indications were appropriately covered by VTE prophylaxis compared to 48% (24/50) of medical indications. No patient received VTE prophylaxis without an indication. Based on the findings of this audit we have seen an improvement in appropriate use of VTE prophylaxis correlating with the use of ward notices highlighting VTE E. O’Sullivan, A. Ni Laoire, C. Buckley, H. Bastaki, M. Walsh and N. A. M. Jaffar are joint second authors.

Staphylococcal Infections, Not Just Skin Deep

To the Editor The recent case report by Clenenden et al.1 describes staphylococcal sepsis occurring in a female patient 8 days after shoulder arthroplasty. Postoperative analgesia was provided by continuous interscalene block for 5 days, with an earlier catheter that had dislodged being replaced after only 1 day. On the basis of the presence of a small hematoma at the site of the first catheter and growth of Staphylococcus aureus from a swab of the patient's neck, the authors concluded that the indwelling catheter was the cause of infection. However, we are not convinced that this is the true source of the infection. Staphylococcus aureus is present on the skin of 25% of the population. Catheter colonization is not uncommon but severe infections associated with continuous nerve blocks remain extremely rare.2,3 Furthermore, in the absence of any demonstrable abscess or significant cellulitis, it seems improbable that the rapid descent into profound septic shock originated from a catheter removed several days earlier. The facts suggest an alternative diagnosis, which, in our clinical opinion, is the more likely source. Staphylococcus aureus is a well-recognized cause of severe, even fatal, enterocolitis in adults. It is frequently, although not invariably, associated with prior antibiotic usage.4,5 Staphylococcal enterocolitis affecting the small bowel of previously healthy adults has been described, with acute patchy disease rapidly progressing to segmental gangrene.6 The authors state that segmental ischemic necrosis of the proximal jejunum was discovered on laparotomy, and that the peritoneal fluid was positive for Staphylococcus aureus. Although it may seem logical to ascribe a staphylococcal sepsis to a foreign body disrupting the skin barrier in this case, the overall clinical picture suggests otherwise. Clenenden et al.1 should consider, and rule out, alternative diagnoses before making such assumptions. In addition, we wish to once again highlight staphylococcal enterocolitis as an oft forgotten cause of nosocomial enterocolitis and sepsis.8 Rory Naughton, MB, MRCPI, FCARCSI Stephen Mannion, MB, FCARCSI Department of Anaesthesia and Intensive Care South Infirmary Victoria University Hospital Cork, Ireland [email protected]

Continuous paravertebral block in a patient with multiple rib fractures: a radiological conundrum?

Free AccessCorrespondenceContinuous paravertebral block in a patient with multiple rib fractures: a radiological conundrum?S Mannion and M MurphyS MannionDepartments of 1Anaesthesiology and 2Radiology, South InfirmaryVictoria University Hospital, Cork, IrelandSearch for more papers by this author and M MurphyDepartments of 1Anaesthesiology and 2Radiology, South InfirmaryVictoria University Hospital, Cork, IrelandSearch for more papers by this authorPublished Online:28 Jan 2014https://doi.org/10.1259/bjr/83773691SectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail AboutThoracic paravertebral block (PVB) is a peripheral nerve block technique that blocks the thoracic somatic spinal nerves in the paravertebral space. The boundaries of the thoracic paravertebral space are traditionally defined as the parietal pleura anteriorly, the costotransverse ligament posterolaterally and limited by the vertebral bodies medially [1]. As PVBs are usually performed in the operating theatre or pain clinic setting, they may be unfamiliar to other medical specialists. A loss-of-resistance technique (LORT) is commonly employed to locate the paravertebral space [1]. The passage of the block needle through the costotransverse ligament and hence into the paravertebral space is detected as a loss of resistance to air or saline. The use of air for this technique will result in air entering the paravertebral space. Continuous PVB has been described in the pain management of patients with multiple rib fractures [2]. We describe a case of a continuous PVB in a patient with multiple rib fractures presenting as a radiological diagnostic conundrum.A 65-year-old man presented with left-sided rib fractures of the 6th to 8th ribs, following a fall. He had a background history of chronic obstructive pulmonary disease. The pain team were asked to review him because he had developed a left basal consolidation and was unable to cough or expectorate sputum because of thoracic pain. A left-sided continuous PVB was performed using a LORT with air and an 18 G Tuohy needle and epidural catheter set. The block was performed at the T7 level, 2.5 cm from the midline. Needle entry into the paravertebral space was confirmed by loss of resistance with 3–5 ml of air. 15 ml of 0.25% bupivacaine with adrenaline (1:200 000) was administered and the catheter inserted. After 15 min, the patient had good pain relief and was able to cough vigorously. 30 min after block performance, the patient underwent a CT of the thorax as part of his respiratory investigations.The radiologist reviewing the CT scan was unaware that a PVB had been performed and reported evidence of air (2–3 ml) outside the left parietal pleura (Figure 1). This was suggestive of a small pneumomediastinum secondary to multiple rib fractures. There followed a period of confusion as to whether this was a resolving or new finding. However, subsequent communication with the pain team confirmed the cause of the diagnosis.This case highlights the need for good communication between healthcare professionals, especially when unfamiliar anaesthetic or analgesic techniques are used. These CT images also confirm previous MRI [3] and radiological [4] findings in that the medial boundary of the paravertebral space can extend anteriorly to the vertebral bodies via the areolar connective tissue between the vertebral bodies and the endothoracic fascia [5].Figure 1. The white arrow indicates air in the paravertebral space with spread medially, anterior to the verterbral body. Download Figure References 1 Vila H Jr, Liu J, Kavasmaneck D. Paravertebral block: new benefits from an old procedure. Curr Opin Anaesthesiol 2007;20:316–8. Crossref Medline ISI, Google Scholar2 Karmakar MK, Critchley LA, Ho AM, Gin T, Lee TW, Yim AP. Continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with multiple fractured ribs. Chest 2003;123:424–31. Crossref Medline ISI, Google Scholar3 Barrett J, Harmon D, Loughnane F, Finucane B, Shorten G. Paravertebral block. In: Barrett J, Harmon D, Loughnane F, Finucane B, Shorten G, editors. Peripheral nerve blocks and peri-operative pain relief. 1st edn. Philadelphia, PA: WB Saunders, 2004. 135–38. Google Scholar4 Karmakar MK, Kwok WH, Kew J. Thoracic paravertebral block: radiological evidence of contralateral spread anterior to the vertebral bodies. Br J Anaesth 2000;84:263–5. Crossref Medline ISI, Google Scholar5 Karmakar MK, Gin T, Ho AM. Ipsilateral thoraco-lumbar anaesthesia and paravertebral spread after low thoracic paravertebral injection. Br J Anaesth 2001;87:312–6. Crossref Medline ISI, Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 82, Issue 981September 2009Pages: 705-e193 © The British Institute of Radiology History RevisedJune 11,2009ReceivedJune 07,2009Published onlineJanuary 28,2014 Metrics Download PDF

Clinic appointment reminders among rheumatology patients

Dear Editor, We read with interest the publication by Hogan AM et al. [1], which looked at the potential impact of text message reminders on non-attendance at surgical outpatient (OPD) clinics in Ireland and reported that such a service would encourage 51% to attend or cancel their missed OPD appointment. As the authors pointed out, little work has been carried out in this area in Ireland. Recently, we also examined the topic, focusing on Rheumatology patients attending our outpatient services, who had a ‘‘did not attend’’ (DNA) rate of almost 18% (525/2,924) in 2007 [2] compared to 16.8% in the Hogan AM et al. study. Many patients DNA their OPD clinic appointments for one reason or another, for example a lapse in memory or forgetfulness has been estimated for up to 50% of DNA cases [3, 4]. The level of DNA can be extremely high in many departments. In the department of care for the elderly at Hammersmith Hospital, London, in 1996–1997, DNA rates were a staggering 21% [5]. This is at the backdrop of a national mean DNA rate of 12% for all clinics in the UK for the same period [6]. These results compare to 16% forgetting their appointment in Hogan et al. with 20% due to clerical errors. DNA has many implications for both the patients and the services involved. Regarding the patient, missed valuable clinical input may result in suboptimal health. This is very well documented among the diabetic population where patients who DNA clinic appointments have significantly greater risk factors and complications from their chronic condition [7]. Focusing on the services provided, the implications include vacant clinic appointments, which can be a waste of scarce financial resources. In our study, we conducted a cross-sectional selfadministered anonymous questionnaire with 166 patients (159 return patients) who attended Rheumatology clinics at the South Infirmary, Victoria University Hospital, Cork, Ireland. Patients were recruited intermittently, but consecutively, while the researchers were in attendance between September and October 2007. A response rate of 98% (163/166) was achieved. New patients were not analysed due to low numbers. Ninety-eight percentage (156/ 159) of return patients responded. Overall, 99% felt OPD appointment reminders to be a good idea. Interestingly, on logical regression analysis, those who had previously attended OPD were significantly more likely to view reminders as a positive idea (P \ 0.0005, OR = 57.72, 95% CI 15.14–220.03). This may suggest that those who have had more OPD exposure appreciate the possibility of missed appointments and the benefits of reminders. These findings were recorded in a setting of 65% (104), 16% (26), 96% (153), 59% (94), and 46% (73) having competence in or access to a mobile phone SMS, e-mail, a landline telephone, a landline voice messaging service and a mobile phone voice messaging service, respectively. Text/SMS messaging (47%) is the most preferred method of appointment reminder followed by a telephone call (26%) and postal letter (25%). The mean age of those M. B. O’Connor (&) Department of Medicine, South Infirmary-Victoria University Hospital, Old Blackrock Road, Cork, Ireland e-mail: mortimeroconnor@gmail.com

John Finbarr Walsh

Born in Yorkshire, John Finbarr Walsh undertook postgraduate training in Portsmouth, Wales, Leeds, and Hong Kong. In 1985 he was appointed consultant anaesthetist to the South Infirmary Victoria University Hospital...