Rectal mucocoele following subtotal colectomy for colitis

We present a unique case of a rectal mucocoele affecting a patient several years after his subtotal colectomy for ulcerative colitis. This was secondary to both a benign anorectal stenosis and a benign mucus secreting rectal adenoma. This case highlights the importance of surveillance in such patients.

Eye dose monitoring of PET/CT workers

OBJECTIVE

The objective of the study was to measure eye dose [Hp(3)] to workers in a busy positron emission tomography (PET)/CT centre. Doses were compared with the proposed new annual dose limit of 20 mSv.

METHODS

We used a newly designed dosemeter to measure eye dose [Hp(3)]. Eye dosemeters were worn with an adjustable headband, with the dosemeter positioned adjacent to the left eye. The whole-body dose was also recorded using electronic personal dosemeter (EPD® Mk2; Thermo Electron Corporation, Waltham, MA). Exposed staff included radiographers, nurses and healthcare assistants.

RESULTS

The radiographers received the highest exposure of the staff groups studied, with one radiographer receiving an exposure of 0.5 mSv over the 3-month survey period. The estimated maximum eye dose for 1 year is approximately 2 mSv. The numeric value for eye dose was compared with the numeric value for personal dose equivalent to see if one could be used as an indicator for the other. From our data, a conservative estimate of eye dose Hp(3) (mSv) can be made as being up to approximately twice the numeric value for whole-body dose [Hp(10)] (mSv).

CONCLUSION

Eye dose was found to be well within the new proposed annual limit at our PET/CT centre. Routine whole-body dose measurements may be a useful starting point for assessing whether eye dose monitoring should be prioritized in a PET facility.

ADVANCES IN KNOWLEDGE

Following the proposal of a reduced eye dose limit, this article provides new measurement data on staff eye doses for PET/CT workers.

A correlation between severe haemolytic disease of the fetus and newborn and maternal ABO blood group

OBJECTIVE

To analyse anti-D quantification levels and frequency of intrauterine transfusion (IUT), per maternal ABO blood group.

BACKGROUND

Maternally derived red cell allo-antibodies can target fetal red cell antigens in utero leading to haemolytic disease and fetal anaemia. When a clinically significant allo-antibody is formed the priority is ascertaining the risk to the fetus and maternal ABO blood groups are not considered relevant.

MATERIALS AND METHODS

This was a 10-year retrospective, observational study carried out on women referred for anti-D quantification (n = 1106), and women whose fetuses required an IUT to treat fetal anaemia (n = 62) due to anti-D, in the Republic of Ireland.

RESULTS

Relative to the overall incidence of RhD allo-immunisation by blood group, women of blood group A were more likely to require IUT compared with those who were blood group O (P = 0.002).

CONCLUSION

It is known that ABO feto-maternal compatibility can influence the incidence and level of red cell allo-antibodies in pregnancy; however, it does not account for the significantly high rate of severe haemolytic disease requiring IUT seen in blood group A women.

Retrospective costing of warfarin

In Ireland, there are four anticoagulants available for prescribing to patients with atrial fibrillation for stroke prevention. A key feature of the three most recent anticoagulants is that monitoring is redundant. Despite this, there is continued prescribing of the incumbent anticoagulant, warfarin, which requires monitoring. Lack of information regarding the cost of monitoring, and the extra burden it places on health budgets and patients, motivated this costing study. Using micro costing, the costs of warfarin treatment (including monitoring) was disaggregated and isolated from both the patients' and health care provider's perspectives in a Cork hospital. Costs to the health care provider per patient per clinic visited were 21.57 Euros. Patient costs incurred per patient per clinic were 48.50 Euros. Thus, the total costs per patient per visit were 70.07 Euros. This result reveals that while the pharmaceutical cost of warfarin is low; it is not an inexpensive therapy when monitoring costs are considered.

The cost of the inpatient management of febrile neutropenia in cancer patients--a micro-costing study in the Irish healthcare setting

The objective was to evaluate the resource use and cost of hospitalisation for febrile neutropenia (FN) from the health-payer's perspective. This was a single centre study. Adults undergoing chemotherapy, who were admitted for FN, were identified prospectively. Patient medical records were reviewed retrospectively. Demographics and resource utilisation data were obtained from a cohort of 32 patients (69% female, mean age = 58.8 years). Twenty-five per cent of patients had more than one FN episode. In total, 42 FN episodes were captured; 60% of episodes had occurred within the first two cycles of chemotherapy. The bootstrap estimation was used to determine mean hospital length of stay (LOS) with standard deviation (±SD) and mean costs ± SD. The mean LOS was 7.3 ± 0.5 days. The mean cost per FN episode was €8915 ± 718. The major cost driver was hospital bed-stay (mean cost of €6851 ± 549). Other cost drivers included antibacterial treatment at €760 ± 156, laboratory investigations at €538 ± 47 and the requirement for blood bank products at €525 ± 189. To our knowledge, this is the first investigation of the cost of chemotherapy induced FN within the context of the Irish healthcare setting.

Should the justification of medical exposures take account of radiation risks from previous examinations?

With the growing availability of dose histories for patients, the question of whether previous diagnostic radiation exposures should affect decisions on future examinations is coming into sharper focus. This article discusses ways in which cumulative dose information may affect our thinking in justifying exposures. Based on a common tendency to see a connection between past and future events even where we know them to be independent-the gambler's fallacy-we may find ourselves treating past risks as if they contribute to the present risk. We take the example of two patients scheduled for CT scans, one with no previous diagnostic radiation exposures, the other with a history of previous CT scans, to show that the risks, and justification process, are equivalent in both cases. For the patient with a history of diagnostic exposures, there are only two possibilities: either harm has been caused or there has been no effect. If previous CT examinations have not caused harm, then, as past risks, they are irrelevant. The patient is in precisely the same position with regard to risk as a patient with no dose history. If harm has been caused, avoiding further diagnostic exposures does not change this outcome; again in this case, a justified radiation examination should proceed. We argue that bringing dose history into the decision process for justifying examinations is contrary to our understanding of risk for low-dose radiation and, rather than improving patient safety, would unnecessarily restrict access to radiation-based diagnostic examinations.

Tumour grade on core biopsy and evidence of axillary involvement on ultrasound predicts response in elderly co-morbid patients treated with primary hormone therapy for oestrogen receptor positive breast carcinoma

INTRODUCTION

Treatment of women with oestrogen-receptor positive breast cancer who are high risk for general anaesthetic remains controversial. Current guidance is based on studies pre-dating aromatase inhibitors (AIs) which may have also included hormone-receptor negative patients. Such studies have demonstrated improved disease-free survival and local disease control following surgery when compared with primary hormone therapy (PHT) alone. However uncertainty persists regarding benefit of surgery over optimal hormone treatment in patients with significant co-morbidity.

METHOD

Retrospective cohort study comparing efficacy of PHT in oestrogen-receptor positive breast cancer patients considered unsuitable for surgery. Co-morbidity was scored retrospectively using the Charlson Index. Overall survival and disease specific survival were noted and multivariate analysis performed to identify predictors of treatment failure.

RESULTS

106 patients treated for breast cancer at Southampton University Hospital with PHT without surgery were identified (Mean age 84.1 years, range 48-101). 94.3% had a probability of 10 year survival of 2.25% or less according to the age-weighted Charlson score. Kaplan-Meier analysis demonstrated a four-year survival of 30% and breast cancer specific survival of 60%. Cox proportional hazards model demonstrated high-grade disease (grade III vs. grade I/II: HR = 2.007; 95% Confidence Interval (CI) = 1.004-4.014. P = 0.049) and ultrasound axillary staging (indeterminate/definite lymphatic involvement vs. no involvement: HR = 1.944; 95% CI = 1.010-3.742. P = 0.047) independently predicted early failure of PHT.

CONCLUSION

A high proportion of elderly and comorbid patients die with breast cancer rather than from breast cancer. Elderly comorbid patients who initially respond to primary hormone therapy have a less than 30% incidence of delayed treatment failure during their life time; however patients with grade III disease or an abnormal axillary ultrasound are twice as likely to fail first choice PHT.

Sleep apnoea and its relationship with cardiovascular, pulmonary, metabolic and other morbidities

Sleep apnoea (OSAS) is a multisystem disorder. There is a high prevalence of cardiovascular and metabolic morbidities in patients investigated for sleep apnoea. We aim to evaluate any association between cardiovascular, metabolic and pulmonary co morbidities in patients investigated for OSAS and whether clinical findings based on Epworth sleep score (ESS) and snoring helps in diagnosing sleep apnoea. 258 consecutive patients who were electively admitted for sleep assessment in Peamount Hospital, Dublin from Sept 2009 to Aug 2011 were retrospectively reviewed. 139/258 were diagnosed as OSAS. Cardiovascular, metabolic and pulmonary co morbidities were 46.12%, 37.2% and 29% respectively. There is no correlation found between ESS, Snoring with Apnoea Hypopnoea Index in OSAS group. Screening for OSAS should be considered in patients with certain cardiovascular and metabolic disorders. PSG is so far considered the gold standard investigation to diagnose OSAS and better clinical evaluating tools need to be formulated.