St Vincent's University Hospital Research Articles

Breast screening in symptomatic women over 35years of age: improvements in service efficiency.

The rationalization of cancer services in Ireland saw all women with symptomatic breast problems referred to one of the eight regional cancer centers. A pilot triaging system was introduced in St Vincent's University Hospital to streamline these services. Women over 35years who do not meet urgent referral criteria are referred for a mammogram prior to a clinic appointment ("image first"). The aim of this study was to retrospectively determine the recall rates, biopsy rates, and rate of breast cancer identification within this cohort of patients. This was compared to a screening population of patients. Patients triaged into the "image first" group within a one-year period were identified. Results of the initial mammogram, further imaging and subsequent biopsies were recorded. Data relating to number of recalls, number of patients biopsied and number of cancers identified within the Merrion Unit of the National Breastcheck Screening Program was obtained for comparison. One thousand six hundred eighty-eight referrals were triaged as "image first" over this period. 185 (11%) of patients required a biopsy of an identified lesion. Breast cancer was diagnosed in 65 patients (3.9%). During the same study period, of the 42,099 women who were screened for breast cancer, 496 (1.8%) underwent biopsy and 267 (0.63%) were diagnosed with breast cancer. Image first patients, who represent a cohort of "symptomatic" non-urgent women, have a greater rate of breast cancer detection than an asymptomatic screening population. This may have an impact on the appropriate triaging of symptomatic women in a national cancer center.

Can we predict your future? Using scores to predict length of stay and discharge destination

Background: This audit was completed within a large teaching hospital in Dublin, St Vincents University Hospital. The cohort of patients are those admitted with an acute stroke under the care of the Stroke Multidisciplinary Team, with confirmed stroke on CTBrain/MRI. Problem: It has always been assumed that poor cognitive scores were associated with longer lengths of stays and increased likelihood of discharge to a location other than the patient’s home. Stroke patients can often wait months to access appropriate care packages, further rehab settings or long term care beds resulting in significant costs as well as causing frustration for patients and their families alike. Achieving safe, timely and person centred discharge from hospital to home is an important indicator of quality and a measure of effective and integrated care (Joint Improvement Team, HSE 2014) Improvement related question: We set out to confirm if early cognitive screening of acute stroke patients in a large Dublin teaching hospital could predict their discharge destination and length of stay. This has never been examined previously within an Irish/UK stroke population using a standardised cognitive assessment (MoCA). Methods: We completed a retrospective audit using paper count method on the charts of 120 newly diagnosed stroke patients admitted to St Vincent's University Hospital over a six month period. The proforma gathered information on patient sex, age, date of admission, length of stay, CT/MRI results, admission Barthel, MOCA score on initial assessment, discharge Barthel score and discharge destination. Intervention/Results: 120 patients were included in the audit with a confirmed stroke on CTB/MRI. The average age was 73. There were 52 males and 68 females and the average length of stay was 44 days. Of the 49 patients that scored within mild-no cognitive impairment, 90% (n=44) went home from SVUH, 2% to further rehab, 6% to LTC and 2% died . The average length of stay for this cohort is 17 days. Of those that scored within the mild- moderate cognitive impairment (n=37) 30% went home, 40% went for further rehab, 27% went to LTC and 3% died. The average length of stay for this group was 49 days (more than twice the first group). Of those that scored within moderate – severe cognitive impairment, 12% went for further rehab, 63% to long term care and 25% died and 0% went home. Their average length of stay was 90days, nearly five times longer than the first cohort. Not every patient was able to complete a standardised cognitive assessment. 42% of these patients went to long-term care and 35% died. This cohorts average length of stay was 82 days, with a the number of deaths shortly after admission Lessons Learnt: The results of this audit confirm that early cognitive screening can help predict discharge destination and length of stay. Early cognitive screening (as recommended in the Royal College Of Physicians Stroke guidelines) are completed within 24 hours of admission to SVUH. Therefore the multidisciplinary has a strong indicator of discharge destination and length of stay early in the course of the patient’s hospital stay. With an increasing emphasis on the delivery of appropriate allocation of resources and constant pressures on delivering cost effective care it is estimated this knowledge will have significant cost saving benefits. This information is also imperative in early planning to reduce the number of delayed discharges. Effects of changes: As a multidisciplinary team we now use these early cognitive scores prospectively, to inform discharge arrangements and the timeliness of interventions for newly diagnosed stroke patients. Family meetings are now arranged within two weeks of admissions as standard, meaning families/NOK are also informed and involved in effective early discharge planning, allowing for a more seamless discharge. We anticipate that this focus on early scores might assist in the better distribution of healthcare resources in the hospital setting.

Optimising the Comprehensive Geriatric Assessment

Introduction: Carew House Day Hospital is an outpatient assessment unit for patients aged 65 years and over and is operated by the Medicine for the Elderly service in St. Vincent’s University Hospital (SVUH). Patients attending Carew House undergo multidisciplinary Comprehensive Geriatric Assessment (Medical, Nursing, Physiotherapy, Occupational Therapy and Social Work) with further access to Speech and Language Therapy, Dietician and Smoking Cessation services as required. The service assesses approximately 600 new patients annually. The National Clinical Programme for Older People advocates a Comprehensive Geriatric Assessment (CGA) of frail older patients as a means to increase independence in the home and reduce inappropriate admissions to nursing homes. Short Description of Practice Change Implemented: Deficiencies in the CGA were identified and discussed at a meeting of the Day Hospital Management involving medical, nursing and allied health staff. These deficits were demonstrated through an initial pilot and retrospective review of patients assessed in the Day Hospital. It was recognised that additional resources and staff for the Day Hospital would not be an available option to alleviate this problem. Once deficits in the CGA were identified and outlined, staff were empowered to engage with the change process immediately in order to develop improvement solutions. Aim and Theory of Change: The aim of this project was to empower members of the multidisciplinary team (MDT) to generate efficiencies within the service and to identify areas where the CGA could be streamlined. In December 2014, the following interventions were implemented: A new vetting process for patient referrals to ensure appropriate MDT members would be available on the date of assessment Nomination of designated nurse leader and senior clinician in the absence of regular staff An additional and timely referral pathway for physiotherapy and occupational therapy assessment using pre-existing additional community services Alternative access routes for medical social work input involving redesign of the referral pathway Targeted Population and Stakeholders: This included all patients assessed in Carew House Day Hopsital and all members of the MDT. Timeline: September 2014 - April 2015 Highlights: Having a Consultant’s clinical opinion directly available for each patient increased from 79% to 88%. The presence and input of a Nurse Manager on the day of assessment increased from 30% to 99%. Completion of Physiotherapy and Occupational Therapy assessment for patients increased from 65% to 73%, and 96% to 99% respectively. In addition to these improvements in the CGA, systems were implemented to ensure that a senior clinical opinion (Registrar or Consultant) was available at all times via telephone and a Deputy Nurse Lead was appointed in the absence of a Nurse Manager. An additional 15% of patients received Physiotherapy assessment via the newly implemented alternative referral pathway. Comments on Sustainability: It is recognised that while this suite of interventions has resulted in progress, our service is in constant need of review and regeneration in order to continue to improve for our patients. Comments on Transferability: This change process engaged staff across the MDT and highlighted that positive change in a service is achievable through improving efficiency and redesigning processes, without budgetary expansion. This model is transferable. Conclusions: Changes in Carew House Day Hospital resulted in improvements in the constituents and overall quality of the CGA for our catchment community. Discussions: While this project resulted in some improvement, the main barrier encountered was in recognising the deficits in our service that required change. Lessons Learned: Resource limitations should never stand in the way of improvement!

Late cardiac effects of chemotherapy in breast cancer survivors treated with adjuvant doxorubicin: 10-year follow-up.

Doxorubicin (Dox), a mainstay of adjuvant breast cancer treatment, is associated with cardiac toxicity in the form of left ventricular dysfunction (LVD), LV diastolic dysfunction, or LV systolic dysfunction. Study objectives were to evaluate the prevalence of LVD in long-term breast cancer survivors treated with Dox and determine if brain-type natriuretic peptide (BNP) may help identify patients at risk for LVD. Patients who participated in prospective clinical trials of adjuvant Dox-based chemotherapy for breast cancer with a baseline left ventricular (LV) ejection fraction evaluation from 1999 to 2006 were retrospectively identified from the St Vincent's University Hospital database. Patients were invited to undergo transthoracic echocardiography, BNP analysis, and cardiovascular (CV) risk factor assessment. LVDD was defined as left atrial volume index >34 mL/m(2) and/or lateral wall E prime <10 m/s, and LVSD as LVEF <50 %. Of 212 patients identified, 154 participated, 19 patients had died (no cardiac deaths), and 39 declined. Mean age was 60.7 [55:67] years. A majority of the patients (128, 83 %) had low CV risk (0/1 risk factors), 21 (13.6 %) had 2 RFs, and 5 (3.2 %) ≥3 RFs. BMI was 27.2 ± 4.9 kg/m(2). Median Dox dose was 240 mg/m(2) [225-298]; 92 patients (59.7 %) received ≤240 mg/m(2) and 62 (40.3 %) > 240 mg/m(2). Baseline LVEF was 68.2 ± 8 %. At follow-up of 10.8 ± 2.2 years, LVEF was 64.4 ± 6 %. Three (1.9 %) subjects had LVEF <50 % and one (0.7 %) had LVDD. Dox >240 mg/m2 was associated with any LVEF drop. BNP levels at follow-up were 20.3 pg/ml [9.9-36.5] and 21.1 pg/ml [9.8-37.7] in those without LVD and 61.5 pg/ml [50-68.4] in those with LVD (p = 0.04). Long-term prospective data describing the impact of Dox on cardiotoxicity are sparse. At over 10 years of follow-up, decreases in LVEF are common, and dose related, but LVD as defined is infrequent (2.6 %). Monitoring with BNP for subclinical LVD needs further evaluation.

Reply to Letter

St Vincent's University Hospital, Dublin, Ireland, [email protected] Disclosure: The author declares there are no conflicts of interest. No funding was received in support of this work.

Should we call the neurologist? The value and cost of a growing neurology consultation service.

St Vincent's University Hospital has an established neurology consultation service. Referral volumes have been growing. The Department regularly reviews its service to monitor changes and seek improvements. We sought to determine the impact of the growing service on patient care, on the department itself in delivering the service, and on inpatient admission trends. We reviewed the electronic referral forms of all consults seen over a 9-week period in 2014 (n=213). We recorded the source of each consult, demographic information, clinical presentation, time from referral to consult, and outcome. We compared the consult list to inpatient admissions list to determine the proportion admitted from consults. We compared our results to previous reviews by this and other neurology departments in Ireland. Three quarters of neurology consults relate to acute admissions. Patients are all seen within one working day of referral. A significant change in management (83.6%) resulted from the majority of consults. Consultants see an average of 4.8 (range 0-10) consults per day, needing up to 7.5h per day to deliver the service. One-third of the department's inpatients come from consults. The service significantly benefits patient care. The increasing number of consults will require increased resources and/or service reorganisation to maintain the current level of service.

7. Positive pre-operative axillary ultrasound guided fine needle aspiration cytology is associated with higher axillary disease burden in breast cancer patients compared with those detected by sentinel lymph node biopsy

7. Positive pre-operative axillary ultrasound guided fine needle aspiration cytology is associated with higher axillary disease burden in breast cancer patients compared with those detected by sentinel lymph node biopsy

Differential expression and function of monocarboxylate transporter 1 (MCT1) in human colon

s / International Journal of Surgery 12 (2014) S13eS117 S35 MDT. Phase II demonstrated the feasibility to routinely collect comorbidity data using ACE-27. 1119: DIFFERENTIAL EXPRESSION AND FUNCTION OF MONOCARBOXYLATE TRANSPORTER 1 (MCT1) IN HUMAN COLON Naomi Fearon, Elizabeth Ryan , Gavin Stewart , Des Winter , Alan Baird . St Vincents University Hospital, Dublin, Ireland; University College Dublin, Dublin, Ireland. Introduction: Butyrate, a short-chain fatty acid, is produced by fermentative bacteria in the colon, and is the primary energy source for colonocytes. It is transported across the colonic epithelium by monocarboxylate transporter 1(MCT1). Optimal butyrate production and transport is imperative for maintenance of gut health. Methods: Western blot studies and immunohistochemistry detected expression of MCT1 transporters in the human colon. Butyrate flux studies were carried out by mounting fresh human colon samples in Using Chambers. Bidirectional flux was investigated using radiolabelled butyrate (C14) and Papp determined by using a scintillation counter. Results: Immunohistochemistry andWestern blotting showed differential expression of MCT1 throughout the colon. There was stronger expression in the ascending colon compared to the descending colon (p<0.01, n1⁄43). Butyrate flux was bidirectional and was significantly greater in the ascending colon compared to the descending colon (p<0.05, n1⁄46). Flux was inhibited by the known butyrate inhibitor Resveratrol. Conclusions: These results illustrate differential expression of MCT1 in the human colon, strongly correlating to regions that contain the largest populations of intestinal bacteria. 1126: COLORECTAL CANCER OPERATIVE NOTES: PRELIMINARY AUDIT RESULTS Jessica Veitch, Thomas Barnes, Nicola Eardley, Michael Johnson, Chris McFaul, Dale Vimalachandran. Countess of Chester NHS Foundation

Orthopaedic triage at a physiotherapist-led ‘Musculoskeletal Assessment Clinic’: a seven-month service evaluation of outcomes

A number of clinical specialist physiotherapist (CSP)-led musculoskeletal triage clinics have been established in the Republic of Ireland as a means of managing patients referred for an outpatient orthopaedic consultation. The purpose of this study was to evaluate the outcomes of a recently established 'Musculoskeletal Assessment Clinic' (MAC) in St Vincent's University Hospital (SVUH) Dublin. We identified the (a) number of patients independently managed by the CSPs and (b) conversion rate to orthopaedic intervention as a useful measure of this. University College Dublin Research Ethics Committee granted ethical exemption and the Clinical Audit Department of SVUH approved the study. A retrospective service evaluation was carried out on all orthopaedic patients who attended the MAC between January and July 2012. Data were analysed using SPSS v20 using descriptive statistics. Seven-hundred and fourteen patients attended the MAC, 54 % of whom were female; mean age 50 years (range 12-89). The majority of patients were diagnosed with low back pain (35 %) and knee osteoarthritis (16 %). The majority of patients who attended the MAC (76 %) were independently managed by the CSPs without need for orthopaedic consultation; from a valid sample (n = 110), 80 patients required orthopaedic intervention, a conversion rate of 73 %. The most common interventions were arthroplasty (22 %) and arthroscopy (16 %). The findings of this service evaluation indicate that a significant number of patients referred for an orthopaedic consultation may be managed independently by a CSP and that onward referrals for orthopaedic consultation were highly appropriate.

AUGIS trainee prize winner: Antimicrobial prophylaxis prior to pancreatico-duodenectomy

AUGIS trainee prize winner: Antimicrobial prophylaxis prior to pancreatico-duodenectomy

Variability in interval from diagnostic biopsy to definitive surgical treatment of malignant melanoma in an Irish tertiary-referral centre

Variability in interval from diagnostic biopsy to definitive surgical treatment of malignant melanoma in an Irish tertiary-referral centre

Internuclear ophthalmoplegia caused by an isolated ischemic lesion affecting the medial longitudinal fascicle

WCN 2013 No: 950 Topic: 3 — Stroke Internuclear ophthalmoplegia caused by an isolated ischemic lesion affecting the medial longitudinal fascicle T. Rab, I. Vastagh, V. Varadi, K. Szőke, G. Bozsik, G. Varallyay, G. Rudas, D. Bereczki. Department of Neurology, Semmelweis University Faculty of Medicine, Hungary; MRA Research Center, Semmelweis University, Budapest, Hungary Background: Internuclear ophthalmoplegia (INO) frequently appears in multiple sclerosis, but is rare as an isolated sign in stroke. Objective: To present clinical and imaging data of 3 cases of ischemic stroke with unior bilateral INO. Patients and methods: Two patients with unilateral and another one with bilateral INOwere investigated by a 3 Tesla Philips Achieva scanner. Results: A 66-year-old female and a 62-year-old male were admitted with acute right sided and an 80-year-old male with bilateral INO. Diffusion weighted MRI scans (DWI) confirmed restricted water diffusion in the medial longitudinal fascicle (MLF) in all cases. Unilateral INO was associated with unilateral MLF lesion whereas in the patient with bilateral signs the MLF was also affected on both sides. Hypertension was present in all three patients. Two patients had hyperlipidemia, one had diabetes, and one was a heavy smoker. The patient with bilateral INO had malignant melanoma which could also have caused prothrombotic state. Antiplatelets (aspirin or clopidogrel) were administered in all patients. The clinical signs were resolved in the patient with bilateral INO after two months. Patients with unilateral INO also improved during the first month after their stroke and their follow-up is ongoing. Conclusion: INO due to a small infarct affecting the MLF may cause unior bilateral signs. As Fisher proved, signs can be bilateral if the terminal branch of a paramedian artery divides and these vessels supply the MLF on both sides. Such small arteries are not visible however even for a 3 Tesla MRI. doi:10.1016/j.jns.2013.07.735 Abstract — WCN 2013 No: 949 Topic: 3 — Stroke Assessment on preadmission treatment of cardioembolic stroke patient in Malaysian hospital WCN 2013 No: 949 Topic: 3 — Stroke Assessment on preadmission treatment of cardioembolic stroke patient in Malaysian hospital N.N. Sidek, Z. Abdul Aziz, I. Looi, P.H. Chee, H. Md. Rafia. Pharmacy Department, Hospital SultanahNur Zahirah, Kuala Terengganu, Malaysia; Neurology Department, Hospital Sultanah Nur Zahirah, Kuala Terengganu, Malaysia; Medical Department, Hospital Seberang Jaya, Seberang Perai, Malaysia; Medical Department, Hospital Kepala Batas, Kepala Batas, Malaysia; Neurology Department, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia Background: Atrial fibrillation (AF) increases the degree of stroke risk up to five times and doubled the overall mortality rate. Hence, anticoagulant as stroke primary prevention is vital. Objectives: We aim to assess the preadmission treatment received by the cardioembolic stroke patients, and review the mortality rate according to pre-treatment received. Method: This prospective study has been carried out from 1st Jan 2010 to 31st December 2012 by 11 Malaysian hospitals. Data have been collected by using Malaysian National Stroke Registry (NSR) case report form which then will be transferred to web application. For analysis, data was extracted and analyzed by using PASW 18. Results: There were 126 cardioembolic stroke patients registered to NSR with mean age of 65.97 ± 12.72 years old. Of all, only 45 patients were on Warfarin with 13 (10.3%) of them were within therapeutic and 32 patients (25.4%) received subtherapeutic Warfarin. 3.2% of patients received dual antiplatelet therapy, 26.2% on single antiplatelet therapy and 34.9% of patient did not received any treatment. The mortality rate was significantly high in no treatment group (34.1%) as compared to Warfarin (13.3%) and antiplatelet group (16.2%) with p value of 0.038. However, the mortality rate between Warfarin therapeutic (7.7%) with sub-therapeutic group (15.6%) and between single antiplatelet (18.7%) with dual antiplatelet were not significantly different. Conclusion: Our findings warrant greater effort to prevent stroke in AF patients, thus high mortality outcome which was significantly associated with treatment received prior to stroke event. doi:10.1016/j.jns.2013.07.736 Abstract — WCN 2013 No: 937 Topic: 3 — Stroke Establishing the aetiology of stroke in a young cohort WCN 2013 No: 937 Topic: 3 — Stroke Establishing the aetiology of stroke in a young cohort R. O'Connor, I. Noone, S. O'Riordan, N. Tubridy, C. Mc Guigan. Department of Neurology, St Vincent's University Hospital,

The Distress Thermometer: a rapid and effective tool for the oncology social worker

The psycho-oncology and social work services recognised that a cancer diagnosis and treatment can result in considerable emotional consequences for patients, yet the referral rate to both services was extremely low. Only very visibly distressed patients were being referred to the service. The "Distress Thermometer" (DT), a distress screening tool, was introduced as a pilot project with day care and inpatient oncology patients of St Vincent's University Hospital, Dublin, in an effort to improve the identification, management and treatment of psychological distress in oncology patients. The purpose of this paper is to evaluate the effectiveness of this new intervention. The Psycho-oncology service in conjunction with the Medical Social Work Department and Nursing Management at St Vincent's University Hospital, Dublin, initiated a Distress Education Management and Training Programme (DEMP). The initiative involved providing a training programme for oncology nursing staff and the introduction of a distress-screening tool for patients. In 1998, the DT was developed and validated for evaluation of distress (and depression) in cancer. It was adopted into recommendations made by the US National Comprehensive Cancer Network. The DT is a simple, self-report, pencil and paper measure consisting of a line with a 0-10 scale anchored at the zero point with "No distress" and at scale point ten with "Extreme distress". Patients are given the instruction, "How distressed have you been during the past week on a scale of 0-10"? Patients indicated their level of distress with a mark on the scale. Patients scoring 4 or above were regarded as requiring intervention. The DT includes a problem checklist. The patient is asked to identify those problems from the checklist which are contributing to their score. The use of the DT was evaluated through interviews with patients and professionals. Patients who scored four or above (38 per cent of patients), were seen by the Oncology Social Worker for psychosocial assessment and mental health triage. Patients who scored above a certain level (usually above 12/20) in the clinical range on the Hospital Anxiety and Depression scale (3 per cent) were referred to Psycho-oncology. That 38 per cent of oncology patients required intervention from a specialist service accurately reflects international findings on the rate of distress among cancer patients. Assessment of cancer patients' distress levels in a structured and planned manner with a Distress Thermometer, as recommended by best international practice, works very effectively and should be considered for all cancer out-patients This will have implications in terms of staff that will be required to manage such a service. This was the first time that this internationally recognised tool was used to such an extent and to positive effect in an Irish context.

PL.52 Placenta Acreta in St Vincents University Hospital 2008–2011

This is a retrospective review of all the patients who had a caesarean section for suspected placenta acreta in St Vincent’s Hospital (SVH) from December 2008 to October 2011.The study...

Endoscopic resection of a large inflammatory fibroid polyp of the caecum

Colorectal DiseaseVolume 15, Issue 2 p. e99-e100 Case report Endoscopic resection of a large inflammatory fibroid polyp of the caecum N. McCawley, N. McCawley Departments of Colorectal SurgerySearch for more papers by this authorK. Sheahan, K. Sheahan Histopathology, St Vincents University Hospital, Elm Park, Dublin, IrelandSearch for more papers by this authorA. M. Hanly, A. M. Hanly Departments of Colorectal SurgerySearch for more papers by this author N. McCawley, N. McCawley Departments of Colorectal SurgerySearch for more papers by this authorK. Sheahan, K. Sheahan Histopathology, St Vincents University Hospital, Elm Park, Dublin, IrelandSearch for more papers by this authorA. M. Hanly, A. M. Hanly Departments of Colorectal SurgerySearch for more papers by this author First published: 03 July 2012 https://doi.org/10.1111/j.1463-1318.2012.03163.x Ms Ann Hanly, Department of Colorectal Surgery, St Vincents University Hospital, Elm Park, Dublin 4, Ireland. E-mail: [email protected] Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume15, Issue2February 2013Pages e99-e100 RelatedInformation

5-Aminosalicylates to Prevent Relapse of Crohn's Disease After Surgery

1 St Vincent's University Hospital, Dublin, Ireland 2 Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA Correspondence: Alan C. Moss, MD, FACG, Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center (BIDMC), 330 Brookline Avenue, Boston, Massachusetts 02215, USA. E-mail: [email protected]

Surgery, Crohn's Disease, and the Biological Era

The management of Crohn's disease (CD) has changed considerably over the last 20 years. Immunomodulators and biological therapies now play a role in treating patients with CD, but little is known of their influence on surgical rates. To review the surgery rates for CD in an Irish university hospital over a 20-year period and to determine whether newer therapies had an impact on surgical rates. Seven hundred twenty-two patients attending St Vincent's University Hospital, Dublin, with CD over a 20-year period (January 1986 to December 2005) were identified. The patients were divided into quartiles. Resection rates were determined in all the quartiles, at both 1 and 3 years from diagnosis. A decline in surgery, 3 years from diagnosis, was noted between the first quartile (72 patients, 40%) and the second quartile (58 patients, 32%; P=0.03). No significant change in surgical rates at 3 years occurred between the other 3 quartiles (32%, 30%, and 35%, respectively; P=NS). The patients who required a resection within 3 years were diagnosed at a younger age in later years. There was a similar predominance of 60% of female patients requiring surgery in all groups. The patients requiring surgery were twice as likely to be ex-smokers or current smokers in all groups. Use of infliximab, within 3 years from diagnosis, increased from 0, 0, and 16 patients (8.8%) to 40 patients (22.1%) in the last quartile. The majority of patients were treated with infliximab on an "on demand" basis. Use of infliximab earlier within the course of the disease was seen in later quartiles (ie, within 1 y of diagnosis): 0, 0, 6, and 21 patients. Despite the introduction of infliximab over the past 10 years, no demonstrable difference has been seen in the rates of patients requiring resection surgery within 3 years of diagnosis. The reasons for this are unclear, but may relate to episodic treatment, rather than regular maintenance treatment. Female patients and smokers seem to be particularly at risk of resection surgery.

Irish Dietitians' Opinions and Use of Probiotics in Patients With Clostridium difficile-associated Disease

*Department of Nutrition and Dietetics St Vincent's University Hospital, Dublin 4 †School of Biological Sciences, Dublin Institute of Technology, Dublin 8 Republic of Ireland The authors declare no conflict of interests or industry support for this work.

Abstract P1-15-08: Comparison of Core Needle Biopsy and Surgical Specimens To Investigate the Percentage of Pre-Operative Ductal Carcinoma In Situ Diagnosis Who Were Found To Have Invasive Breast Cancer after Surgery at University Hospitals of Leicester (UHL)

Abstract Introduction: Ductal carcinoma in situ (DCIS) accounts for 25% of all breast cancer diagnosis. This study was carried out to investigate the percentage of patients at UHL who are diagnosed to have DCIS on core needle biopsy but found to have invasive cancer from the surgical specimen. In addition, we analysed how many of these patient went on to have further surgery for removal of residual invasive cancer and axillary staging. Method: Data of all patients who presented between 2008 and 2010 was retrospectively analysed. Clinical presentation, histology pre-and post-procedure, cancer grade, treatment methods, axillary node involvement and calcification were recorded. Results: A total of 177 patients with DCIS were recorded. The mean age was 61.1 years (range 31 — 102). The most common site of cancer was upper outer quadrant (28.2%). Majority of patients were identified through the screening programme (67.2%) as opposed to symptomatic presentation (32.8%). The most common procedure was Wide Local Excision (59.3%) followed by Mastectomy (31.7%). 9% of patients who had positive histology did not have any surgery. Post-procedure histology proved that the mean size of DCIS was 25.4mm and 62.7% was high grade. Most patients had no axillary node involvement and no malignant calcification (91.5% and 74.6% respectively). In 54 of 177 (30.5%) patients who were histopathologically diagnosed as DCIS by core needle biopsy, final diagnosis was changed to invasive carcinoma in surgical specimens The mean size of the invasive tumour in these patients was 13.4 mm and majority of the patients had grade 2 invasion (46.2%). Out of these 54 patients with new invasion, core biopsy results showed 31 patients (57.4%) had high grade DCIS, 10 patients (18.5%) had intermediate grade DCIS, 5 patients (9.2%) had low grade DCIS and 8 patients (14.8%) had unknown DCIS grade. Nineteen out of 54 patients (35.2%) went on to have further surgery after invasion was detected. Conclusion: The most common site was upper outer quadrant and majority of patients have been identified through the screening programme. Wide local excision was the most common surgical intervention. Our study showed almost 1/3 patients who were originally diagnosed with DCIS were found to have invasion post surgery at UHL and majority had high grade DCIS on core needle biopsy. This value is in keeping with the findings from previous studies[1]. However, only a small percentage of these patients went on to have further surgery. [1] Predictors of invasive disease in breast cancer when core biopsy demonstrates DCIS only. Dillon MF, McDermott EW, Quinn CM, O'Doherty A, O'Higgins N, Hill AD. Department of Surgery, St Vincent's University Hospital, Dublin, Ireland. J Surg Oncol. 2006 Jun 1;93(7):559- 63. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-15-08.

An audit of airway device optimization including cuff pressures, sizing and ventilation modes in a university teaching hospital

Department of Anaesthesia, Intensive Care & Pain Management, St. Vincent's University Hospital (SVUH), Dublin, Ireland