1-84 Oct, Nov, Dec 2006 - IJMS | Irish Journal of Medical Sciences

EDITORIAL BOARDEditor-in-ChiefEditorEditorial AssistantEditorial ConsultantStatistical ConsultantInformation Systems ConsultantJMS Doctor Awards EditorEditorial AdvisersEXECUTIVE OF THE ACADEMYPresidentGeneral SecretaryImmediate Past PresidentMembersDavid Bouchier-HayesBrian SheppardHelen MooreJohn DalyAlan KellyC ShieldsTN WalshOS BreathnachCF DoneganJ FentonADK HillF HowellH O’ConnorS SreenanS TierneyFD O’KellyJ O’ConnorD Bouchier-HayesTN WalshK O’BoyleE KayD McCormackD CurtinThis journal is indexed by Current Contents,Embase and is included in the abstracting andindexing of the Bio Sciences Information Serviceof Biological Abstracts. It is available in microfilmfrom University Microfilms Ltd.All communications to the Editorshould be addressed to:Irish Journal of Medical Science,2nd Floor, Frederick House,19 South Frederick Street, Dublin 2Tel: 00353-1-633 4820 Fax: 00353-1-633 4918Email: ijms@rami.ieWebsite: www.rami.ie www.iformix.comAnnual Subscription:Ireland and EU Countries E 156Non-EU E 192Single Copy E 42Published byThe Royal Academy of Medicine in IrelandISSN 0021-1265Designed byAustin ButlerEmail: austinbutler@mac.comIRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4

C O N T E N T SOriginal Papers5 Elevated BNP with normal systolic function in asymptomatic individuals at-risk for heart failure:A marker of diastolic dysfunction and clinical riskS Karuppiah, F Graham, M Ledwidge, C Conlon, J Cahill, C O’Loughlin, J McManus, K McDonald14 Feasibility and long term outcome of home vs hospital initiated thrombolysisB McAleer, MPS Varma20 The experiences and attitudes of general practitioners and hospital staff towards pre-hospitalthrombolysis in a rural communityD Tedstone Doherty, J Dowling, P Wright, J Cuddihy26 Low molecular weight heparin prophylaxis in day case surgeryJ Shabbir, PF Ridgway, W Shields, D Evoy, JB O’Mahony, K Mealy30 Validation of a point of care lipid analyser using a hospital based reference laboratoryM Carey, C Markham, P Gaffney, G Boran, V Maher36 Lipid lowering targets are easier to attain than those for treatment of hypertension in type 2 diabetesM Sherlock, D Mylotte, J Mac Mahon, KB Moore, CJ Thompson42 Structuring diabetes care in general practices: Many improvements, remaining challengesS Jennings, DL Whitford, D Carey, SM Smith48 FDG-PET scanning in the management of cancer of the oesophagus and oesophagogastric junction:Early experience with 100 consecutive casesV Malik, M Keogan, C Gilham, G Duffy, N Ravi, JV Reynolds55 Poor awareness of colorectal cancer symptoms; a preventable cause of emergency and late stagepresentationAT Manning, R Waldron, K Barry58 HRT: Have we changed?O Conlon, K McKinney62 A review of neonatal attendances out of hours in a Dublin maternity hospitalLFA Wong, KT Lim, A Twomey, J MurphyGRAND ROUND66 Management of spontaneous rupture of the oesophagus (Boerhaave’s syndrome): Single centreexperience of 18 casesR Prichard, J Butt, N Al-Sariff, S Frohlich, S Murphy, B Manning, N Ravi, JV Reynolds71 Endovascular aneurysm repair in a patient with a horseshoe kidney and impaired renal functionMS Sajid, N Ahmed, J Tibbals, G Hamilton74 Encrusted Cystitis — An Unusual Cause of Recurrent Frank HaematuriaO O’Sullivan, O Clyne, J Drumm76 Comminuted fracture of the thoracic spineJP Cashman, FL Carty, M Ryan, K Mahalingham79 Small bowel volvulus secondary to a mesenteric lipoma: a case report and review of the literatureAS McCoubrey, RLE ThompsonCORRESPONDENCE81 Extensor tendon rupture of finger while playing Uileann pipeSM Ali, DO’Farrell82 Ultraviolet phototherapy risks in IrelandC Dupont82 Repetitive transcranial magnetic stimulation: A psychiatric treatment of the future?H O’Connell, R Goggins, PG DoyleBOOK REVIEWS83 The Menopause: what you need to knowE V Mocanu84 Private Practice — In the early twentieth century medical office of Dr. Richard CabotC S Breathnach IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4

PRESS RELEASEPRESS RELEASEElevated BNP with normal systolic function in asymptomatic individuals at-risk for heart failure:a marker of diastolic dysfunction and clinical riskORIGINAL PAPERSpringer and the Royal Academy of Medicineof Ireland enter into publishing partnershipIrish Journal of Medical Science added to growing medical portfolioLondon/New York, 17 November 2006Elevated BNP with normal systolic functionin asymptomatic individuals at-risk for heartfailure: a marker of diastolic dysfunction andclinical riskSpringer, one of the world’s leading scientificpublishers, has announced a partnership with theRoyal Academy of Medicine of Ireland (RAMI) topublish their journal, the Irish Journal of MedicalScience (IJMS), starting in 2007. The addition ofthis journal to Springer’s portfolio accentuates itsgrowing strength in medical publishing.Established in 1832, the Irish Journal of MedicalScience is one of the first and foremost scientificjournals in the Anglo-Celtic islands. With articleswritten by international specialists, it covers allbranches of medicine and publishes papers relevantto the daily practice of the medical professional.IJMS will be published quarterly and will containreviews, original articles and commentaries. TheEditor-in- Chief is Professor David Bouchier-Hayes,a surgeon with a strong reputation in Ireland andinternationally.Dr. Fergus O’Kelly, President of the RAMI, said, “Thisis an exciting and most important time for the RoyalAcademy of Medicine of Ireland and its official organ,the Irish Journal of Medical Science. The ExecutiveBoard of the Royal Academy is most positive aboutour association with Springer.” Dr. John O’Connor,General Secretary, continued, “We look forwardto this partnership and the many benefits thatSpringer’s publishing experience will bring to thejournal.”Christiane Notarmarco, Executive Editor at SpringerLondon, echoed their sentiments, “We are proud tobe associated with such a respected and historicbody as the RAMI and are delighted to be supportingtheir mission. Through global distribution andelectronic publishing on SpringerLink, IJMS willcontinue to grow.”Springer will publish the Irish Journal of MedicalScience in both electronic and print formats toserve the needs of librarians and readers around theworld. The journal will be available via SpringerLink,Springer’s fully integrated, online informationplatform. Both Online First, a feature where articlesare published online before they appear in print, andEditorial Manager, an online peer review and authorsubmission system, will be fully implemented for thejournal. The Springer Open Choice program offers allpotential IJMS authors the option of publishing theirarticles using the open access model once they havebeen accepted for publication.About RAMIThe Royal Academy of Medicine of Ireland(www.rami.ie) was formed in 1882, following anamalgamation of the four main medical societiesin Ireland. At present there are over 1,200 fellowsand members of the Academy representing 22medical specialty sections. The primary role of theAcademy is to provide a forum for the exchange ofscientific information and to promote the academicdiscussions essential to scientific progress.About SpringerSpringer (www.springer.com) is the second-largestpublisher worldwide in the science, technology,and medicine (STM) sector and publishes on behalfof more than 300 academic associations andprofessional societies. Springer is part of SpringerScience+Business Media, one of the world’s leadingsuppliers of scientific and specialist literature.The group owns 70 publishing houses, togetherpublishing a total of 1,450 journals and more than5,000 new books a year. The group operates in over20 countries in Europe, the USA, and Asia, and hassome 5,000 employees.Media Contact: Joan Robinsonjoan.robinson@springer.comtel +49 (0) 6221 487 8130Editorial Contact: Christiane Notarmarcochristiane.notarmarco@springer.comtel +44 (0) 1483 734620ABSTRACTBackground B-type natriuretic peptide (BNP) is widely accepted in the evaluation of leftventricular systolic dysfunction and heart failure. However, little is known of theimplications of elevated BNP levels in individuals with preserved systolic function (PSF).Aims To investigate the drivers and clinical implications of elevated BNP levels inasymptomatic individuals with established PSF.Methods We enrolled 154 individuals who all underwent physical examination, BNPevaluation and Doppler-echocardiographic studies. They were divided into thoseabove and below the median BNP level (50pg/ml).Results Independent predictors of higher BNP were older age, more severe left ventricularhypertrophy (LVH), reduced E/A ratio and ischaemic heart disease. Survival andmultivariable analysis demonstrated more death and/or admission in those abovethe median BNP (HR: 4.79, p=0.007).Conclusions Elevated BNP is the strongest, independent predictor of serious adversecardiovascular outcomes in this population and requires closer clinical follow-up.INTRODUCTIONB-type natriuretic peptide (BNP) is a member of thefamily of genetically distinct natriuretic peptides,synthesized and released by cardiomyocytesin response to myocyte stretch due to volumeexpansion and pressure overload. 1-3 It ispredominantly released from ventricular myocytes asNT-BNP (76 amino acid fragment) and BNP (32 aminoacid fragment). In addition to natriuretic effects, BNPhas been shown to relax vascular smooth muscleand exert anti-proliferative and antifibrotic effects. 4, 5Increases in plasma BNP concentration havediagnostic and prognostic implications in selectedpopulations. This was shown initially in the presenceof heart failure due to left ventricular systolicdysfunction (LVSD) and subsequently in both earlystage and asymptomatic LVSD. 6-14 More recently, thediagnostic and prognostic value of BNP has beenunderlined in a range of settings including theemergency room, 10 in heart failure due to diastolicdysfunction, 11 post-MI 12,13 and in an at-risk renalpopulation. 14 McDonagh and colleagues were amongthe first to explore the value of BNP screening inthe general population, and while they found BNPto be an independent predictor of mortality, suchscreening programs may be limited by the lowscreening return and event rates. 15 Recent data fromthe Framingham Offspring Study support the roleof BNP in predicting the risk of death, cardiovascularevents, heart failure and stroke, independently oftraditional risk factors. 16 Therefore, while BNP iswidely accepted in the evaluation of LVSD and heartfailure, there are emerging data on its prognosticbenefits in the general population. 15-18 However,there has been little analysis of the drivers, andclinical implications of elevated BNP levels in acommunity population possessing risk factors forheart failure. The aim of this study was to investigatethe prevalence, drivers, and clinical implications ofelevated BNP levels in asymptomatic individuals withestablished cardiac risk factors for HF with provennormal systolic function.METHODSThis was a collaborative study between St VincentsUniversity Hospital Heart Failure Unit and a largeGeneral Practice in the South Eastern Area. The studyS Karuppiah,F Graham,M Ledwidge,C Conlon,J Cahill,C O’Loughlin,J McManus,K McDonaldHeart Failure Unit,St Vincent’sUniversity Hospital,Dublin and *CarltonClinic, Bray4 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4

ORIGINAL PAPERS Karuppiah et alElevated BNP with normal systolic function in asymptomatic individuals at-risk for heart failure:a marker of diastolic dysfunction and clinical riskORIGINAL PAPERTable 3UNIVARIATE PREDICTORS OF HIGHER BNP LEVELS FOR THE ENTIRE STUDY COHORT AT BASELINE (N=154)Variable R 2 F β (Unstandardised) P CI-Lwr CI-UprAge 0.172 31.602 0.415 (0.057)

ORIGINAL PAPERS Karuppiah et alElevated BNP with normal systolic function in asymptomatic individuals at-risk for heart failure:a marker of diastolic dysfunction and clinical riskORIGINAL PAPERvalue over conventional and newer risk stratificationmethods must be examined in larger studies.Secondly, more work is needed to define optimal BNPcut-off levels depending on screening objectives, 17,22population assessed, 22,29 and BNP assay used. 30It is interesting to note that McDonagh et aldemonstrated that a truly “normal” communitypopulation will have BNP values below 20 pg/ml, 15Wang et al identified values above 20 pg/ml formales and 23 pg/ml for females as conferringsubstantial risk 16 and the present work demonstrates100% sensitivity for subsequent serious clinicalevents using a cut-off of 25pg/ml. Althoughasymptomatic, the present study population ismore selected and has a higher prevalence ofcardiovascular disease than the general communitypopulations described in the aforementioned studiesand may, therefore warrant a higher screeningthreshold. Therefore, the BNP cut-off of 50pg/mlin this setting may offer a reasonable compromisebetween sensitivity and specificity in predictingsubsequent serious clinical events.Thirdly, a cut-off of LVEF

ORIGINAL PAPERFeasibility and long term outcome of home vs hospital initiated thrombolysisB McAleer & MPS VarmaORIGINAL PAPERFeasibility and long term outcome of homevs hospital initiated thrombolysisABSTRACTBackground Thrombolytic therapy improves mortality in acute myocardial infarctionespecially in those who receive treatment early. Pre-hospital therapy can reduce thetime to treatment.Methods Open, randomized study of patients with acute myocardial infarction of lessthan six hours duration in a rural community. Pre-hospital thrombolysis wasadministered using a mobile coronary care unit (MCCU) and all patients received IVstreptokinase.Results Two-hundred and forty-eight patients were studied, 82 in the MCCU and 166in the hospital group. The mean delay time to treatment was 136 minutes (MCCUgroup) and 196 minutes (hospital group) (p < 0.001). Reperfusion time was 116minutes for the MCCU group and 118 minutes for the hospital group. Mortality at30 days was 4.9% for the MCCU group and 15.7% for the hospital group (p = 0.014).Mortality at one year was 9.8% for the MCCU group and 23.5% for the hospitalgroup (p = 0.009). Mortality for patients followed up to five years was 17.7% for theMCCU group and 35.2% for the hospital group (p = 0.005). There were no significantadverse events in either treatment group.Conclusion Pre-hospital thrombolysis by MCCU is feasible and allows significant reductionin the delay time to treatment initiation. There are encouraging improvements inshort- and long-term survival with no apparent reduction in safety profile.INTRODUCTIONIn recent years, several studies have shown thatthrombolytic therapy used in acute myocardialinfarction leads to a reduction in infarct size,improved left ventricular function and consequentimprovement in mortality. 1-4 Much of this work,however, has been carried out in large centresserving mainly urban populations and with readyaccess to invasive facilities for investigation andfurther treatment of ischaemic heart disease. Use ofpre-hospital thrombolysis is limited, but encouragingimprovement in left ventricular function has beenshown following its use in an urban area. 5We have studied the feasibility and outcome ofpre-hospital thrombolysis in an area that is almostentirely rural and these patients have been comparedwith a similar group who received thrombolysis inthe coronary care unit of a district general hospital.GEOGRAPHYThe study was carried out in the Erne hospital,a 212 bed district general hospital. There is adedicated coronary care unit comprising 12 bedsand the hospital is the only acute hospital in CountyFermanagh, which is located in the western partof Northern Ireland. The catchment area is over800 square miles with communities up to 30 milesradius from the hospital. The total population isapproximately 60,000. The nearest tertiary referralcentre is located in Belfast, a distance of 90 miles.PATIENTS AND METHODSPatient eligibilityOver a four-year period (1988-1992) all patientswith a suspected acute myocardial infarction wereseen by a mobile coronary care unit (MCCU). Thisunit was staffed by a physician (SHO level) and asenior coronary care trained nurse. Those patientswhose major symptoms were of less than six hoursduration were considered for thrombolysis. ECGevidence of myocardial infarction was required: STsegmentelevation of at least 1 mm in two or morestandard leads and/or at least 2 mm in two or morepraecordial leads.After initial assessment by the MCCU staff, patientswere randomly allocated to receive treatment withB McAleerMPS VarmaCardiac Unit, ErneHospital, Enniskillen,N. Irelandthrombolysis at home (administered by the MCCUstaff) or alternatively to wait until transfer to thehospital coronary care unit. Randomisation wasdetermined by using the on-call rota – one particularSHO commenced treatment at the patient’s home,whereas the other SHOs waited until arrival in thehospital CCU.Patients were included irrespective of age, priorinfarction, cardiogenic shock, pulmonary oedema,or life-threatening arrhythmias. Clinical groundsfor exclusion were bleeding disorders, concurrentanticoagulant therapy, active peptic ulceration,recent stroke (

ORIGINAL PAPERFeasibility and long term outcome of home vs hospital initiated thrombolysisB McAleer & MPS VarmaORIGINAL PAPERTable 1BASELINE CHARACTERISTICSof one hour (p < 0.0001). The mean time to reperfusion(as judged by indirect evidence) was marginallyreduced in those patients treated by the mobile unit.Over 92% of those treated by the mobile unit showedindirect evidence of reperfusion, as opposed to 81% inMCCUHOSPITALMale (%) 76.8 76.5Age (mean, years) 61.0 60.5Age (range, years) 37 – 78 37 – 95Previous infarction (%) 17.1 22.3Anterior infarct (%) 40.2 41.6Angina (%) 43.9 41.0VF prior to Rx (%) 6.1 7.2Table 2Delay times / reperfusion dataMCCUHOSPITALDelay time to Rx (mean, mins) 136 196 p < 0.0001Distance from hospital (km) 16.1 15.8Reperfusion (%) 92.7 81.3 p < 0.01Reperfusion time (mean, mins) 116 118 p = NSTable 3Cardiac enzyme / LV function dataMCCUHOSPITALPeak CK level (mean) 2474 2128Time to peak CK (hrs) 13.9 16.4 P < 0.01Peak CKMB level (mean) 234 247Time to peak CKMB (hrs) 12.2 14.0 P = 0.012Ejection fraction (%) 53 52Heart failure on CXR ( %) 43 47Table 4Mortality dataMCCUHOSPITAL30 days 4/82 (4.9%) 26/166 (15.7%) P = 0.0141 year 8/82 (9.8%) 39/166 (23.5%) P = 0.0092 years 9/82 (11.0%) 46/166 (27.7%) P = 0.0035 years 14/81 (17.3%) 58/165 (35.2%) P = 0.005One patient lost to follow-up in each group.those treated in the hospital coronary care unit andthis difference was significant (p < 0.01).In Table 3, comparisons of LV function are shown.However, ejection fraction was determined in under30% of each group and was rarely determined inthose who died in the acute phase. This almostcertainly is the reason for the non-significantdifference in the ejection fraction data. The times topeak CK and CKMB are shorter in the MCCU groupreflecting the earlier reperfusion.Mortality figures are shown in Table 4 and it can beseen there are significant differences in both shortterm and long term results up to five years posttreatment.There were no significant bleeding events in eithertreatment group, but minor bleeding episodes(bruising at venepuncture, haematuria) were notedin 16% of the MCCU group and in 15% of the hospitalgroup. Blood transfusion was not required. Onepatient in the hospital treated group suffered astroke (infarct). There were no significant allergic orhypotensive events in either group.DISCUSSIONSeveral large studies 1-4 have shown that thrombolyticagents can reduce mortality from acute myocardialinfarction, especially when given within six hoursof the onset of symptoms. The importance of earlytreatment is well shown in the GISSI study, 2 inwhich the mortality of those treated within thefirst hour was reduced by nearly 50%. Koren et al 5had previously reported significant improvementin left ventricular function following the use ofthrombolysis in nine patients treated by a mobilecoronary care unit.Most of these papers, however, relate to work intertiary centres in predominantly urban areas wherefacilities for invasive investigation and treatment arereadily available. The majority of patients with acutemyocardial infarction are treated in district generalhospitals and our results relate to the use of prehospitalthrombolysis in a community served by adistrict general hospital. By administering the agentat the place of onset of attack by means of a mobilecoronary care unit, significant reduction in delay timeto treatment has been achieved, as compared to asimilar group who received treatment in hospital.Reperfusion was assessed noninvasively and is highin both groups. A number of studies have shownthat noninvasive markers of reperfusion, such as STsegmentchanges 6 and creatinine kinase isoenzymes, 7are useful predictors of reperfusion. However otherstudies 8,9 have shown that their usefulness todetermine reperfusion early is questionable andare only accurate if there is concordance of severalcriteriae, as is the case with our study.Mortality is encouragingly low in both the shortterm and the long term for those treated in the prehospitalphase and the difference is significantlylower than in the hospital group. Although thehospital treated group appears to have a highmortality when compared to the large studies ofthrombolysis, this may be explained by the fact thatpatients in our study were included irrespective ofage, the presence of cardiogenic shock or pulmonaryoedema. A more valid comparative group might bethat of MacLennan et al, 10 who used intravenousstreptokinase in a group of 50 patients in a tertiarycardiac centre with similar hospital mortalityrates. Recently, other studies 11-14 with pre-hospitalthrombolysis have shown the feasibility of thistreatment and the time gains that can be achieved.Morrison and colleagues published a meta-analysis 12of six trials of pre-hospital thrombolysis carriedout by paramedics, general practitioners or mobileintensive care units in Europe or the UK. The “call-toneedletime” was reduced by 33 to 130 minutes andshort-term hospital mortality was reduced by 17%.Because of delays in admission to hospital, lessthan 30% of patients with chest pain are suitablefor thrombolysis. Methods of improving thepercentage of patients who might benefit from thistreatment have been suggested: (a) reducing thedelay in the admission of patients with chest pain,primarily by encouraging such patients to contactthe emergency services directly, thus bypassing thegeneral practitioner, (b) initiation of treatment inthe pre-hospital phase by ambulance crews, generalpractitioners, or mobile coronary care units and (c)reducing in-hospital delays such as time spent inA&E departments awaiting bedspace.Although significant reductions in delay to admissionhave been achieved in some areas, notably Brighton,general practitioners in general are reluctant torelinquish their role in the management of acutemyocardial infarction and they would contend thatthey are ideally placed to institute thrombolytictherapy at home. However, Rawles 15 in a survey of GPsin the Aberdeen area has highlighted the problemsthat may occur should this approach be used - only18% of GPs carried an ECG machine on call and only30% carried a defibrillator. The vast majority statedthat they were reluctant to use any drugs other thanopiates or atropine in the treatment of patients withchest pain.16 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 17

ORIGINAL PAPERFeasibility and long term outcome of home vs hospital initiated thrombolysisB McAleer & MPS VarmaORIGINAL PAPERIn the Grampian Region Early Anistreplase Trial(GREAT) 16 it was shown that general practitioner useof thrombolysis was feasible and safe and resultedin a time saving of about two hours in the delay totreatment and there was an associated decline inmortality. Indeed the five-year mortality results ofthe GREAT study 17 are similar to our results using amobile coronary care unit. However, some authorities,notably Julian, 18 qualify their support for GP use ofthrombolytics and question whether the GP shoulduse thrombolysis without an electrocardiogram.Even Rawles 19 in a follow-up study of the attitudes ofgeneral practitioners who had taken part in the GREATstudy found that less than 20% of respondents hadused thrombolysis in the previous year.AcknowledgementsWe thank the Nursing Staff at the Erne HospitalCCU for their help with this study; Dr E Turkingtonfor the statistical analysis and Mrs JM Cecil for thepreparation of the type script.REFERENCES1. AIMS Trial Study Group. Effect of intravenous APSAC onmortality after acute myocardial infarction: Preliminaryreport of a placebo-controlled trial. Lancet 1988; 1:545-549.2. Gruppo Italiano per lo Studio della Streptochinasinell’infarto miocardico (GISSI). Effectiveness ofintravenous thrombolysis in acute myocardialinfarction. Lancet 1986; 1:397-402.3. ISIS Steering Committee. Intravenous streptokinasegiven within 0-4 hours of onset of myocardial infarctionreduced mortality in ISIS-2. Lancet 1987; 1:502.4. ISAM Study Group. A prospective trial of intravenousstreptokinase in acute myocardial infarction (ISAM).Mortality, morbidity and infarct size at 21 days. N Engl JMed 1986; 314:1465-1471.5. Koren G, Weiss AT, Hasin Y, et al. Prevention ofmyocardial damage in acute myocardial ischaemia byearly treatment with intravenous streptokinase. N EnglJ Med 1985; 313:1384-1389.6. Hogg KJ, Hornung RS, Howie CA, et al.Electrocardiographic prediction of coronary artrypatency after thrombolytic treatment in acute MI: Useof the ST-segment as a non-invasive marker. Br Heart J1988; 60:275-280.7. Tsukamoto H, Hashimoto H, Matsui Y, et al. Detectionof myocardial reperfusion by analysis of serum creatinekinase isoforms. Clin Cardiol 1988; 11:287-291.8. McCaliff MR, O’Neill W, Stack RS, et al. Failure of simpleclinical measurements to predict perfusion statusafter intravenous thrombolysis. Ann Intern Med 1988;108:658-662.9. Kircher BJ, Topol E, O’Neill W, et al. Prediction of infarctcoronary artery recanalisation after intravenousthrombolytic therapy. Am J Cardiol 1987; 59:513-515.10. MacLennan BA, McMaster A, Webb SW, et al. Highdose intravenous streptokinase in acute myocardialinfarction - short and long term prognosis. Br Heart J1986; 55:213-239.11. Sauval P, Artigou JY, Cristofini P, et al. Pre-hospitalthrombolysis with rcombinant tissue plasminogenactivator in acute myocardial infarction (Fren). Arch MalCoeur Vaiss 1989; 82:1957-1961.12. Morrison LJ, Verbeek PR, McDonald AC, et al. Mortalityand pre-hospital thrombolysis for acute myocardialinfarction. JAMA 2000;283:2686-92.13. Dubous-Rande JL, Herve C, Dubal-Moulin AM, et al. Prehospitalthrombolysis in acute myocardial infarction:Preliminary results in the Val-de-Marne department(Fren). Arch Mal Coeur Vaiss 1989; 82:1963-1966.14. Cazaux P, Leclercq G, Vahanian A, et al. Intravenousthrombolysis with tissue-type plasminogen activator(rt-PA) in the pre-hospital phase of acute myocardialinfarction. 49 cases (Fren). Arch Mal Coeur Vaiss 1989;82:1967-1971.15. Rawles JM. General practitioner management of acutemyocardial infarction and cardiac arrest: Relevance tohrombolytic therapy. Br Med J 1987; 295:639-640.16. GREAT Group. Feasibility, safety, efficacy of domiciliarythrombolysis by general practitioners. BMJ 1992;305:548-53.17. Rawles JM. Quantification of the benefit of earlierthrombolytic therapy: five year results of the GrampianRegion Early Anistreplase Trial (GREAT). Journal of theAmerican College of Cardiology 1997. 30(5):1181-6.18. Julian DG. Thrombolysis, the general practitioner, andthe electrocardiogram. Br Heart J 1994; 72:220-221.19. Rawles J. Attitudes of general practitioners to prehospitalthrombolysis. BMJ 1994; 309:379-82.20. Geddes JS. Twenty years of pre-hospital coronary care.Br Heart J 1986; 56:491-495.21. The European Myocardial Infarction Project Group.Prehospital thrombolytic therapy in patients withsuspected acute myocardial infarction. N Engl J Med1993; 329:383-9.Correspondence to: Dr B McAleer, Erne Hospital,Enniskillen, Co. Fermanagh BT74 6AYAdministration of thrombolytic therapy viaambulance personnel has also been suggested, butmany clinicians are still unhappy about the legalresponsibilites with this approach, as well as the factthat this would almost certainly involve thrombolysisbeing administered without ECG evidence of infarction.Treatment given by means of MCCU is a thirdalternative. Geddes 20 in a review of 20 years of prehospitalcoronary care has highlighted the benefitsof using such a service at a time before thrombolysisbecame widely used. Enthusiasm for such unitsis not widespread in the UK, except for NorthernIreland. However, the trial performed by the EuropeanMyocardial Infarction Project Group 21 has shown thatif the staff and equipment are available then prehospitalthrombolysis by mobile coronary care unitscan reduce mortality, especially in those patients forwhom the delay to hospital treatment is longest. Ourstudy, based in a rural area where a delay to hospitaltreatment is invariably more than 60 minutes,suggests that a mobile coronary care unit can reducemortality in the short and the long term.In summary, pre-hospital thrombolysis using amobile coronary care unit:1. Is feasible and safe;2. Allows significant reduction in delay time totreatment;3. Reduces mortality in both short term and longterm; Use of MCCUs should be developed furtherin order to optimize the number of patients whocould benefit from thrombolytic therapy.18 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 19

ORIGINAL PAPERThe experiences and attitudes of general practitioners and hospital stafftowards pre-hospital thrombolysis in a rural communityD Tedstone Doherty et alORIGINAL PAPERThe experiences and attitudes of generalpractitioners and hospital staff towards prehospitalthrombolysis in a rural communityABSTRACTBackground In rural areas it is impossible for eligible patients presenting with acutemyocardial infarction (AMI) to receive thrombolysis within the recommended 90minutes unless administered in the community by the general practitioner.Aims The aim of this study was to describe the attitudes of hospital staff and generalpractitioners towards pre-hospital administration of thrombolysis.Method General practitioners, consultant physicians and nursing staff participated inthe survey.Results General practitioners were convinced of the added benefits of administrationof thrombolysis in the community and believed the hospital had a role to play.Likewise the hospital staff agreed with the benefits of pre-hospital thrombolysis.However, they felt that the decision to thrombolyse patients should be made inconsultation with the hospital.Conclusions Pre-hospital thrombolysis programmes must be continuously monitored andevaluated to identify important factors that may prevent wider use of thrombolytictreatment.INTRODUCTIONThe Cardiovascular Health Strategy hasrecommended that eligible patients receivethrombolysis within 90 minutes of alerting medicalor ambulance services. 1 Previous research in theDonegal area has shown a median call to needletime of 200 minutes, which clearly exceeds thisguideline. 2 The aim of DARTS was to determinethe feasibility of the administration of domiciliarythrombolysis by rural general practitioners. 4 Prehospitalthrombolysis resulted in a median call toneedle time of 62 minutes – a time saving of 142minutes compared to a control group thrombolysedin the hospital (median call to needle time of204 minutes). The report recommended that prehospitalthrombolysis be extended to other areaswhere the recommended call to needle timescannot be achieved.Few studies have assessed the general practitioners’or hospital staff attitudes to pre-hospitalthrombolysis. One study in the Grampian regionconcluded that general practitioners were morelikely to use thrombolysis if they were encouragedto do so by the local cardiologist. 5 A follow-upof this study 6 to investigate the adoption of apre-hospital thrombolysis policy argued that theattitudes of hospital consultants were generallynegative and that they lacked confidence in thegeneral practitioners’ ability to read and analyse anelecrocardiogram (ECG). It was felt that this was asignificant barrier to the adoption of a pre-hospitalthrombolysis policy by the general practitioner asthey felt that encouragement and support from localhealth authorities was necessary.Given the previous findings, there is a need toexamine the attitudes of general practitionerswho took part in a pre-hospital thrombolysis study(DARTS) within an Irish context. If a pre-hospitalthrombolysis policy is to be instigated, it is beneficialto be aware of the possible barriers to the use ofthrombolytic treatment. The aim of this study soughtto determine the participating general practitioners’attitudes to pre-hospital thrombolysis followingcompletion of DARTS. A questionnaire was designedto identify possible advantages for and barriers tothe administration of pre-hospital thrombolysis in arural community. Furthermore, the study extendedprevious work by investigating the attitudes ofhospital staff including consultants and nursing staff.D TedstoneDoherty 1 ,J Dowling 2 ,P Wright 1 ,J Cuddihy 1Dept of PublicHealth Medicine,NSE–NWA,Bishop Street,Ballyshannon,Co Donegal 1 ; NorthWest ImmediateCare Programme 2METHODAll general practitioners involved in DARTS wereasked to complete a questionnaire designed toassess attitudes towards thrombolysis and problemsthat may be associated with administering prehospitalthrombolysis. It contained questions relatingto benefits and safety of pre-hospital thrombolysis,education, training and support in pre-hospitalthrombolysis, and confidence in the treatment ofacute myocardial infarction. All of the consultantphysicians and nursing staff of the ED and CCU wereadministered questionnaires assessing the benefitsand safety of pre-hospital thrombolysis.The questionnaire relating to benefits and safetyof pre-hospital thrombolysis was comprised ofstatements requiring participants to indicateagreement, disagreement, or neutrality. Questionsrelating to confidence in the administration ofthrombolysis were on a five-point Likert type scaleand general practitioners indicated how confidentthey were by circling the appropriate responsefrom ‘not at all confident’ to ‘extremely confident’.Following completion of the questionnaires,participants were given the opportunity to elaborateon answers that they had given. The researcherrecorded these responses by hand.RESULTSResponse rateA total of 82% (13 / 16) of the participating generalpractitioners completed the questionnaires. Of these,38% (5 / 13) administered thrombolysis to patientsin the community during the study period. All theconsultant physicians (100%; n = 5), 54% (25 / 46) ofthe nursing staff from CCU and ED completed thequestionnaires. Table 1, Table 2 and Table 3 show thepercentage of the general practitioners’ responsesto the individual questions, while Table 4 shows thepercentage of the hospital staffs’ responses to theindividual questions.General benefits of thrombolysis and earlyadministrationAll general practitioners (100%) were convinced of thebenefits of thrombolysis in the treatment of acutemyocardial infarction and were convinced of theadditional benefits derived from administration inthe community at the earliest opportunity. A total of97% (29 / 30) of the hospital staff were convinced ofthe benefits of thrombolysis and 3% (1 / 30) remainedneutral. Ninety-four per cent (28 / 30) were convincedof additional benefits from early administration inthe community. Only 3% (1 / 30) disagreed with theadditional benefits of pre-hospital thrombolysis and3% (1 / 30) remained neutral.Time, cost and safetyA total of 77% (10 / 13) of general practitioners feltthat administering thrombolysis in the communitywould result in appreciable time saving and 85% (11 /13) felt that they could make time to give thrombolysis.The majority of the general practitioners (92%; 12 /13) and hospital staff (97%; 29 / 30) disagreed thatthrombolysis was too expensive for general practice.All the general practitioners (100%) agreed that it wasnot too difficult to administer in general practice and69% (9 / 13) agreed that it was not inconvenient foruse in general practice. The majority of the hospitalstaff also agreed that eligible patients are not toodifficult to diagnose for pre-hospital thrombolysis(90%; 27 / 30). A total of 61% (8 / 30) of generalpractitioners and 67% (20 / 30) of the hospital staffagreed that it was safe to administer thrombolysis inthe community. One general practitioner disagreedwhile three hospital staff disagreed and 30% (4 / 13) ofthe general practitioners remained neutral, as did 23%(7 / 30) of the hospital staff.EquipmentA total of 92% (12 / 13) of the general practitionershad an ECG machine that they could use on call andall (100%) were willing to record an ECG in cases ofsuspected AMI. A total of 85% (11 / 13) of the generalpractitioners reported being able to interpret theECG, while two reported that they would not beable to interpret the ECG recording. A total of 77%(10 / 13) of the general practitioners always carriedthe thrombolytic kit while on duty. Regardingdefibrillation, 92% (12 / 13) of general practitioners hadaccess to a defibrillator while on duty and 85% (11 / 13)agreed that they knew how to use a defibrillator.Training, education and supportTable 2 shows the percentage responses from thegeneral practitioners in each of the categories for theindividual questions pertaining to training, educationand support of prehospital thrombolysis. In terms ofthe training received prior to the initiation of DARTS,61% (8 / 13) of the general practitioners agreed thattraining was sufficient. However, 62% (8 / 13) agreedthat more training in pre-hospital emergency cardiaccare is necessary. A total of 62%(8 / 13) agreed thattraining in ECG interpretation is sufficient, but 54%(7 / 13) felt that more training in the use of ECGequipment was necessary. In terms of the telemetry20 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 21

ORIGINAL PAPERThe experiences and attitudes of general practitioners and hospital stafftowards pre-hospital thrombolysis in a rural communityD Tedstone Doherty et alORIGINAL PAPERTable 1GP ATTITUDES TOWARDS PREHOSPITAL THROMBOLYSIS.THE PERCENTAGE OF GENERAL PRACTITIONERS RESPONDING IN EACH OF THE CATEGORIES (N=13)I am convinced of the benefits of thrombolytic treatment in acutemyocardial infarctionI am convinced that there are additional benefits from givingthrombolytic treatment in the community at the earliestopportunity after symptom onsetFrom the point of view of my practice, giving thrombolytic treatmentat home would not result in any appreciable time savingI could make time to give thrombolytic treatment to patients with anacute myocardial infarctionto transmit the ECGs to the hospital, just overhalf the general practitioners (54%; 7 / 13) felt thattraining was sufficient. The majority (62%; 8 / 13) alsofelt that more training in administering thrombolysiswas warranted.AGREE DISAGREE NEUTRAL100 (13)100 (13)15 (2) 77 (10) 8 (1)85 (11) 8 (1) 8 (1)Thrombolytic treatment is too expensive for use in general practice 92 (12) 8 (1)Thrombolytic treatment is safe for use in general practice 61 (8) 8 (1) 30 (4)Thrombolytic treatment is too difficult for use in general practicebecause it needs to be given intravenouslyThrombolytic treatment is too inconvenient for use in general practicebecause you may have to travel to the hospital with the patient1008 (1) 69 (9) 23 (3)I do not have an ECG machine that I could use on call 8 (1) 92 (12)I would be willing to record an ECG in cases of suspected AMI 100 (13)I could interpret an ECG in cases of suspected AMI 85 (11) 15 (2)The decision to thrombolyse a patient is entirely the generalpractitioner’sThe general practitioner’s decision to thrombolyse patients shouldbe made in consultation with the hospital61 (8) 31 (4) 8 (1)23 (3) 59 (7) 23 (3)I do not have access to a defibrillator 8 (1) 92 (12)I know how to use a defibrillator 85 (11) 8 (1) 8 (1)I always carry a defibrillator with me when on duty 92 (12) 8 (1)I always carry a thrombolytic kit with me when on duty 77 (10) 15 (2) 8 (1)I am not willing to use thrombolytic treatment unless encouraged todo so by the Department of Health and ChildrenI am not willing to use thrombolytic treatment unless encouraged todo so by the ICGPI am willing to use thrombolytic treatment if it is promoted by thedrug manufacturers for use in general practiceI am not willing to use thrombolytic treatment without furthertraining8 (1) 77 (10) 15 (2)77 (10) 23 (3)8 (1) 77 (10) 15 (2)15 (2) 77 (10) 8 (1)I am not willing to thrombolyse patients other than my own patients 92 (12) 8 (1)Responsibility and supportThe majority of the general practitioners (61%; 8 /13) felt that the decision to thrombolyse the patientwas entirely the general practitioner’s and overhalf (59%; 7 / 13) thought that the decision shouldnot be made in consultation with the hospital. Incontrast, over half of the hospital staff felt that theTable 2GENERAL PRACTITIONERS’ ATTITUDES TOWARDS TRAINING, EDUCATION AND SUPPORT.PERCENTAGE OF GENERAL PRACTITIONERS RESPONDING IN EACH OF THE CATEGORIES (N=13)decision to thrombolyse patients was not solelythe responsibility of the general practitioner (53%;16 / 30) and that the decision to thrombolysepatients should be made in consultation with thehospital (53%; 16 / 30). The majority of the generalpractitioners did not feel that support for theuse of thrombolysis in the community from theDepartment of Health and Children (77%; 10 / 13),the Irish College of General Practitioners (77%; 10 /13), or the drug manufacturers was necessary (77%;10 / 13). Of the hospital staff, 97% (29 / 30) agreedthat general practitioners should be allowed toadminister thrombolysis with sufficient training, andthat the hospital had a role to play in pre-hospitalthrombolysis. A total of 92% (12 / 13) of the generalAGREE DISAGREE NEUTRALThe training received prior to the initiation of the study was sufficient 61 (8) 15 (2) 23 (3)I feel that more training in prehospital emergency cardiac care isnecessary62 (8) 23 (3) 15 (2)I feel that the training in ECG interpretation was sufficient 62 (8) 30 (4) 8 (1)I feel that more training in administering thrombolytic treatment isnecessary62 (8) 23 (3) 15 (2)I feel that more training in the use of the ECG equipment is necessary 54 (7) 38 (5) 8 (1)I feel that the training given on ECG telemetry was sufficient 54 (7) 31 (4) 15 (2)I receive sufficient support from the project team in terms oftraining and education54 (7) 15 (2) 30 (4)I feel that there is a need for a refresher course in cardiac care 77 (10) 23 (3)Table 3QUESTIONNAIRE ASSESSING THE PARTICIPATING GP’S CONFIDENCE IN THE ABILITY TO RECORD AND INTERPRET AN ECGAND TO ADMINISTER THROMBOLYTIC THERAPY. THE PERCENTAGE OF GENERAL PRACTITIONERS RESPONDING IN EACHOF THE CATEGORIES (N=13)1a 2 3 4 5My ability to record an ECG 8 (1) 23 (3) 69 (9)My ability to interpret an ECG 46 (6) 46 (6) 8 (1)My ability to transmit the ECG to the CCU 15 (2) 23 (3) 31 (4) 31 (4)My awareness of the three indications to thrombolysepatients as outlined by DARTS23 (3) 46 (6) 8 (1) 23 (3)My knowledge of the contraindications to thrombolysis 8 (1) 46 (6) 23 (3) 23 (3)My ability to administer the current thrombolytic agent 23 (3) 31 (4) 31 (4) 15 (2)My ability to provide post thrombolytic Treatment 8 (1) 23 (3) 31 (4) 31 (4) 8 (1)My ability to deal with possible adverse reactions 15 (2) 31 (4) 31 (4) 23 (3)1a=not at all confident; 2=slightly confident; 3=moderately confident; 4=very confident; 5=extremely confidentpractitioners were willing to thrombolyse patientsother than their own and 77% (10 / 13) were willing toadminister thrombolysis without further training.Confidence in prehospital cardiac caretreatmentTable 3 shows the percentage of responses ineach of the categories pertaining to confidence inthe pre-hospital treatment of AMI patients. Themajority (69%; 9 / 13) of the general practitionersreported that they were extremely confident inthe ability to record an ECG, while 23% (3 / 13)were very confident and 8% (1) were moderatelyconfident. Regarding interpretation, 46% (6 / 13)were moderately confident, 46% (6 / 13) were very22 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 23

ORIGINAL PAPERThe experiences and attitudes of general practitioners and hospital stafftowards pre-hospital thrombolysis in a rural communityD Tedstone Doherty et alORIGINAL PAPERTable 4TABLE SHOWING THE PROPORTION % (N) OF RESPONSES FROM HOSPITAL STAFF IN EACH OF THE CATEGORIES FOR THEINDIVIDUAL QUESTIONS (CONSULTANT PHYSICIANS N = 5; NURSING STAFF N = 25; TOTAL N=30)I am convinced of the benefits of thrombolytic treatment in acutemyocardial infarctionI am convinced that there are additional benefits from givingthrombolytic treatment in the community at the earliestopportunity after symptom onsetconfident and one (8%) general practitioner wasextremely confident. Confidence in the transmissionof the ECG to the hospital showed that 15% (2 / 13)were not at all confident, 23% (3 / 13) were slightlyconfident, 31% (4 / 13) were moderately confident and31% (4 / 13) were very confident. General practitionersreported that they were slightly confident (23%; 3 /13), moderately confident (46%; 6 / 13), very confident(23%; 3 / 13) or extremely confident (23%; 3 / 13) in theirknowledge of the three indications for thrombolysisas outlined by the study protocol. Knowledge of thecontraindications to thrombolysis showed that onlyone general practitioner reported slight confidence,46% (6 / 13) reported moderate confidence and 23% (3/ 13) reported very confident and extremely confident.A total of 23% (3 / 13) of general practitioners reportedthat they were slightly confident in their ability toadminister the current thrombolytic agent, while31% (4 / 13) reported moderate confidence, 31% (4 / 13)were very confident, and 15% (2 / 13) were extremelyconfident. Finally, a total of 15% (2 / 13) of the generalpractitioners were not at all confident in the abilityto deal with adverse reactions to thrombolysis while31% (4 / 13) felt slightly confident, 31% (4 / 13) felt veryconfident and 23% (3 / 13) felt extremely confident.DISCUSSIONAGREE DISAGREE NEUTRAL97 (29) 3 (1)94 (28) 3 (1) 3 (1)Thrombolytic treatment is too expensive for use in general practice 97 (29) 3 (1)Thrombolytic treatment is safe for use in general practice 67 (20) 10 (3) 23 (7)Thrombolytic treatment is too difficult for use in general practicebecause it is to difficult to diagnose eligible patientsThe decision to thrombolyse a patient is entirely the generalpractitioner’sThe general practitioner’s decision to thrombolyse patients shouldmade in consultation with the hospitalOnly certain thrombolytic treatments are suitable for use in thecommunityGeneral practitioners should be allowed to administer thrombolytictreatments with sufficient trainingEMT’s should be allowed to administer thrombolytic treatment withsufficient training90 (27) 10 (3)37 (11) 53 (16) 10 (3)53 (16) 27 (8) 20 (6)67 (20) 26 (8) 7 (2)97 (29) 3 (1)27 (8) 63 (19) 10 (3)The hospital has a role to play in prehospital thrombolysis 86 (26) 7 (2) 7 (2)Acknowledgement of the benefits of rapid treatmentfor AMI patients was presented in the CardiovascularHealth Strategy and the report recommended thateligible patients receive pre-hospital thrombolysiswithin 90 minutes of alerting medical help. 1 In ruralareas, however, it is often impossible to achievethis guideline. DARTS was the first study in Irelandto introduce general practitioner administeredthrombolysis. This study was a follow-up of generalpractitioners involved in DARTS and the aim wasto investigate the attitudes towards pre-hospitalthrombolysis of both the participating generalpractitioners and relevant hospital staff.Benefits of thrombolysis and earlyadministrationResponses to the questionnaire suggest thatboth the general practitioners and hospital staffbelieve in the efficacy of thrombolysis and of theadded benefits of early administration. The generalpractitioners also felt that appreciable timesavingswould be incurred if thrombolysis were to beadministered in the community.Cost, administration and safetyBoth groups agreed that it was safe to administerthrombolysis in the community. In terms of thecost of thrombolysis, the general practitioners andhospital staff both agreed that thrombolysis is nottoo expensive for use in general practice. Likewise,the general practitioners did not see thrombolysis astoo difficult or too inconvenient to administer. Themajority of the hospital staff had confidence in thegeneral practitioners’ ability to assess and diagnoseeligible patients for thrombolysis. This is in contrastto the findings from Scotland. 6EquipmentThe possession of equipment such as an ECGand defibrillator are necessary for domiciliarythrombolysis. Practically all the general practitionershad access to an ECG and were willing to use it inthe case of suspected AMI. Likewise, all but one hadaccess to a defibrillator. Only two of the generalpractitioners reported being unable to interpretan ECG and two reported being unable to use adefibrillator.Training and education needsPrevious work has estimated that the generalpractitioners in this area will on average see threeAMI cases per year 6 . Given the rare occurrenceof AMI, continued training and education in prehospitalcardiac care must become an integral partof any pre-hospital thrombolysis policy. The majorityof the general practitioners felt that training wassufficient prior to the initiation of the project.However, it is clear that the general practitionersfeel that refresher courses in pre-hospital cardiaccare and in interpretation of the electrocardiogramare needed. Regarding ECG telemetry, only half thegeneral practitioners felt that training was sufficient.Findings from the DART study 4,8 showed that none ofthe general practitioners made use of the facility totransmit the ECG to the hospital prior to the arrivalof the patient. At the initiation of the project therewas a shortage of hospital on-call staff makingit difficult to obtain assistance from the hospitalfor diagnostic support. The general practitionerswere confident in their diagnostic ability and feltthat the decision to thrombolysis was entirely theirown. Using the ECG telemetry especially when notcompetent in its use would only increase the delay topre-hospital thrombolysis.CONCLUSIONThese results show that the general practitioners area willing, enthusiastic and confident group for theprovision of pre-hospital thrombolysis. Furthermore,the hospital staff acknowledges the important roleof general practitioners and are willing to providesupport to those general practitioners who wish toprovide this service. General practitioners shouldbe supported in terms of equipment, trainingand education in pre-hospital thrombolysis andincentives should be offered to those who are willingto provide this service.AcknowledgementsWe wish to acknowledge and express ourappreciation to the general practitioners, nursingstaff and consultants for their time and enthusiasmto participate in this study.REFERENCES1. Cardiovascular Health Strategy Group (1999). BuildingHealthier Hearts. Department of Health and Children.2. O’Neill J, Dowling J, Wright P et al. Patients presentingwith acute myocardial infarction to a district generalhospital: Baseline results and effect of audit. Irish Med J2003; 96; 3.3. GREAT Group. Feasibility, safety and efficacy ofdomiciliary thrombolysis by general practitioners:Grampian region early anistreplase trial. Br Med J 1992;305: 548 – 53.4. North West Immediate Care Programme (2003).Donegal Area Rapid Treatment Study (DARTS): FinalReport. North Western Health Board.5. Rawles J. Attitudes of general practitioners toprehospital thrombolysis. Br Med J 1994; 309: 3796. Rawles J, Ritchie L. Thrombolysis in peripheral generalpractices in Scotland: another rule of halves. Health Bull1999; 57:1: 10 – 16.7. Doherty D, Dowling J, Wright P, Murphy AW, Bury G,Bannan L. The potential use of prehospital thrombolysisin a rural community. Resus 2004, 61: 303 – 307.8. Doherty D, Dowling J, Wright P, Murphy AW, BuryG, Bannan L. Prehospital thrombolysis in a ruralcommunity: A case series and clinical follow-up.Submitted to Irish Journal of Medical Sciences.Correspondence to: Dr Donna Tedstone Doherty,Health Research Board, Third Floor, Knockmaun House,42 - 47 Lower Mount Street, Dublin 2.Email: dtedstonedoherty@hrb.ie24 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 25

ORIGINAL PAPERLow molecular weight heparin prophylaxis in day case surgeryJ Shabbir ET ALORIGINAL PAPERLow molecular weight heparin prophylaxisin day case surgeryABSTRACTBackground The role of Low molecular weight heparins (LMWH) in day case/ short-staysurgery is unknown.Aim To characterise the current national use of LMWH prophylaxis in specific day andshort stay surgeries.Methods A standardised anonymous postal questionnaire was sent to all consultantgeneral surgeons in Ireland. The operations selected were herniorraphy, anorectal,varicose vein and laparoscopic cholecystectomy.Results Questionnaires were sent to 82 surgeons in 2003. There was a response rate of68.3% (56). Fifty-four per cent of respondents said there was a protocol in placefor administration of LMWH in day case surgery. Of these 41% were not confidentthat their protocols were being adhered. Fifty-nine per cent of all respondents saidthey stratified patients according to individual risk. Thirteen per cent reportedoccurrence of VTE post day case surgery.Conclusion This study demonstrates a heterogeneous pattern of administration ofLMWH. In the absence of published validated protocols, the authors suggest aconsensus day case protocol.INTRODUCTIONVenous thromboembolism (VTE) remains animportant complication amongst surgical inpatients.Before the widespread introduction of heparinprophylaxis, as many as 25% of patients developeddeep venous thrombosis (DVT). 1,2 Due to thelargely silent nature of DVT, the true incidence andprevalence rates is probably substantially higher. 3Several meta-analyses have revealed that LowMolecular Weight Heparins (LMWH) are as effectiveas unfractionated heparins for VTE prophylaxisin general surgical patients and have practicallyreplaced unfractionated heparin for VTE prophylaxisas well as treatment for inpatients. 4,5The prevalence of VTE after day case and short staysurgeries is less clear. The literature base upon whichputative prophylaxis regimens may be based islargely absent. The authors identified one large studyconducted in Denmark studying VTE post day caseherniorrhaphy. 6The study period was between 1982 and 1992and documented rates of VTE were less than 1%.Intuitively, these patients should be at inherentlylower risk as they tend to be a well populationundergoing short duration surgery. Surprisingly, thereare no other correlative studies confirming incidencein day case herniorrhaphy or other common shortstay procedures.Thus as surgeons we practice in a time where mostunits have clear guidelines in place for their surgicalinpatients, whereas for our day case or short staypatients no clear guidelines for VTE prophylaxis exist.In the absence of higher-level evidence, the authors’sought to elucidate a national consensus withrespect to VTE prophylaxis for four specific day caseand short stay procedures.METHODSA standardised anonymous postal questionnairewas utilised. The operations selected for reviewwere day case herniorraphy, minor anorectal surgeryand varicose vein surgery. Day case or overnightlaparoscopic cholecystectomy was also included. Thequestionnaire was posted to all Consultant Surgeonson the active register in Ireland in 2003. Replieswithin one month of posting were included in thesample. One postal reminder was sent to those whodid not respond within four weeks.Consultant surgeons were asked whetherstandardised protocols for prophylaxis againstJ Shabbir,PF Ridgway,W Shields,D Evoy,JB O’Mahony,K MealyDept of Surgery,Wexford GeneralHospital, WexfordVTE were in place and adhered to for each of theprocedures. Usage and dosage, timing of LMWHswere investigated as well as attitudes toward riskstratification. Surgeons’ individual recollections ofwhether they had known cases of VT post day casesurgery were assessed. The use of mechanical aidssuch as intermittent compression or thromboembolicevent deterrent (TED) stockings was recorded.RESULTSQuestionnaires were sent to 82 general surgeons.There was an overall response rate of 68.3% (56).Sixty one per cent (50) responded within first fourweeks and further 7% (6) following reminders.Fifty-four per cent of respondents said there was aprotocol in place for administration of LMWH in daycase surgery. Of these 41% were not confident thattheir protocols were being adhered to leaving 59%with working protocols (Figure 1).Only one respondent utilised TED stockings inprophylaxis for patients undergoing laparoscopiccholecystectomy. Individual procedures investigatedin this study with presence or absence of protocolsare shown in (Figure 2 and Table 1). Enoxaparinand Tinzaparin were the two commonest LMWHpreparations in use. Dosages ranged from low dose(20 mg Enoxaparin or 3,500 IU Tinzaparin) to highdose (40mg Enoxaparin or 4,500 IU Tinzaparin).Timing where stated, ranged from within an hourprior to surgery to greater than two hours (Table 2).Interestingly, 59% of all respondents said theystratified patients according to individual risk,although this appeared to be on an individualbasis as protocols were not structured to includestratification.In the varicose vein group, 43% have protocols in place,although 16% are not confident they are in use. Themajority select low dose LMWH within an hour priorto surgery. Thirty-two per cent of day case herniaehave LMWH prophylaxis, usually within one hour ofsurgery. Once again, high dose LMWH is only usedin a small per centage. Anorectal day case surgery israrely given prophylaxis. Working protocols are seenin 13%. Low dose LMWH is used exclusively. Day caseand short stay laparoscopic cholecystectomy had thehighest per centage of protocols in place (46%). Onceagain the commonest dosage is low dose LMWH givenwithin one hour prior to the procedure.Thirteen per cent of surgeons reported documentedoccurrence of VT post day case surgery within a Table 1TIMING FOR PROPHYLAXIS (HOURS BEFORE SURGERY)% 2NOTSTATEDVaricose Veins 60 20 8 12Hernia 50 22 6 22Anorectal 25 25 13 37Lap Chole 44 20 12 24Table 2LMWH DOSAGE REGIMEN FOR INDIVIDUAL PROCEDURESVARICOSEVEINSLAPAROSCOPICCHOLECYSTECTOMYHERNIA ANORECTALLD LD None NoneLD LD None NoneHD HD IPB IPBLD=Low dose, HD= High dose,IPB=Individual patient basisFigure 1 —PRESENCE ANDPERCEIVEDADHERENCE TOTHROMBOPROPHY-LAXIS REGIMENS FORDAY CASE SURGERIESFigure 2 —PRESENCE ORABSENCE OFPROTOCOL PERPROCEDURE (%).“?Do” refersto those withprotocols who arenot confident ofadherence26 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 27

ORIGINAL PAPERLow molecular weight heparin prophylaxis in day case surgeryJ Shabbir ET ALORIGINAL PAPERTable 3WEXFORD GUIDELINES FOR DAY CASE/ SHORT STAY SURGERYone-month period post operatively. There was nostatistically significant increased reports of knownVTE in the group without a protocol (14% versus 11%in protocol group; p=0.76 Mann Whitney U test).DISCUSSIONVARICOSE VEINSLAPAROSCOPICCHOLECYSTECTOMYPrevalence of VTE is not known with respect today case and short stay surgical patients. The lasttwo decades have seen a consensus regardingprophylactic regimens reducing the risk of postoperative VTE amongst longer stay patients. 1, 2 This isfurther supported by investigation of patients dyingas a consequence of VTE, showing that prophylaxiswas omitted in a high proportion. 4 Thus mostauthors extrapolate from surgical inpatient datawhich may or may not be relevant to the short staysetting. Increasing pressures on hospital inpatientbeds due to long waiting times for surgery has ledto more procedures being carried out as day case orshort stay. Most institutions now perform varicoseveins and hernia surgery as day cases and somehospitals perform laparoscopic cholecystectomies asday case although in the main, an overnight stay ismandated.Against this backdrop, the current survey showedthat a protocol for VTE prophylaxis for daycase surgery was in place in a little over half ofrespondents’ hospitals. Furthermore compliancewith the protocols was doubted in over a third.Considerable variation was noted within similarpostal districts although due to the anonymousnature of the questionnaire further conclusionswith respect to this point could not be made. Almostuniversally, where protocols were in place, LMWHsHERNIAANORECTALLow risk LD LD None NoneModerate risk LD LD None NoneHigh Risk HD HD IPB IPBLD: low or standard dose LMWH (e.g. Tinzaparin 3,500IU) given 1 hour preoperatively (as per consensus timing)HD: high dose LMWH (e.g. Enoxaparin 40mg) given at least 2 hours preoperatively (as per manufactures’ safetyguidelines)IPB: Individual patient basisRisk Stratification:Low: 30minute surgeryHigh: >30minute surgery and additional risk factor(s) for VTE*(*Oral contraceptive pill, Obesity, Medical Co morbidity, Immobility (4/7+), Cancer, hx DVT, PE, Thrombophillia)were used as thromboprophylaxis. Selection ofthe lower dose was common with some timingdifferences noted between the individual procedures.Surgeons’ anecdotal experience of over 1 in 10surgeons reporting knowledge of VTE post day case/short stay surgery is interesting. This is probablysignificant as the local referral pattern for VTE ismedical and the attending surgeon is not alwaysinformed of the occurrence. Hence, this personalexperience may be underestimated, and the truefigure being higher than the 13%. There are no daycase incidence rates published to give a reliableincidence of VTE per procedure apart from a study ofover 2000 day case herniae conducted in Denmark inthe 1980s. 6 The authors found a non-significant rateof VTE and although assertions are made regardingspecific thromboprohylaxis, mention is made ofencouraging ambulation at discharge and advicethereafter. It is therefore uncertain whether thisreflects a true rate without thromboprophylaxis orindeed whether these data can be extrapolated tolaparoscopic herniorrhaphy.Minimally invasive surgery, such as laparoscopiccholecystectomy, might be considered to reducethe rate of post-operative VTE. However, the raisedintra abdominal pressure reduces the venousreturn, leading to venous pooling in the legs. 7This may be associated with increased risk of DVTand subsequent Pulmonary Embolus. A survey ofmembers of ASGBI looking particularly into VTEprophylaxis for laparoscopic cholecystectomy amongUK and Irish surgeons showed that VTE prophylaxiswas used as a routine in 74% of patients undergoinglaparoscopic cholecystectomy and selectively inanother 20% of patients. 7 This is contrary to ourresults which show that under half of surgeonsuse routine prophylaxis for short stay laparoscopiccholecystectomy.There is a well-known association between varicoseveins and VTE and a number of studies haveshown an increased risk of deep vein thrombosisof calf in patients with varicose veins. 9 A survey ofWelsh surgeons showed that 30% routinely useVTE prophylaxis for patients undergoing unilateralvaricose vein surgery and 44% for bilateral varicoseveins. 9 In our survey 43% of surgeons use routine VTEprophylaxis for varicose veins surgery which is similarto the Welsh experience. As expected fewer surgeonsuse prophylaxis for hernia surgery and anorectalprocedures because duration of surgery is short andVTE risk is perceived as minimal.Risk stratification is now supported for allthromboprophlaxis protocols (THRIFT) guidelines. 10Although nearly two thirds reported they stratifiedpatients according to risk, little evidence was seen in theprotocols regarding formalising this tenet. Hence, it isassumed that this is carried out on a patient-by-patientbasis which may have clinical as well as medicolegalimplications for units with working protocols.This survey highlights the uncertainties regardingVTE and day case/short stay surgeries thatare present in today’s practice in Ireland. Weacknowledge postal surveys have several limitationsincluding the possibility of responder bias towardsthe use of prophylaxis. We believe our responserate of 68.3% is adequate to draw conclusion aboutcurrents trends.Given that so many issues are unclear includingactual incidence figures, the heterogeneity ofdepartmental protocols and guidelines is perhapsunsurprising. It is nevertheless alarming and requiresto be addressed, as VTE and PE are serious butpreventable complications of surgery. In the absenceof high level evidence in the existing literature andbased on the findings of this survey, we recommendthat a national audit or prospective study shouldbe carried out to find out the true incidence ofVTE following day case/short stay surgeries. Theauthors also suggest a consensus protocol based onthe survey findings but recognise this represents asummation of current standard care rather than aprospectively validated regimen (Table 3).CONCLUSIONThis national survey of LMWH prophylaxis inday case/short stay surgery demonstrates aheterogeneous pattern of administration ofthromboprophylaxis by surgeons. VTE post day caseoccurs, and in the absence of published validatedprotocols for day case surgery, the authors suggest aconsensus day case protocol.REFERENCES1. Claggett GP, Reisch JS. Prevention of venousthromboembolism in general surgical patients. Resultof meta-analysis. Ann Surg 1988;208:227-402. Lowe GDO, Greer IA, Cooke TG, et al. Risk of andprophylaxis for venous thromboembolism in hospitalpatients. BMJ 1992;305:567-743. Gillies TE, Ruckley CV, Nixon SJ. Still missing the boat withfatal pulmonary embolism. Br J Surg 1996; 83:1394-954. Nurmohamed MT, Rosendaal FR, Buller HR, et al. Lowmolecular weight heparin versus standard heparinin general and orthopaedic surgery: a meta-analysis.Lancet 1992; 340:152-565. Hollingsworth J, Ghadban W, Kelly A, et al.Unfractionated heparin, time for a change? IMJ 1999;92:302-66. Riber C, Alstrup N, Nymann T, et al. Postoperativethromboembolism after day-case herniorrhaphy. Br JSurg. 1996;83(3):420-217. Bradbury AW, Chan YC, Darzi A, et al. Thromboembolismprophylaxis during laparoscopic cholecystectomy. BJS1997;84:962-648. Lowe GD, Osborne DH, McArdle BM. Prediction andselective prophylaxis of venous thrombolism in electivegastrointestinal surgery. Lancet 1982;i: 409-129. Williams EV, Williams RS, Hughes JL, et al. Preventionof venous thrombolism in Wales: results of a surveyamong general surgeons. Postgrad Med J 2002;78:78-8810. Risk of and prophylaxis for venous thromboembolismin hospital patients. Thromboembolic Risk Factors(THRIFT) Consensus Group. BMJ 1992;305:567-74.Correspondence to: Mr J Shabbir, SpR Colorectal Surgery,Gloucestershire Royal Hospital, Greatwestern Road,Gloucester GL1 3NNTel: 084 5422 2222/ Fax: 084 5422 5612Email: Jshabbir@aol.com28 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 29

ORIGINAL PAPERValidation of a point of care lipid analyser using a hospital based reference laboratoryM Carey et alORIGINAL PAPERValidation of a point of care lipid analyserusing a hospital based reference laboratoryABSTRACTBackground Lipid measurements are essential in cardiovascular disease management inprimary care. However, utilizing hospital laboratories may result in excess patienttravel, sample loss and repeat clinic visits. Point of care (POC) lipid measurementwould overcome these difficulties but has not been validated in an Irish setting.Aim To compare POC lipid profile measurements using a cholestech LDX analyser with ahospital reference laboratory (Lab).Method One-hundred subjects (30 men, 70 women) participated. Finger prick and venoussamples were analysed directly by Cholestech LDX and the Lab.Results A broad range of lipid values were measured. Absolute differences betweenPOC and Lab measurements were insignificant except for a small over-estimationby the POC method of triglyceride 0.25mmol/l (95% CI 0.17 to 0.24), and anunderestimation of HDLc – 0.11mmol/l (95% CI – 0.143 to –0.078). There weresignificant correlations between POC and Lab. levels; total cholesterol r=0.92,triglyceride r=0.93, HDLc r=0.92 and LDLc r=0.86 (all p< 0.0001).Conclusion These results validate the use of the Cholestech LDX® analyser for point ofcare lipid measurements in clinical practice, provided well trained operators aresupported by a hospital laboratory delivering quality assurance support.INTRODUCTIONIreland has a very high incidence of prematurecoronary heart disease (CHD) mortality 1 . Risk factorassessment and in particular lipid screening hasbecome increasingly important. Since the primary caresetting is where the main battle against CHD will befought, 2 risk assessment and prevention needs to beoptimized at this point. However, in order to measurelipid levels, patients often have to travel to hospitalsor their blood samples are sent to laboratories. Thiscan result in excess patient travel, sample loss and arepeat visit to their GP. The latter can result in a delayin initiation of treatment and loss of continuity of care.A point of care lipid measurement would avoid thesepotential problems and afford better patient care.Point of care lipid analysers have been available forsome time in Ireland 3 but the accuracy of this methodhas yet to be established. We therefore conducted astudy to compare the results of full lipid profiles usingthe point of care lipid analyser (Cholestech LDX) tothat of the reference hospital laboratory.Subjects and Methods100 subjects were recruited. These subjects wereeither attending the Cardiac Risk Factor Clinic atthe Adelaide Meath incorporating the NationalChildren’s Hospital because of coronary heartdisease or hypertension, or were hospital staffmembers who volunteered to participate in thestudy. Seventy per cent of the subjects were femaleand 30% male. All subjects were Caucasian.Fasting (80%) and non-fasting lipid profile samples(20%) were taken so that a broad range of lipidmeasurements could be compared. Followinginformed consent, subjects donated both a fingerpricksample and a venous whole blood sample.The finger prick sample and a portion of the venoussample were subjected to analysis in the point ofcare (POC) analyser. The rest of the venous samplewas sent to the reference laboratory. All POC sampleswere analysed for a full lipid profile (total cholesterol,triglyceride, low-density lipoprotein cholesterol, highdensity lipoprotein cholesterol) and glucose level.Laboratory samples were analysed for lipid (n=100)and glucose levels (n =40).Performance characteristics of the Cholestech LDXanalyser – analytical limits, imprecision, interferencefactors are outlined in the Cholestech LDX SystemProcedure manual (www.cholestech.com).M Carey, 1C Markham, 1P Gaffney, 2G Boran, 2bV Maher 1Depts of Cardiology 1and ChemicalPathology 2 , TheAdelaide andMeath Hospitalincorporating TheNational Children’sHospital, DublinTwo research nurses who were trained in the useof the Cholestech machine performed all the bloodsampling and data collection. Finger-prick samplinginvolved ensuring the subject was seated and theirhands warmed to ensure good circulation. This wasachieved by subjects washing their hands withwarm water or gently massaging their fingers fromthe base to the tip to help the circulation in theirfingertips. The finger was cleansed with an alcoholswab and dried thoroughly with a gauze strip beforepricking the side of the finger (to reduce pain) witha lancet. To determine if alcohol swabbing interferedwith the lipid results, a number of subjects (n=30)did not have the finger site swabbed with alcohol.The first drop of blood from the puncture site waswiped away to reduce the potential influence ofinterstitial fluid 4 . The second drop of blood wasthen collected in a capillary tube. The capillary tubewas filled with 35µl of blood for analysis within 10seconds of blood sampling. This was to avoid bloodcoagulation interfering with the capillary action. Carewas taken to avoid the collection of air bubbles. Itwas necessary to insert the blood from the capillarytube into the sample well of the cassette within 5minutes to avoid blood clotting. The cassettes wereplaced in a cassette holder and analysed by a fullyautomated procedure in less than 10 minutes. Theconcentration of each lipid fraction was proportionalto the intensity of the coloured product obtainedand measured by reflectance photometry 5 . Resultswere automatically printed (Figure 1). The storageand handling of the cassettes is important and clearguidelines accompany each analyser. Cassettes werestored in a fridge at 2 to 8ºc and only removed 10minutes before use. Unused cassettes were neverreturned to the fridge for future use.The hospital laboratory staff were blinded as towhich samples were part of this validation study.Total cholesterol, HDL cholesterol, triglycerides andplasma glucose were analysed in the laboratory usinga Hitachi Modular P® analyser and Roche® reagents.All methods have a between run imprecision of

ORIGINAL PAPERValidation of a point of care lipid analyser using a hospital based reference laboratoryM Carey et alORIGINAL PAPERCI 0.87 to 1.06), intercept –0.07 (95% CI -0.21 to 0.29).These results are all highly significant. Table 1Ademonstrates that total cholesterol measurementsusing these methods differed by 0.037 (CI -0.03– 0.11 mmol/l) which were small and not statisticallysignificant. Triglyceride values were higher usingPOC than laboratory by 0.25 mmol/l (CI 0.17 to 0.24mmol/l) (p

ORIGINAL PAPERValidation of a point of care lipid analyser using a hospital based reference laboratoryM Carey et alORIGINAL PAPER Figure 3 —TRIGLYCERIDEMEASUREMENTFigure 4 —DIFFERENCE PLOTSOF LABORATORY ANDFINGER PRICK LIPIDMEASUREMENTSmeasured glucose levels. Absolute differencesin glucose measurements were not statisticallysignificant. However, this was not the primary aimof this study and a more detailed study of a largersample of glucose measurements would be neededto confirm its accuracy.This study did not directly test how accurate thepoint of care results would be in the primary caresetting as comparative samples would have had tobe transported to hospital laboratories. Prolongedtransport time, altered sample temperature and mayhave added variables which could have confoundedthe results. For this reason it was thought that itwould be most appropriate to perform the studydirectly in the hospital setting to avoid sampletransportation difficulties but the results wouldbe applicable in all settings. One importantconsideration in the primary care setting is operatortraining which may differ from practice to practice.However, with careful instruction, as was the case forthe two nurses who performed this study, there wasno evidence of any measurement inaccuracies or of alearning curve effect. All operators need to be awareof possible confounders as already outlined. There isa need for a validation of the Cholestech LDX or otherpoint of care lipid analysers in individual clinicalpractices before this service could be offered.There should be sufficient training of staff in the safeoperation and maintenance of the equipment withstandard operating procedures fully documented.Quality assurance measures 9 both internal andexternal need to be established to ensure qualitycontrol in the clinical setting. Support structureswith a local clinical laboratory are advocated forthe long-term success of the service, particularlyfor the ongoing training and quality assurance. Useof point of care analysis in settings where medicalinput for result interpretation is not present or whereappropriate medical guidelines 10 are unavailable,should be cautioned.The cost-effectiveness of the service needs to beexamined further taking into account the current costof each cassette (E12 for each full lipid and glucosecassette) versus the cost to the patient for travel (E1 toE40 private car versus taxi) parking (E5) and hospitallaboratory costs (E5) per sample for phlebotomy,reagents and staffing. This would nearly break evenfor a person with their own transport (E11 hospitallab attendance versus E12 per cassette at GP surgery).However, the cost of repeat GP visits (E20 – E50,GMS or Private) has not been considered. In addition,the inconvenience for patients, the potential forsample and result loss and the time delay in startingtreatment need to be factored into the equation.When used appropriately, point of care testing willimprove patient management and fortify the servicesthat are provided for patients at the primary care level.AcknowledementsThe authors would like to thank all the patients andhospital personnel who volunteered to participatein this study. While this study was initiated andcontrolled entirely by the authors, a small amount offunding was received from Cardiac Services to coverthe staff nurse time for patient visits and samplemanagement and the Cholestech cassettes wereprovided free of charge. We would also like to thankElaine Hand, Biostatistician, Health Science centre forperforming the Passing Bablock Regression analysis.REFERENCES1. 50 years of Heart Disease in Ireland. Mortality,morbidity and health services implications. Dublin: IrishHeart Foundation, 2001.2. Heartwatch. The national programme in generalpractice for the secondary prevention of cardiovasculardisease in Ireland. Annual Report 2004 -2005 ICGP3. Point of Care Diagnostic testing – world markets reportGuinness Centre, Taylor’s Lane, Dublin 84. CH Sloop, L Dory, PS Roheim. Interstitial fluidlipoproteins J Lipid Res, 1987; Vol 28, 225-237,5. Cummings MH, Watts GF, Mazurkiewicz JC, Slavin BM.An evaluation in the diabetes clinic of the CholestechL-D-X analyser. Practical Diabetes July/August 1994;11(4):151-153.6. Friedewald, WT, et al., Estimation of the Concentrationsof Low-Density Lipoprotein Cholesterol in Plasma,Without Use of the Preparative Ultracentrifuge, Clin.Chem., 1972; 18/6:499.7. UK Joint Working Group on Quality Assurance. Near toPatient or Point of Care Testing Guidelines. Associationof Clinical Biochemists, Institute of Biomedical Sciences,Royal College of Pathologists January 19998. Policy Guidelines on Near Patient Testing. Academy ofMedical Laboratory Science 19989. Additional essential criteria for quality systems ofmedical laboratories. Jansen R.T.P., Blaton V., Burnett D.,Huisman W., Queralto J.M., Zerah S. Allman B. Clin. ChemLab. Med. 1998; 36(4):249-252.10. European guidelines on Cardiovascular disease preventionin clinical practice. Eur Heart J 2003; 24 , 1601 – 1610.Correspondence: Vincent Maher, Dept of Cardiology,Adelaide Meath Hospital, Tallaght, Dublin 24 Ireland; Tel.+353 1 414 2112; Fax +353 1 414 3052;Email: vincent.maher@amnch.ie34 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 35

ORIGINAL PAPERLipid lowering targets are easier to attain than those for treatment of hypertension in type 2 diabetesM Sherlock et alORIGINAL PAPERLipid lowering targets are easier to attainthan those for treatment of hypertension intype 2 diabetesABSTRACTAim To assess the impact of therapeutic strategies to reduce cardiovascular risk inpatients with type 2 diabetes.Methods Five-hundred patients with type 2 diabetes were studied, using retrospectivecase note analysis in 1997 (followed by a unit policy targeting vascular risk) andagain in 2001.Results The mean BP of the hypertensive patients was unchanged, 151/83 ± 23/12mmHg(1997) and 149/84 ± 19.1/9.8mmHg (P=0.2) (2001) (despite increase in patientsreceiving ≥3 antihypertensives (4.2% to 18.0%, P

ORIGINAL PAPERLipid lowering targets are easier to attain than those for treatment of hypertension in type 2 diabetesM Sherlock et alORIGINAL PAPERTable 1PREVALENCE OF VASCULAR RISK FACTORS AND VASCULAR DISEASE AND NUMBER OF PATIENTS ON ANTIPLATELETTHERAPY IN 1997 AND 2001. FIGURES EXPRESSED AS TOTAL NUMBER (PERCENTAGE). * = P < 0.01 COMPARED TO 1997CARDIOVASCULARRISK FACTOR ORMACROVASCULAR DISEASERESULTSNO. OF PATIENTS(%)(N=500)Patient demographicsMedian age of population was 68 years (range 31to 91) in 1997 and 69 years (range 34-91) in 2001.All patients were Caucasian with 58% and 60% ofpatients of male sex in 1997 and 2001 respectively(p=0.55). Duration of diabetes was 8.0 + 6.12 and 7.7+ 6.36 years (Mean +SD) respectively (p=0.46).Prevalence of vascular risk factors andvascular diseaseThe prevalence of individual vascular risk factorsand established macrovascular conditions aredemonstrated in Table 1. The prevalence ofestablished macrovascular disease was 32.2% in 1997and 29% in 2001 (P=0.27).NO. OFPATIENTS ONANTIPLATELETRX (%)NO. OFPATIENTS (%)(N=500)NO. OFPATIENTS ONANTIPLATELETRX (%)1997 1997 2001 2001Hypertension 213 (42.6) 64/213 (30.0) 255* (51.0) 183/255* (71.8)Albuminuria 200 (40.0) 78/200 (39%) 242* (48.4) 141/242* (58.3)Hyperlipidaemia 304 (61.0) 81/304 (26.6) 311 (62.2) 206/311* (66.2)Angina 56 (11.2) 35/56 (62.5) 62 (12.4) 47/62* (75.8)MI 67 (13.4) 46/67 (68.7) 38* (7.6) 31/38 * (81.6)PVD 29 (5.8) 22/29 (75.8) 35 (7.0) 27/35 (77.1)TIA/ CVA 32 (6.4) 28/32 (87.5) 29 (5.8) 24/29 (82.7)Primary prevention group 339 47/339 (13.9) 355 198/355* (55.8)Secondary prevention group 161 91/161 (56.5) 145 108/145* (74.5)Table 2ANTIHYPERTENSIVE PRESCRIBING IN 1997 AND 2001. FIGURES EXPRESSED AS TOTAL NUMBER (PERCENTAGE) OF THESUBSET OF PATIENTS WITH HYPERTENSION. NS = NON SIGNIFICANTANTIHYPERTENSIVETREATMENTNO. OF HYPERTENSIVE PATIENTSON TREATMENT 1997 (%)NO. OF HYPERTENSIVE PATIENTSON TREATMENT 2001 (%)P VALUEACE inhibitor 121 (56.8) 163 (63.9) 0.08B Blocker 53 (24.9) 84 (32.9) 0.057Ca Channel Blocker 88 (41.3) 133 (52.1) 0.02Other classes 40 (18.8) 106 (41.5) 2 agents 9 (4.2) 46 (18.0)

ORIGINAL PAPERLipid lowering targets are easier to attain than those for treatment of hypertension in type 2 diabetesM Sherlock et alORIGINAL PAPERall patients with diabetes over 40 years of age,who have no contraindication to treatment. Thiswould apply to over 97% of patients. Our datademonstrated increased antiplatelet treatment inboth primary and secondary prevention groups,which compares favourably to some publishedstudies, and is similar to the results of the VA healthcare group study, which demonstrated 66% uptakeof aspirin among patients with diabetes whoresponded to a questionnaire. 11The most disappointing aspect of the programmewas the failure to impact on blood pressure. Poorcompliance with antihypertensive medication wasan unlikely explanation for this as the group withuncontrolled hypertension had similar glycaemiccontrol and similar improvement in plasmacholesterol to both those with well-controlledhypertension and those with normal blood pressure.Blood pressure reduction to achieve recommendedtargets for type 2 diabetes is difficult, particularlyin those with albuminuria. 23 The UKPDS study alsoexperienced difficulties in controlling blood pressurein patients with hypertension and type 2 diabetes,though the mean blood pressure in the intensivelytreated group was 144/ 82 mmHg with 29% ofpatients requiring three or more antihypertensivemedications. Our data demonstrated a higher meanBP of 149/84mmHg with only 18% of patients onthree or more agents. Extrapolation from this datasuggests that in order to achieve a mean bloodpressure in clinical practice of less than 140/90mmHg,approximately 50% of patients will need to be onthree or more antihypertensive agents. Current ADAguidelines recommend a target blood pressure of130/80mmHg for patients with diabetes. 19 Gaede etal reported that less than 50% of patients achievedtheir target systolic BP of

ORIGINAL PAPERStructuring Diabetes Care in General Practices: many improvements, remaining challengesS Jennings et alORIGINAL PAPERStructuring diabetes care in generalpractices: Many improvements, remainingchallengesABSTRACTBackground For people with type 2 diabetes to enjoy improved longevity and quality oflife, care needs to be organised in a systematic way.Aim To test if processes and intermediate outcomes for patients with type 2 diabeteschanged with the move to structured care in general practice shared withsecondary care.Methods An audit of process and intermediate outcomes for patients with type 2diabetes before and after the change to structured care in 10 Dublin generalpractices shared with secondary care four years on.Results Structured diabetes care in general practice has led to more dedicated clinicsimproved processes of care and increased access to multidisciplinary expertise.Improvement in blood pressure control, the use of aspirin and the use of lipidlowering agents indicate a significant decrease in absolute risk of vascular eventsfor this population.Conclusions Structured care in general practice improves intermediate outcomes forpeople with type 2 diabetes. Further improvements need to be made to reachinternational targets.INTRODUCTIONDiabetes is an important chronic condition whichis set to increase in prevalence in the comingdecades. The complications of type 2 diabetes can besignificantly reduced by appropriate treatment. 1-3For people with type 2 diabetes to enjoy thesebenefits, care needs to be organised in a systematicand integrated way. This has been shown to beeffective in general practice settings 4 and sustainableover 10 years. 5 A trial in North Dublin 6 showed thatstructured care in general practice can producesignificant improvements in diabetes care delivery inthe Irish healthcare environment.Ten general practices in the south inner city of Dublinagreed to provide structured diabetes care in theirpractices in 2001. Care was shared with one localhospital diabetes service for patients attending thatservice. This study was carried out to determinewhether delivery of care and intermediate outcomesof care for patients in these practices have alteredafter the move to structured care for diabetes.METHODSA baseline audit of diabetes care was carried out in2000 in ten general practices and repeated in 2004after the introduction of structured diabetes care fortype 2 diabetes. Two practices declined to participatein the re-audit. System of care for patients withdiabetes is outlined in Figure 1. All patients, over 16years of age, attending the participating practices,were included in the baseline (n= 293) and repeataudits (n = 324) with the exception of pregnant1. Registration of patients2. General Practitioners (GP) and practice nursetraining3. Diabetes care guidelines adapted fromnational (ICGP) and international (Diabetes UK)guidelines4. Regular review of patients in general practice(consisting of quarterly visits to GP with annualassessment in hospital)5. Annual ophthalmological review6. Support staff (dietician, specialist nurse andchiropodist) were employed and available in thecommunity to participating practicesS Jennings, 1DL Whitford, 2D Carey, 1SM Smith 3Dept of PublicHealth Medicine 1 ,Health ServiceExecutive,Dr SteevensHospital, Dublin;Dept of GeneralPractice 2 , RoyalCollege of Surgeonsin Ireland, Dublin;Dept. of PublicHealth and PrimaryCare 3 , Trinity CollegeDublin, TrinityHealth SciencesInstitute, TallaghtHospital, DublinFigure 1—SYSTEM OF CAREIN PARTICIPATINGPRACTICES FORPATIENTS WITHDIABETESwomen. Data on patients with type 2 diabetes arepresented here. Practice diabetes registers werecompiled in autumn 2000 and were used for thebaseline audit (n = 234). In summer 2004 the registerswere reviewed prior to carrying out the re-audit (n =271). Patients with type 2 diabetes comprise 80% and84% of the diabetes population in the participatingpractices in 2000 and 2004 respectively.As the GP practices had patients from a widecatchment area, attending a number of hospitals, alltype 2 patients were analysed in the re-audit thoughonly 167 (61.6%) type 2 patients had care formallyshared with the one participating hospital.The audit instrument was finalised afterconsulting other Irish and international audits andrecommendations 7;8 and employed variables in thefollowing categories: demography, evidenced basedmeasures of process and intermediate outcome aswell as activity data in the 12 months prior to theaudits. A nurse researcher collected the data frompractice medical records. Patient confidentiality wasmaintained with only anonymous patient data heldon computer. Ethical approval was obtained from theIrish College of General Practitioners.Data were analysed using both Excel and SASpackages. Chi-square, Wilcoxon rank sum and z testswere used for independent data analysis. A cohortof patients, common to both audits, was identifiedand McNemar’s and paired t-tests were used forthese paired data. One sample z tests were usedfor age and gender comparisons of the cohort andmain study group. All tests were two-tailed and thesignificance level was set at 5%.RESULTSCharacteristics of the patients in the baseline and inthe re-audit are shown in Table 1. Mean age, genderand duration of diabetes remained the same inboth audits. More patients were covered by generalmedical services (GMS) in 2004.Process measuresRecording of the majority of processes of careincreased between 2000 and 2004 (Table 2). However,the recording of examination of foot pulses and fundiwithin the previous 12 months decreased. In the lattercase there was an increase in specialist ophthalmicscreening. Notably, when all eye examinations arecombined there was no change (p=0.95) in theoverall proportion of patients recorded as receivingeye examination from 131 in 2000 (56.0%) to 151 in2004 (55.7%). The proportion of patients prescribedtherapeutic agents of proven benefit improvedbetween 2000 and 2004 as did referrals to thedietician, chiropodist and ophthalmologist.WorkloadThe GP consultation rate of patients with type 2diabetes prior to July 2000 was 9.23 consultationsper patient per annum. This declined to 6.02consultations per patient per annum in the12 months prior to October 2004 (p< 0.0001).Admissions to hospital for all causes rose from0.21 admissions per patient per annum to 0.40 perpatient per annum for the same periods (p=0.0001).Intermediate outcome measuresThere was no change in the proportion of recordedsmokers (Table 3) and no change in diabetes controlas measured by HbA 1c. There were significantimprovements in blood pressure control between2000 and 2004.Paired data for processes and intermediate outcomesPaired data on patients present in both audits(n=58) are shown in Table 4. The cohort of patientscommon to both audits was similar in age andgender to the main study group in 2000. Similarchanges in recording of process measures, referralsand prescribing were seen for this group as for thetotal population with the exception of the recordingof BP, smoking and dietician visit which remainedunchanged. However there was a non-significantdecrease in the proportion of patients recorded asreceiving any eye examination. There were significantimprovements in blood pressure and no change inHbA 1cover the four-year period in these patients.Changes at practice levelThe eight practices grew in size during the periodof observation with the total patient populationestimated to have grown by 68%. The GMS populationincreased by 45% from 7,490 to 10,890 patients. Thenumber of doctors in the practices increased from 17to 24 and the number of nurse hours from 171 to 233.The prevalence of type 2 diabetes (and both type 1and 2 together) among the GMS population showed asmall but non-significant increase from 1.76% (2.08%)in 2000 to 1.93% (2.23%) in 2004.Of the eight practices six now run dedicated diabetesclinics with the two others following the agreedproforma of care in ordinary appointments. Also42 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 43

ORIGINAL PAPERStructuring Diabetes Care in General Practices: many improvements, remaining challengesS Jennings et alORIGINAL PAPERTable 1CHARACTERISTICS OF PATIENTS WITH TYPE 2 DIABETES IN 2000 AND 2004 AUDITSBASELINE 2000(N=234)RE-AUDIT 2004(N=271)Number of Practices 10 8P VALUEMean age – years (SD) 67.75 (13.98) 66.84 (12.91) NSNumber males (%) 120 (51.3%) 145 (53.5%) NSNumber GMS Status (%) 156 (67.8%) 210 (77.8%) 0.01Mean duration of diabetes – years (SD) 6.12 (6.18) 6.52 (6.30) NSSD = standard deviation, NS = not significant.Missing data excluded from analysis as follows: (a) Age 3 cases for 2000; (b) GMS status 4 and 1 cases for 2000and 2004 respectively, c) Duration of diabetes 59 and 73 cases for 2000 and 2004 respectively.Table 2PROCESS MEASURES RECORDED IN 2000 AND 2004 FOR PATIENTS WITH TYPE 2 DIABETESBASELINE 2000(N=234)RE-AUDIT 2004(N=271)P VALUESmoking status 132 (56.4%) 179 (66.1%) 0.03Blood pressure 204 (87.2%) 252 (93.0%) 0.03Weight 66 (28.2%) 187 (69.0%)

ORIGINAL PAPERStructuring Diabetes Care in General Practices: many improvements, remaining challengesS Jennings et alORIGINAL PAPERThe increase in the proportion of patients with GMScover is most likely due to the introduction of GMScover for all patients aged over 70 years in April 2001.The mean age of the two groups in 2000 and 2004did not differ in spite of the passage of four years.This highlights one difficulty in monitoring the care ofchronic illness. In every day practice there is an influxof newly diagnosed patients with earlier diseaseand the exit of patients who die or move to moredependant care. This leads to a problem in interpretingaudit data over time. Consequently, a strength of thisstudy was the ability to identify a cohort of patientswho participated in both audits. Changes in thiscohort were on paired data from the same patientsand therefore demonstrate true change.The design of this study was that of a repeat auditof care and intermediate outcomes. We are thereforenot able to attribute the changes demonstratedin this study to the introduction of structuredcare. However, the evidence that general practicecan provide structured diabetes care and achieveintermediate outcomes similar to this study isnow overwhelming. 4;9 This is an inner city group ofpractices and so results may not be generalised toor reflect the whole country. However, this study,in tandem with international literature and theNorth Dublin randomised control trial, is a furtherdemonstration of the need for structured communitybased diabetes care in Ireland.The improvements in processes of care demonstratedin this audit after the introduction of structureddiabetes care are similar to those demonstratedelsewhere. 10;11 However, the level of recording ofprocesses of care in these patients is still below thoseadvocated by the Irish College of General Practitionersand those achieved in these other studies. BothNorth Tyneside 5;10 and Cardiff 11 demonstrated thedocumentation of all relevant process measuresin more than 70% of patients. On the other handthe data on controls in an Irish randomised controltrial 12 of diabetes shared care reveal similar levels ofdocumentation to this study. This would indicate thateven after the introduction of structured diabetescare, general practice in Ireland has still to improvethe management of this chronic disease. Interestingly,prevalence has remained the same for the subgroupof GMS patients indicating a lack of improvementin disease detection compared to other studies. 11;13Contributory factors to consider in understandingthese comparative deficiencies are a) the lack ofplanning and resourcing of diabetes care in Irishgeneral practice, b) the deskilling of Irish generalpractitioners in diabetes care over many years and c)the absence of a systematic screening programmefor fundus examination. These need urgent attentionin order to further improve care and outcomes forpatients with diabetes. Indeed as a result of theaudit one initiative undertaken was an outreachophthalmological screening programme for this groupof patients in the south inner city.The most striking feature of this audit is that ofimprovement in blood pressure. In both the maingroup, and more particularly in the paired group,the improvement in systolic and diastolic bloodpressure over the four years is a major achievementwith significant implications for reduction incardiovascular risk for this group of at risk patientsas demonstrated by UKPDS. 2 Over the ten-yearperiod the cohort saw a reduction in mean systolicblood pressure of 10mmHg. This equates to a riskreduction of 15% for deaths related to diabetes, 11%for myocardial infarction, and 13% for microvascularcomplications. 14 However, if the cohort is comparedwith the UKPDS group, absolute levels of bloodpressure control are similar. This would equate to arisk reduction of 32% for deaths related to diabetes,44% in strokes, and 37% in microvascular endpoints. 2 Furthermore, the increase in prescribingof lipid lowering agents and aspirin alongside thereduction of blood pressure indicates a significantdecrease in absolute risk of vascular events forthis population with type 2 diabetes. There was nochange demonstrated in levels of diabetes control.This would initially appear disappointing but UKPDSdemonstrated an inevitable decline in diabetescontrol. 1 The maintenance of diabetes control inthis study is therefore an achievement and wouldcontribute to further risk reduction for this groupof patients.The decrease in consultation rates with generalpractitioners as demonstrated in this study hasnot been shown elsewhere and merits furtherinvestigation. Potential reasons for this findingare more efficient care at each visit, better patientsatisfaction with consultation or measurement errorin regard to recording GP consultations at practicelevel. Routine care by nurses only was not a feature ofthis programme. The increase in hospital admissionsis at odds with a previous study that showed areduction in hospital referrals in patients attendinggeneral practice structured diabetes care. 15 We didnot have a breakdown of the reasons for admissionand this would also need further research as the aimof structured care is to improve outcomes and reducethe costs of diabetes that are largely hospital based.This study is in line with previous studies showingthat the introduction of structured diabetes care ingeneral practice and supported by secondary careis associated with improvements in both processesand intermediate outcomes of care. However,there is a need for further improvements in orderto bring the standards up to international norms.Consequently, we point to the urgent need forplanning and resourcing of initiatives of this natureas well as a programme of retinal screening as partof high quality community based diabetes carein Ireland. The aim must be to provide care to thewhole population with diabetes in order to achieveimproved long term outcomes for these patients.AcknowledgementsWe would like to acknowledge the hard work andcooperation of the ten general practices who havehad the commitment to initiate this programme ofcare, the two nurses (Bronagh Peelo and Ruth Bowie)who dedicated time and energy to accurate datacollection and to the staff of the SIC PartnershipOffice who contributed in many ways to the changemanagement programme.REFERENCES1. UK Prospective Diabetes Study Group. Intensiveblood-glucose control with sulphonylureas or insulincompared with conventional treatment and risk ofcomplications in patients with type 2 diabetes(UKPDS 33). Lancet 1998;352:837-53.2. UK Prospective Diabetes Study Group. Tight bloodpressure control and risk of macrovascular andmicrovascular complications in type 2 diabetes: UKPDS38. BMJ 1998;317:703-13.3. Gaede P, Vedel P, Larsen N, et al. Multifactorialintervention and cardiovascular disease in patientswith type 2 diabetes. N Engl J Med. 2003;348:383-93.4. Griffin S. Diabetes care in general practice: metaanalysisof randomised controlled trials. BMJ1998;317:390-6.5. Whitford DL, Roberts SH, Griffin S. Sustainability andeffectiveness of comprehensive diabetes care to adistrict population. Diabet Med 2004;21:1221-8.6. Smith S, Bury G, O’Leary M, et al. The North Dublinrandomized controlled trial of structured diabetesshared care. Fam Pract 21(1):39-45, 2004.7. British Diabetic Association. Recommendations for themanagement of diabetes in primary care. 1997. London,BDA.8. Brennan, C., De La Harpe, D., and Harkins, V. Audit Reportof the Midland Health Board: Diabetes Shared CareProject 1998-1999. 2001. Midland Health Board.9. Olivarius NdF, Beck-Nielsen H, Andreason AH, et al.Randomised controlled trial of structured personal careof type 2 diabetes mellitus. BMJ 2001;323:970-5.10. Whitford DL, Southern AJ, Braid E, et al. Comprehensivediabetes care in North Tyneside. Diabet Med1995;12:691-5.11. Butler C, Smithers M, Stott N et al. Audit-enhanced,district-wide primary care for people with diabetesmellitus. Eur J Gen Pract 1997;3:23-7.12. Smith S, Bury G, O’Leary M, et al. The North DublinDiabetes Shared Care (DiSC) Project: a profile of currentdiabetes care in Ireland. IMJ 2001;94:240-3.13. Whitford DL,.Roberts SH. Changes in prevalence and siteof care of diabetes in a health district 1991-2001. DiabetMed 2004;21:640-3.14. Adler AI, Stratton IM, Neil HAW, et al. Associationof systolic blood pressure with macrovascular andmicrovascular complications of type 2 diabetes (UKPDS36): prospective observational study. BMJ 2000;321:412-9.15. Farmer A, Coulter A. Organization of care for diabeticpatients in general practice: influence on hospitaladmissions. Br J Gen Pract 1990;40:56-8.Correspondence to: Dr Siobhan Jennings;Email: siobhan.jennings@mailf.hse.ie46 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 47

ORIGINAL PAPERFDG-PET scanning in the Management of Cancer of the Oesophagus and Oesophago-gastricJunction: Early Experience with 100 Consecutive CasesV Malik et alORIGINAL PAPERFDG-PET scanning in the managementof cancer of the oesophagus andoesophagogastric junction: Early experiencewith 100 consecutive casesABSTRACTBackground The aim was to evaluate the impact of FDG-PET scan on tumour staging andmanagement decisions in oesophageal cancer.Methods One-hundred consecutive patients referred for consideration of surgeryunderwent a whole body FDG-PET scan in addition to CT imaging.Results Based on CT scan, a curative approach could be considered in 62 patients. ThePET scan altered regional nodal (N) staging in 16 patients overall, but did not altermanagement decisions. Metastatic status (M) was increased in 14 patients, withaltered management in 10/62 (16%). Nine were downstaged, with managementchanged in 3/38 (8%). Seventeen patients underwent 19 additional tests to clarifyfindings on PET, in 15 patients (88%) the tests revealed no pathology.Conclusion FDG –PET alters M stage in 23% of patients and may impact on surgicaldecision-making. The spurious investigations and cost of the high false-positive rateof further tests is of concern.INTRODUCTIONCarcinoma of the oesophagus and gastroesophagealjunction represent aggressive diseases with a poorprognosis even in patients undergoing curativeresection. 1 The risk of treatment-related, in particularsurgical morbidity and mortality is high, and accuratestaging guiding appropriate treatment planshas considerable value and clinical importance. 2Staging of oesophageal cancer incorporates theUICC or AJCC staging which is based on TNM. 3,4The objective of accurate staging is to preciselyselect patients in whom a curative approach basedprincipally on an aggressive loco-regional therapy,including surgery, is appropriate, accordingly,patients with M1 disease must be excluded. A furtherconsideration, although controversial, is that patientswith locally advanced disease, such as T4, bulkyT3 and possibly node-positive disease are betterconsidered for multmodality approaches ratherthan surgery alone. The traditional armamentariumfor staging oesophageal cancer is cross-sectionalimaging with computerized tomography (CT) ormagnetic resonance imaging (MRI), both standardfor identifying T4 or M1 disease. 5 Endoscopicultrasonography (EUS) has increased the accuracy ofT staging, and this may be of value in the staging, butit offers no greater advantage to good quality crosssectionalimaging in discriminating patients suitablefor a palliative rather than a curative regimen. 6Positron emission tomography (PET) imagingprovides qualitatively different information fromCT and MRI, as it relies on the metabolic function oftumours instead of tumour size alone. PET utilizesthe glucose analogue FDG (2-[18Fluorine]-Fluro-2-deoxy-D-glucose), providing physiological informationthat enables the diagnosis of malignancy to bebased on altered tissue metabolism. In the processof transformation from normal cells, malignantcells develop significant alterations in metabolism.The major changes occurring include increases inDNA synthesis, amino-acid use and glycolysis. 7,8Tumours studied to date, where PET has shown ahigh diagnostic accuracy, include carcinoma of thelung, breast, colon, head and neck, brain as well aslymphoma, melanoma and sarcoma. 9-15Oesophageal cancer has a high glucose metabolismand thus has an avid FDG consumption, and thereis an emerging literature on the use of PET imagingin the staging of tumours of the oesophagus andoesophago-gastric junction. 16-21 This has beenV Malik,M Keogan 1 ,C Gilham 2 ,G Duffy 3 , N Ravi,JV ReynoldsDept of ClinicalSurgery, Dept ofRadiology 1 , Dept ofRadiotherapy 2 ,St James’s Hospitaland Trinity CollegeDublin & Dept ofNuclear Medicine 3 ,Blackrock Clinic,Dublinassociated with decreased use of invasive proceduresincluding EUS-directed nodal biopsies, thoracoscopy,and laparoscopy. 22-24 This study aimed to assess theclinical impact of the introduction of staging FDG-PET on the management of oesophageal cancerat a single institution, in particular the numberof patients who had surgery either deferred orfacilitated based on PET findings, as well as impactof PET in generating further investigations and theoutcome of those additional studies.MATERIALS AND METHODSStudy designA prospective study was performed from November2003 to December 2004 on 100 consecutive patientswith biopsy proven carcinoma of the oesophagus orthe gastro-oesophageal junction.Computed TomographyEach patient underwent a spiral CT examination, 91at this institution and nine at the referring centre.Spiral CT scanning at this institution was carriedout on a Siemens Somatom scanner, followingadministration of oral and intravenous contrast.In all patients imaging included neck, thorax andabdomen to the iliac crest, using a slice thicknessof 8mm. Intravenous contrast medium (100ml)with concentration of 300ml iodine/l (Omnipaque,Amersham) was injected by power injector with a30-second delay before scanning the neck/thoraxand 65-second delay before scanning the liver.CT images provided by the referral hospital (slicethickness 3mm-10mm) were re-evaluated by anexperienced on-site radiologist (MK). These wereread independent of the PET findings. The CT analysisincluded extent of primary tumour, tumour invasionof adjacent structures, lymph node enlargement anddistant metastases. Perioesophageal invasion wasconsidered present when direct invasion into thesurrounding tissue was noted or when there wasabsence of fat cleavage planes between the tumourand adjacent organs. Lymph nodes were consideredpositive when the short axis was greater than 1 cmin diameter. Lymph nodes less than 1 cm in diameterwere considered to be indeterminate for metastases(Nx). Lesions in the liver were considered suspiciousfor metastases (Mx) if not characteristic of a cyst orhaemangioma.Positron Emission Tomography ScanningAll patients underwent a whole body FDG-PETscan using a PET Advance full ring PET scanner(General Electric). Patients fasted for a minimum offour hours. Blood glucose was measured and thusadditional blood glucose manipulation was notrequired. Patients were given 5mg Valium orally 20to 35 minutes prior to the FDG injection and werewell hydrated orally in the two-hour period prior toFDG injection. Between 237 and 490 MBq of FDG wasinjected intravenously and patients remained lying ina quiet dark room for 60 minutes prior to scanning.Patients voided before going on to the scanner. Thescan extended from the mid thigh to the base of theskull; six to eight bed positions were obtained, fiveminutes per emission scan and three minutes pertransmission scan per bed position. Images werereconstructed using an interactive reconstructedalgorithm with segmented attenuation correction.Scan images were viewed in the transaxial, coronaland sagittal plains, and cine projections on adedicated work station and reported by a consultantphysician in nuclear medicine with experience in PETinterpretation.FDG-PET images were compared with the mostrecent CT images. Maximum standardized uptakevalues (SUV) were obtained and a maximum SUVof 3.5 was used to assist the visual interpretationin differentiating inflammatory tissue and normaltissue from malignant tissues (malignant SUV > 3.5).Metastatic lesions were divided into local, regionaland distant metastases. Further CT imaging, MRI,Ultrasound (U/S), ENT consultations and invasiveprocedures such as colonscopy were performedwhere PET identified equivocal metastatic lesionsand patients were considered fit for surgery.StagingStaging was based on TNM classification, dependingon the localization of the primary tumour. 4Suspected nodes were classified as locoregional (N1),and non-local lymph nodes were considered as M1a.According to this system, the definition of N changesdepending on the location of the primary tumour(Table 1).A curative approach to treatment involved eithersurgery alone or chemotherapy and radiationtherapy prior to surgery. A curative resection denoteswide clearance of the primary tumour and a radicallymphadenectomy, including peri-oesophagealnodes as well as N2 nodes on the left gastric,common hepatic and splenic arteries, along withsub-carinal and mediastinal lymph nodes.48 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 49

ORIGINAL PAPERFDG-PET scanning in the Management of Cancer of the Oesophagus and Oesophago-gastricJunction: Early Experience with 100 Consecutive CasesV Malik et alORIGINAL PAPERRESULTSPatients (Table 2)Seventy-eight male and 22 female patients withoesophageal carcinoma were enrolled prospectively.Their age ranged from 37 years to 86 years. Meanage at time of diagnosis was 61.5 years. Preoperativediagnosis was confirmed by pathologicalexamination of endoscopic biopsy specimens, asadenocarcinoma in 56 patients and squamous cellcarcinoma in 40 patients.Based on the CT imaging, 62 (61%) were consideredto have resectable disease and suitable for acurative approach involving either resection alone orpreceded by chemotherapy and radiation therapy.Nodal StageA total of 16 patients (16%) of the 100 enrolled hadtheir N stage altered as a result of the FDG-PETscan. Five patients (5%) had upstaging of nodalstatus, four from N0 to N1, and one from Nx to N1.In two patients, surgery was not performed becauseof evidence of both nodal and systemic (bony)metastases. Two patients with nodal upstagingunderwent curative resections, and one hadmultimodality therapy. In no case was managementaltered based on FDG-PET N upstaging. Elevenpatients had decreased nodal staging, eight from Nxand three from N1, in no case did this influence thedecision to proceed with or defer surgery.M StagingA total of 23 patients of the 62 enrolled withpotentially resectable disease had their M stagealtered as a result of FDG-PET. Fourteen patientshad upstaging of M status by FGD-PET (Table 3), andnine patients had their M status downstaged. Of the14 upstaged patients, six did not undergo surgerybecause of systemic metastases, four because ofdistant nodal disease, two underwent surgery withradical lymphadenectomy, and one patient withsmall cell cancer continued with chemotherapy, andone patient was deemed unfit for any treatment.Thus M upstaging impacted on management in 10 ofthese cases, or 10/62 (16%) considered treatable withcurative intent.Nine patients had their M stage downstaged byFDG-PET, 5 from M1b to M0, and four from M1a toM0. Three underwent surgery, in four other patientssurgery was not performed as they were unfit for theprocedure, one patient developed intercurrent brainmetastases, and one patient refused surgery. ThusM downstaging may have impacted in 9% of casesoverall, or 9/38 (24%) patients initially CT-staged aspalliative. However, in fact the management wasaltered in just three cases, 3% overall or 8% deemedto be in the palliative cohort.Although not strictly upstaging or downstaging, sixfurther patients with initial M0 staging became Mx anda further 16 patients initially categorized as Mx becameM0 following FDG-PET. In the former group furthertests including focused liver ultrasound and bone scanswere required, but management was not altered inany case, all of whom went on to have surgery.Additional InvestigationsOf the 100 patients enrolled in our study, 17 patientshad FDG-PET scans which identified possiblemetastatic lesions not seen on CT scans. Theselesions were indentified in the liver, the bone, thenasopharynx, the colon, the tongue, the thyroid, thepharynx and larynx, the tongue and in the leg. Whilethe nature of many abnormalities on PET were notproblematic (i.e. focal uptake in the liver was taken torepresent metastatic disease, and widespread bonyuptake was accepted as M1b), other areas were moreequivocal, particularly focal colonic uptake. As a result19 additional procedures and scans were performed(Table 4). Six patients were identified by FGD-PETto have possible colonic lesions, as a result they allunderwent colonscopy, revealing benign changes (fourpolyps, two normal) in six patients. Six underwentfurther imaging investigations for suspected isolatedbony metastases, in just one confirmed by MRI. In onepatient a second primary in the nasopharynx wasidentified. Thus the additional investigations werefalsely positive in 15 of 17 (88%) patients.DISCUSSIONOesophageal cancer is increasing in incidence,it carries a poor outlook, it is often advanced atdiagnosis, and the treatment modalities utilized in thecurative approach to this disease have considerableattendant risks of morbidity and mortality. 1 Onlypatients with localized regional disease can be treatedwith curative intent, either surgery alone, surgeryas a component of a multimodality regimen, orcombination chemotherapy and radiation therapy. Inthis era the rate of unnecessary surgical explorationshould be continually decreasing, and some haveadvocated reporting of one-year survival rates asan index of the appropriateness of staging andmanagement decisions. 25,26Table 1OESOPHAGEAL CARCINOMA: THE TNM STAGING SYSTEMPRIMARY TUMOUR (T)TXT0TisT1T2T3T4REGIONAL LYMPH NODES (N)NXN0N1DISTANT METASTASIS (M)MXM0M1TUMOURS OF THE LOWER THORACIC OESOPHAGUSM1aM1bTUMOURS OF THE MIDTHORACIC OESOPHAGUSM1aM1bTUMOURS OF THE UPPER THORACIC OESOPHAGUSM1aM1bTable 2DEMOGRAPHICSPATIENTSDemographicsMaleFemaleNO.7823Mean age at diagnosis 61.5SiteGastro-oesophageal junctionThoracic oesophagusUpper oesophagusMiddle oesophagusLower oesophagusHistologyAdenocarcinomaSquamous cell carcinomaSmall cellIntramucosal3441646564022Primary tumour cannot be assessedNo evidence of primary tumourCarcinoma in situTumour invades lamina propria or submucosaTumour invades muscularis propriaTumour invades adventiaTumour invades adjacent structuresRegional lymph nodes cannot be assessedNo regional lymph node metastasesRegional lymph node metastasisDistant metastasis cannot be assessedNo distant metastasisDistant metastasisMetastasis in celiac lymph nodesOther distant metastasisNot applicableNon-regional lymph nodes and/or otherdistant metastasisMetastasis in cervical nodesOther distant metastasisSince its introduction in 1974, computerisedtomography has been the imaging modality of choicefor the preoperative evaluation of gastrointestinalmalignancies. Detection of malignancy is basedonly on structural change however, thus there areinherent limitations in specificity, particularly falsepositive findings in enlarged inflammatory lymphnodes, and sensitivity, in particular false negativefindings in non-enlarged invaded lymph nodes. 27Increased metabolism associated with malignanttransformation was first described by Warburg andforms the basis for imaging of cancer with FDG-PET. 28,29 The ability to generate images on the basisof tissue metabolism allows PET to complementCT imaging which provides anatomical focus. Inaddition, the generation of whole body images inthree dimensions, offers the option of replacingmultiple imaging investigations, such as brain CT /MRI or bone scans with a single study. 30Several studies to date have reported a highsensitivity of FDG-PET for staging cancer of theoesophagus and of the gastroesophageal junction50 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 51

ORIGINAL PAPERFDG-PET scanning in the Management of Cancer of the Oesophagus and Oesophago-gastricJunction: Early Experience with 100 Consecutive CasesV Malik et alORIGINAL PAPERTable 3MANAGEMENT IN PATIENTS WITH INCREASED M STAGEPATIENT CHANGE IN M STAGING MANAGEMENT CHANGEDID PET INFLUENCESURGERY?1 M1a--------------M1b Yes, (distant mets in liver) Yes2 M0---------------M1b Yes (Liver mets) Yes3 M0---------------M1b No, (chemotherapy for small cell histology) No4 M0---------------M1a No, Pt underwent surgery No5 M0---------------M1a Yes, (distant nodal spread) Yes6 Mx---------------M1a Yes, (distant nodal spread) Yes7 M0---------------M1a No, (Pt not fit for surgery) No8 Mx---------------M1b Yes (liver mets) Yes9 Mx---------------M1b Yes, (distant mets in liver) Yes10 Mx---------------M1a No, Pt underwent surgery No11 Mx---------------M1a Yes, (distant nodal spread) Yes12 M1a--------------M1a Yes, (distant nodal spread) Yes13 Mx---------------M1b Yes, (distant mets in liver) Yes14 M0---------------M1b Yes, (distant mets in bone) YesTable 4FDG-PET: ADDITIONAL INVESTIGATIONS, AND IMPACT ON MANAGEMENTPATIENT FDG-PET LESION ADDITIONAL INVESTIGATIONIMPACT OF FDG-PET ONSURGICAL DECISION1 Bony metastases CT pelvis- normal No, Other (pt unfit for surgery)2 Lesion in nasopharynx ENT review No, Other (DTX over surgery)3Lesion in posterior triangleof neckCT-indeterminateU/S & Bx-normalNo, Other ( Small cell CA,chemotherapy4 Lesion in colon Colonscopy-normal No, Pt underwent surgery5 Bone-marrow & colonic uptake MRI & colonscopy - normal No, Pt underwent surgery6 Lesion in nasopharynx ENT review normal No, Other (pt unfit for surgery)7 Lesion in colon Colonscopy-normal No, Pt underwent surgery8 Lesion in colon Colonscopy-normal No, Pt underwent surgery9 Bony metastases MRI-normal No, Pt underwent surgery10 Lesion in tongue ENT review No, Pt underwent surgery11 Thyroid uptake U/S thyroid-normal No. Pt underwent surgery12 Lesion in colon Colonscopy-normal No, Other (pt unfit for surgery)13 Lesion in leg Clinical assessment No, Other (pt unfit for surgery)14 Bony metastases Bone scan-normal No, Pt underwent surgery15 Bony and Adrenal metastases Bone scan-normal Yes16 Bony uptake and colonicColonscopy-normalBone scan- normalNo, Pt underwent surgery17 Bony metastases MRI-abnormal Yes, (distant metastases)but few large studies of the impact of this modalityin day-to-day practice have been undertaken. 21,30,31,32Previous studies have reported a high sensitivity(72% - 90%) and specificity for nodal disease (82%- 90%). 27, 30 In this study, sensitivity and specificitywere not addressed, but the practical impact of achange of N staging by PET scanning in 16 patientswas negligible, being directly responsible forwithholding surgery in just one case. This in partrelates to the modern staging nomenclature whichdefines extra-regional nodes such as cervical, celiacand para-aortic as M1a disease. It is the Unit policyto advocated a radical curative approach involvinglymphadenectomy even where N1 disease exists.For nodal assessment, the authors recognize thata limitation of the study with respect to nodalinvolvement is the lack of EUS availability for allpatients, and EUS-directed nodal biopsies, and thismodality may have reduced the marked impact ofFDG-PET on CT-determined management decisionsin this cohort. The use of preoperative chemotherapyalone or in combination with radiation therapy iscontroversial but it may be that this will becomeincreasingly standard in patients with gross T3 or T4disease, and patients with N1 disease, and perhapsthe combination of PET with CT/EUS may betterselect patients in the node-positive subset. 33,34For M staging PET has been shown to be superior toCT both in sensitivity (69% vs. 46%) and specificity(93.4% vs 73.8%). 17,31 In this study, 23 patients hadtheir M stage altered, with 14 upstaged. Ten patientshad surgery avoided by the PET finding, representing16% of the group considered suitable for a curativeapproach. The M stage was downstaged in ninepatients, four of whom went on to curative surgery.The limitations in specificity of PET relate to theuptake of glucose by inflammatory, hyperplasticand lymphoid tissue. In this study 24 patients hadpossible metastatic lesions on PET not seen onCT scan, with uptake identified in the liver, bone,nasopharynx, colon, tongue, thyroid, pharynx andlarynx, tongue and in the lower limb. Additionalinvestigations in 16 patients included colonoscopies,MRI, CT pelvis, ultrasound of neck and bone scans.Metastatic disease was confirmed in just one of the16 (6%) and in another tumour, a second primary inthe nasopharynx altered the management decision.Focal activity in the colon was a common cause ofconcern leading to colonoscopies for clarification insix cases, all negative for significant pathology. Sixpatients underwent further investigations of FDG-PET – suspected bone metastases, and in five of sixcases (86%) this was negative. While it is possiblethat the introduction of CT-PET fusion imagingmay help to resolve these issues it is likely thatfalse positive findings will remain an unavoidablelimitation of PET scanning until tumour-specificisotopes are developed.This study set out to study the practical implicationsof PET in a tertiary centre. Several conclusions can bedrawn. The positive message is that in 62 patientsconsidered for curative treatment based on CTimaging,M upstaging through PET impacted onmanagement in almost 16% of cases. Downstaging,although impacting in this study in just three casesoverall, had the potential to influence managementin nine of 38 (24%) patients CT-staged withmetastatic disease. The principal negative of PDG-PET evident in this study is the frequent need forfurther investigations with the attendant anxietyfrom predominantly false positive uptake. Advancesin PET scanner technology and the introductionof fused PET/CT scanners may help to reducecosts and increase availability of PET scanning.Notwithstanding the cost-benefit debate, outsidethe focus of this study, the improved M stagingwhere PET is performed in combination with CTimaging may support the routine use of FDG-PET inpatients with apparent localized disease.REFERENCES1. Enzinger PC, Mayer RJ. Esophageal Cancer. N. Engl J Med,2003;349: 562-5722. Hulscher JB, Tijssen, Obertop H, van Lanschot JJ.Transthoracic versus transhiatial resection forcarcinoma of the esophagus: A meta-analysis. AnnThorac Surg 2001; 72: 306-133. Beahrs OH, Henson DE, Hunter RVP, et al: American JointCommittee on Cancer: Manual for staging of cancer(ed 3). Philadelphia, PA, JB Lippincott, 1998,99 63-67.4. Sobin LH, Wittekind C: TNM Classification of MalignantTumours, 6 th ed. New York: John Wiley & Sons, 2003.5. Kumbasar B. Carcinoma of esophagus: radiologicdiagnosis and staging. 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Feasibility studies for cancer imaging withpositron emission tomography. Cancer 1991;67:1544-50.30. Block MI, Patterson GA, Sundaresan S, et alImprovement in staging of oesophageal CA with theaddition of positron emission tomography. Ann ThoracSurg 1997;64:770-7.31. Fukahagan T, Okazumi S, Koide Y, Zsoho K, Zwnazeki K.Evaluation of esophageal cancers using fluorine-18-fluorodeoxyglucose PET. J Nucl Med 1998;39:1002-7.32. Flanagan FL, Dehdashti F, Seigel BA, et al Staging ofesophageal cancer with (F-18) fluorodeoxyglucosepostron emission tomography. AJR 1997;168:417-24.33. MRC Trial. Surgical resection with or withoutpreoperative chemotherapy in oesophageal cancer: Arandomised controlled trial. Lancet 2002;359:1727-173334. Fiochha F, DiBona D, Schepis F, Licata A, Shahied L, etal Preoperative chemoradiotherapy for oesophagealcancer: a systematic review and meta-analysis. Gut2004; 53:925-930.Correspondence to: Professor John V. Reynolds, Deptof Clinical Surgery, Trinity Centre, St.James’s Hospital,Dublin 8. Tel: (01)4162500; e-mail: reynoljv@tcd.ie54 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4

Poor awareness of colorectal cancer symptoms; a preventable cause of emergency and late stage presentationORIGINAL PAPERPoor awareness of colorectal cancersymptoms; a preventable cause ofemergency and late stage presentationABSTRACTAims To assess knowledge of colorectal cancer (CRC) symptoms among outpatientattendees, and to review disease stage, presentation and duration of symptoms inpatients diagnosed with CRC.Methods A questionnaire survey was used to evaluate knowledge of symptoms of CRCand other malignancies. A review of patients diagnosed with CRC during a two-yearperiod was performed.Results Of 350 survey participants 26.6% could name a CRC symptom, compared to 53.4%for lung cancer and 71.5% for breast cancer. Of 102 patients diagnosed with CRC3.9% had Dukes A disease, 32.4% had Dukes B, 39.2% had Dukes C and 24.5% haddistant metastases. Forty per cent of patients presented acutely. The mean durationof symptoms was 24 weeks.Conclusions Knowledge of CRC symptoms is poor and is reflected in the percentage oflate stage and emergency presentations. Increasing public awareness of CRC maylead to earlier presentation and improved survival.AT Manning,R Waldron,K BarryDept of Surgery,Mayo GeneralHospital, Castlebar,Co. MayoINTRODUCTIONColorectal cancer (CRC) is the most frequentlydiagnosed non-cutaneous cancer in Ireland andEurope, 1,2 and the second most common oncologicalcause of death. Approximately one in every twentymen and one in every thirty women will developthis malignancy before the age of 75 with adocumented 50% mortality rate. 3 Prognosis in CRCis closely related to disease stage at diagnosis, andpatients with early disease may be candidates forcurative operative treatment. Unfortunately a largepercentage of patients diagnosed with CRC alreadyhave advanced disease at presentation, and theirsurvival is therefore greatly reduced.It is expected that screening for CRC may effect areduction in mortality of up to 15%. 4 With the highincidence of CRC in Europe it is likely that the demandfor screening is going to increase. According to thecriteria for an effective screening programme it isnecessary that all cost-effective primary preventioninterventions should be implemented as far aspracticable before commencement of screening for acondition. Primary prevention for CRC would includeincreasing public awareness of risk factors, relevantsymptoms, as well as dietary recommendationsand lifestyle modifications. It is our hypothesis thatlate stage presentation may be attributed at leastin part to poor public awareness of CRC symptoms.In this study we analysed the level of knowledge ofCRC and its symptoms among a random populationof outpatient attendees and compared this withknowledge of other common malignancies. We alsoperformed a review of all patients diagnosed withCRC at our unit over a two-year period to determineduration of symptoms prior to presentation, thepercentage of emergency presentations, and diseasestage at the time of diagnosis.PATIENTS AND METHODSThis prospective study was performed at MayoGeneral Hospital between January and March 2004.All attendees at outpatient clinics were asked totake part in an anonymous questionnaire surveyin which their knowledge of CRC symptoms wasevaluated. Knowledge of lung cancer and breastcancer symptoms was evaluated for comparison. Theterm “bowel cancer” was also used as well as CRCin the questionnaire, and participants were asked towrite down any symptoms they knew for each of thecancer types. Acceptable symptoms included changein bowel habit, bleeding per rectum and abdominalpain for CRC, persisting cough, haemoptysis andshortness of breath for lung cancer, and a breastIRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 55

ORIGINAL PAPERAT Manning ET ALPoor awareness of colorectal cancer symptoms; a preventable cause of emergency and late stage presentationORIGINAL PAPERlump, nipple discharge and skin changes for breastcancer. Those attending colorectal or breast clinicswere not asked to participate. Details including age,sex and relevant family history were recorded foreach participant. Using SPSS software (v12.0) a chisquaredanalysis was used to test for differencesbetween knowledge of the three cancer types, and ap-value of less than 0.05 was accepted as significant.All patients diagnosed with CRC between 2002 and2004 at Mayo General Hospital were identified usingthe hospital in-patient enquiry database (HIPE). Aretrospective chart review was performed. Detailsof mode of presentation (accident and emergencydepartment or out-patient referral) and total durationof symptoms prior to presentation were determinedfrom the medical notes. Histological reports wereexamined to determine the Dukes’ staging for eachcase. Operation notes and radiological investigationswere reviewed to determine if distant metastaseswere present at diagnosis.RESULTSIn the questionnaire survey data were collectedfrom 350 outpatient attendees. The mean ageof participants was 43 years (range 18 – 84) and25.4% were male. As shown in Figure 1, only 26.6%of participants could name one symptom of CRC,compared with 53.4% for lung cancer and 71.1% forbreast cancer (p = 0.0001 vs. CRC). Patients with afamily history of colorectal cancer in a first degreerelative were more likely to name a symptomcompared to those with no family history (38.6%versus 24.8%; p = 0.053). Female respondents weresignificantly more likely to name a symptom ofcolorectal cancer compared to males (31% versus12.4%; p = 0.0001). Seventy-three per cent of thosequestioned were unaware that CRC is a commondisease. Ninety-seven per cent of participantsstated that they would participate in a screeningprogramme for colorectal cancer.A total of 102 patients were diagnosed with CRC overthe two-year period from January 2002 to December2003. The mean age at diagnosis was 67 years (range33 – 90), and 65 patients (63.7%) were male. Forty-twopatients (41.2%) presented acutely to the Accidentand Emergency department, the remainder werefirst seen in the out-patient department. Of the 102patients diagnosed with CRC, histological examinationrevealed that 3.9% had Dukes A tumours, 32.4% hadDukes B, 39.2% had Dukes C, and 24.5% had distantmetastases at the time of diagnosis (Figure 2). Patients who presented acutely were more likely to havedistant metastases at time of diagnosis (38.1% versus15%). The mean duration of symptoms for all patientswas 24 weeks. There was no significant difference indisease stage at diagnosis or duration of symptomsbetween male and female patients.DISCUSSIONWe have demonstrated that despite being the mostcommonly diagnosed non-cutaneous cancer in thiscountry, awareness of CRC and knowledge of itssymptoms is poor, with almost three quarters of thosequestioned unable to name a symptom of the disease.In a similar study in the United Kingdom, 44% ofgeneral practice attendees could name a CRC symptomwhereas 85% could name a breast cancer symptom. 5Although this shows a better knowledge of CRCsymptoms than seen in our survey, the unfavourablecomparison with breast cancer is very similar.In this study 63.7% of patients diagnosed withCRC had advanced disease at presentation (DukesC or distant metastases) and 42% presented asemergencies. The possibility of long-term survival withFigure 1 —PERCENTAGE OF OUT-PATIENT ATTENDEES(N = 350) CAPABLE OFNAMING ONE SYMP-TOM OF COLORECTAL,LUNG AND BREASTCANCER. P

ORIGINAL PAPERHRT: Have We Changed?O Conlon & K McKinneyORIGINAL PAPERHRT: Have we changed?ABSTRACTBackground In recent years, medical controversy, has surrounded the prescribing ofhormone replacement therapy (HRT).Aim This study aimed to establish whether prescribing of HRT in Northern Ireland haschanged and what the current prescribing patterns are.Method A structured questionnaire was sent by post to all medical staff in Obstetrics andGynaecology in Northern Ireland. A stamped addressed envelope was included.Results Overall 54% of respondents indicated that they had changed their prescribingpractice on HRT in the past year. The primary indication for prescribing HRT wasvasomotor symptoms (93%). Fifty-six per cent of doctors recommended 1-5 years asduration of use. Oral preparations were those most commonly prescribed (57%). Thedose and type chosen were the same whether prescribing had changed or not.Conclusions More than half of all doctors who responded had changed their prescribingpractices on HRT, yet some respondents still preferred more traditional prescribing.INTRODUCTIONIn the last few years, Hormone Replacement Therapy(HRT) prescribing has changed. This has been largelydue to the publication of recent studies. The ‘MillionWomen Study’ in the United Kingdom recruited1084110 women aged 50-64 years between 1996 and2001. 1 This observational study provided informationabout their use of HRT and other personal details.These women were followed-up for cancer incidenceand death. 1The ‘Women’s Health Initiative’ in the United Statesenrolled 161809 postmenopausal women aged 50 to79 years. 2 This study focused on defining the risks andbenefits of strategies that could potentially reducethe incidence of heart disease, breast and colorectalcancer, and fractures in postmenopausal women.The trial of combined oestrogen and progestogenin women with a uterus was stopped early basedon health risks that exceeded health benefits overan average follow-up of 5.2 years. A parallel trialof oestrogen alone in women who have had ahysterectomy was allowed to continue. 2The aim of this study was to establish whetherprescribing of HRT in Northern Ireland has changedsince the publication of these studies and to identifythe current prescribing patterns.METHODA structured questionnaire was posted to all hospitalbased Consultants, Specialist Registrars and SeniorHouse Officers in Obstetrics and Gynaecology inNorthern Ireland. Questions included the mainindications for HRT prescribing, (sequential orcontinuous combined preparations), duration of use,presence of associated risk factors and discussionregarding alternative methods for symptom controland prophylaxis. A stamped addressed envelope wasincluded to aid reply.RESULTSSeventy-five per cent of Consultants (39/52), 42% ofSpecialist Registrars (16/38) and 26% of Senior HouseOfficers (16/60) replied. Overall 54% of respondentsindicated that they had changed their prescribingpractice on HRT in the past year; 52% of Consultants,56% of Specialist Registrars and 63% of Senior HouseOfficers (Figure 1).The most common primary indication for prescribingHRT was vasomotor symptoms (93%). This was notdependant on changed prescribing practices. Sixtysixper cent of respondents felt it was justified toprescribe HRT for osteoporosis prevention in patientswith a strong family history of osteoporosis in theabsence of vasomotor symptoms. This was morecommon among the Consultants and SpecialistRegistrars who had not changed their prescribingpractice in the last year.Fifty-six per cent of respondents recommended1-5 years treatment as the optimum duration ofuse; 45% of the Consultants, 78% of the SpecialistO Conlon,K McKinneyDept of Obstetricsand Gynaecology,Daisy Hill Hospital,NewryRegistrars and 88% of the Senior House Officers.Twenty-three per cent of doctors recommended 5-10 years as duration of use and only 4% of doctorsrecommended > 10 years of use. Consultants whostated they had not changed their prescribingpractices indicated a longer duration of use. Themost commonly quoted short-term risk for HRT usewas venous thromboembolism (79%). The mostcommon long-term concern with HRT use was breastcarcinoma (94%), with 26% of respondents quotingendometrial carcinoma as a long-term concern.Ten per cent of respondents indicated that ovariancarcinoma was a long-term risk of HRT.Oral preparations were the most commonly prescribedmethod of HRT (57%) (Figure 2). The dose and typewere the same, whether or not prescribing practiceshad changed. There was a wide variation in theduration of use of sequential preparations. Seventy-sixper cent of respondents used a low starting dose i.e.1mg of oral oestradiol / 50mcg patch of oestradiol, 16%of doctors indicated their starting dose was high i.e.2mg of oral oestradiol / 100mcg patch of oestradioland 26% of doctors indicated tibolone as their initialprescription of HRT (some respondents indicated botha low dose preparation and tibolone). Ten per cent ofrespondents indicated that they would not change toa continuous combined preparation until the age of 54years. This was not dependant on whether prescribingpractice had changed.Fifty-seven per cent of respondents indicated thatthey would recommend other preparations in placeof HRT. The most common preparation mentionedwas edidronates (37%) (Figure 3). Others includedselective serotonin reuptake inhibitors (24%),soya/ phyto-oestrogens (21%), black cobosh (19%),red clover (14%), progestins (9%), clonidine (1%),cimetidine (1%) and calcium (1%) (some respondentsquoted more than one alternative preparation).DISCUSSIONIn the UK the ‘Million Women Study’ and in the USthe ‘Women’s Health Initiative’ (WHI) have causedconsiderable debate in the field of HRT prescribing. 1,2The Chairman of the Committee on Safety ofMedicines (CSM) in the UK issued further adviceon the use of HRT on 3 rd December 2003, threemonths prior to issuing this questionnaire. 3 Therecommendation was that the minimum effectivedose should be used for the shortest duration. Thiswas reflected in the prescribing practices of thosewho had changed their practice within the lastyear. However many doctors, especially Specialist Registrars, who had not changed their practice wereusing small doses for short durations anyway prior tothe publication of these recommendations.The recommendations for the use of oestrogenreplacement for osteoporosis and hip fractureschallenged the recent randomised controlled trials.FIGURE 1 —CHANGE INPRESCRIBINGPRACTICE (%)FIGURE 2 —TYPES OF HRTPREPARATIONSMOST COMMONLYPRESCRIBEDFIGURE 3 —OTHERPREPARATIONSPRESCRIBED IN PLACEOF HRT58 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 59

ORIGINAL PAPERHRT: Have We Changed?O Conlon & K McKinneyORIGINAL PAPERLong-term data show a reduced risk of fracturesin women who used oestrogen for 10-20 years. 4Cauley et al also showed a reduction in vertebral,hip fractures and other non-vertebral fractures withHRT in healthy post menopausal women not at riskof osteoporosis. 5 There are no long-term studieson use of alternatives to HRT for osteoporosisprevention. Most studies on bisphosphonate use inthe treatment of osteoporosis are directed towardsolder women who already have osteoporosis orthose at high risk of developing it. 6 Long-term useof bisphosphonates may cause bones to be morebrittle due to suppression of bone formation, whichmay increase risk of fractures. 7 In this study it wasthe majority of doctors who had not changed theirprescribing practice who indicated osteoporosisas an indication for HRT use. The pre-mentionedstatement from the Committee on Safety ofMedicines issued a few months earlier may havechanged prescribing practice related to osteoporosis.Raloxifene was indicated as a treatment forosteoporosis prevention by 2% of doctors. Ettinger etal have shown that raloxifene only reduces vertebralfractures and not fractures of the hip. 8Overall one in three women in the UK are affectedby osteoporosis during their lifetime. 9 The majorityof women by the age of 80 years will have sustainedat least one fracture. 9 The cost is not only humancost and quality of life issues, but also financialcost. The National Health Service in the UK spendsapproximately £1.7 billion on peri-fracture care. 9Therefore, although HRT is now not recommendedfor osteoporosis prevention, it may still be consideredin selected patients.Breast cancer remains the most serious long-termrisk with HRT. Ninety-four per cent of respondentsindicated this. The Million Women Study askedwomen who had mammography to complete aquestionnaire on HRT. 1 It must be rememberedthat this was an observational study in healthywomen and did not provide direct evidence on thosewomen who have breast cancer and their use andrequirement of HRT.Dr John Stevenson in a press release from the BritishMenopause Society concluded that the MillionWomen Study had a very small number of deathsfrom breast cancer and the follow-up was too shortand that the statistical significance of the finding isborderline. 10 He also concluded that the increasedrisk of breast cancer remains much the same asthe risk of breast cancer from drinking alcohol andthat it is still less than the increased risk for breastcancer associated with being overweight. 10 Marsdenand Sacks showed that short-term exposure to HRTin symptomatic patients with a personal historyof breast cancer might not significantly increaserecurrence rates. 11Another gynaecological cancer mentioned in thisstudy was the risk of endometrial cancer. This wasindicated by 26% of doctors. The risk of endometrialcancer though, is reduced in those patients usingcontinuous combined preparations of HRT. Only10% of doctors indicated a long-term risk of ovariancancer. La Vecchia et al showed a statisticallysignificant risk of ovarian carcinoma in womenusing oestrogen only preparations and not thoseusing continuous combined preparations. 12 Thequestionnaire was limited on this topic as it was a‘tick’ box and the duration or type of HRT was notspecified to change risk.There are many alternatives to HRT, includingtibolone. This was indicated as a first line treatmentby 26% of respondents. There was no significantdifference in those whose prescribing practices hadchanged. The Million Women Study was the firststudy to provide risk data about tibolone and breastcancer. This suggests that the reported lack of effectof tibolone on mammographic density may not bean accurate indicator of its effect on the breast. 13Historically sequential preparations were usedfor longer durations and this is reflected in thevaried responses. The risk of use with sequentialpreparations is endometrial carcinoma, which haspreviously been discussed. Another aspect is qualityof life issue where women who change to continuouscombined preparations will not have a monthly bleed.The British Menopause Society Council Consensusstatement on HRT attempts to clarify the recentcontroversial findings of the WHI and Million WomenStudies. 14 It concludes that important points toconsider before prescribing HRT are:• long-term use needs to be assessed for eachindividual at regular intervals,• women with premature menopause shouldnormally be offered HRT until the age of 51 years,• the effects of HRT on cardiovascular disease andAlzheimer’s disease are still uncertain and HRTshould not be solely prescribed for preventionof these.The final question asked was the use of alternativesto HRT. Fifty-seven per cent of doctors indicatedthey would prescribe an alternate to HRT. The mostcommon alternative was the use of edidronates andthe next was selective serotonin reuptake inhibitors.Phyto-oestrogens were the most common ‘herbal’preparation advised, which gives some benefitto some women. One consultant commented, ‘ifit helps, use it.’ Other comments included adviceon exercise and to stop smoking. Finally a SeniorHouse Officer concluded that ‘the menopause is aself limiting, non-lethal condition mostly requiringtender loving care (TLC)’. Many doctors and patientswould regard this as trivialising a condition causingserious morbidity and quality of life problems formany women. The questionnaire was designed to bebrief and easy to complete. It gives us some insightinto the prescribing practices and wide variations onHRT in Northern Ireland.There are several areas within the study which couldbe explored in more detail in future research projects.REFERENCES1. Million Women Study Collaborators. Breast cancer andhormone- replacement therapy in the Million WomenStudy. Lancet 2003; 362: 419-427.2. Writing Group for the Women’s Health InitiativeInvestigators. Risks and benefits of oestrogen plusprogestin in healthy postmenopausal women: principalresults from the Women’s Health Initiative randomisedcontrolled trial. JAMA 2002: 288: 321-33.3. Further confusion in postmenopausal health:Committee on Safety of Medicines Message 3 rdDecember 2003.4. Cauley JA, Zmuda JM, Ensrud KE, Bauer DC, Ettinger B.Timing of oestrogen replacement therapy for optimalosteoporosis prevention. J Clin Endocrinol Metab 2001;86: 5700-5.5. Cauley JA, Robbins J, Chen Z, et al Women’s HealthInitiative Investigators. Effects of oestrogen plusprogestin on risk of fracture and bone mineral density:the Woman’s Health Initiative randomised trial. JAMA2003; 290:1729-38.6. Marcus R, Wong M, Heath H, Stock JL. Antiresorptivetreatment of postmenopausal osteoporosis:comparisons of study designs and outcomes in largeclinical trials with fracture as an endpoint. Endocr Rev2002; 23: 16-37.7. Chavassieux PM, Arlot ME, Reda C et alHistomorphometric assessment of the long-termeffects of alendronate on bone quality and remodellingin patients with osteoporosis. J Clin Invest 1997; 100:1475-80.8. Ettinger B, Black DM, Mitlak BH, et al Reduction invertebral fracture risk in postmenopausal women withosteoporosis treated with raloxifene: results from a3-year randomised clinical trial. Multiple Outcomes ofRaloxifene Evaluation (MORE) Investigators. JAMA 1999;282: 637-45.9. Royal College of Physicians. Osteoporosis: clinicalguidelines for prevention and treatment. Update onpharmacological interventions and an algorithm formanagement. London, Royal College of Physicians 2000.10. Stevenson J. Hormone Replacement Therapy andBreast Cancer: a Response to the Million Women Studyfrom Women’s Health Concern. Press Release from theBritish Menopause Society; August 2003.11. Marsden J, Sacks N. The national randomised trial ofhormone replacement therapy in women with a historyof early stage breast cancer: an update. J B MenopauseSoc 2002; 8: 129.12. La Vecchia C, Brinton LA, McTiernan A. Cancer riskin menopausal women. Best Pract Res Clin ObstetGynaecol 2002; 16: 293-307.13. Lundstrom E, Christow A, Kersemaekers W et al Effectsof tibolone and continuous combined hormonereplacement therapy on mammographic breast density.Am J Obstet Gynaecol 2002; 186: 717-722.14. Managing the Menopause. British MenopauseSociety Council Consensus Statement on HormoneReplacement Therapy. January 2004.Correspondence to: Dr Orla Conlon, 6 Portadown Road,Armagh, BT61 9EETel: 04837523890, Mobile: 00447767271208Email: orla.conlon@btinternet.com60 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 61

ORIGINAL PAPERA review of neonatal attendances out of hours in a Dublin maternity hospitalLFA Wong et alORIGINAL PAPERA review of neonatal attendances out ofhours in a Dublin maternity hospitalABSTRACTBackground All neonates have free open access to the Baby Clinic at the maternityhospitals in Dublin for assessment of neonatal health issues. Through observation,however there is an increase in number of neonates attending the hospital outsidethe Baby Clinic hours.Aims To determine the number of neonates attending the acute neonatal service out ofhours and to identify the percentage of neonates treated as true emergency.Methods Retrospective chart review over a twelve-month period.Results Seven hundred and thirty-two neonates attended the hospital out of hours. Themajority were diagnosed with gastrointestinal problems (228 / 31%), jaundice (101/ 13.7%), respiratory problems (82 / 11.1%) and skin disorders (79 / 10.7%). Only 106(14.4%) attendances warranted admissions.Conclusions A large number of neonatal attendances did not require acute assessmentout of hours and were managed by reassurance and maternal education. Acentralized phone-in-triage system was suggested to relieve the strain on the acuteneonatal service.INTRODUCTIONThe maternity hospitals in Dublin have a longtradition in caring for the mothers and neonates. Allneonates have free open access to the Baby Clinicon weekdays at the maternity hospitals in Dublinfor routine assessment of all neonatal health issues.Recent observation, however suggested an increasein number of neonates attending the hospitaloutside the scheduled 9 am to 1 pm Baby Clinichours. This has added considerable workload to theacute neonatal service and the hospital staff on duty.Despite this service being run for many years, it isnot formally funded by the Health Service Executive(HSE). This paper examines the number and natureof neonates attending the maternity hospital outsidethe Baby Clinic hours and to identify potentialsolutions for improvement and rationalization of theservices provided.METHODSThis study was conducted at The National MaternityHospital, Holles Street in Dublin. Neonates attendingoutside the clinic hours of 9 am to 1 pm were seenas un-booked emergency cases. This acute neonatalservice was staffed by a senior house officer (SHO), aregistrar and a consultant in neonatology (off-site).A peadiatric nurse will assist up to 8 pm. Thereaftera midwife with peadiatric experience will come onduty until 8 am the following day.There were 8,466 live births recorded by the hospitalin 2003. The total number of neonates who attendedthe emergency department during this period outof hours were obtained from the acute neonatalregister book.The nature of the presenting complaints andsubsequent diagnoses were ascertained byreviewing all case notes retrospectively fromJanuary to December 2003. Neonatal attendanceswere categorized according to the presentingcomplaints. These data were collected onto aspreadsheet and analyzed using SPSS package 11.1for Microsoft Windows.RESULTSThere were 736 acute neonatal attendances overthe twelve-month period. Four attendances wereexcluded from the study because of incomplete data.Out of the 732 attendances, 106 neonates (14.4%)required further investigation and treatment. Eightyoneneonates were admitted to the neonatologyunit at the maternity hospital and the other 25 weretransferred directly to a tertiary paediatric hospital.LFA Wong 1 ,KT Lim 2 ,A Twomey 1 ,J Murphy 1Dept ofNeonatology,National MaternityHospital, Dublin, 1Dept of Surgery,Scunthorpe GeneralHospital, UnitedKingdom 2Table 1THE NUMBER OF ATTENDANCES THAT WERE ADMITTED ACCORDING TO THE MAIN PRESENTING COMPLAINTS ORDIAGNOSES (n=732)PRESENTING COMPLAINTS OR DIAGNOSESGastrointestinalVomiting/refluxdiarrheaconstipation/colicpoor feedingoral candidiasisOf the 732 attendances, 681 (93.0%) were term babiesand 51 (6.97%) were preterm babies. Three hundredand nineteen (43.3%) neonates were female while 417(56.7%) were males. The median age of the neonateson presentation was 13.0 days (range 1-167 days).Only 132 neonates (17.9%) were either referred bytheir general practitioner or public health nurse tothe emergency department and 18 (13.6%) of thesewere admitted. Six hundred (81.5 %) attendancespresented directly to the emergency departmentand 88 (14.7%) of these were admitted. A minority ofthese had telephoned the SHO prior to presentation.The main presenting complaints or diagnoses areoutlined in Table 1 along with those admitted.NUMBER OFATTENDANCES (%)DISCUSSION228 (31)88 (12.0)17 (2.32)70 (9.56)40 (5.46)13 (1.78)NUMBER OFADMISSIONS (%)26 (24.6)Jaundice 101 (13.7) 15 (14.2)Respiratorysnufflestransient tachypnoea/ periodic breathingcough/sneezeapnoeacyanosisSkinerythma toxicumbacterial skin infectionothers82 (11.1)36(4.12)10 (1.37)22 (3.01)7 (0.96)7 (0.96)79 (10.7)43 (5.87)18 (2.46)18(2.46)10 (9.4)8 (7.5)Umbilical cord concerns 38 (5.2) 1 (0.9)Neurologicalirritability/lethargicseizures/twitches/jittery35 (4.8)13 (1.78)22 (3.01)12 (11.3)Eye Discharge/ Sticky Eye 34 (4.6) 3 (2.8)Weight Loss 12 (1.6) 7 (6.6)Pyrexia 24 (3.3) 16 (15.1)Musculoskeletal Injury 8 (1.1) 0 (0)Cardiac 2 (0.3) 1 (0.9)Others 89 (12.1) 7 (6.7)TOTAL 732 (100) 106 (100)This paper identified about 8.7% of the live neonatesdelivered at The National Maternity Hospital,Holles Street in Dublin would attend the acuteneonatal service out of hours. Only 14.4% of these732 neonates were admitted and treated as trueemergency that required further investigation andtreatment. The majority of these neonates presentedto the acute neonatal service out of hours did notrequire urgent intervention and could be assessedand reviewed the following morning at the BabyClinic. About a quarter of the neonates who requiredadmission had to be transferred to a specialistpaediatric hospital. The admission rate of neonatesout of hours referred by the general practitioners orpublic health nurses was not much different to the62 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 63

ORIGINAL PAPERA review of neonatal attendances out of hours in a Dublin maternity hospitalLFA Wong et alORIGINAL PAPERwalk-in/phone-in attendances. More importantly,this paper showed the majority of these neonatalattendances out of hours were dealt with by givingadvice, education and reassurance. It is sensible toencourage parents to bring their neonates to thescheduled Baby Clinic. A telephone triage system issuggested to identify the category of neonates whodo not require urgent assessment and treatment andto book them for the scheduled Baby Clinic.In our institution, neonates are discharged routinelyat day 2 in uncomplicated vaginal deliveries and at day5 after caesarean sections. Our results are in line withother institutions, that early discharge post partumat day 2 does not increase readmission rates. 1,2,3Readmission was less likely in neonates who hadhome visits or telephone contacts by the public healthnurse within the first three days after discharge. 4 Thereadmission rate were more frequent in neonateswith feeding difficulties, jaundice and pyrexia atpresentation. This is in contrast with the low 2.8%readmission rate in the study conducted by Oddie. 2The causes of concern for readmission in their studywere somewhat similar which includes suspectedinfection, colic, convulsions, vomiting and jaundice.The majority of breastfeeding mothers were worriedabout neonatal loose stools, which in fact werenormal breastfed consistency stools. All breast fedneonates should either be visited by the publichealth nurse or booked into the health centre forregular weight checks and breast feeding techniquechecks upon discharge from the maternity hospital.This will help to alleviate fear and anxiety and toprovide some continuity of care to the mother andneonates. Support for breastfeeding mothers in thecommunity is an important area for improvement ofmaternal and neonatal health.Most parents would have thought neonatal noisybreathing, snuffles and periodic breathing equates tochest infection and jitteriness being seizures. Thesesymptoms are considered normal in neonates andcan be reassured. Most rashes are due to erythematoxicum and not from meningitis and can bereassured unless there is a doubt.Our institution now adopts a pre-dischargeeducation on common neonatal symptoms andsigns, feeding techniques, umbilical cord care, rash,eye care, snuffles, umbilical cord care, constipationand colic in an effort to reduce these presentingcomplaints out of hours. This information can bereinforced by the public health or community nursesand at the six-week postnatal check. In an articleby Nelson et al on six-week postnatal check, 26%planned to attend hospital clinics and 55% plannedto attend the GP. The remainder planned to attenda consultant privately or had been referred to aspecialized paediatric clinic. Factors influential forthose choosing GPs were convenience, familiarityand opportunity for discussion. Hospital instructionsand the expected quality of examination wereimportant for those choosing the hospital. 5Upon discharge from the maternity hospital, thenext point of contact for mothers should be theirgeneral practitioners or local public health nurse forany concern on their neonates. General practitionersshould receive adequate training and exposure inneonatal care through their continuing medicaleducation in lectures and workshops. It is importantto note that newborn training in a paediatricresidency program is insufficient for primary care. 6With the nationwide practice of early discharge,this study clearly identifies the need for supportiveorganized community care provided by the generalpractitioners, public health nurses and communitymidwives. Resources should be allocated andtailored to provide adequate training to healthcareprofessionals in the community. Issues of neonatalcare should be addressed by the respective healthboards under the HSE by means of education ata community level by means of leaflets or webeducation. Usage of credible web information canaugment parental education on healthcare issues. 7During out of hours, the feasibility of a telephonetriage system could reduce the need of presentationout of hours. These findings would support a triagesystem and telephone advice line, handled by trainedpaediatric nurses or doctors on call. Large scale afterhourstelephone coverage systems is shown to beeffective and achieved satisfaction of 96% to 99%among parents. 8 A 24-hour telephone service similarto the NHS Direct 9 in the United Kingdom could bemodelled here. Its concept would reduce parentsfrom turning up out of hours for advice. Advice givenis based upon the skills and experience of nursesassisted with a comprehensive computer system.Many studies on telephone advice were basedin paediatric emergency department settings, asituation which could be easily be adapted in ourinstitution.Majority of attendances to our emergencydepartment were not acute, did not requireadmissions and could have been dealt with throughappropriate structured telephone call advice. Acentralized neonatal health line advice system couldbe implemented offering advice to new parentson neonatal issues. This could be implementedcentrally in the three Dublin maternity hospitals ornationwide and could potentially reduce out of hourshealthcare costs, workload and staffing levels.Appropriate support mechanisms are likely to playa key role in ensuring the safety of early dischargeand emphasis should be placed on the application ofscientific research methods for the development andrefinement of guidelines around neonatal care. 10In conclusion, a significant number of neonatesattend out of hours for various reasons. Majorityof neonates who presented did not requireadmission but managed with advice, education andreassurance. Current resources are not designed todeal with these attendances, with the need of morestaff on duty and a properly equipped assessmentarea. An alternative neonatal care delivery througha centralized phone-in triage system could benefitboth parents and staff.REFERENCES1. Escobar GJ, Greene JD, Hulac P, et al. Rehospitalisationafter birth: patterns among infants of all gestations.Arch Dis Child 2005; 90(2):125-31.2. Oddie SJ, Hammal D, Richmond S, Parker L. Early dischargeand readmission to hospital in the first month of life inthe Northern Region of the UK during 1998: a case cohortstudy. Arch Dis Child 2005; 90(2):119-24.3. Scott-Jupp R. Readmission of neonates. Arch Dis Child2005; 90(2):111-2.4. Nelson E, Brannagain DO, McCabe B, Moran D. Thesix week postnatal check: women’s choice of serviceprovider. Ir Med J 2002; 95(10): 302-4.5. Cappleman J. Community neonatal nursing work. J AdvNurs 2004; 48(2):167-74.6. Walton DM, Edwards MC. Nationwide survey ofpaediatric residency training in newborn medicine:preparation for primary care practice. Paediatrics 2002;110(6):1081-7.7. Peters R, Sikorski R. Paediatrics on the PC. JAMA 1998;279(19):1583-4.8. Poole SR, Schmitt BD, Carruth T, Peterson-Smith A,Slusarski M. After hours telephone coverage: theapplication of an area-wide telephone triage andadvice system for paediatric practices. Paediatrics 1993;92(5):670-9.9. http://www.nhsdirect.nhs.uk10. Danielsen B, Castles AG, Damberg CL, Gould JB.Newborn discharge timing and readmissions:California, 1992-1995. Paediatrics 2000; 106(1 Pt 1):31-9.Correspondence to: Dr LFA WongE-mail: wlfaud@yahoo.co.uk64 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 65

CASE REPORTManagement of spontaneous rupture of the oesophagus (Boerhaave’s syndrome):single centre experience of 18 casesR Prichard et alCASE REPORTManagement of spontaneous rupture of theoesophagus (Boerhaave’s syndrome): Singlecentre experience of 18 casesABSTRACTBackground Spontaneous oesophageal rupture (Boerhaave’s syndrome) is rare, andcarries a high attendant risk of mortality.Methods A retrospective eight-year review from a tertiary unit.Results Eighteen patients were managed, with a mean age of 57 (39 - 88 years). Eightpatients presented early and underwent surgery, seven with primary closure andone with exclusion and diversion. There was one death in this group. Ten patientswere managed conservatively. In this group, two underwent an oesophagectomybecause of failed conservative measures, and four had an endoprosthesis inserted.One patient died in this group on the first admission, but two patients with stentsin situ died from massive bleeding relating to an aorto-oesophageal fistula at 39days and 189 days respectively following presentation.Conclusions Surgical intervention remains the gold standard when the diagnosis is madeearly. For late diagnoses, this series suggests caution in the use of endoprostheses.INTRODUCTIONBoerhaave’s syndrome, also known as spontaneousperforation of the oesophagus, is a rare condition.Hermann Boerhaave, Professor of Medicine at LeidenUniversity, initially described the syndrome in 1724following treatment of the Grand Admiral of theDutch fleet, Baron Jan van Wassenaer. 1 The Baronhad feasted on duck and beer, began vomiting andthen developed severe pain, complaining to hisservants that something near the upper part of hisstomach had torn. Death occurred 18 hours later, andat autopsy Boerhaave observed emphysema of thechest wall and abdomen, and a rupture of the leftposterolateral wall of the oesophagus 3 inches abovethe diaphragm, without evidence of oesophagealpathology. In 1946 Norman Barrett reported the firstearly diagnosis and successful repair. 2 The mortalityrate was approximately 50% up to the 1980s, butmore recently the mortality rate is approximately30% because of earlier diagnosis, surgical repair andimprovements in intensive care. 3 - 7The typical pattern, so-called Mackler’s Triad, ofspontaneous oesophageal perforation is violentretching or vomiting following food and very oftenalcohol, which is then followed by severe chest painand surgical emphysema. 8 A sudden rise in theintraoesophageal pressure leads to a transmuralperforation of the oesophagus. Anatomically theoesophagus has no serosal layer, which allowsgastric contents direct access into the mediastinumand pleural cavity, resulting in early mediastinitis,sepsis and frequently multi-organ failure. A delayin diagnosis is common. Because of its rarity, theclassical picture may be missed, and in at least40% of cases the picture is not classical, and it mayhave been mistaken for a myocardial infarction,pancreatitis, perforated ulcer, pericarditis, mesentericthrombosis, dissecting aneurysm and other causes ofsevere upper abdominal or chest pain.There is general consensus on management principleswhere the diagnosis is established early, and surgerywithin 24 hours of presentation has a better chanceof successful oesophageal repair and patientsurvival than surgery beyond this time point. 3-7 Themanagement of patients presenting late due to amissed diagnosis is controversial, with advocates forsurgical repair, repair over a T-tube, oesophagectomy,or a conservative approach. 9-11 The first successfuloutcome from a conservative approach was publishedin 1975 12 , and the advent of covered endoprostheticdevices has improved the therapeutic options. 13Case series in the literature are few, and mainlyemanate from tertiary oesophageal units. The twoR Prichard,J Butt,N Al-Sariff,S Frohlich,S Murphy,B Manning,N Ravi,JV ReynoldsDept of ClinicalSurgery, St James’sHospital and TrinityCollege Dublinmost recent, an 18-case series from Siewert et alfrom Munich in 1997, and a 14-case series, publishedin 2000, from Griffin and colleagues in Newcastle,underline this point. 6,7 We present herein theexperience of this Unit in the management of 18cases, and highlight the lessons learned.METHODSA retrospective review of all patients with a diagnosisof spontaneous oesophageal perforations whopresented or who were referred to St James’sHospital from 1997 to 2004 was undertaken. Patientswere identified through the hospital HIPE system.Cases were excluded if the oesophageal perforationwas as a result of instrumentation, trauma or anunderlying malignancy.RESULTSThe details of all 18 patients who fulfilled thecriteria are detailed in Table 1. Five further caseswere referred in this time period with suspectedBoerhaave’s syndrome, all young males withsubcutaneous emphysema, chest discomfort, and nohistory of vomiting, and a diagnosis of mediastinalrupture of bullae was confidently made after anegative contrast swallow.Eight cases presented with classical symptomatologyand were diagnosed and arrived in this centre within24 hours of their first symptom. In three cases, thesite of perforation was not in the classical lowerleft position, but in the middle right side of theoesophagus. The operation in eight cases involveda thoracotomy, debridement and drainage of themediastinum and pleural spaces, visualisation andrepair (with interrupted 3.0 Polydioxanone, Ethicon)of the entire mucosal defect, and a pleural (n=5) ordiaphragmatic (n=2) flap. All patients had a wide-borednaso-gastric tube securely positioned, received broadspectrumantibiotics, and were fed postoperativelyby total parenteral nutrition. In one case (no.9) whowas profoundly ill on arrival, the perforation was atthe oesophagogastric junction within a large hiatushernia, with contamination of both the abdominaland thoracic cavity, and partial gastrectomy with bluntoesophagectomy, feeding jejunostomy and cervicaloesophagostomy was required. She survived againstconsiderable odds, and has always declined anyconsideration of reconstruction. One patient died, a 60-year-old man who had presented profoundly shockedand with acute tubular necrosis and haemodynamicfailure, succumbing to ARDS and overwhelmingmultiple organ failure on the 19 th postoperative day.Two of 10 cases assigned for conservativemanagement underwent oesophagectomy afterconservative measures were considered to havefailed. In one case, considered too unstable atinitial presentation for thoracotomy, a large leakpersisted after one month despite a stent. Thepatient survived a 3-stage oesophagectomy. Oneother patient, a female aged 58, underwent a 2-stageoesophagectomy for persistent sepsis, an oesophagobronchialfistula, and failure of the stent.An endoprosthesis was considered in all cases andused with apparent initial success in controllingthe leak and ongoing sepsis in four cases. Strikingly,however, two patients have survived the earlyeffect of the insult to die later from massive uppergastrointestinal haemorrhage from an aortooesophagealfistula. One elderly patient also died ofsepsis, and thus three of ten patients conservativelymanaged succumbed to either sepsis or haemorrhage.DISCUSSIONThe term spontaneous perforation of the oesophagus,although commonly used, is an inappropriate term,as the rupture is rarely spontaneous and almostinvariably follows barotrauma from a sudden postemeticrise in oesophageal pressure. Although theoriginal report of Boerhaave describes a transversetear in the lower left oesophagus, most tears arelongtitudinal, varying in length from 0.5 to 20cm, located on the left posterolateral wall of theoesophagus, 2 to 6 cm above the diaphragm in 80%of cases. 1 The predilection for this site is unclear, butit may results from splaying of muscle fibres andthe entrance of blood vessels and nerves at thissite. In this series, seven patients had spontaneousperforation into the right thorax. In a small series, thisis probably a chance finding, but it does emphasisethe important point that perforations are not alwaysin the classical lower left site, and that a contrastswallow is mandatory in the investigation of allsuspected cases to determine the site of perforationand guide the operative approach.The commonest age of presentation is between40 and 60 years of age, with a slight malepredominance with male to female ratio of 2:1. In ourseries of patients the mean age of presentation was57 years with a 2.2: 1 male to female predominance.Clinically, Boerhaave’s syndrome presents in 60%of cases with a triad of symptoms, which is knownas Mackler’s Triad. This encompasses a history ofvomiting followed by the sudden onset of severe66 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 67

CASE REPORTManagement of spontaneous rupture of the oesophagus (Boerhaave’s syndrome):single centre experience of 18 casesR Prichard et alCASE REPORTTable 1PATIENTAGESEXLENGTH OFSTAY IN DAYS1 39 M 172 60 M 193 52 M 91PRESENTATIONHaematemesis, leftsided Chest PainVomiting, left sidedchest pain, shockVomiting, leftsided chest pain,peritonitis, shockCONTRASTSWALLOWOGDDIAGNOSISDELAYSUSPECTEDDIAGNOSISLower third, left Yes

CASE REPORTManagement of spontaneous rupture of the oesophagus (Boerhaave’s syndrome):single centre experience of 18 casesEndovascular aneurysm repair in a patient with a horseshoe kidney and impaired renal functionCASE REPORTcompared with modern benchmarks, one death in apatient already manifesting multiple organ failure.A conservative approach is justified in those delayedin presentation who are perhaps self-selected tosurvive. The experience of the unit to date cautionsagainst the liberal use of endoprostheses in thiscohort, and, if used, they should be removed ifpossible within three to four months. Consistentwith other series, oesophagectomy can be consideredin selected cases.REFERENCES1. Boerhaave H. Atrocis, Nec Descripti Pruis, MorbidHistoria: Secundum Medicae Artis Leges Conscripta.Lugduni Batavorum: Boutesteniana, 1724.2. Barrett NR. Spontaneous perforation of the oesophagus;review of the literature and report of 3 new cases.Thorax 1946; 1: 48-56.3. Lawrence DR, Ohri SK, Moxon RE et al. Primaryoesophageal repair for Boerhaave’s syndrome. AnnThorac Surg 1999; 67: 818 – 204. Bufkin BL, Miller JI, Mansour KA. Esophageal perforation:Emphasis on management. Ann Thorac Surg 1996; 61:1447 – 525. Pate JW, Walker WA, Cole FH Jr et al. SpontaneousRupture of the oesophagus: a 30 year experience. AnnThoracic Surg 1989; 47: 689 – 6926. Brauer RB, Liebermann-Meffert D, Stein HJ, BartelsH, Siewert JR. Boerhaave’s Syndrome: analysis of theliterature and report of 18 new cases. Dis Esophagus1997; 10: 64 – 87. Shenfine J, Dresner SM, Vishwanath Y, Hayes N, GriffinSM. Management of spontaneous rupture of theoesophagus. Br J Surg 2000; 87: 362-73.8. Mackler SA. Spontaneous rupture of the esophagus:An experimental and clinical study. Surg Gynaec Obstet1952; 92: 345-50.9. Jougon J, McBride T, Delcambre F et al. Primaryoesophageal repair for Boerhaave’s syndrome whateverthe free interval between perforation and treatment.Eur J Cardithorac Surg 2004; 25: 475 – 47910. Altorjay A, Kiss J, Voros A. The role of esophagectomyin the management of oesophageal perforations. AnnThorac Surg 1998; 65: 1433 – 611. Ojaima H, Kuwano H, Sasaki S, Fujisawa T, IshibashiY. Successful late management of spontaneousesophageal rupture using T-tube mediastinoabdominaldrainage. Am J Surg 2001; 182: 192-612. Larrieu AJ, Kieffler R. Boerhaave’s syndrome: report of acase treated non-operatively. Ann Surg 1976; 183: 401-40813. Tsunoda S, Shimada Y, WatanabeG, Nakau M,Imamura M. Covered metallic stent of a patient withspontaneous rupture of the esophagus. Dis Esophagus2001; 14: 254-7.14. Lawrence DR, Ohri SK, Moxon RE et al. Primaryoesophageal repair for Boerhaave’s syndrome. AnnThorac Surg 1999; 67: 818 – 2015. Harries K, Masoud A, Brown TH, Richards DG.Endoscopic placement of fibrin sealant as a treatmentfor long-standing Boerhaave’s fistula. Dis Esophagus2004; 17: 348-5016. Davies AP, Vaughan R. Expanding mesh stent in theemergency treatment of Boerhaave’s syndrome. AnnThorac Surg 1999; 67: 1482-3Correspondence to: Professor John V Reynolds, Dept ofSurgery, Trinity Centre, St James’s Hospital, Dublin 8Tel: 01 4162500; Fax: 01-4546534;e-mail:makenny@stjames.ieEndovascular aneurysm repair in a patientwith a horseshoe kidney and impaired renalfunctionABSTRACTBackground We present the case of an 80-year-old female with a three-week history oflower backache and a pulsatile mass in her epigastrium.Method Using CT angiogram, the presence of an infra-renal abdominal aortic aneurysm(AAA) and co-existent horseshoe kidney was confirmed.Results Due to associated multiple co-morbidities of hypertension, moderate renal failure,COPD and morbid obesity, she underwent endovascular aneurysm repair (EVAR).Conclusion The presence of a horseshoe kidney (HSK) poses significant difficulty duringopen repair of an AAA, as satisfactory anatomical exposure of the aorta mayprove potentially hazardous. This problem may be circumvented in suitable casesby endovascular repair, although treatment is not risk free. EVAR is usually onlyrecommended if renal function is normal. We report a case of AAA coexistent withan HSK and moderate renal impairment, which was treated successfully using anEVAR technique, and with no subsequent renal complication.CASE REPORTAn 80-year-old female was referred to our unit witha 6.3 cm AAA and coexistent HSK. She presented toa district general hospital with six months of lowerbackache, worsening over the recent few weeks.Co-morbidities included morbid obesity, NIDDM,hyperlipidemia and moderate renal impairment(Urea: 14mmol/l; Creatinine: 175µmol/l) secondary tohypertensive nephropathy (BP: 140/90 mmHg) andmild left renal artery stenosis.A computed tomography (CT) angiogram revealedcomplex renal artery anatomy; juxtaposition of theorigins of the main renal arteries; mild left renalartery stenosis and at least two accessory renalarteries (2mm diameter each) supplying the bridgeof the HSK. The inferior mesenteric artery originatedfrom the aorta immediately superior to the renalbridge. Beyond the aneurysmal aorta, the distalaortic segment was stenotic (11 mm), as were boththe external iliac arteries (6 mm). CT scan did notindicate any obvious AAA rupture. However, due topressure symptoms arising from the aneurysm sacshe was prepared for aneurysm repair.Pulmonary function testing and stressechocardiography revealed severe respiratory andcardiac compromise. She was considered high risk foropen AAA repair and was therefore offered an EVAR.ProcedurePreliminary, the patient underwent balloonangioplasty of her distal aorta from 11mm to18mm. Similarly, both external iliac arteries wereangioplastied from 6mm to 9mm. However, thedistal aortic segment was still not wide enough toaccommodate a bifurcated endograft; therefore anaorto-uni-iliac device was deployed instead.Simultaneous on-table aortography confirmed thatthe major source of renal perfusion was from theanatomical renal arteries and that there would below chance of compromise after an EVAR.Following this primary procedure, the advice ofa reno-vascular physician was sought in order toprovide the best renal protective strategy. Sodiumbicarbonate was therefore administered beforeand after the EVAR. She was also given a salineinfusion from midnight (6 hourly per litre) forplentiful renal hydration. The renovascular teamdid not recommend left renal artery angioplasty asstenosis was mild, though the concluding decisionwas deferred until postoperative renal functionassessment. (Indeed, postoperatively the patient’srenal profile remained unchanged and her bloodpressure was controlled, so renal artery angioplastywas not necessary).MS Sajid,N Ahmed,J Tibbals*,G HamiltonDept of VascularSurgery &Radiology*, RoyalFree Hospital,London, UK70 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 71

CASE REPORTMS Sajid Et alEndovascular aneurysm repair in a patient with a horseshoe kidney and impaired renal functionCASE REPORTTen days after the initial procedure the EVAR waspossible. Under combined spinal and epiduralanaesthesia both femoral arteries were exposed,controlled and cannulated in the standard manner.Under image intensification, a single-limbed, 20mmaorto-uni-iliac stent graft was deployed (Zenithsuprarenal fixation device) with preservation ofthe anatomical renal arteries. The procedure wascompleted with endovascular deployment of acontralateral, 10mm common iliac artery occluder(Zenith) and femoro-femoral bypass, using asynthetic graft (Supported Vascutek).Her postoperative recovery was quick, uneventfuland unremarkable, apart from left groin wounddehiscence and subsequent superficial woundinfection. Her renal function (Urea: 11-15mmol/l;Creatinine 150-180 µmol/l) and blood pressure (140-150mmHg systolic; 85-95mmHg diastolic) remainedunchanged. Eight weeks after the procedure, therewas no evidence of endoleak or renal infarction on CTangiogram and duplex scan. Her renal function wasequal to her pre-operative base line.cabacbFIGURE 2 —DSA DEPICTINGa & b: ANATOMICALRENAL ARTERIESc: ABDOMINALAORTIC ANEURYSMd: LOWER AORTICSTENOSISFIGURE 2 —DSA DEPICTINGa & b: ANATOMICALRENAL ARTERIESc: ABDOMINALAORTIC ANEURYSMd: LOWER AORTICSTENOSIShorseshoe kidney is primarily via anatomicalarteries, endovascular repair may be the preferredmethod provided the aneurysm is morphologicallysuitable and renal function is normal 5 . However,in our patient, renal function was pre-operativelymoderately deranged and post-operatively it did notdeteriorate. Based on our experience of this case, ithas been shown that EVAR can be offered to suchpatients with mild to moderate renal impairmentand is probably the best modality for treatment of anAAA with a coexistent horseshoe kidney.REFERENCES1. Greenberg PK, Chuter TA, Lawrence-brown M, Haulon S,Nolte L. Analysis of renal function after aneurysm repairwith Zennith AAA Endovascular graft in contrast toopen repair. J Vasc Surg. 2004 Jun; 6:1219-282. Noguchi M, Hirashima S, Eishi K et al. Surgical treatmentof AAA associated with horseshoe kidney andcoagulopathy J Cardiovasc Surg. (Torino).2004 Oct;5: 505-9.3. Davidovic LB, Kostic DM, Jakovljevic NS et al. Abdominalaortic surgery and horseshoe kidney. Ann Vasc Surg.2004 Nov; 6: 725-84. Jackson RW, Fay DM, Wyatt MG, Rose JD. The renalimpact of aortic stent-grafting in patients withhorseshoe kidney. Cardiovasc Intervent Radiol. 2004Nov-Dec; 6: 632-65. Ruppert V, Umscheid T, Reiger J et al. Endovascularaneurysm repair: Treatment of choice for AAAcoincident with horseshoe kidney? J Vasc Surg. 2004Aug; 2: 367-70.Correspondence to: Mr MS Sajid, Senior Clinical FellowVascular Surgery, Dept of Vascular Surgery,Royal Free Hospital, Hampstead, London NW3 2QG;Email: surgeon1wrh@hotmail.com);Tel. 0044 789 166 7608DISCUSSIONThere are very few cases in the literature describingrepair of an AAA coexistent with a horseshoekidney and impaired renal function. Detailed preoperativeassessment of renal anatomy and itsvasculature by various imaging modalities is crucial.Anomalous renal arteries are found in 67 % ofpatients of abdominal aortic aneurysm coexistentwith horseshoe kidney preoperatively. In most casesanatomical renal arteries predominantly supplyrenal tissue. Accessory renal arteries are alwayspresent but are minor and can be sacrificed withoutdeveloping significant renal infarction or renalimpairment . After careful preoperative assessmentand optimization, patients with mild to moderaterenal impairment can be offered endovascular repairof an AAA coexistent with a horseshoe kidney. Aorticstent-grafting is a good alternative to open surgeryfor such patients but it is not without difficulties.In all patients the aneurysm can successfully beexcluded with occlusion of between one and fouranomalous renal arteries without significantrenal impairment or renovascular hypertension 4 .EVAR provides several potential advantages. It is aminimally invasive procedure and reduces respiratoryand cardiovascular stress compared to opensurgery. It can be performed under spinal/epiduralanaesthesia which assists rapid recovery, decreasingrequirements for major anaesthesia.Renal dysfunction occurs in both groups of patientsregardless of type of repair (open or endovascularwith supra-renal fixation) 1 . Management of ourpatient and a successful outcome provides evidenceto support treatment of an AAA with coexistenthorseshoe kidney and renal impairment, using theendovascular method.Postoperative causes of renal impairment areprobably multifactorial. The observed dysfunctionoccurs in a small number of patients (12 % at 12months); the effect in the endovascular groupappears to be transient 5 . The initial dysfunction,apparent in both groups over 12 months of follow-up,stabilizes or improves at 12 to 24 months. This maybe due to the development of intra-renal collateralblood flow 5 .In the presence of multiple comorbidities as inour patient, outcome after open repair is usuallymuch compromised. If the blood supply to thed72 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 73

CASE REPORTEncrusted Cystitis — An Unusual Cause of Recurrent Frank HaematuriaO O’Sullivan et AlCASE REPORTEncrusted cystitis — An unusual cause ofrecurrent frank haematuriaABSTRACTBackground Encrusted cystitis associated with malakoplakia is described in the literatureas a rare condition characterized by the formation of calcified plaques adherent toor embedded in the bladder mucosa.Aims We present the case of a 51-year-old male, presenting with recurrent haematuriaassociated with minimal exercise. Despite normal ultrasound, IVP, two calcifiedlesions on his bladder were found on cystoscopy. Conservative management wasineffective thereby necessitating a curative partial cystectomy.O O’Sullivan,O Clyne,J DrummDept of Urology,Mid-WesternRegional Hospital,Limerick1(a)1(b)Figure 1a —ANTERIOR BLADDERWALLFigure 1b —POSTERIOR BLADDERWALLConclusion We would like to illustrate/discuss this rare but problematic condition withgross and microscopic pictures.INTRODUCTIONFrank haematuria is a common symptom ofcarcinoma of the urinary tract; 85% of patientswith bladder cancer present with intermittenthaematuria. It is also associated with benignconditions such as urinary tract infections andcalculi. We report a rare cause of recurrent frankhaematuria.CASE REPORTA 51-year-old male presented with recurrenthaematuria associated with minimal exercise. Healso complained of urinary frequency, poor streamand penile pain. Investigations included ultrasound(normal), IVP (normal), MSU and cystoscopy. MSUrevealed leucocytes but no organisms were isolated.At cystoscopy two small areas of inflammation withoverlying calcification were demonstrated (Figure 1).Subsequent biopsy and histological examinationrevealed a chronic inflammatory infiltrate with areasof calcification, and no evidence of malakoplakia(Figure 2).However the haematuria persisted and repeatcystoscopy showed extensive ulceration of thebladder midline. Transurethral resection of thelesions was performed. Histology again confirmedthe presence of chronic inflammation andcalcification. In spite of complete resection hissymptoms recurred and the decision was taken tocarry out a partial cystectomy. Histology of the grossspecimen confirmed a diagnosis of encrusted cystitis.One year post- surgery he is asymptomatic and thereis no evidence of recurrence on cystoscopy.DISCUSSIONEncrusted cystitis is a rare inflammatory conditioncharacterised by the formation of calcified plaquesadherent to or embedded in the bladder mucosa. 1It is associated with infection by urea-splittingorganisms and thereby alkaline urine. 2 Ammoniumproduced from the breakdown of urea damages theglycosaminoglycan layer of the bladder mucosa. Thisfacilitates bacterial adherence, tissue inflammation,production of an organic matrix, and crystal matrixinteraction. Gram positive and negative bacteria alongwith mycoplasma and yeasts produce urease. Themost common organism associated with encrustedcystitis is corynebacterium urealyticum. However itcan also develop in the absence of these states.Other predisposing factors for encrusted cystitis arelong-term indwelling catheterisation and previousrenal transplantation.Symptoms include chronic urinary discomfort andmacroscopic haematuria.Treatment is with antibiotics, local diathermy and/ orsurgical resection of the encrusted lesions.2(a) 2(b) Figure 2a —MICROSCOPY OFBIOPSYREFERENCES1. Aguado JM, Morales JM, Salto E et al. Encrusted Pyelitisand Cystitis by Corynebacterium Urealyticum (CDCgroup D2): a New and Threatening ComplicationFollowing Renal Transplant. Transplantation1993;56:617-22.2. Huguet Perez J, Salvador Bayarri J, Vicente Rodriguez J.Encrusted Cystitis. Is it Always Alkaline? [Spanish]. ArchEsp Urol 1999;52:157-64.Correspondence to: Orfhlaith O’Sullivan, Annapurna,Lower Park, Corbally, LimerickTel: 087 9272894; E-mail:orfhlaith.osullivan@ucd.ieFigure 2b —MICROSCOPY OFGROSS SPECIMEN74 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 75

CASE REPORTComminuted Fracture of the Thoracic SpineJP Cashman et alCASE REPORTComminuted fracture of the thoracic spineABSTRACTBackground Road deaths fell initially after the introduction of the penalty points butdespite this, the rate of spinal injuries remained unchanged.Aims We report a patient with a dramatic spinal injury, though without neurologicaldeficit. We discuss the classification, management and economic impact of theseinjuries.Methods We describe the management of a patient with a comminuted thoracic spinalfracture without neurological injury. We conducted a literature review with regardto the availability of literature of the management of these injuries.Results This 17-year-old female was managed surgically and had a good functionaloutcome. There is no clear consensus in the published literature on themanagement of these injuries.Conclusions Comminuted thoracic spinal factures are potentially devastating. Such apatient presents challenges in determining the appropriate treatment.INTRODUCTIONComminuted fractures of the spine are anuncommon group of injuries that most frequentlyoccur following high-speed collisions. Thoracic spinalfractures occur whenever forces exceed the strengthand stability of the spine. They are a major cause ofmorbidity, particularly with regard to neurologicaldisability and carry huge social and economicimplications. While many options are available,scant evidence exists supporting operative over nonoperativetreatment.In this case report, we describe a patient who suffereda comminuted fracture of the sixth, seventh andeighth thoracic vertebral bodies without neurologicaldeficit following a road traffic accident with afavourable outcome.CASE REPORTA 17-year-old girl was brought by ambulance toEmergency Department following a road trafficaccident in which she was a restrained front seatpassenger. She was cut free from the car by theemergency services. She complained of mid-thoracicback pain and chest pain. She was tachycardic anddyspnoeic. Clinical assessment confirmed that shewas tender over her left chest and over her midthoracicspine. There was no distal neurologicaldeficit. Her Glasgow Coma Score was 14 out of 15.Chest x-ray confirmed three broken ribs, apulmonary contusion, a widened mediastinum anda mid thoracic fracture. CT of Thorax confirmedthese findings and also demonstrated a smallhaemothorax. CT of Thoracic spine showedcomminuted fractures of the bodies of the sixth,seventh and eighth thoracic vertebrae, withoutviolation of the spinal canal or impingement of thespinal cord. Aortography outruled associated thoracicaortic injury. CT brain showed an undisplacedoccipital fracture but no intra-cranial injury.Following resuscitation, she was nursed overnighton a Turning Frame. Thereafter, she was treatedsurgically. Under general anaesthetic, she waspositioned prone on a Wilson frame. Instrumentedreduction and internal fixation of the fracture wascarried out from the fourth thoracic vertebra tothe tenth, using AO pedicle screws and rod fixationthrough a posterior approach. She had an uneventfulpost-operative period, being maintained on bedrest until the third day. She was mobilised in aspinal orthosis under physiotherapy supervision.She was discharged on the tenth day mobilisingwith crutches. At four-month follow-up, she wasfunctioning normally and had no neurological deficit.DISCUSSIONThis case demonstrates a very dramatic injury withgood functional outcome. In managing such aninjury, it is important to consider the mechanism ofinjury and to classify the injury so as to determineappropriate management. We highlight difficultiesin selecting treatment for unstable thoracolumbarfractures and discuss pertinent economic issues.JP Cashman 1 ,FL Carty 2 ,M Ryan 2 ,K Mahalingham 1Dept of Trauma andOrthopaedics 1 , Deptof Radiology 2 , CorkUniversity Hospital,Wilton, CorkThe introduction of the penalty points system inIreland in 2001 saw an initial reduction in overalltrauma figures, although there was no change inthe rate of spinal injuries. 1 Spinal injury occurs inapproximately 11% of motorcyclists and 14% of caroccupants involved in motor vehicle accidents.The majority of victims are young, with mean agesof 30.2 years for motorcyclists and 37.8 years forcar occupants, and there is a male predominance(motorcycle 88.9%, car 60.6%). 2Formal classification allows for assessmentof fracture pattern stability and the need foroperative intervention. Denis proposed that forassessment of stability, the spine be consideredas three columns - anterior, middle and posterior. 3The Denis classification, while relatively simple, isincomplete and incomprehensive. The AO groupuse a comprehensive classification system whichincludes three types of fractures with 55 differentsubtypes. While more complete, it is cumbersome fordaily practice. Both systems have been found to havesignificant inter-observer variability in their use. 4 Thisraises difficulties in determining which system toapply, and importantly, which fractures to operate on.There is a paucity of evidence from high qualityrandomised trials on the relative effectiveness ofoperative and conservative treatment of unstabletraumatic thoracolumbar fractures. Retrospectivestudies have found favourable radiological outcomesfollowing operative intervention with betterresorption of retropulsed fractures in that group. 5However, it has been found that surgical interventioncarries a higher risk of wound infection (8% vs 0%),while nonoperative treatment results in longerhospital stay (24 days). 6 With regard to thoracolumbarspinal fractures without neurological injury, somestudies indicate favourable short-term pain controlwith surgery, though there is no appreciable differencein long-term outcome in either group. 7There is considerable range in hospital costs incurreddepending on how such an injury is treated. In onereview of the economic impact of these, stablefractures without neurological deficits which weretreated nonoperatively inferred a cost of €5,100.Unstable fractures without neurological deficitswhich were treated nonoperatively had an averagecost of €12,500, while those treated operatively hadan average cost of €19,700. Unstable fractures withneurological deficits were usually treated surgicallyat an average cost of €31,900. 8 These factorsFigure 1—3D RECONSTRUCTIONOF CT THORACICSPINE SHOWINGA COMMINUTEDFRACTURE OF THE 6 TH ,7 TH AND 8 TH THORACICVERTEBRAEFigure 2—SAGITTAL SECTIONOF CT OF THORACICSPINE SHOWINGTHE EXTENT OF THETRANSLATION OFTHE FRAGMENTS,THOUGH WITHOUTIMPINGING ON THESPINAL CANALFigure 3—AXIAL SECTION OFCT THORACIC SPINESHOWING DEGREE OFCOMMINUTION OFTHE ANTERIOR ANDMIDDLE COLUMNS,AND A PATENTSPINAL CANAL76 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 77

CASE REPORTComminuted Fracture of the Thoracic SpineSmall bowel volvulus secondary to a mesenteric lipoma: a case report and review of the literatureCASE REPORTcontribute in selecting treatment with increasingfrequency in a more consumer driven health system.CONCLUSIONThis case highlights difficulties with regard tooptimal treatment of comminuted spinal fractureswithout neurological deficit and illustrates the higheconomic and personal cost associated with thistype of injury. The optimal management of traumaticthoracic injuries remains a controversial issue.Adequate assessment is paramount in selectingthe appropriate management. There is no clearconsensus on the treatment of unstable thoracicfractures without neurological injury. In the absenceof concomitant neurological injury, it is possibleto achieve a good outcome regardless of how thefracture is treated.REFERENCES1. Lenehan B, Street J, Barry K, Mullan G Immediate impactof ‘penalty points legislation’ on acute hospital traumaservices. Injury 2005;36(8):912-6.2. Robertson A, Branfoot T, Barlow IF, Giannoudis PV. Spinalinjury patterns resulting from car and motorcycleaccidents. Spine. 2002;27(24):2825-30.3. Denis F The three column spine and its significancein the classification of acute thoracolumbar spinalinjuries. Spine. 1983;8(8):817-31.4. Wood KB, Khanna G, Vaccaro AR, Arnold PM, Harris MB,Mehbod AA Assessment of two thoracolumbar fractureclassification systems as used by multiple surgeons. JBone Joint Surg Am. 2005;87(7):1423-9.5. Gotzen L, Puplat D, Junge A. Indications, techniqueand results of monosegmental dorsal spondylodesisin wedge compression fractures (grade II)of thethoracolumbar spine. Unfallchirurg 1992 95:445–4546. Rechtine GR, Cahill D, Chrin AM Treatment ofthoracolumbar trauma: comparison of complications ofoperative versus nonoperative treatment. J Spinal Disord1999 12:406–4097. Shen WJ, Liu TJ, Shen YS Nonoperative treatmentversus posterior fixation for thoracolumbar junctionburst fractures without neurologic deficit. Spine 200126:1038–10458. Van der Roer N, de Bruyne MC, Bakker FC, van TulderMW, Boers M. Direct medical costs of traumaticthoracolumbar spine fractures. Acta Orthop.2005;76(5):662-6.Correspondence to: James Cashman, Dept ofOrthopaedics, Cork University Hospital, Wilton, Cork;Tel: (021) 4546400; Email: james.cashman@gmail.comSmall bowel volvulus secondary to amesenteric lipoma: a case report and reviewof the literatureABSTRACTBackground Small bowel volvulus is rare in adults and often has a precipitating factor.Methods This report describes a case of small bowel volvulus secondary to a mesentericlipoma and reviews the literature describing this condition.Conclusion Mesenteric lipoma is a rare precipitating cause of small bowel volvulus inadults. Computed tomography scanning may be useful for diagnosis preoperatively.The treatment of choice is surgery with complete excision of the lipoma.INTRODUCTIONSmall bowel volvulus is a condition in which thereis torsion of the small bowel about the axis of itsmesentery. 1, 2 It is rarely described in adults althoughis well recognised in children. 2 This report describes acase of small bowel volvulus in an adult secondary toa lipoma in the small bowel mesentery.CASE REPORTA 40-year-old man presented with a one-weekhistory of constipation associated with colickyabdominal pain and vomiting. He continued topass flatus. There was no past medical history ofnote. On examination he was clinically dehydrated.His abdomen was distended but non-tender withincreased bowel sounds and no evidence of anyherniae. White cell count was normal but a C-reactiveprotein level was raised at 67. A plain abdominal X-ray was taken and revealed markedly distended smallbowel loops in keeping with high grade mechanicalsmall bowel obstruction.Retrospective review of the CT scan revealedthe characteristic ‘whirlpool’ appearance of themesenteric vessels associated with small bowelvolvulus (Figure 1) and 10mm below this, a lowdensity lesion in keeping with a lipoma was shownto be leading into the volvulus (Figures 2 and 3).The patient had an uneventful post-operative recoveryand was discharged home on day 8 post-operatively.AS McCoubrey,RLE ThompsonDept of GeneralSurgery, AltnagelvinArea Hospital,Londonderry, NIA computed tomography (CT) scan was carried outto try to elucidate the cause of the small bowelobstruction. This simply confirmed the X-ray findingsand did not show any obvious cause. As his symptomswere not improving he was taken for laparotomy.At laparotomy, there was rotation of mid smallbowel about a mesenteric lipoma resulting inobstruction. The lipoma measured 16 x 8 x 5 cm andweighed 302g. Eleven centimetres of small bowelwere resected along with the lipoma. Histologyconfirmed oedema of the small bowel consistentwith some degree of torsion and mature adiposetissue in keeping with a lipoma.DISCUSSIONSmall bowel volvulus is rare in adults and can becategorised as either primary (no predisposing factors)or secondary (predisposing anatomical abnormalitiespresent). 2, 3, 4 This case describes secondary smallbowel volvulus caused by a mesenteric lipoma.Mesenteric lipomas are rare, with less than 50 casesdescribed in the English language literature. 5, 6A lipoma is a benign tumour of mature adiposetissue. 7, 8 They can occur anywhere in the body butintraperitoneal lipomata are very rare. 5, 7, 8 An increasedincidence of lipomata is associated with obesity,diabetes mellitus, hypercholesterolaemia, familialtendency, trauma and chromosomal abnormalities. 7, 8Mesenteric lipomata are usually asymptomatic butcan cause symptoms secondary to distension of theabdomen 7 or symptoms of small bowel obstruction5, 6, 8, 9, 10secondary to volvulus.Primary mesenteric tumours are difficult to detectand are often not diagnosed preoperatively. 6, 8Imaging modalities such as computed tomography(CT) or magnetic resonance imaging (MRI) can beuseful 1, 2, 6, 8 showing a characteristic ‘whirlpool’pattern of small bowel loops around the superior78 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 79

CASE REPORTAS McCoubrey and RLE ThompsonCorrespondenceCASE REPORTmesenteric artery consistent with volvulus 2, 3, 8 ora ‘peacock’s tail’ sign due to torsion of the bowelaround the mesenteric axis. 3 CT scanning may alsobe helpful in highlighting potential small bowelischaemia. 3 MRI provides similar information to CTscanning but can define tissue characteristics withgreater sensitivity. 4 There are no data to compare thetwo imaging modalities at present. The radiographicimaging should also identify the mesenteric lipomaas a homogenous fat attenuation mass on CTscanning or with a homogenous signal intensity7, 11identical to fat on MRI.Surgery is the treatment of choice to relieve thevolvulus and excise the lipoma. 1, 2, 8 Complete excisionof the lipoma is recommended due to the potentialfor malignant transformation (especially in larger5, 6, 7, 8lipomata) and low recurrence rate (

CORRESPONDENCECorrespondenceBook reviewBOOK REVIEWUltraviolet phototherapy risks in IrelandThe Menopause: what you need to knowDear EditorThere were two articles of dermatological interest in yourJune 2006 issue. O’Connor and O’Hare’s analysis of ultravioletphototherapy risks in Ireland was most informative. Couldthey extend their findings to the risks of sun parlours in thiscountry? Hazards associated with these emporia have beenfound in Great Britain and the United States.The article on Vitamin D intake and its importance in respectof sunscreen usage was also noteworthy. 1, 2Obviously the amount of Vitamin D in the diet will varyconsiderably and production by sunlight will depend onpigmentation, duration of exposure, sun protection etc. Forexample, how much Vitamin D is produced in the skin ofa middle-aged patient with a ‘normal’ diet and how muchis obtained from food? Like all dermatologists I have beenproselytising for sunscreens for years. Are my patients toexchange rickets for skin cancer?References1. Marks R, Foley PA, Jolley D et al. The effect of regularsunscreen use on Vitamin D levels in an Australianpopulation. Results of a randomised controlled trial ArchDerm 1995 131 42. Glerup H, Mikkelsen Kl, Poulsen L et al Commonlyrecommended daily intake of Vitamin D is not sufficient ifsunlight exposure is limited J Internal Med 2000 247; 260Repetitive transcranial magnetic stimulation:A psychiatric treatment of the future?Dear EditorRepetitive transcranial magnetic stimulation (rTMS) hasreceived increased attention in recent years as a potentiallysafe and effective alternative to electroconvulsive therapy(ECT). It is a non-invasive means of electrically stimulatingor indeed inhibiting neurons in the cortex and it can modifyneuronal activity locally and at distant sites when deliveredin a series of pulses. The type of excitability on the cortexdepends on the frequency of stimulation used. Whilethe specific mode of action of rTMS is unclear, it has beendemonstrated to have effects on metabolism in the frontallobes leading to a consequent elevation in mood. Painlessmagnetic pulses are delivered to the cortex of a fully awakepatient, using a hand-held stimulating coil applied directlyto the head. In contrast to ECT where electricity gets diffusedby bone, high intensity magnetic pulses pass readily throughthe skull. This in theory makes it possible to attempt to focusmagnetic pulses on particular brain structures.There is an emerging evidence base that suggests theremay be benefits associated with use of rTMS. However, thenumber and quality of clinical trials are low and there areno established guidelines on the optimal clinical use ofrTMS. A systematic review and meta-analysis by Martin et al 1included only 14 small randomised controlled trials deemedto be of sufficient quality. These trials compared rTMS withsham in patients with depression. Pooled analysis showedan effect in favour of rTMS compared with sham after twoweeks of treatment, but this was not significant at the 2-week follow-up. The authors concluded that the currentevidence base was of a poor quality and did not support useof rTMS in the treatment of depression. Furthermore, a recentstudy comparing rTMS and ECT in major depression foundECT to be more effective, especially in the short-term. 2Despite these findings however, there are enough potentialadvantages associated with rTMS use over ECT, and evensome pharmacotherapeutic approaches, to justify furthermore rigorous research in this area. Such advantages includethe lack of a requirement for general anaesthetic and themedical risks and financial costs of this, the potential foradministration in an outpatient setting and the recentlydemonstrated lack of cognitive impairment in rTMS patientswhen compared to patients receiving ECT, despite similarclinical benefits from both treatments in that study. 3Furthermore, TMS may prove to be beneficial for treatmentfor other psychiatric illness, and for diagnostic purposes.Ideally, future rTMS research should involve large numbersof participants in multiple centres, comparable to drugtrials. Randomising and blinding of participants should beoptimised. Efforts must be made to address the optimalintensity, duration, intertrain frequency and frequency of themagnetic stimulus applied, and clear guidelines on potentialadverse effects should be clarified. Questions have also beenraised about the nature of sham treatment and how thisis best delivered; double-blinding of both patient and rTMSadministrator does not appear to be possible at present. So itappears that the questions about rTMS currently outnumberthe answers, but a general view among experts in the areais that further research is required before rTMS can bediscounted as a psychiatric treatment of the future.References1. Martin JLR, Barbanoj MJ, Schlaepfer TE, et al. (2003)Repetitive transcranial magnetic stimulation for thetreatment of depression: systematic review and metaanalysis.Brit J Psyc, 182:480-91.2. Eranti S, Mogg A, Pluck G et al, A randomised, ControlledTrial With 6-Month Follow-Up of Repetitive TranscranialMagnetic Stimulation and Electroconvulsive Therapy forSevere Depression. Am J Psych. 2007;164(1):73-81.3. Schulze-Rauschenbach SC, Harms U, Schlaepfer TE, et al.(2005) Distinctive neurocognitive effects of repetitivetranscranial magnetic stimulation and electroconvulsivetherapy in major depression. Brit J Psyc 186:410-416.C DupontConsultantDermatologist18 Merlyn Road,DublinH O’Connell 1 ,R Goggins 2PG Doyle 3Dept of Old AgePsychiatry,St Camillus’Hospital, 1 Limerick;St. Senan’s Hospital 2 ,Enniscorthy,Co. Wexford;Tevere Day Hospital, 3LimerickMargaret Rees, David W Purdie, Sally HopePublished by RSM PressISBN 1-85315-672-8Price Stg £10.95This book is easy to read and covers the menopausein a comprehensive manner without going intomuch medical jargon. The space allocated isproportionate with the topic’s importance, the bookcontaining 14 chapters in 104 pages.There is an elegant balance between scientificevidence and patient relevance, yet sometimestoo much detail leaves the non-medical readeroverwhelmed by the complexity of this condition, itstreatment and research related to it. Otherwise, theinformation provided is up to date and helpful.The boxes at the beginning of each chapter allowfor ease of use and illustrations are of high quality.The book covers very well issues like alternativemedicines and their interaction with other“orthodox” medications, as well as, warning on lackof quality control with non-HRT medicines. Thebibliography is well organised, offering both paperand web resources. The necessary word list is verycomprehensive.One criticism, considering the targeted audience, isthe general organisation of the book. It would havebeen more appropriate to have the non-medicalchapters (i.e. lifestyle, alternatives to HRT) before theHRT related and medical ones. For example, chapter14 contains excellent advice on what the doctor inthe clinic would like to know, which chronologicallystays before the visit to the doctor. On the plusside, an excellent chapter on early menopause, veryrelevant, considering the increasing incidence andlong term health and reproductive consequences.This is a book written by experts in the field,targeting the lay public. If you are a patient you willfind all aspects of the menopause clearly covered.Each public and hospital library should have a copy.Medical students and junior doctors will find this avaluable companion.Published by the Royal Society of Medicine Press Ltd.with a retail price of £ 10.95, it is good value for thetargeted audience. It is a small, light, well-boundpaperback that could be easily read anywhere.E V MocanuConsultantGynaecologist,ReproductiveMedicine Specialist82 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4 83

BOOK REVIEWBook reviewPrivate Practice— In the early twentieth century medical office of Dr. Richard CabotChristopher CrennerPublished by Johns Hopkins University Press, Baltimore and London, 2005ISBN: 0-8018-8117, pp. xv + 303Price Stg £32The subtitle tells more about this book than the title.To pursue his analyses of private practice Dr. Crennerhas used the extensive collection of records built upby Richard Cabot in his office, after first establishinghimself as a haematologist, in Boston from 1897 to1936. His story as a physician therefore portrays thegrowth of technological medicine, not to be confusedwith scientific medicine. The author makes usefulcontrasts between illness and disease, referrals andconsultations, ‘physiological’ versus symptomatictreatment, and frankness versus ‘deception’ inhopeless cases. Cabot vehemently proclaimed theunassailable right of the patient to absolute truth inregard to prognosis, but when Ella, his wife of fortyyears, was dying from lung cancer he did not tell her,even in her last days, an omission highlighting thefoolhardiness of his intransigence.Not as elegantly written perhaps as the AutocratOliver Wendell Holmes would have demandedfor the Arch-Brahmin, the monograph captures, ifthe random walk into anthropology in the closingchapter is ignored, the realities of the transition frompatient to client to consumer in medical practicewith enviable clarity and concision.C S BreathnachSchool of Medicineand Medical Science,NUI UCDNotes for an intended biography made in 1936 threeyears before his death were retained in the cache.They reveal that in 1893, when he was barely ayear qualified, he used chloroform to anaesthetiseand finally suffocate his eldest brother who hadlapsed into recurring bouts of diabetic ketosis.Unrepentant, Cabot’s boundless hubris neverwavered; throughout his long career he delightedin scourging the American medical profession, andhe was loud in applause of Bernard Shaw’s Doctor’sDilemma when it was published in the U S A in 1911.Establishing the clinico-pathological conference(CPC) at Massachusetts General Hospital in 1909was ‘perhaps his most lasting and significantcontribution to medicine’ according to Crenner(p. 78); in fact the first series began in 1900 at thebehest of a medical student, Walter B Cannon (Theuse of clinical records in teaching medicine, Bull.Amer. Acad. Med. 1900-02; 5: 203-213).84 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 • NUMBER 4