1343 ADVANCE CARE PLANS (ACP) IN SECONDARY CARE: WHAT ARE THE PATIENT OUTCOMES FOLLOWING DISCHARGE FROM HOSPITAL WITH AN ACP?

Introduction

Treatment escalation plans are discussed in hospital but not always communicated to community care on discharge, leading to avoidable admissions to hospital and hospital deaths which may be not what the patient wants. The project aimed to review what happened to patients discharged from hospital with an ACP over a 12-month period.

Method

Older person service (OPS) inpatients were identified for ACP discussions, using Clinical frailty score, presence of life limiting conditions, co-morbidities, significant decline. Over a 12-month period 155 ACP's were completed using the ACP document on the Trust electronic record (EPR), including the level of appropriate care and preference for location of on-going care. On discharge copies of the ACP were sent with the patient, to their GP and the ambulance service. EPR was used to review patients up to 12 months post discharge.

Results

Of patients with an ACP; the wish of all patients was to remain out of hospital and be cared for in the community; 63% were discharged to care home setting; 19% were readmitted as inpatients (43.7% Trust OPS/no ACP readmissions); 8% of patients died before discharge; 92% of patients who died after discharged, died out of hospital (47.5% Trust OPS/no ACP deaths); 25% were still alive at 12 months. The process of completing the ACP and communicating the ACP was found to be long and not user friendly with multiple steps and needed refining.

Conclusion

ACP's offer support to facilitate patient's wishes. The use of ACP's in secondary care benefits patients on discharge, it reduces readmissions and in-hospital deaths. The current ACP document is lengthy and requires simplifying. This has led to a work group to redevelop the ACP into a more user friendly/shareable document, which will encourage on-going use of ACP's and can be adopted throughout the Trust.

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.

Ligamentum teres reconstruction: indications, technique and minimum 1-year results in nine patients

Ligamentum teres (LT) tear is a recognized cause of hip pain. Debridement of tears and capsule plication has shown satisfactory results. However, a group of patients with complete tears do not improve after debridement and physiotherapy. The purpose of this work was to describe the senior author's technique and clinical results for the early series of LT reconstructions. Retrospective analysis of prospectively collected data. Patients who underwent isolated LT reconstruction between 2013 and 2018. All the patients had previous debridement of a completely torn LT, capsule plication and rehabilitation. Patients who had any other associated procedure during LT reconstruction surgery and dysplastic acetabular features were excluded. Demographic and clinical data was reviewed. Complications, type of graft and modified Harris hip scores (mHHSs) were recorded preoperatively and at 1-year follow-up. Fifteen LT reconstructions were performed during the study period. Six were excluded (as they had additional procedures performed during surgery) and nine patients aged a mean 30 (range: 22-48) years old were included. The patients had a mean of 2 (range: 1-4) prior surgeries. At minimum 12 months (range: 12-24) 9/9 patients reported reduction of pain and instability symptoms with mHHSs of 84.2 (73.7-100) versus 51.7 (36.3-70.4) preoperatively (P = 0.00094). Three patients (of the total cohort of 15) underwent second-look arthroscopy (11-22 months after reconstruction). None of these patients underwent total hip replacement at a mean of 4 (range: 1-6) years. Arthroscopic LT reconstruction improved function and pain in patients with persistent pain and instability after resection of the LT.

Molecular epidemiology of multi- and extensively-drug-resistant Mycobacterium tuberculosis in Ireland, 2001-2014

OBJECTIVES

The primary objective of this work was to examine the acquisition and spread of multi-drug resistant (MDR) tuberculosis (TB) in Ireland.

METHODS

All available Mycobacterium tuberculosis complex (MTBC) isolates (n = 42), from MDR-TB cases diagnosed in Ireland between 2001 and 2014, were analysed using phenotypic drug-susceptibility testing, Mycobacterial-Interspersed-Repetitive-Units Variable-Number Tandem-Repeat (MIRU-VNTR) genotyping, and whole-genome sequencing (WGS).

RESULTS

The lineage distribution of the MDR-TB isolates comprised 54.7% Euro-American, 33.3% East Asian, 7.2% East African Indian, and 4.8% Indo-Oceanic. A significant association was identified between the East Asian Beijing sub-lineage and the relative risk of an isolate being MDR. Over 75% of MDR-TB cases were confirmed in non-Irish born individuals and 7 MIRU-VNTR genotypes were identical to clusters in other European countries indicating cross-border spread of MDR-TB to Ireland. WGS data provided the first evidence in Ireland of in vivo microevolution of MTBC isolates from drug-susceptible to MDR, and from MDR to extensively-drug resistant (XDR). In addition, they found that the katG S315T isoniazid and rpoB S450L rifampicin resistance mutations were dominant across the different MTBC lineages.

CONCLUSIONS

Our molecular epidemiological analyses identified the spread of MDR-TB to Ireland from other jurisdictions and its potential to evolve to XDR-TB.

Decrease in the Uptake of Seasonal Influenza Vaccine in Persons Aged 65 Years and Older In Ireland since the 2009 Influenza A (H1N1) Pdm09 Pandemic

In Ireland, there is year-on-year variation in the seasonal influenza vaccine uptake for people aged 65 years and older. We obtained aggregate vaccine uptake data (2004/05-2014/15) by area and age group and applied the 2011 relative deprivation score and GP-density by area. Using Poisson regression model, we estimated the associations between those variables and uptake before and after the 2009 pandemic. After adjusting for age, deprivation status and GP-density, overall persons aged ?65 years were less likely to receive the vaccine after the pandemic compared to before (RR=0.89, 95%CI: 0.82-0.96). Uptake increased with age; both those in the 70-74 and ?75 year age groups were more likely to receive the vaccine compared to those aged 65-69 years (RR=1.18, 95%CI:1.14-1.24; RR=1.34, 95%CI:1.28-1.39 respectively). Qualitative studies should be undertaken to explore whether changes in public perception on risks of the disease and the vaccine and/or public funding and policy influenced the uptake.

HMGCR-associated myositis: a New Zealand case series and estimate of incidence

Statins are one of the most commonly prescribed drugs in New Zealand, with 525 772 or 16.5% of the adult New Zealand population prescribed a statin between June 2013 and July 2014. While generally well-tolerated, statins are known to cause a range of muscle-related side effects, ranging from myalgia to life-threatening rhabdomyolysis. Recently, it has been recognised that in rare instances, statins can induce an immune-mediated necrotising myositis with antibodies against 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR), the enzymatic target of statins. In 2014, anti-HMGCR antibody testing was introduced to Canterbury Health Laboratories (CHL), with this being the only laboratory in New Zealand performing this test during the period of this case series. This article describes an index case and characterises the clinical features of a subsequent 12-month series. From this series, we estimated the yearly incidence of HMGCR-associated myositis at 1.7/million/year or ~1/90 000 New Zealand statin users.

The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement

The 2016 Warwick Agreement on femoroacetabular impingement (FAI) syndrome was convened to build an international, multidisciplinary consensus on the diagnosis and management of patients with FAI syndrome. 22 panel members and 1 patient from 9 countries and 5 different specialties participated in a 1-day consensus meeting on 29 June 2016. Prior to the meeting, 6 questions were agreed on, and recent relevant systematic reviews and seminal literature were circulated. Panel members gave presentations on the topics of the agreed questions at Sports Hip 2016, an open meeting held in the UK on 27-29 June. Presentations were followed by open discussion. At the 1-day consensus meeting, panel members developed statements in response to each question through open discussion; members then scored their level of agreement with each response on a scale of 0-10. Substantial agreement (range 9.5-10) was reached for each of the 6 consensus questions, and the associated terminology was agreed on. The term 'femoroacetabular impingement syndrome' was introduced to reflect the central role of patients' symptoms in the disorder. To reach a diagnosis, patients should have appropriate symptoms, positive clinical signs and imaging findings. Suitable treatments are conservative care, rehabilitation, and arthroscopic or open surgery. Current understanding of prognosis and topics for future research were discussed. The 2016 Warwick Agreement on FAI syndrome is an international multidisciplinary agreement on the diagnosis, treatment principles and key terminology relating to FAI syndrome.Author note The Warwick Agreement on femoroacetabular impingement syndrome has been endorsed by the following 25 clinical societies: American Medical Society for Sports Medicine (AMSSM), Association of Chartered Physiotherapists in Sports and Exercise Medicine (ACPSEM), Australasian College of Sports and Exercise Physicians (ACSEP), Austian Sports Physiotherapists, British Association of Sports and Exercise Medicine (BASEM), British Association of Sport Rehabilitators and Trainers (BASRaT), Canadian Academy of Sport and Exercise Medicine (CASEM), Danish Society of Sports Physical Therapy (DSSF), European College of Sports and Exercise Physicians (ECOSEP), European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), Finnish Sports Physiotherapist Association (SUFT), German-Austrian-Swiss Society for Orthopaedic Traumatologic Sports Medicine (GOTS), International Federation of Sports Physical Therapy (IFSPT), International Society for Hip Arthroscopy (ISHA), Groupo di Interesse Specialistico dell'A.I.F.I., Norwegian Association of Sports Medicine and Physical Activity (NIMF), Norwegian Sports Physiotherapy Association (FFI), Society of Sports Therapists (SST), South African Sports Medicine Association (SASMA), Sports Medicine Australia (SMA), Sports Doctors Australia (SDrA), Sports Physiotherapy New Zealand (SPNZ), Swedish Society of Exercise and Sports Medicine (SFAIM), Swiss Society of Sports Medicine (SGMS/SGSM), Swiss Sports Physiotherapy Association (SSPA).

FDG-PET imaging in hematological malignancies

The majority of aggressive lymphomas is characterized by an up regulated glycolytic activity, which enables the visualization by F-18 FDG-PET/CT. One-stop hybrid FDG-PET/CT combines the functional and morphologic information, outperforming both, CT and FDG-PET as separate imaging modalities. This has resulted in several recommendations using FDG-PET/CT for staging, restaging, monitoring during therapy, and assessment of treatment response as well as identification of malignant transformation. FDG-PET/CT may obviate the need for a bone marrow biopsy in patients with Hodgkin's lymphoma and diffuse large B cell lymphoma. FDG-PET/CT response assessment is recommended for FDG-avid lymphomas, whereas CT-based response evaluation remains important in lymphomas with low or variable FDG avidity. The treatment induced change in metabolic activity allows for assessment of response after completion of therapy as well as prediction of outcome early during therapy. The five-point scale Deauville Criteria allows the assessment of treatment response based on visual FDG-PET analysis. Although the use of FDG-PET/CT for prediction of therapeutic response is promising it should only be conducted in the context of clinical trials. Surveillance FDG-PET/CT after complete remission is discouraged due to the relative high number of false-positive findings, which in turn may result in further unnecessary investigations. Future directions include the use of new PET tracers such as F-18 fluorothymidine (FLT), a surrogate biomarker of cellular proliferation and Ga-68 CXCR4, a chemokine receptor imaging biomarker as well as innovative digital PET/CT and PET/MRI techniques.

Influenza vaccine effectiveness estimates in Europe in a season with three influenza type/subtypes circulating: the I-MOVE multicentre case-control study, influenza season 2012/13

In the fifth season of Influenza Monitoring Vaccine Effectiveness in Europe (I-MOVE), we undertook a multicentre case-control study (MCCS) in seven European Union (EU) Member States to measure 2012/13 influenza vaccine effectiveness against medically attended influenza-like illness (ILI) laboratory confirmed as influenza. The season was characterised by substantial co-circulation of influenza B, A(H1N1)pdm09 and A(H3N2) viruses. Practitioners systematically selected ILI patients to swab ≤7 days of symptom onset. We compared influenza-positive by type/subtype to influenza-negative patients among those who met the EU ILI case definition. We conducted a complete case analysis using logistic regression with study as fixed effect and calculated adjusted vaccine effectiveness (AVE), controlling for potential confounders (age, sex, symptom onset week and presence of chronic conditions). We calculated AVE by type/subtype. Study sites sent 7,954 ILI/acute respiratory infection records for analysis. After applying exclusion criteria, we included 4,627 ILI patients in the analysis of VE against influenza B (1,937 cases), 3,516 for A(H1N1)pdm09 (1,068 cases) and 3,340 for influenza A(H3N2) (730 cases). AVE was 49.3% (95% confidence interval (CI): 32.4 to 62.0) against influenza B, 50.4% (95% CI: 28.4 to 65.6) against A(H1N1)pdm09 and 42.2% (95% CI: 14.9 to 60.7) against A(H3N2). Our results suggest an overall low to moderate AVE against influenza B, A(H1N1)pdm09 and A(H3N2), between 42 and 50%. In this season with many co-circulating viruses, the high sample size enabled stratified AVE by type/subtype. The low estimates indicate seasonal influenza vaccines should be improved to achieve acceptable protection levels.

Switching clotting factor concentrates: considerations in estimating the risk of immunogenicity

The development of neutralizing antibodies to factor VIII (FVIII) is the most serious complication of therapy for haemophilia A. There is now excellent documentation that a large number of both genetic and environmental factors contribute to the risk of FVIII inhibitor incidence. One of the environmental factors that has been proposed as an influence on this complication is the occurrence of FVIII product switching. There are only a small number of clinical studies that have addressed this question, and thus, the amount of objective information available to assess this association is limited. In this review, in addition to summarizing past evidence pertinent to this subject, we present the results of a complementary strategy, a Delphi analysis, to add to the considerations of product switching and FVIII immunogenicity. With the imminent arrival in the clinic of several new FVIII products, the haemophilia community must be prepared to collect prospectively controlled data to better address this important management issue.

Low and decreasing vaccine effectiveness against influenza A(H3) in 2011/12 among vaccination target groups in Europe: results from the I-MOVE multicentre case-control study

Within the Influenza Monitoring Vaccine Effectiveness in Europe (I-MOVE) project we conducted a multicentre case–control study in eight European Union (EU) Member States to estimate the 2011/12 influenza vaccine effectiveness against medically attended influenza-like illness (ILI) laboratory-confirmed as influenza A(H3) among the vaccination target groups. Practitioners systematically selected ILI / acute respiratory infection patients to swab within seven days of symptom onset. We restricted the study population to those meeting the EU ILI case definition and compared influenza A(H3) positive to influenza laboratory-negative patients. We used logistic regression with study site as fixed effect and calculated adjusted influenza vaccine effectiveness (IVE), controlling for potential confounders (age group, sex, month of symptom onset, chronic diseases and related hospitalisations, number of practitioner visits in the previous year). Adjusted IVE was 25% (95% confidence intervals (CI): -6 to 47) among all ages (n=1,014), 63% (95% CI: 26 to 82) in adults aged between 15 and 59 years and 15% (95% CI: -33 to 46) among those aged 60 years and above. Adjusted IVE was 38% (95%CI: -8 to 65) in the early influenza season (up to week 6 of 2012) and -1% (95% CI: -60 to 37) in the late phase. The results suggested a low adjusted IVE in 2011/12. The lower IVE in the late season could be due to virus changes through the season or waning immunity. Virological surveillance should be enhanced to quantify change over time and understand its relation with duration of immunological protection. Seasonal influenza vaccines should be improved to achieve acceptable levels of protection.

A snapshot of genetic lineages of Mycobacterium tuberculosis in Ireland over a two-year period, 2010 and 2011

Mycobacterial interspersed repetitive-unit-variable-number tandem repeat typing alone was used to investigate the genetic lineages among 361 Mycobacterium tuberculosis strains circulating in Ireland over a two-year period, 2010 and 2011. The majority of isolates, 63% (229/361), belonged to lineage 4 (Euro-American), while lineages 1 (Indo-Oceanic), 2 (East-Asian) and 3 (East-African–Indian) represented 12% of isolates each (42/361, 45/361, and 45/361, respectively). Sub-lineages Beijing (lineage 2), East-African–Indian (lineage 1) and Delhi/central-Asian (lineage 3) predominated among foreign-born cases, while a higher proportion of Euro-American lineages were identified among cases born in Ireland. Eighteen molecular clusters involving 63 tuberculosis (TB) cases were identified across four sub-lineages of lineage 4. While the mean cluster size was 3.5 TB cases, the largest cluster (involving 12 Irish-born cases) was identified in the Latin American–Mediterranean sub-lineage. Clustering of isolates was higher among Irish-born TB cases (47 of 63 clustered cases), whereas only one cluster (3/63) involved solely foreign-born individuals. Four multidrug-resistant cases identified during this period represented lineages 2 and 4. This study provides the first insight into the structure of the M. tuberculosis population in Ireland.

A pain in the neck--a review of deep space neck infections in the emergency department

We report a case of prevertebral abscess in a 37-year-old male, presenting with a 2-day history of neck pain radiating to the right shoulder. We also review the current literature relating to the presentation and the emergency management of deep neck space infections.

First reported cases of human adenovirus serotype 14p1 infection, Ireland, October 2009 to July 2010

We report the first nine confirmed cases of human adenovirus 14p1 infection (HAdV-14p1), identified at different locations in Ireland between October 2009 and July 2010. These were the first notifications in Ireland and all were sporadic cases. Following these notifications, the Health Protection Surveillance Centre set up an enhanced surveillance system for HAdV-14p1 infection. Seven cases were male and five were aged less than one year. Three patients died, giving a case fatality rate of 33%. It should be noted that cases presented here were diagnosed on presentation to hospital and may represent the severe end of the spectrum of HAdV 14 disease in Ireland.

Arthroscopic femoral osteochondroplasty for cam lesions with isolated acetabular chondral damage

This study evaluates the outcome of arthroscopic femoral osteochondroplasty for cam lesions of the hip in the absence of additional pathology other than acetabular chondral lesions. We retrospectively reviewed 166 patients (170 hips) who were categorised according to three different grades of chondral damage. The outcome was assessed in each grade using the modified Harris Hip Score (MHHS) and the Non-Arthritic Hip Score (NAHS). Overall, at the last follow-up (mean 22 months, 12 to 72), the mean MHHS had improved by 15.3 points (95% confidence interval (CI), 8.9 to 21.7) and the mean NAHS by 15 points (95% CI, 9.4 to 20.5). Significantly better results were observed in hips with less severe chondral damage. Microfracture in limited chondral lesions showed superior results. Arthroscopic femoral osteochondroplasty for cam impingement with microfracture in selected cases is beneficial. The outcome correlates with the severity of acetabular chondral damage.

Solvent–detergent plasma as replacement therapy in a pregnant patient with factor V deficiency

This case illustrates the successful treatment of factor V deficiency in pregnancy using solvent-detergent plasma.

Surveillance of the first 205 confirmed hospitalised cases of pandemic H1N1 influenza in Ireland, 28 April - 3 October 2009

From 28 April 2009 to 3 October 2009, 205 cases of confirmed pandemic H1N1 influenza were hospitalised in Ireland. Detailed case-based epidemiological information was gathered on all hospitalised cases. Age-specific hospitalisation rates were highest in the age group of 15 to 19 year-olds and lowest in those aged 65 years and over. Nineteen hospitalised cases (9%) were admitted to intensive care units (ICU) where the median length of stay was 24 days. Four hospitalised cases (2%) died. Fifty-one percent of hospitalised cases and 42% of ICU cases were not in a recognised risk group. Asthma was the most common risk factor among cases; however, people with haemoglobinopathies and immunosuppression were the most over-represented groups.

Enhanced surveillance of initial cases of pandemic H1N1 2009 influenza in Ireland, April-July 2009

From 28 April to 18 July 2009 there were 156 cases of pandemic H1N1 2009 influenza confirmed in Ireland. During this time, Ireland was in containment phase, and detailed case-based epidemiological information was gathered on all cases presenting in the community and acute health care setting. Active case finding was performed among contacts of cases. Eighty percent of cases were in people less than 35 years of age and 86% were imported. The most frequent symptoms were fever, sore throat, myalgia and dry cough. Nine people were hospitalized, no fatalities occurred.

Arthroscopic excision of a giant-cell tumour of the ligamentum teres

Primary giant-cell tumour of soft tissue arising in the ligamentum teres has not been previously described. We report a case of such a tumour in a 46-year-old woman. The lesion was only detected at the time of hip arthroscopy despite pre-operative MRI being performed. It was successfully excised arthroscopically with resolution of the symptoms.

Activated protein C resistance, factor V Leiden and assessment of thrombotic risk

Venous thromboembolism comprises deep vein thrombosis (DVT) and pulmonary embolism (PE). Acute venous thromboembolism (VTE) is a serious and potentially fatal disorder which often complicates the course of hospitalized patients, but also affects ambulatory and otherwise healthy people. The annual incidence of venous thromboembolism is 1 to 2 cases per 1000 person and the risk of the disorder rises exponentially with age, from an annual rate of less than 5 per 100,000 children to greater than 400 per 100,000 adults older than 80 years.

The temporal relationship between erectile dysfunction and cardiovascular disease

BACKGROUND

Erectile dysfunction (ED) and cardiovascular disease (CVD) share similar risk factors, and ED may be a marker of CVD progression. The study assessed: (i) the temporal relationship between ED and CVD and (ii) the UK incidence of ED, in patients with CVD and an age-matched control group.

DESIGN

After ethics approval, 207 patients (CVD group) attending cardiovascular rehabilitation programmes and 165 age-matched subjects (control group), from GP practices across the UK, completed up to four questionnaires [ED details, The International Index of Erectile Function (IIEF) (before and after a cardiovascular event) and ED related Quality of Life]. A health professional also completed a medical details questionnaire.

RESULTS

Erectile dysfunction was reported by 66% of individuals with CVD, with a mean duration of 5 +/- 5.3 years. The control group was significantly different (p < 0.05) in both incidence (37%) and mean duration (6.6 +/- 6.8 years). Only 53% of the CVD group and 43% of the control group had discussed their symptoms of ED with a health professional. The IIEF demonstrated that ED became significantly worse (p < 0.05) after a cardiovascular event, changing from moderate to severe (13-10).

CONCLUSIONS

From these data, it is now evident that ED may precede a cardiovascular event by as much as 5 years. In almost half of the men with ED, there were missed opportunities to undertake a CVD risk assessment and provide an intervention, because the men did not acknowledge the problem. Men with ED should be specifically targeted for CVD preventative strategies in terms of lifestyle changes, and appropriate pharmacological treatments.

Effect of repeated administration of clenbuterol on the regulation of beta-adrenoceptors in the central nervous system of the rat

The effect of the centrally acting beta-adrenoceptor agonist clenbuterol on beta-adrenergic responsiveness, beta-receptor density and N-protein coupling was studied in the rat cerebral cortex (which contains primarily beta 1-receptors) and cerebellum (containing mostly beta 2-receptors). The objective was to determine whether clenbuterol's effect on these variables was similar to that produced by standard antidepressants. When given to rats repeatedly, clenbuterol caused a decrease in beta-adrenergic responsiveness in slices from either the cerebral cortex or the cerebellum. The decreased beta-responsiveness in the cerebellum was associated with a decrease both in the density of beta-receptors and in receptor/N-protein coupling. In the cortex, only reduced receptor/N-protein coupling was observed by in vitro ligand-binding methods. However, when quantitative autoradiography was employed, clenbuterol treatment was found to reduce the binding of [125I]iodopindolol to beta 2-receptors throughout the brain, whereas binding to beta 1-receptors was not reduced. The down-regulation of beta 2-receptors by clenbuterol is due to its acting centrally as a beta 2-agonist. Although clenbuterol has about an equal affinity for beta 1-receptors and beta 2-receptors, no evidence was found for agonist activity of this drug at beta 1-receptors in the cerebral cortex. The strategies described here should be helpful in investigating important properties of centrally acting beta-agonists that might have potential as antidepressants.

Audit of pneumocystis pneumonia in patients seen by the Christchurch Hospital rheumatology service over a 5-year period

AIM

The aim of the study was to review all cases of Pneumocystis carinii pneumonia (PCP) in patients seen by the Christchurch Hospital Rheumatology service over a 5-year period and to determine the annual incidence of PCP.

METHODS

The Canterbury Health Laboratory database was searched for rheumatology patients testing positive for PCP from 31 December 2000 to 31 December 2005. The rheumatology database was then searched to identify patients receiving the same immunosuppressant medication as those who developed PCP to determine the annual incidence of PCP in this group.

RESULTS

Four rheumatology patients were diagnosed with PCP during the 5-year period. Two were receiving oral methotrexate (MTX) for rheumatoid arthritis and two were receiving cyclophosphamide (CYC), one each for Wegener's granulomatosis and dermatomyositis. None of the four cases was receiving PCP chemoprophylaxis. Five hundred and forty-seven patients commenced MTX over the same 5-year period and 47 commenced CYC. Only 14 of 47 (29.7%) CYC-treated patients received PCP prophylaxis. The annual incidence of PCP was 0.17% (95% confidence interval (CI) 0.02-0.63) and 5.33% (95%CI 0.65-19.24) in patients prescribed MTX and CYC, respectively. For the 33 patients receiving CYC without concomitant PCP prophylaxis the annual incidence was 9.50% (95%CI 1.15-34.33).

CONCLUSION

In our study the annual incidence of PCP in patients taking MTX was low and would not support the use of routine PCP chemoprophylaxis. In patients receiving CYC without concomitant PCP chemoprophylaxis the annual incidence of PCP was higher although the number of cases was small. Given the high morbidity and mortality in this group, PCP chemoprophylaxis should be considered.

Genomic DNA pooling for whole-genome association scans in complex disease: empirical demonstration of efficacy in rheumatoid arthritis

A pragmatic approach that balances the benefit of a whole-genome association (WGA) experiment against the cost of individual genotyping is to use pooled genomic DNA samples. We aimed to determine the feasibility of this approach in a WGA scan in rheumatoid arthritis (RA) using the validated human leucocyte antigen (HLA) and PTPN22 associations as test loci. A total of 203 269 single-nucleotide polymorphisms (SNPs) on the Affymetrix 100K GeneChip and Illumina Infinium microarrays were examined. A new approach to the estimation of allele frequencies from Affymetrix hybridization intensities was developed involving weighting for quality signals from the probe quartets. SNPs were ranked by z-scores, combined from United Kingdom and New Zealand case-control cohorts. Within a 1.7 Mb HLA region, 33 of the 257 SNPs and at PTPN22, 21 of the 45 SNPs, were ranked within the top 100 associated SNPs genome wide. Within PTPN22, individual genotyping of SNP rs1343125 within MAGI3 confirmed association and provided some evidence for association independent of the PTPN22 620W variant (P=0.03). Our results emphasize the feasibility of using genomic DNA pooling for the detection of association with complex disease susceptibility alleles. The results also underscore the importance of the HLA and PTPN22 loci in RA aetiology.

Primary thromboprophylaxis for cancer patients with central venous catheters--a reappraisal of the evidence

Venous thromboembolism (VTE) is responsible for an estimated 25 000 deaths per annum in UK hospital practice. It is well established that many of these deaths could be prevented through the use of appropriate thromboprophylaxis. This issue is of particular relevance in oncology practice, where the risks of VTE and bleeding are both significantly higher than those observed in general medical patients. Cancer patients with in-dwelling central venous catheters (CVCs) are at particularly high risk of developing thrombotic complications. However, the literature has produced conflicting conclusions regarding the efficacy of using routine primary thromboprophylaxis in these patients. Indeed such is the level of confusion around this topic, that the most recent version of the American College of Chest Physicians (ACCP) guidelines published in 2004 actually reversed their previous recommendation (published in 2001). Nevertheless, minidose warfarin continues to be routinely used in many oncology centres in the UK. In this article, we have performed a systematic review of the published literature regarding the efficacy and the risks, associated with using thromboprophylaxis (either minidose warfarin or low-dose LMWH) in cancer patients with CVC. On the basis of this evidence, we conclude that there is no proven role for using such thromboprophylaxis. However, asymptomatic CVC-related venous thrombosis remains common, and further more highly powered studies of better design are needed in order to define whether specific subgroups of cancer patients might benefit from receiving thromboprophylaxis.

Prevention and Management of Venous Thromboembolism in People with Cancer: A Review of the Evidence

Venous thromboembolism (VTE) constitutes an important health problem in developed countries. Owing to their underlying malignancies, people with cancer are at particularly high risk of VTE. The level of this risk is influenced by several factors, including type of cancer and the presence or absence of metastases. However, different types of oncology treatment can also further increase the thrombotic risk. Consequently, primary and secondary thromboprophylaxis in people with cancer should be considered as part of any integrated oncology treatment. Moreover, recent exciting studies have suggested that low molecular weight heparins (LMWH) may also influence overall survival in people with cancer. Clearly, these findings raise the likelihood that the use of LMWH in oncology practice may increase significantly in the near future. However, it is important to appreciate that the use of thromboprophylaxis in people with cancer is complicated by a number of specific problems. In this overview, we have systematically addressed the difficult clinical issues that are involved in the selection of appropriate primary and secondary thromboprophylaxis for people with cancer.

Improving Clinical Practice: Should We Give Influenza Vaccinations to Heart Transplant Patients?

BACKGROUND

Current practice recommends that immunosuppressed patients (pts) receive yearly influenza (flu) vaccinations. However, disparity exists between current recommendations and clinical practice regarding the decision to administer flu vaccinations to heart transplant (Tx) pts. The purpose of this study was to examine the common clinical practices and outcome characteristics in Tx pts in a multi-institutional database. We assess the incidence of rejection, infection and flu in the months after administration of flu vaccinations.

METHODS

Between 1990 and 2001, 5,581 pts underwent Tx at 28 institutions. Pts who were >1 year post-Tx as of January 1, 2002 (N = 3,601) constituted the study group.

RESULTS

During the years 2002 and 2003, 89% of the institutions administered flu vaccines, with 7 institutions requiring pts to be >3 months (N = 1), 6 months (N = 1) and 12 months (N = 5) post-Tx. All 25 centers that vaccinated pts used trivalent inactivated vaccines during the months of October through January. Three centers did not vaccinate Tx pts due to a purported association with increased allograft rejection. There were no significant differences in the total number of rejection episodes (0.4% vs 0.3%, p = 0.7), rejection episodes by month (January: 0.4% vs 0%, p = 0.2; February: 0.5% vs 1.5%, p = 0.08; March: 0.5% vs 0%, p = 0.14), all infections (0.7% vs 0.6%, p = 0.6) and viral infections (0.1% vs 0%, p = 0.17) between centers that administered flu vaccines and those that did not, respectively. The incidence of flu was low in both groups.

CONCLUSIONS

Flu vaccinations can be given safely to heart transplant pts without an increased incidence of rejection or infection. This information provides clinicians with data to improve clinical practice.

Warfarin, hematoma expansion, and outcome of intracerebral hemorrhage

BACKGROUND

Warfarin increases mortality of intracerebral hemorrhage (ICH). The authors investigated whether this effect reflects increased baseline ICH volume at presentation or increased ICH expansion.

METHODS

Subjects were drawn from an ongoing prospective cohort study of ICH outcome. The effect of warfarin on baseline ICH volume was studied in 183 consecutive cases of supratentorial ICH age > or = 18 years admitted to the emergency department over a 5-year period. Baseline ICH volume was determined using computerized volumetric analysis. The effect of warfarin on ICH expansion (increase in volume > or = 33% of baseline) was analyzed in 70 consecutive cases in whom ICH volumes were measured on all subsequent CT scans up to 7 days after admission. Multivariable analysis was used to determine warfarin's influence on baseline ICH, ICH expansion, and whether warfarin's effect on ICH mortality was dependent on baseline volume or subsequent expansion.

RESULTS

There was no effect of warfarin on initial volume. Predictors of larger baseline volume were hyperglycemia (p < 0.0001) and lobar hemorrhage (p < 0.0001). Warfarin patients were at increased risk of death, even when controlling for ICH volume at presentation. Warfarin was the sole predictor of expansion (OR 6.2, 95% CI 1.7 to 22.9) and expansion in warfarin patients was detected later in the hospital course compared with non-warfarin patients (p < 0.001). ICH expansion showed a trend toward increased mortality (OR 3.5, 95% CI 0.7 to 8.9, p = 0.14) and reduced the marginal effect of warfarin on ICH mortality.

CONCLUSIONS

Warfarin did not increase ICH volume at presentation but did raise the risk of in-hospital hematoma expansion. This expansion appears to mediate part of warfarin's effect on ICH mortality.

Management of patients undergoing splenectomy in an Irish teaching hospital: impact of guidelines

INTRODUCTION

Overwhelming post-splenectomy infection (OPSI) has a 50-70% mortality rate and carries a lifetime risk for the asplenic patient. Specific British guidelines have been developed to reduce its incidence.

AIMS

To determine whether British guidelines were being followed in our own institution and what impact they had on overwhelming post-splenectomy infection.

METHODS

Retrospective chart review of 100 splenectomies performed by Department of Surgery, Beaumont Hospital from January 1990 to January 2000.

RESULTS

Twenty per cent of patients were discharged without any recommended vaccinations. Prophylactic antibiotics were not prescribed in 53% of patients. Just 12% of charts document a verbal explanation of the complications and management of asplenia to the patient. Overall septic mortality was 12%, of whom 8% died in hospital and 4% after discharge.

CONCLUSION

Management of the asplenic patient has improved but is far from complete. A central register of asplenic patients and national asplenic guidelines should be established in Ireland to ensure optimum patient care.

Never forget the risks of immunosuppression

It has been widely reported in the literature that malignant neoplasms are a recognised complication of immunosuppression following organ transplantation. These days, immunosuppressive drugs are being used for many conditions outside the transplant setting. A case of a de novo astrocytoma in a patient on long-term immunosuppression for psoriatic arthritis is described.

Neuronal and inducible nitric oxide synthase expressions and activities in the hippocampi and cortices of young adult, aged cognitively unimpaired, and impaired Long-Evans rats

Nitric oxide (NO) is a neurosignaling molecule that appears to play a significant role in learning and memory. This molecule has also been implicated in neurotoxicity due to its oxidative properties. Previous experiments from our laboratories have demonstrated elevated hippocampal and cortical neuronal nitric oxide synthase (NOS) mRNA levels in aged cognitively unimpaired and impaired Long-Evans rats, which could represent either increased neuronal NOS activity thereby leading to NO-mediated neurotoxicity, or a compensatory response by aged neurones to maintain physiological nitric oxide output. The current study measured the protein expression and activity levels of neuronal and inducible NOS in young adult (6 months) and aged (24-26 months) Long-Evans rats by means of western blotting and NOS activity assay. Aged animals were assigned as either cognitively unimpaired or aged with moderate cognitive impairments based on their performances in the Morris water maze behavioural task. Our results showed that hippocampal and cortical neuronal NOS expressions were significantly decreased in aged animals. These aged animals also exhibited increased hippocampal and cortical inducible NOS expressions. Between the two aged animal groups, cognitively impaired rats showed significantly lower hippocampal and cortical neuronal but higher hippocampal inducible NOS expressions. Young adult rats exhibited significantly higher hippocampal and cortical NOS activities than the aged animals. Aged animals with cognitive deficits showed significantly lower hippocampal NOS activity than cognitively unimpaired aged rats. Our data indicate that aging is associated with a decline in neuronal but elevated inducible NOS functioning in brain areas involved in learning and memory. These phenomena could contribute to the cognitive deficits observed in a sub-population of aged animals.