Angiographic cross-filling between inferior petrosal sinuses and alteration of adrenocorticotropic hormone sampling results for tumor localization in Cushing disease

OBJECTIVE

Inferior petrosal sinus (IPS) sampling (IPSS) is a diagnostic procedure used to guide diagnostic localization of imaging-negative adrenocorticotropic hormone (ACTH)-secreting pituitary microadenomas. However, the efficacy of IPSS has been suboptimal at accurately lateralizing the adenoma, reducing surgical cure rates and leading to unintended pituitary dysfunction due to the added exploration. One rationale for the occasional imprecision is the existence of additional petrosal sinus collateral channels that connect the IPS bilaterally, which may lead to false localization results during sampling. The aim of this study was to explore a potential connection between normal anatomical variation in the angioarchitecture of the IPSs and the ACTH results obtained in subsequent IPSS tests.

METHODS

A retrospective review was performed on all cases between 1998 and 2013 involving patients at a single institution who underwent IPSS for radiographically equivocal pituitary microadenomas. Cases were reviewed for tumor laterality noted on either operative or pathology reports, as well as the presence of angiographic evidence of cross-filling between the sinuses. In addition, ACTH levels from the right and left IPSs were documented at baseline and at 2, 5, and 10 minutes after corticotropin-releasing hormone (CRH) administration. A ratio of the change in ACTH levels measured at the time of maximal response (10 minutes) versus the levels measured at the initial response (2 minutes) was computed for each patient and compared between patients by their angiographic cross-filling status.

RESULTS

There were 41 patients with a histopathologically confirmed right- or left-sided ACTH-secreting pituitary microadenoma who underwent preoperative IPSS. Among these patients, 28 (68%) showed angiographic evidence of cross-filling between the IPSs, and 13 showed no cross-filling. On average, ACTH levels increased by a factor of 3.91 ± 0.77 in the contralateral IPS in patients with angiographic cross-filling, compared with a factor increase of only 1.80 ± 0.27 in patients without cross-filling (p = 0.014). In comparison, ACTH levels increased by a factor of 2.01 ± 0.57 in the ipsilateral IPS in patients with cross-filling, and by 8.78 ± 7.30 in those without cross-filling (p = 0.373).

CONCLUSIONS

The presence of angiographic cross-filling, suggestive of a greater degree of vascular channel networking between the right and left IPS, is a significant factor influencing the measured rates of change of ACTH in IPSS and may impact the specificity of this test to accurately determine microadenoma laterality in the preoperative setting.

A qualitative evaluation of a telehealth healthy lifestyle intervention for people with serious mental illness

OBJECTIVES

There are high levels of nutritional and metabolic, cardiovascular, and respiratory tract diseases among people diagnosed with serious mental illness (SMI). Consequently, we developed a pragmatic, affordable nutritional and exercise intervention: Choices4Health. Due to the COVID-19 pandemic, we modified this intervention so it could be delivered online. The aim of this study was to explore the experience of participating in online Choices4Health, in a real-world clinical setting, from the perspectives of service users with SMI.

METHODS

The study aim was addressed using thematic analysis. Service users who had attended online Choices4Health, received a SMI diagnosis (defined as a schizophrenia spectrum disorder or an affective disorder), and resided in a South Dublin catchment were invited to participate. Nine participants were purposefully sampled. Semi-structured interviews were conducted by telephone. Data analysis was guided by thematic analysis procedures.

RESULTS

Six themes were generated: Being ready and not overburdened (Engagement); Gaining knowledge and implementing it (Learning and doing); Viewing the intervention as appropriate and effective (Targeted impact); Being at home with others online (Belonging); Having a positive affective attitude towards the intervention (Feeling); and Perceiving problems with intervention delivery (Recommended change).

CONCLUSIONS

Findings suggest that online Choices4Health is, broadly speaking, acceptable from a service user perspective, but that further refinement is required to address specific issues participants identified. These relate to follow-up or programme extension, technology access, in-person contact preference, and participant inclusion criteria. Further research is required into online Choices4Health efficacy, innovations to reduce digital exclusion, and managing group dynamics in telehealth interventions.

Clare Island Digital Health Project - using technology to enable health for all

INTRODUCTION

Island communities have a different experience of health services compared with urban dwellers. Islanders face challenges of accessing equitable health services with varied availability of local services and the added difficulty of sea and weather conditions on top of the physical distance to reach specialised services. In a 2017 review of primary care island services in Ireland, it was proposed that telemedicine solutions could potentially improve delivery of health services. However, these solutions must meet the unique needs of the island population.

AIMS AND METHODS

This collaborative project brings together healthcare professionals, academic researchers, technology partners, business partners and the Clare Island community, to improve the health of the island population via novel technological interventions. The Clare Island project aims to identify specific healthcare needs of the island through community engagement, develop innovative solutions, and assess the impact of the interventions via a mixed-methods approach.

RESULTS

Preliminary engagement with the Clare Island community via facilitated round table discussions has identified Islanders' overarching enthusiasm for digital solutions and added benefit of provision of 'health at home' for Island communities, particularly, the potential to better support the older person at home via technology. Key challenges including basic infrastructure, useability and sustainability of digital health initiatives were common themes identified. We also will discuss in detail the needs-led process of innovation of telemedicine solutions deployed on Clare Island. Finally, we will present the anticipated impact of the project and the challenges and opportunities of telehealth for island health services.

DISCUSSION

Technology has the potential to narrow the gap of inequity of health services for island communities. This project is an example of how through cross-disciplinary collaboration, and needs-led, specifically 'island-led', innovation of digital health solutions, the unique challenges for island communities can be addressed.

Vaccine-induced thrombosis and thrombocytopenia (VITT) in Ireland: A review of cases and current practices

Since the beginning of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS CoV-2) virus pandemic, several highly effective and safe vaccines have been produced at remarkable speed. Following global implementation of vaccination programmes, cases of thrombosis with thrombocytopenia following administration of adenoviral vector-based vaccines started being reported. In this review we discuss the known pathogenesis and epidemiology of so-called vaccine induced thrombocytopenia and thrombosis (VITT). We consider the available guidelines, diagnostic laboratory tests and management options for these patients. Finally, we discuss important unanswered questions and areas for future research in this novel pathoclinical entity.

Use of powered air-purifying respirators during surgical interventions

This clinical study confirms user acceptability of PAPR during surgery both at operating room team level as well as by groups of surgeons, anaesthesiologists and nursing level. While some care is needed in the use of this equipment, surgery can be performed safely with satisfactory user experience.

Therefore PAPR is useable for surgery but scope exists for improvement.

Best Practice Guidance for Digital Contact Tracing Apps: A Cross-disciplinary Review of the Literature

BACKGROUND

Digital contact tracing apps have the potential to augment contact tracing systems and disrupt COVID-19 transmission by rapidly identifying secondary cases prior to the onset of infectiousness and linking them into a system of quarantine, testing, and health care worker case management. The international experience of digital contact tracing apps during the COVID-19 pandemic demonstrates how challenging their design and deployment are.

OBJECTIVE

This study aims to derive and summarize best practice guidance for the design of the ideal digital contact tracing app.

METHODS

A collaborative cross-disciplinary approach was used to derive best practice guidance for designing the ideal digital contact tracing app. A search of the indexed and gray literature was conducted to identify articles describing or evaluating digital contact tracing apps. MEDLINE was searched using a combination of free-text terms and Medical Subject Headings search terms. Gray literature sources searched were the World Health Organization Institutional Repository for Information Sharing, the European Centre for Disease Prevention and Control publications library, and Google, including the websites of many health protection authorities. Articles that were acceptable for inclusion in this evidence synthesis were peer-reviewed publications, cohort studies, randomized trials, modeling studies, technical reports, white papers, and media reports related to digital contact tracing.

RESULTS

Ethical, user experience, privacy and data protection, technical, clinical and societal, and evaluation considerations were identified from the literature. The ideal digital contact tracing app should be voluntary and should be equitably available and accessible. User engagement could be enhanced by small financial incentives, enabling users to tailor aspects of the app to their particular needs and integrating digital contact tracing apps into the wider public health information campaign. Adherence to the principles of good data protection and privacy by design is important to convince target populations to download and use digital contact tracing apps. Bluetooth Low Energy is recommended for a digital contact tracing app's contact event detection, but combining it with ultrasound technology may improve a digital contact tracing app's accuracy. A decentralized privacy-preserving protocol should be followed to enable digital contact tracing app users to exchange and record temporary contact numbers during contact events. The ideal digital contact tracing app should define and risk-stratify contact events according to proximity, duration of contact, and the infectiousness of the case at the time of contact. Evaluating digital contact tracing apps requires data to quantify app downloads, use among COVID-19 cases, successful contact alert generation, contact alert receivers, contact alert receivers that adhere to quarantine and testing recommendations, and the number of contact alert receivers who subsequently are tested positive for COVID-19. The outcomes of digital contact tracing apps' evaluations should be openly reported to allow for the wider public to review the evaluation of the app.

CONCLUSIONS

In conclusion, key considerations and best practice guidance for the design of the ideal digital contact tracing app were derived from the literature.

Sentiment analysis of user feedback on the HSE's Covid-19 contact tracing app

BACKGROUND

Digital Contact Tracing is seen as a key tool in reducing the propagation of Covid-19. But it requires high uptake and continued participation across the population to be effective. To achieve sufficient uptake/participation, health authorities should address, and thus be aware of, user concerns.

AIM

This work manually analyzes user reviews of the Irish Heath Service Executive's (HSE) Contact Tracker app, to identify user concerns and to lay the foundations for subsequent, large-scale, automated analyses of reviews. While this might seem tightly scoped to the Irish context, the HSE app provides the basis for apps in many jurisdictions in the USA and Europe.

METHODS

Manual analysis of (1287) user reviews from the Google/Apple playstores was performed, to identify the aspects of the app that users focused on, and the positive/negative sentiment expressed.

RESULTS

The findings suggest a largely positive sentiment towards the app, and that users thought it handled data protection and transparency aspects well. But feedback suggests that users would appreciate more targeted feedback on the incidence of the virus, and facilities for more proactive engagement, like notifications that prompt users to submit their health status daily. Finally, the analysis suggests that the "android battery" issue and the backward-compatibility issue with iPhones seriously impacted retention/uptake of the app respectively.

CONCLUSION

The HSE have responded to the public's desire for targeted feedback in newer versions, but should consider increasing the app's proactive engagement. The results suggest they should also raise the backward compatibility issue, regarding older iPhones, with Apple.

Can mHealth Technology Help Mitigate the Effects of the COVID-19 Pandemic?

Goal: The aim of the study herein reported was to review mobile health (mHealth) technologies and explore their use to monitor and mitigate the effects of the COVID-19 pandemic. Methods: A Task Force was assembled by recruiting individuals with expertise in electronic Patient-Reported Outcomes (ePRO), wearable sensors, and digital contact tracing technologies. Its members collected and discussed available information and summarized it in a series of reports. Results: The Task Force identified technologies that could be deployed in response to the COVID-19 pandemic and would likely be suitable for future pandemics. Criteria for their evaluation were agreed upon and applied to these systems. Conclusions: mHealth technologies are viable options to monitor COVID-19 patients and be used to predict symptom escalation for earlier intervention. These technologies could also be utilized to monitor individuals who are presumed non-infected and enable prediction of exposure to SARS-CoV-2, thus facilitating the prioritization of diagnostic testing.

OR32-1 Endocrine Manifestations of Erdheim-Chester Disease: The Mayo Clinic Experience

Objective: Erdheim- Chester disease (ECD) is a rare form of non-Langerhans cell histiocytosis characterized by multisystem tissue infiltration of foamy histiocytes. Very few studies have investigated the prevalence of endocrine abnormalities in patients with ECD. Based on limited data, it is known that endocrine manifestations are not uncommon. The objective of this study was to characterize the extent of endocrine gland involvement and hormonal function abnormalities in the largest reported endocrine cohort of patients with ECD. Design: Retrospective chart review study of patients with ECD evaluated at the Mayo Clinic from January 1990 to June 2018. A tissue biopsy confirming the diagnosis of ECD was necessary for inclusion in this study. In all cases, the diagnosis of ECD was confirmed using clinical criteria in conjunction with histopathologic findings. Clinical, laboratory, and imaging data were collected. Results: Eighty-three patients with confirmed ECD were included in our study (71.1% women, 83.1% Caucasian, median age at time of diagnosis 55.2[46.3-66.1]). Symptom onset preceded the diagnosis by a median time of 2.7[1.0-6.9] years. Forty-eight patients (57.8%) had at least one hormonal deficiency. Central diabetes insipidus (25.3%) was the most common endocrine manifestation at initial presentation. Fifty percent of patients with central diabetes insipidus had at least one co-existent anterior pituitary deficiency at presentation, most commonly hypogonadism (40%). Among patients that had further endocrine evaluation, 16/64 (25.0%) had primary hypothyroidism and 7/64 (10.9%) had central hypothyroidism. 7/34 (20.3%) had central secondary adrenal insufficiency and 2/34 (5.8%) had primary adrenal insufficiency. Central hypogonadism was found in 18/31 (58.1%) of patients, whereas 6/31 (19.4%) had primary hypogonadism. Growth hormone deficiency was found in 7/59 (29.7%) patients and 4/27 (14.8%) patients had hyperprolactinemia. Imaging revealed involvement of the pituitary/hypothalamus in 18 (21.7%) patients, adrenal glands in 18 (21.7%) patients and testicles in 5 (6.0%) patients. Thirty-five patients (42.2%) had at least one gland involved seen on imaging, Visible gland infiltration did not correlate with hormonal deficiencies. New hormonal deficits appeared during follow-up. Conclusions: This is the largest case series of endocrine manifestations in patients with ECD. Endocrine involvement is frequent in these patients, 57.8% have at least one hormonal deficiency. Because endocrine abnormalities can evolve throughout the course of the disease, patients should have endocrine evaluation periodically.

MON-586 Practice Variation in the Management of Subclinical Hypothyroidism During Pregnancy: Results From a National Survey of Endocrinologists in the US

Background: Evidence regarding subclinical hypothyroidism (SCH) effects on pregnancy and the benefits of levothyroxine (LT4) treatment is inconsistent. The American Thyroid Association (ATA) Guidelines for the management of thyroid diseases in pregnancy were published in 2017; the impact of these guidelines on clinical practice remains uncertain. Aim: To conduct a national survey among endocrinologists studying knowledge and perception regarding SCH diagnosis, treatment and impact on pregnancy. Methods: An online survey was sent by email invitation to endocrinologists who are active members of the Endocrine Society in the U.S. (n=5914). The questionnaire included demographic data and clinical scenarios with multiple choice questions to assess diagnostic evaluation, initiation of therapy, and follow up in pregnant women with SCH. Results: The survey was completed by 154 endocrinologists (9/5/18-10/31/18). On average each clinician had treated 5 (IQR 3-10) women with SCH in the past 6 months. The 2017 ATA guidelines were reviewed by 75% of whom 52% consider that these guidelines actually changed their clinical practice. Universal screening is done by 53%, 31% screens when there are associated risk factors for thyroid disease (e.g. clinical symptoms, family history, etc.) and 16% never screens. For the diagnosis of SCH, only 25% uses a TSH>4.0 mIU/L and 5.8% a population-based cutoff as recommended by ATA, while the most used cutoff was TSH>2.5 mIU/L (52%). Following ATA guidelines, 87% would immediately treat a woman with a 1^st trimester TSH>4.0 mIU/L and TPO-Abs+ (strong recommendation) vs. 50% if TPO-Abs– (weak recommendation), followed by the option of repeating TSH within a month in 12% and 45% respectively. If a woman had TSH between 2.5-4.0 mIU/L, 58% would treat her if TPO-Abs+ (weak recommendation) vs. 17% if TPO-Abs- (no recommendation), followed by the option of repeating TSH within a month in 39% and 55% respectively. We found similar practices for the treatment of women in the 2^nd trimester with the same clinical and laboratory characteristics. Clinicians reported considering the following factors for LT4 treatment decision: TSH level, TPO-Abs, history of miscarriages, and guidelines recommendations. Interestingly, 70-80% of the clinicians who would start LT4, consider treatment would have a small impact (10-20% reduction) or very small impact (<10% reduction) on maternofetal complications regardless the clinical scenario. Only 50% of the clinicians take into consideration the patient’s preferences and 19% the side effects related to LT4 use. Conclusions: Despite recently updated guidelines, there is still a wide variation in the clinical practice regarding the diagnosis and management of SCH in pregnancy. Although LT4 is frequently used as the treatment for SCH in pregnancy, the expected risk reduction is small, and patient’s preferences are often disregarded.

SUN-132 Investigating the Accuracy of Risk Factor Calculators in Diagnosing Maturity Onset Diabetes of the Young (MODY)

MODY is a rare form of diabetes caused by impaired insulin production attributable to autosomal dominant monogenic mutations. It is an important diagnosis as it results in a treatment change for 25% of patients, allows for the screening of 1^st degree relatives and identifies patients who have MODY subtypes associated with reduced rates of micro- and macro-vascular complications. Diagnosing MODY is challenging and several MODY risk factor calculators have been proposed to guide rational genetic testing. The aim of this study was to retrospectively apply the MODY risk factor calculators to patients with diagnosed MODY who attended the diabetes service at a tertiary hospital in the West of Ireland to identify the most accurate calculator in predicting MODY in this patient cohort. MODY risk factor calculators in the literature focus on young age at diagnosis, low BMI and low HbA1c as defining features of MODY. Ellard, Bellanne-Chantelot et al. (2008) proposed age at diagnosis ≤25, BMI <30 and HbA1c ≤58.8 mmol/L as the recommended criteria for genetic testing in MODY, and this captured 6/21 (28.57%) patients with MODY in our cohort. Thanabalasingham, Pal et al. (2012) proposed age at diagnosis ≤30, BMI <30 and HbA1c ≤63.9 mmol/L, which accounted for 8/21 (38.1%) of our MODY patients. The MODY Probability Calculator proposed by Shields et al. (2012) was developed using logistic regression to determine the probability of MODY. Variables include current age, age at diagnosis, sex, treatment with insulin, time to insulin treatment, BMI, HbA1c and parental history of diabetes. The MODY Probability Calculator cannot be directly compared to the other calculators, as it does not define clinical criteria in a binary fashion but assigns a weighting to each factor. Patients have to be aged ≤35 at diagnosis for this calculator to be applied, which resulted in the exclusion of 3/22 patients in our cohort. 9/22 (40.9%) patients had a positive predictive value (PPV) of >50%, which conferred a 0.47/100 false negative rate and a 3/100 false positive rate if used as the basis for referring for genetic testing. 5/22 (22.73%) patients had a PPV of >75%, which conferred a 0.9/100 false negative rate and a 1.2/100 false positive rate, which is highly sensitive and specific. 12/22 (54.55%) patients had a PPV of >20%, which conferred a 0.14/100 false negative rate and a 16.8/100 false positive rate. This work demonstrates that the MODY Probability Calculator currently achieves the best balance of sensitivity / specificity in diagnosing patients with MODY. Nevertheless, a significant portion (10/22) of known MODY patients were not identified. Limitations include excluding patients aged >35 at diagnosis and excluding patients with a strong family history of diabetes who do not have an affected parent. These calculators are diagnostic adjuncts in the Endocrinologist’s toolbox to stratify MODY risk but do not replace clinical judgement.

Patient acceptability and experiences of therapeutic switching of proton pump inhibitors within the National Preferred Drugs initiative in Ireland

INTRODUCTION

A 'Preferred Drugs' initiative was introduced into Ireland in 2013. This identified a single recommended drug to be prescribed to patients requiring treatment from a particular class of drugs.

AIMS

This study investigates how patients on established proton pump inhibitor (PPI) therapy experienced the therapeutic switching of their medication to the 'preferred drug', and the extent to which they regarded it as an acceptable practice.

METHODS

The experiences of 61 patients on established proton pump inhibitor (PPI) therapy were sought before and after their drug was switched to the 'preferred drug'.

RESULTS

Eighty per cent of patients were happy to switch medications. When asked for their opinions on medications in general, 71% felt doctors should prescribe the least expensive medication, 84% agreed that all licensed medications were safe while 67% felt their GP changing medication for cost reasons was safe. After 8 weeks, 20% of patients had switched back to their old PPI. When asked how they felt about their medication change, 74% felt happy or pleased.

CONCLUSIONS

The majority of patients in our study were satisfied to have their medication switched. However, prescribers should be mindful that 1 in 5 patients encountered problems as a result of the switching process.

Diagnostic accuracy of thyroid nodule growth to predict malignancy in thyroid nodules with benign cytology: systematic review and meta-analysis

BACKGROUND

Thyroid ultrasound to assess for nodular growth is commonly performed during the follow-up of patients with benign thyroid nodules, with the goal of identifying patients with a missed diagnosis of thyroid cancer. The objective of this study was to summarize the evidence regarding the diagnostic accuracy of growth during follow-up of benign thyroid nodules for thyroid cancer.

METHODS

We searched multiple electronic databases using a search strategy designed by an experienced medical librarian from inception to March 2015. Eligible studies included patients with benign thyroid nodules assessed for growth during follow-up and evaluated for thyroid cancer either by surgical histology or a repeat fine needle aspiration biopsy. Reviewers working independently and in duplicate recorded data and assessed each study.

RESULTS

The seven eligible studies lacked safeguards against bias and generated results that were imprecise with wide confidence intervals and inconsistent across studies. This warrants very low confidence in these results. The odds of nodule growth in patients with thyroid cancer on histopathology over these odds in patients without thyroid cancer (diagnostic odds ratio) was 0·58 (95% CI: 0·26-1·3); the diagnostic odds ratio was 2·2 (95% CI: 0·26-18) when an abnormal repeat biopsy was the reference standard.

CONCLUSION

The body of evidence linking nodule growth with thyroid cancer during the follow-up of benign nodules warrants very low confidence. In the era of high-value health care, the commonplace practice of following benign thyroid nodules with serial ultrasound assessment of growth to diagnose cancer can be questioned, calling for imminent evaluation.

Nuchal Translucency Quality Review (NTQR) program: first one and half million results

OBJECTIVE

To evaluate the performance of first-trimester nuchal translucency (NT) measurement by providers (physician-sonologists and sonographers) within the Nuchal Translucency Quality Review (NTQR) program.

METHODS

After training and credentialing providers, the NTQR monitored performance of NT measurement by the extent to which an individual's median multiple of the normal median (MoM) for crown-rump length (CRL) was within the range 0.9-1.1 MoM of a published normal median curve. The SD of log10 MoM and regression slope of NT on CRL were also evaluated. We report the distribution between providers of these performance indicators and evaluate potential sources of variation.

RESULTS

Among the first 1.5 million scans in the NTQR program, performed between 2005 and 2011, there were 1 485 944 with CRL in the range 41-84 mm, from 4710 providers at 2150 ultrasound units. Among the 3463 providers with at least 30 scans in total, the median of the providers' median NT-MoMs was 0.913. Only 1901 (55%) had a median NT-MoM within the expected range; there were 89 above 1.1 MoM, 1046 at 0.8-0.9 MoM, 344 at 0.7-0.8 MoM and 83 below 0.7 MoM. There was a small increase in the median NT-MoM according to providers' length of time in the NTQR program and number of scans entered annually. On average, physician-sonologists had a higher median NT-MoM than did sonographers, as did those already credentialed before joining the program. The median provider SD was 0.093 and the median slope was 13.5%. SD correlated negatively with the median NT-MoM (r = -0.34) and positively with the slope (r = 0.22).

CONCLUSION

Even with extensive training, credentialing and monitoring, there remains considerable variability between NT providers. There was a general tendency towards under-measurement of NT compared with expected values, although more experienced providers had performance closer to that expected.

Inflammatory bowel disease and thromboembolism. Is inflammation at the centre of the clot?

Thromboembolic events are well recognised in patients with inflammatory bowel disease (IBD). We present three cases which highlight the need for vigilance with respect to this complication. We also propose that consideration be given to re-evaluating disease activity in those patients who develop thromboembolic complications.

A quick, least-invasive, inexpensive and reliable method for sampling Gadus morhua postlarvae for genetic analysis

The present study describes the successful design and testing of a quick, least-invasive, reliable and inexpensive sampling procedure for Atlantic cod Gadus morhua. This protocol can be easily applied to postlarval fish following a simple three-step procedure, without availing of commercial DNA extraction kits, while ensuring survival of sampled individuals.

Coping with stress in surgery: the difficulty of measuring non-technical skills

BACKGROUND

Non-technical skills are relevant to surgical performance but are difficult to quantify. The aim of this study was to investigate the relationship between self-efficacy, which is a measure of stress-coping ability, and surgical performance.

METHODS

Two hundred and sixteen basic surgical trainees were assessed on their performance of three bench model-type open and laparoscopic surgical tasks. They also completed a 10-item General Self-Efficacy (GSE) questionnaire to assess their stress-coping abilities. Their assessment scores were correlated with the GSE scores.

RESULTS

The mean GSE score of 31.39 was higher than the recorded population norms. There was no significant correlation between GSE and surgical performance for open or laparoscopic tasks.

CONCLUSION

Junior surgical trainees have high self-belief scores, but these abilities are difficult to measure and quantify. More refined methods may be necessary to measure non-technical skills relevant to surgery.

Sestamibi scan-directed, minimally invasive video-assisted parathyroidectomy: an effective treatment for solitary parathyroid adenoma

BACKGROUND

Solitary adenomas have been shown to be responsible for almost 90% of cases of primary hyperparathyroidism.

AIM

The purpose of this study was to determine the utility of sestamibi scanning pre-operatively to guide minimally invasive video-assisted (MIVA) parathyroidectomy.

METHODS

We reviewed 40 patients who underwent parathyroidectomy between 2003 and 2004. All patients underwent a pre-operative sestamibi scan.

RESULTS

Thirty-three (82%) patients had a localized solitary adenoma on sestamibi scan. Of these patients 29 underwent attempted MIVA parathyroidectomy. MIVA parathyroidectomy was successful in 22 patients. When pre-operative sestamibi scanning was correlated with pathological diagnosis it was shown to have a sensitivity of 82% and positive predictive value of 94%.

CONCLUSION

Pre-operative sestamibi scan localization of a parathyroid adenoma offers a 94% positive predictive value for adenoma location. This facilitates MIVA parathyroidectomy to be used effectively to treat primary hyperparathyroidism in the majority of patients.

The application of a use case/task based approach in the development of software for a portable neuromuscular stimulator device

This paper describes the use of a use case/task based method in the development of a portable neuromuscular stimulator device. The developed unit allows a variety of stimulus delivery algorithms to be incorporated dependent on the patient's requirements. The developed system consists of a stimulator unit, stimulator firmware, external sensors, a programmer unit, two stimulation channels and electrodes. A clinician specifies a suitable algorithm for a particular patient and then selects the relevant stimulus parameters for that algorithm using the programmer unit. The stimulator unit's architecture supports the addition of future algorithms. The device was developed in accordance with the European Medical Devices Directive 93/42/EEC resulting in the need for a well-defined development lifecycle during the design and development of the neuromuscular stimulator. This development lifecycle must place emphasis on the need to identify potential hazards. Therefore, the adoption of a use case/task driven approach as one of the strategies in eliciting the requirements, both functional and non-functional and specification stages of the development lifecycle resulted in a more rigid hazard/risk analysis leading ultimately to a more robust final system. A comprehensive review of the literature has revealed that use cases have been in use in other contexts but not so in a biomedical context. Therefore, this is a novel strategy to the development of a device in this field. A brief background on the historical development of drop foot stimulators shall be presented thereby displaying the benefits of the programmability feature of our stimulator.

The need for a national strategy for chronic pain management in Ireland

BACKGROUND

Chronic pain is defined as pain on a daily basis for more than six months. It affects 13% of the Irish population. Despite its prevalence and the impact on patient's quality of life there is no national strategy for this problem.

AIM

To determine the need for a national strategy for chronic pain in Ireland.

METHODS

The cost of low back pain (LBP) (common chronic pain condition), the level of education and research and current chronic pain clinic resources were investigated.

RESULTS

The cost of LBP in Ireland is enormous: disability payments from the Department of Social and Family Affairs amounted to euros 348 million and insurance payments cost euros 10.5 million. The number of teaching hours timetabled for pain education in the schools of Medicine, Physiotherapy, Dentistry, Nursing and Psychology in Ireland's six universities varied significantly (e.g. 11.5-72 hrs in nursing). Research grants awarded from state organisations were limited to one over a four-year period. No current chronic pain clinics comply with recommended International Association for the Study of Pain (IASP) guidelines.

CONCLUSION

A national strategy is needed to reduce costs, standardise teaching and increase pain clinic resources to maximise patient care.

Complex regional pain syndrome: the case for spinal cord stimulation (a brief review)

Complex regional pain syndrome is a disabling disorder with an unknown mechanism which is extremely resistant to conventional pharmaceutical and therapeutic therapies. In this paper we present the underlying theories of this disorder. We present spinal cord stimulation as an alternative to conventional interventions in the management of this disabling condition spinal cord stimulation significantly improves pain, reduces narcotic intake and improves activity levels and overall quality of life. There is now a significant body of evidence to support the utilization of spinal cord stimulation in the management of complex regional pain syndrome.

A review of technological approaches to venous ulceration

Leg ulceration is a chronic condition affecting about 1-2% of the adult population. The main causes of leg ulceration are venous hypertension, arterial insufficiency, diabetes, or a combination of these aetiologies (causes) or malignancy. Venous ulcers account for approximately 80% of all leg ulcers and are a result of venous hypertension. The current mainstay of treatment of venous ulcers is the application of graduated compression bandaging to the limb. In spite of the application of the best evidence-based therapy, healing rates for venous leg ulcers remain disappointing, at 50-70% after 12 weeks of treatment, depending on initial size and chronicity of the ulcer. Thus, a large number of ulcers are unhealed by this time, and many patients suffer from long-term leg ulceration, some remaining for years, and those that heal often recur. There is an obvious need to develop new treatments that would improve healing rates. This review provides a complete overview of the anatomy of venous circulation and the physiology pertaining to it, the pathophysiology of venous disease, the pathogenesis of ulceration, and a review of treatments currently employed in healing venous leg ulcers and their supporting evidence. The aim of this article is to encourage a fresh look at this chronic problem and stimulate ideas on how healing rates can be improved.

Osteomyelitis of the ischiopubic synchondrosis: imaging findings

Osteomyelitis of the ischiopubic synchondrosis in children is not rare and presents a diagnostic problem because of the diversity of presentation and the deceptive nature of symptoms. Radiological assessment is extremely difficult because of the variation in normal ossification on radiography and normal physiological uptake on radioisotope bone scan. We present two cases of osteomyelitis of the ischiopubic synchondrosis and describe findings on radiographs, isotope bone scan, computed tomography (CT) and magnetic resonance imaging (MRI). MRI changes have not been described in any of the case reports in the English literature. Aspiration and biopsy remain the gold standard for diagnosis. However, MRI appearances can significantly increase diagnostic confidence prior to intervention.

Efficacy of spinal cord stimulation for neuropathic pain following idiopathic acute transverse myelitis: a case report

Spinal cord stimulation (SCS) involves the electrical stimulation of dorsal structures within the spinal cord, and is the most widespread application of neurostimulation for the relief of chronic pain. Idiopathic acute transverse myelitis (IATM) is an acute monophasic lesion of the spinal cord that presents with symptoms associated with loss of cord function. The incidence of chronic pain secondary to this condition is unknown, but is considered rare. We report the efficacy of SCS for relief of severe neuropathic pain in both lower limbs secondary to IATM, which had failed to respond to conventional pain therapies.

What cost chronic pain?

Chronic non-malignant pain costs the American economy $40 billion a year. An attempt to quantify the total cost to the Irish economy of 95 patients attending a Multi-Disciplinary Pain Clinic was made. The cost to the Health Services was estimated and added to the amount of Social Welfare payments received and the lost earnings of each patient. The results indicated that the 95 patients cost 1.9 million pounds at the time of referral. A subgroup of 22 patients who were younger and unemployed, accounted for 1.5 million pounds. Allocation of resources to treat these patients is necessary.

Pain clinic attenders: an audit

An audit of the first 135 referrals to a new Multidisciplinary Pain Clinic was conducted. Demographic data, pain experience and pain effects were recorded. Chronic Non-Malignant Pain was the diagnosis found most frequently. In that group, the mean duration of pain was seven years, the mean number of surgical operations was 1.95 and the mean number of medications being consumed at the time of presentation 3.5. Impaired occupational, social and recreational functioning was noted. Twice as many women were affected as men and all educational and socio-economic groups were represented. Patient profiles were similar to data published on chronic pain patients attending the Mayo Clinic, Minnesota, USA.

ABC of emergency radiology. The ankle

The os trigonum is a common normal variant of the talus and is due to a separate ossification centre arising from the posterior tubercle. The appearance may resemble an old ununited fracture fragment. However, it is triangular, well corticated, in a classic location, and usually bilateral, which enables it to be distinguished from a fracture. Transverse, sclerotic, linear lines located at the metaphysis of growing long bones are due to short periods of growth arrest and have no clinical importance (fig 5). They may be confused with compression fractures, but again these lines are usually bilateral. Fibrous cortical defects are the most commonly seen benign lesions of long bones and are usually identified incidentally in radiographs taken for another reason. The defect is limited to the cortex, commonly found at the metaphysis, but may be located in the diaphysis as the bone grows. The lesion is well corticated (sclerotic margins) and usually does not produce signs or symptoms.

The ABC of emergency radiology. The foot

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Metabolic bone disease. Morphometry

The history of the development of radiologic morphometric techniques is traced, emphasizing their pathophysiologic background and relevance to possible therapies. The techniques are described and longitudinal and comparative studies assessed. Technical limitations of the various methods are presented.

Metastatic ependymoma of the sacrum

Ependymomas originating in the sacrum or extraspinal parasacral soft tissues are rare tumors. The majority are of the myxopapillary type and may be locally destructive. Even though metastases are not uncommon in retrosacral ependymomas, they have been rarely described in intrasacral locations. A case is reported of a large intrasacral ependymoma with metastases to several vertebrae. Radiologic and pathologic studies are presented. Treatment options are discussed.

Metastatic ependymoma of the sacrum

Ependymomas originating in the sacrum or extraspinal parasacral soft tissues are rare tumors. The majority are of the myxopapillary type and may be locally destructive. Even though metastases are not uncommon in retrosacral ependymomas, they have been rarely described in intrasacral locations. A case is reported of a large intrasacral ependymoma with metastases to several vertebrae. Radiologic and pathologic studies are presented. Treatment options are discussed.

Rheumatoid arthritis of the cervical spine: early and progressive radiographic features

One hundred thirty-three cervical spine radiographs of 50 patients with rheumatoid arthritis were examined. The patients were a representative random sample chosen from among 675 patients followed up for more than 10 years. The frequency of occurrence for each radiographic finding was correlated with the duration of rheumatoid arthritis. The six radiographic findings that occurred in 30% or more of patients with a disease duration of less than 10 years included odontoid erosions, subaxial subluxation, superficial apophyseal joint erosions, apophyseal joint sclerosis at levels C-4 through C-7, and diskovertebral joint narrowing and osteophytosis at C-4 through C-7. Familiarity with these early findings in the cervical spine may be helpful in both diagnosing and managing rheumatoid arthritis. Subaxial subluxation and superficial apophyseal joint erosions did not progressively increase in frequency with increasing duration of disease, but the other four features did. Other features that were uncommon in early disease became significantly more frequent in later decades.