Journal of Medical Students, Galway: Fourth Volume, 2018

CHAMPIONING STUDENT RESEARCH

Volume No. 4 | SPRING 2018

MEDICAL INNOVATION Foreword by Ms. Carmel Malone Further insight by Professor Tim O’Brien

UNIVERSAL TRUTHS AND THE FUTURE OF MEDICINE Observations by forensic physician and writer Dr. Roger Derham

STUDENT ENCOUNTERS Clinical experiences in Germany and Japan A rare case of pneumoperitoneum

JMSG JOURNAL OF MEDICAL STUDENTS, GALWAY

Volume no. 4 | SPRING 2018

Cover image: Glycosignature of nucleus pulposus in degenerated intervertebral disc stained with Ulex Europaeus Agglutinin I plant lectin (green) with DAPI counterstain (blue). Joyce K, Isa ILM, Creemers L, Pandit A

Copyright Š 2018 Journal of Medical Students, Galway School of Medicine, Clinical Sciences Institute, National University of Ireland, Galway, Ireland ISSN (Print): 2018-728X ISSN (Online): 2018-7298 Printed and bound in Co. Galway, Ireland by PrintThat.

The content published in this journal is entirely the responsibility of a student organisation, supervised by the Faculty of Medicine at the Clinical Sciences Institute, and operates independently from the National University of Ireland, Galway (NUI Galway). The opinions expressed do not necessarily reflect those of the University or University Hospital Galway. NUI Galway shall not be held liable for any damages resulting directly or indirectly from the use or misuse of the published content.

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Volume no. 4 | SPRING 2018

JMSG | CONTENTS 4 Foreword by Prof. Kerin, Vice-Dean of the School of Medicine, NUI Galway 7 JMSG Committee, Messages from the Director and Editor-in-Chief

Abstracts 8 Healing the Healer: A Qualitative Study on Medical Student Burnout 9 Mild traumatic brain injury biomarkers and testing methods for point-of-care assessment 10 Tumour conditioned stromal cells secrete high levels of IL-10 and low levels of GM-CSF which is associated with the induction of a pro-tumorigenic …...macrophage phenotype 11 Retrospective Clinical Audit of Carotid and Vertebral Artery Dissection in a Tertiary Referral Hospital 12 New toys for the neurologist: application of sensor technology for monitoring Parkinson’s disease 13 Factors affecting time to reach target in patients with early rheumatoid arthritis (ERA): An observational cohort study 14 Can triage nurses accurately predict admissions and discharges?

15 Glycosignature in healthy and degenerated human intervertebral disc 16 Analysis of H2AX protein abundance in luminal breast cancer 17 Apparent Treatment Resistant Hypertension – a Feasibility Study 18 Comparison of the Effects of Infliximab on IL-1β Production 19 The changing role of prostate specific antigen (PSA) measurements in the assessment of suspected prostate cancer 20 A study of the correlation between the verbal Months Backwards Test (MBTv) and a novel computerised version (MBTc) 21 Knowledge, attitudes and behaviours (KAB) of medical students towards sexual health 22 Neutrophil to Lymphocyte Ratio (NLR) in Luminal A Breast Cancers: Relationship with Oncotype DX score 23 Transcatheter Tricuspid Valve Intervention – Is There a Clinical Need?

24 Hippocampal Connectivity Implicated in Sleep Disruption in Bipolar Disorder 25 Unplanned Re-operation and Interventional Radiology Post-Appendicectomy: A Meta-Analysis 26 Exploring the attitudes and barriers to Home Haemodialysis in end-stage kidney disease patients 27 Cord blood lymphocyte count as a potential screening tool for Severe Combined Immunodeficiency 28 Investigations in Bone Morphometry and Bone Mineral Density Distribution among Osteoarthritic, Osteoporotic, and Type 2 Diabetic Patients 29 Development of Discrete Choice Experiment to determine patient’s preferences for the treatment of prostate cancer: a focus group discussion.

30 The Road to Consultancy – What It Takes to Get to the Top 31 Different forms of resilience- a key predictor of functioning and potential therapeutic target for those with chronic mental illness

Case Reports 32 A Case of Foot in Mouth: fibular free flap reconstruction of the mandible using custom virtual surgical planning 36 The Dangers of a Rolling Stone

Editorials 38 Gardasil Vaccine and Human Papilloma Virus 41 NASA, NEEMO and Telemedicine

Student Experiences 44 AFMC and AMSI: Acronyms for an amazing summer 46 My WHO Europe Internship Experience

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JMSG | WELCOME Foreword — Patient Safety, Medical Training and our Healthcare Systems Prof. Michael J Kerin Vice Dean of the School of Medicine, NUI Galway Hospitals can be very dangerous places and the concept that

guidelines and enhance quality improvement measures across

patients are at much greater risk in hospitals than at home is

Hospital Groups.

absolutely correct. The scale of medical error in the western

environment of discussing and learning from adverse events or

world is enormous and is exemplified by the finding that in the

outcomes. Open disclosure is a HSE implemented national

USA, 440,000 people die every year from errors, injuries,

policy on open communication with patients when things go

accidents or infections that occur during their hospital stay. This

wrong in healthcare. It is a critical component of professional

problem is not confined to the USA and improving the quality of

practice and the improvements in healthcare agenda, with the

care has become a priority for healthcare providers and now

purpose of learning from the experience and ensuring that any

affects how we practice in all countries around the globe. This

learning points are implemented to prevent a recurrence if

risk of medical error to hospitalised patients has implications for

possible.

Institutions and Healthcare Providers and especially for individuals practising medicine.

In the UK, all hospitals are

monitored according to CQC (Core Quality Commission) guidelines and in this country the Health Information and Quality Authority (HIQA) address patient safety issues including infection control and cleanliness, in addition to defining standards for safer healthcare services.

Recent examples of mass process improvement to combat

It incorporates the “open disclosure”

“Lessons and systems adapted from the airline industry are being increasingly applied to medical and surgical training.”

These include critical incident reporting, near miss analysis and simulated task and team-based training.”

errors and medical misadventure include reduction in residents’ working hours in the USA, the implementation of the European

It is thought to reduce litigation and improve consumer

Working time directive limiting trainee working hours in Europe,

confidence in healthcare providers. The principles of open

and the implementation of a patient safety checklist by the

disclosure are laudable but in some circumstances such as

World Health Organisation (WHO) to reduce the number and

emergency surgery where the reasons for imperfect outcomes

scale of systems errors and increase safe surgery worldwide. All

are complex and multidimensional, the effect of open disclosure

of these developments have been introduced with a view to

can be to disincentivise and direct young doctors to a less

increase the safety of hospital practice and improve outcome for

onerous and more predictable environment. The same learning

patients. Lessons and systems adapted from the airline industry

and system improvement can come from well-run morbidity and

(where it is proven that human factors contribute to crashes in

mortality meetings and the personal and institutional/team

every case) are being increasingly applied to medical and surgical

resilience required to cope with imperfect outcomes are

training. These include critical incident reporting, near miss

enhanced by encounters such as Schwartz rounds (very

analysis and simulated task and team-based training.

successfully implemented in GUH), which can evoke personal

These

activities have been part of pilot training culture for decades with consequent documented.

improvements They

are

in now

outcome applied

and in

the

safety

well

healthcare

“Declare the past, diagnose the present, Theforetell Quality the and Patient Agenda is now part of future”Safety - Hippocrates environment.

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and emotional supports and shared insights.

Patient care needs to be delivered by competent teams in a safe and effective hospital environment. The concept of a safety rating for Hospitals is now being implemented across a broad range of

the

International Institutions with different rates and scales. In the

Standard Operating procedures for all healthcare providers in

USA, the insurers who pay for healthcare rate hospitals A – F on

this country. It aims to standardise processes, procedures and

how safe they keep their patients from errors, injuries, accidents Volume no. 4 | SPRING 2018

JMSG | WELCOME and infections. These ratings can be based on the quality of the

patient safety, resident wellbeing and education. The Royal

recruited staff working in the hospital (e.g. do specialists care for

College of Physicians and Surgeons of Canada performed a major

patients in the ICU); surgical site infections after colon surgery,

meta-analysis of all of the issues related to restricted duty hours

practices to prevent error and rates of MRSA colonisation in the

and confirmed improvement in resident wellness but worryingly

ICU. The practice is based on the terms “what you measure, you

suggested that there was a decline in patient safety mainly due to

implement”, and has catalogued improvements in medication

reduced continuity of care and increased number of handovers

error year by year.

[2]. This relatively new phenomenon (handover) is particularly

Surgery remains a mainstay of patient care but by its nature is associated with morbidity and mortality. Like all clinical activities there is a realisation that surgery can be made safer and the relatively universal application of a Surgery Safety Checklist has occurred across the world in the past decade. This checklist now forms an essential component of surgical practice and is done in 3 phases: before anaesthesia, at the time of incision and before the patient leaves the operating theatre. Evidence that the World Health Organisation checklist works across a range of hospitals in a variety of countries of different economic status was first published in the New England Journal of Medicine in 2009 [1] and demonstrated a reduction in hospital mortality (1.5% to 0.8%) and in hospital morbidity (11% to 7%).The Safe Surgery checklist involves simple factors including oral confirmation of patient’s identity, use of pulse oximetry and routine documentation and use of prophylactic antibiotics and risk of major blood loss. Most hospitals around the world have now adopted and routinely implemented a version of the checklist with consequent significant improvement in patient outcome.

“The Safe Surgery checklist involves simple factors including oral confirmation of patient’s identity, use of pulse oximetry and routine documentation and use of prophylactic antibiotics and risk of major blood loss.”

challenging in surgery where identification of signs of clinical deterioration leading to early intervention in patients with sepsis or bleeding saves patients from serious consequences. These short term and subtle signs are readily evident to an experienced clinician who has observed the natural history of similar situations and is in the habit of carefully monitoring patients during their entire hospital course. Providing a similarly safe situation for the patient with a team-based approach will demand careful oversight and monitoring to ensure that learning opportunities are not lost to the trainees but especially that patient outcomes are not negatively impacted.

“Providing a similarly safe situation for the patient with a team-based approach will demand careful oversight and monitoring to ensure that learning opportunities are not lost to the trainees but especially that patient outcomes are not negatively impacted.”

Healthcare systems have introduced applied patient safety and simulation systems to modernise and develop an appropriate approach encapsulating what is best in the airline industry and other systems to train and develop doctors of the future. At NUI Galway, the Irish Centre for Applied Patient Safety and Simulation is leading the way in research and education in this system to cope with the major issues in Irish healthcare at the present time. The real difficulty with quality improvement and

The reduction in residents’ working hours in the USA resulted from the perception that the death of a young woman, Libby Zion, in a New York hospital was contributed to by resident fatigue. The reduction in resident hours was expected to improve

safety in the national programmes at the moment lie with the mismatch between demand and capacity due to the aging population, the lack of appropriate community access to diagnostics and primary care facilities, the competition between emergency and elective patients for the same beds, poor access

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JMSG | WELCOME to diagnostics tests outside of the hospital setting and poor step down and rehab facilities. We have a suboptimal infrastructure for healthcare delivery with the constant trolley crisis, the relatively unfit for purpose hospital environment with shared toilet facility in an era of hospital acquired infections etc. The challenge will be to adapt the system to cope with the major issues in Irish healthcare at the present time.

Our traditional system which has been productive in recruiting and training doctors has been replaced by a new system where the art of the perfect handover can seem more worthy than the system of team-based continuity of care. The difficulty in creating a rich clinical experience from caring for multiple patients in a complex team environment with twice daily ward rounds, senior supervision, mentorship and direction has been replaced by environments involving simulated handover, simulated patients and shift work. We will need to apply science, art and audit to ensure that modern day complexity will lead to improved outcomes in a safe environment for patients.

Professor Michael J Kerin is the Chair of Surgery and Vice Dean of Medicine at the National University of Ireland, Galway. As Consultant Surgeon he has a special interest in breast cancer and endocrine surgery. Professor Kerin is the Director of the Lambe Institute for Translational Research, Research Director of Breast Cancer Research and co-investigator of numerous other cancer research initiatives. He leads the Cancer Strategy Group for the Saolta University Healthcare Group Cancer Centre. Professor Kerin’s research interests include molecular profiling in cancer, cancer risk prediction, cellular interactions in the cancer microenvironment and emerging methods for breast cancer diagnosis and management.

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References

2. Ahmed N et al. A systematic review of the effects of resident duty hour

1. Haynes AB et al, A Surgical Safety Checklist to Reduce Morbidity and

restrictions in surgery: impact on resident wellness, training and patient

Mortality in a Global Population. N Engl J Med 2009: 360; 491-499

outcomes. Ann Surg 2014: 259 (6); 1041-53

Volume no. 4 | SPRING 2018

JMSG | WELCOME Message from the Director “Medicine is a science of uncertainty and an art of probability” -Sir William Osler I am delighted to present the fourth edition of JMSG. The theme of the journal this year is ‘Safety in Medicine.” This journal includes contributions from medical students from each year, as well as contributions from eminent Professors and lecturers at NUI Galway.

am pleased to leave this journal in the capable hands of Niamh Lang and Maggie Frere. I would also like to thank Ms. Carmel Malone for her continued championing of this journal, and for her role in helping to solidify JMSG as a permanent fixture at NUI Galway.

I hope you enjoy the contents of this publication.

I am pleased to include articles which address the reduction in the uptake of the HPV vaccine, and how we can learn from expertise in telemedicine applied at NASA to improve patient monitoring and safety.

I would like to thank our dedicated student committee and staff reviewers for their role in preparing the journal for publication. I have enjoyed my tenure as Director and former Editor-in-Chief of JMSG, and I

Editorial Board Margaret Frere Kieran Joyce Evelyn Fennelly Staff Reviewers Professor John Morrison Professor Gerard Flaherty Professor Matthew Griffin Professor Francis Finucane Dr. Brian Hallahan Dr. Dara Cannon Ms. Gloria Avalos Ms. Dibyangana (Dana) Bhattacharyya

Copy Editors Alan Keane Martin Mulligan Hasan Ashkanani Idy Udoeyop Siti Mardhiah Public Relations Diana Alrumhí Salar Daud Artistic Editors Salar Daud Kieran Joyce

Aisling McCarthy Director JMSG 2017-2018

Margaret Frere Editorial Board

Evelyn Fennelly Editorial Board

Message from the Editor-in-Chief Undergraduate research is recognised as a way of cultivating the skills and attitudes that are necessary for future professional practice of evidencebased medicine. Vital among these skills is the communication and dissemination of research results.

JMSG proudly continues to provide a platform to showcase the hard work that students have undertaken with the aim of contributing to and advancing medical knowledge.

As editor-in-chief, I was excited to oversee our largest committee to date, which enabled each submission to be reviewed with increased rigor.

The breadth of submissions received this year have enabled us to publish pieces as wide-ranging as a case report about custom virtual surgical planning in maxillofacial surgery, to a

student’s experience of an elective spent developing public health strategies.

I would like to echo our Director in thanking the committee and all staff and student contributors. Without your work, this edition of JMSG would not have been possible.

Idy Udoeyop Copy Editor

Alan Keane Copy Editor

Missing from photos: Kieran Joyce, Martin Mulligan, Hasan Ashkanani, Siti Mardhiah, Diana Alrumhí

Niamh Lang Editor-in-Chief JMSG 2017-2018

Salar Daud Public Relations & Artistic Editor

Please email comments and/or questions to contact@jmsgalway.com, visit our website at www.jmsgalway.com and join our Facebook page.

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JMSG | ABSTRACT Healing the healer: a qualitative study on medical student burnout Al-Imari, H.1, Do, K.2, Brubaker-Zehr, E.2, Abdul-Fattah, S.1, Amaladoss, N.3 1 School of Medicine, NUI Galway, Ireland 2 University of Toronto, Canada 3 Department of Psychiatry, McMaster University, Canada

Introduction Burnout phenomenon has objectively been described as emotional exhaustion, depersonalization and a decreased sense of accomplishment1. Amongst medical students experiencing burnout, it has been associated with impaired academic performance, academic dishonesty, cynicism, and increased substance use2. The objective assessment of burnout in medical students has been investigated extensively in various nations in terms of the prevalence and associated causes of burnout.

However, the subjective perspective of medical students on burnout has hardly been investigated.

Aim This interview-structured study examined the views of medical students training in Canada and Ireland on burnout. In addition, it attempts to distinguish between pre-clinical and clinical medical students, as well as Canadian-trained and Irish-trained medical students.

Methods A qualitative interview-structured study on 6-8 medical students studying in Canada and Ireland was conducted. Students were selected at varying stages of their medical education.

Interviews were semi-structured and contained standardized open-ended questions. A total of 10 questions examining the definition, determinants, stigma, prevention, and management of burnout were asked. In addition, the students’ perspectives about help -seeking, the responsibilities, and initiatives or services of their medical school on burnout were investigated.

Informed consent and ethical approval were obtained. Research assistants, who are also

medical students, conducted the interviews. All interviews were audio-recorded, then transcribed verbatim, and manually coded for common themes using a thematic analysis.

Results Medical students defined burnout as “physical and mental exhaustion”. Students recognize the high prevalence of burnout, as perhaps due to the competitive nature of medicine. They agree that multiple factors, including biological, psychological and social determinants contribute to burnout. There is also agreement that a stigma attached to being burned-out as a medical student prohibits seeking help, and that medical schools have a significant role in impacting burnout prevalence and are perhaps the best avenue to manage it. Students seem to name a few services or changes their medical schools have put into place to manage burnout, but agree that it is perhaps not enough or they require feedback and future modifications. Furthermore, Students appear to agree that screening for burned-out students would not be beneficial, as it might actually be counter-productive and create more anxiety for burnout-prone selected students.

Conclusion Preventing and managing burnout first begins with understanding the medical culture and environments students experience and tailoring services based on student feedback.

We hope to provide further understanding on this complex phenomenon through the use of examining the various factors contributing to medical student burnout. We hope this information can be useful for future medical school curriculum development and changes.

References 1.Ishak W, Nikravesh R, Lederer S, Perry R, Ogunyemi D, Bernstein C. Burnout in medical students: a systematic review. The Clinical Teacher. 2013Aug;10(4):242–5.

2.Dyrbye LN, Thomas MR, Shanafelt TD. Medical Student Distress: Causes, Consequences, and Proposed Solutions.

Mayo Clinic Proceedings. 2005;80(12):1613–22.

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JMSG | ABSTRACT Mild traumatic brain injury biomarkers and testing methods for point-of-care assessment Blake, C.1, Gonzalez, D.2, McMahon, J.3 1 School of Medicine, NUI Galway, Ireland 2 Department of Kinesiology, University of Waterloo, Canada 3 Galway Neuroscience, NUI Galway, Ireland

Introduction

Results

Successive mild traumatic brain injury (mTBI) sustained in contact sports can lead to serious injury or death. However, mTBI is difficult to diagnose and there is high demand for reliable biomarkers to allow objective point-of-care testing and improve prognostic outcomes.

Detection of Tau protein was found to be most sensitive, with a detection limit of only 0.02pg/ mL. Phosphorylated Neurofilaments (NFHp), microRNA, and Myelin Basic Protein (MBP) have been shown to have 100% specificity in some studies. AUC of 1.0 was found for NFHp. S100B, Tau and glutamate receptor 2 (GluR2) had the shortest peak serum level (~1 hour). Tau and GluR2 are detectable using ultra-sensitive assays, with GluR2 currently detectable through a smartphone-enabled device. Majority of biomarkers were present in serum post-injury and many were in concentrations that were proportional to severity of injury.

Aim The primary aim of this investigation was to evaluate candidate biomarkers and detection methods based on their suitability for use in point-of-care mTBI testing.

Methods Literature analysis on the status of current fluid biomarkers was performed, focusing specifically on criteria for ideal mTBI biomarkers and testing methods. 28 biomarkers were assessed based on sensitivity, specificity, AUC (specificity vs. sensitivity), timing of peak serum interval, testing method, availability in biofluids, and concentration proportionality.

Conclusion Currently, no substance exists with all properties of an ideal mTBI biomarker. Results of this investigation were limited by conflicting data among studies. We suggest that future point-of-care devices be able to detect a panel of mTBI biomarkers due to wide fluctuation in individual properties.

References 1. Boellner S, Becker K. Reverse Phase Protein Arrays—Quantitative Assessment of Multiple Biomarkers in Biopsies for Clinical Use. Microarrays. 2015;4(2):98-114.

2. Ko J, Hemphill M, Gabrieli D, Wu L, Yelleswarapu V, Lawrence G et al. Smartphone-enabled optofluidic exosome diagnostic for concussion recovery. Scientific Reports. 2016;6(1).

3. Kövesdi E, Lückl J, Bukovics P, Farkas O, Pál J, Czeiter E et al. Update on protein biomarkers in traumatic brain injury with emphasis on clinical use in adults and pediatrics. Acta Neurochirurgica. 2009;152(1):1-17.

4. Kulbe J, Geddes J. Current status of fluid biomarkers in mild traumatic brain injury. Experimental Neurology.

2016;275:334-352.

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JMSG | ABSTRACT Tumour conditioned stromal cells secrete high levels of IL-10 and low levels of GM-CSF which is associated with the induction of a protumourigenic macrophage phenotype Cahill, S.¹, O’Malley, G.²,³, Ryan, A.²,³ 1 School of Medicine, NUI Galway, Ireland 2 Immunology Group, Regenerative Medicine Institute, Galway, Ireland 3 Department of Pharmacology and Therapeutics, NUI Galway, Ireland

Introduction

Results

Mesenchymal Stromal Cells (MSCs) acquire a distinct tumour-promoting phenotype in the tumour-microenvironment. Macrophages in this environment can be anti-tumorigenic or protumorigenic. The effect of tumour-associatedstromal cells on anti-tumour macrophages is unknown. NF-kB, upregulated in >60% of colorectal cancers, is known to promote tumour growth and a pro-tumorigenic macrophagephenotype.

MSCs treated with EV-TNF-TCM produced little GM-CSF, similar to that of CT26 tumour cells, which we have shown to induce pro-tumorigenic macrophages. In contrast, CT26/IκB-αSR cells produce significantly higher levels of GM-CSF and can induce NO-production in macrophages, indicating an anti-tumour/M1-like phenotype.

Furthermore, IL-10 production is significantly induced in MSC-TNF-TCM suggesting the ability to induce a pro-tumorigenic macrophagephenotype. IL-10 secretion is significantly reduced in MSCs treated with TCM from NF-κBdeficient tumour cells. Together our results suggest that tumour-conditioned-MSCs secrete factors capable of inducing tumour-promoting macrophage-phenotype.

Aim To investigate tumour-conditioning of stromal cells, their ability to alter macrophage phenotype, and the effect of NF-κB on this process.

Methods NF-κB-deficient CT26 colon tumour cell lines were established by stable expression of an IκB-α -super-repressor-plasmid (CT26/IκB-αSR), with transfection of an empty-vector as control (CT26/EV). Balb/c-derived bone-marrow MSCs were treated with this medium (MSC-TCM), or medium from CT26 pre-treated with TNF-α (MSC-TNF-TCM). Tumour cell/MSC soluble factors were measured by ELISA and macrophage -phenotype assessed using Griess Assay.

Conclusion MSCs exposed to the inflammatory-tumoursecretome produce potent inducers of a protumorigenic macrophage-phenotype. This effect depends upon tumour cell NF-kB signalling, thus suggesting that targeting tumour-cell NF-kB may be key to overcoming the immunosuppressive milieu established in the tumour microenvironment .

References 1. Ryan, A., Colleran, A., O’Gorman, A., O’Flynn, L., Pindjacova, J., Lohan, P.,O’Malley, G., Nosov, M., Mureau, C., and Egan, L. (2014). Targeting colon cancer cell NF-ĸB promotes an anti-tumour M1-like macrophage phenotype and inhibits peritoneal metastasis. Oncogene, 34(12), pp.1563-1574.

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JMSG | ABSTRACT Retrospective clinical audit of carotid and vertebral artery dissection in a tertiary referral hospital Doherty, G.1,2, DeBhulbh, A.1, Tawfick, W.1,2, Sultan, S.1,2,3 1 School of Medicine, NUI Galway, Ireland 2 Western Vascular Institute, University College Hospital, Ireland 3 Galway Clinic, Royal College of Surgeons of Ireland, Ireland

Introduction The process of arterial dissection in the carotid and vertebral arteries is a common cause of stroke in the young and middle-aged, accounting for up to 25% of strokes in this group1,2. Trauma or mechanical triggering events are welldocumented causes of carotid and vertebral artery dissection1-3. Ischemic stroke and transient ischemic attack (TIA) caused by carotid and vertebral artery dissection are treated with either anticoagulation or antiplatelet drugs. The CADISS trial concluded that recurrent stroke after carotid or vertebral dissection at three months is rare, with no significant difference between the two treatments4.

Aim To perform a clinical audit of the practice in the management of carotid and vertebral artery dissection over the past 12 years. To compare the outcomes of anticoagulation vs antiplatelet therapy, age of patients, and cause of the dissection, to those of the published international standards.

Methods The project was approved by the Galway Clinical Research Ethics Committee. It is a retrospective study of clinical details of all patients that presented to the stroke and vascular tertiary referral centre with symptoms and signs of carotid and vertebral artery dissection since

2005. The patients’ clinical notes were reviewed to collect data on the patients’ presentation, demographics, procedures, and progress. All collected data was analysed using SPSS. Results 39 patients from 2005-June 2017. 12 female (30.8%), 27 male (69.2%). 24 (61.5%) under 55 years, mean age 50.4, minimum 7, maximum 82.

No significant difference in hypertensive/nonhypertensive patients. Majority treated with antiplatelet therapy – 15 (38.5%), next Anticoagulant and Antiplatelet combined therapy – 10 (25.6%), 5 for both Anticoagulant and Surgery. 18 (46.2%) presented with stroke, headache (28.2%) and Vision Disturbances (20.5%) being the most common symptoms. Gym related injuries were most common – 4(10.3%), car accident and other trauma accounting for 3 patients each. 29 patients (74.4%) had no history of trauma, genetic testing will be carried out in the future of this project. None of the patients had a stroke following treatment with any therapy. No significant difference in treatment choice if patients presented with a stroke (pvalue=0.483).

Conclusion In keeping with CADIDS there is no obvious difference in patient outcomes according to treatment. 25.6% of dissections were the result of trauma.

References 1. Dziewas, R., et al., Cervical artery dissection—clinical features, risk factors, therapy and outcome in 126patients.

Journal of Neurology, 2003. 250(10): p. 1179-1184.

2. Schievink, W.I., Spontaneous Dissection of the Carotid and Vertebral Arteries. New England Journal of Medicine, 2001. 344(12): p. 898-906.

3. Engelter, S.T., et al., Cervical artery dissection: trauma and other potential mechanical trigger events. Neurology, 2013. 80(21): p. 1950-7.

4. Markus, H.S., et al., Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial. The Lancet Neurology, 2015. 14(4): p. 361-367.

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JMSG | ABSTRACT New toys for the neurologist: application of sensor technology for monitoring Parkinson’s disease Fahy, Y.1, Browne, P.1,2,3, Clancy, C.1, Counihan, T.1,2 1School of Medicine, NUI Galway, Ireland 2Neurology Department, University Hospital Galway, Ireland 3Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland, Ireland

Introduction Parkinson’s disease (PD) is a progressive, neurodegenerative disorder which most patients experience fluctuations in motor symptoms. Fluctuations may not be apparent during standard clinical encounters. Patient diaries allow further collection of information, however, quite subjectively. Emerging wristworn sensor technology has attempted to address this issue using objective, real-world monitoring of patients.

Aim The aim of this study is to compare fluctuation recordings from commercially-available Parkinson’s Kinetigraph (PKG) sensor with best clinical practice results to identify sensor’s accuracy.

Methods Following ethical approval, 36 patients consented to participate in this cohort study.

UPDRS clinical motor examination divided patients into non-fluctuators NF), possiblefluctuators (PF) or clear-fluctuators (F).

Subsequently, patients wore PKG sensor for 6 days. Each PKG generated a Fluctuation Dyskinesia Score (FDS), a validated composite

movement score derived from an algorithm (>12.8=F;<7.7=NF). Statistical analysis using ANOVA and Pearson’s correlation tests were performed using SPSS to compare FDS values with clinical data.

Results 73%(n=27) of participants were male, median disease duration was 9.5 years (2-25 years), mean age was 67±7years. 47%(n=17) were clinically categorised as F, 22%(n=8) as NF. Mean FDS value was 9.5±2. Mean UPDRS was 30±12. Post-Hoc showed statistically significant mean difference of 3 between FDS of F and NF (p<0.005, 95% CI[0.79, 5.13]. Correlation between FDS and UPDRS had r-value 0.156 (p=0.37), thus not statistically significant.

However, there was moderate correlation between UPDRS and disease duration (years) with r-value 0.417(p=0.02) .

Conclusion Initial data shows statistical significance in the PKGs concordance with clinical assessments of the F and NF subgroups. PKG could potentially be useful for detecting PD motor fluctuations, however, further studies would be required using a larger cohort of patients .

References 1. Ossig, C., Antonini, A., Buhmann, C., Classen, J., Csoti, I., Falkenburger, B., ... & Storch, A. (2016). Wearable sensor-based objective assessment of motor symptoms in Parkinson’s disease. Journal of neural transmission, 123(1), 5764.

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JMSG | ABSTRACT Factors affecting time to reach target in patients with early rheumatoid arthritis: an observational cohort study Faris, T.1,3, McGowan, B.1,2, Harrington, N.1, Silke, C.1,3, O Sullivan, M.1, Whelan, B.1,3 1 North Western Rheumatology Unit, Our Lady’s Hospital, Ireland 2 Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, Trinity College Dublin, Ireland 3 School of Medicine, NUI Galway, Ireland

Introduction Several prognostic markers have been identified as influencing time to target in patients with early rheumatoid arthritis (ERA) including AntiCitrullinated Protein Antibodies (ACPA), Rheumatoid Factor (RF), age, and BMI. Aim The aim of this study is to explore the effect, if any, of prognostic factors on the time to reach target (remission or low-disease activity) in a cohort of patients with ERA attending the North Western Rheumatology Unit (NWRU).

Methods All data on patients with ERA attending the NWRU between September 2014-March 2017 for a 12 months period (n=79) under the T2T program was prospectively recorded on an Statistical Package for the Social Sciences (SPSS) database and updated during each clinic visit.

Statistical analyses were performed using SPSS (V24.0). Association between individual and composite measures of disease activity affecting time to target were analysed using independent T -tests. Time to target was measured using Kaplein Meier survival analyses and log-rank tests. The association between sub groups of categorical data and time to target were further analysed using the chi-square test.

Results The mean time to reach steroid free LDAS/ remission was 7.09 (+4.45) months. There was a statistically significant mean difference of 2.6 months (p=0.010) in T2T between DMARDs monotherapy group (5.8 +/- 3.8 months) and the DMARDs combination (8.4 +/- 4.7 months) group. No other variables showed significant pvalues (p<0.05) in the t-test analyses. Duration of symptoms before referral to the clinic was significantly associated with time to reaching target in the log-rank test (p=0.034) with patients with symptoms < 6 months achieving their target in 6.31 (+ 3.61) months and patients with symptoms for > 6 months achieving their target in 8.50 (+5.5). In the chi-square tests there were significant association identified between Time to Target and BMI status, smoking status, and CDAI group at initiation with p-values of 0.031, 0.031, and 0.026 identified respectively.

Conclusion The mean time to target steroid free was 7.09 months. Factors identified as influencing the time to target were duration of symptoms prior to referral, BMI and smoking status along with CDAI status at baseline visit and drug combination used to reach target.

References 1. Scott DL, Symmons DP, Coulton BL, Popert AJ. Long-term outcome of treating rheumatoid arthritis: results after 20 years. Lancet 1987;1:1108–11.

2. Mitchell DM, Spitz PW, Young DY, Bloch DA, McShane DJ, Fries JF. Survival, prognosis, and causes of death in rheumatoid arthritis. Arthritis Rheum 1986;29:706–14.

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JMSG | ABSTRACT Can triage nurses accurately predict admissions and discharges?

Fauzi, S.1, O’Gorman, S.2 1 School of Medicine, NUI Galway, Ireland 2 Letterkenny University Hospital, Ireland

Introduction Admitted patients often wait in the Emergency Department (ED) for a bed. If it were known earlier which patients will require admission a bed could be booked earlier and the patient’s length of stay in the ED could be reduced to minimize overcrowding. Triage is the first point of clinical assessment.

Aim This study aims to determine whether triage nurses can accurately predict which patients will be admitted and which will be discharged at the point of triage.

Methods Triage nurses triaged patients in the usual way when patients arrived at the Emergency Department. In addition, they were asked to predict whether each patient would be admitted or discharged and how confident they were in their prediction. This data was recorded by the

triage nurses on a specially designed questionnaire, which was not available to the treating doctors and nurses.

Results During the study period a total of 895 forms were filled by the triage nurses representing 25% of attendances at the ED. There was a statistically significant association between triage nurses’ prediction of patients’ disposition and patients’ ultimate disposition, p < 0.0001.

Accuracy of prediction of discharge was 90% and accuracy of prediction of admission was 59%.

Conclusion Triage nurses have a high accuracy (90%) of predicting discharges. They can predict which patient will be admitted with an accuracy of 59%.

Patient flow in ED could be improved by requesting beds at the time of triage based on the triage nurses’ assessment.

References 1. Cameron A, Ireland AJ, McKay GA, et al. Predicting admission at triage: are nurses better than a simple objective score?

Emergency Medicine Journal. 2017; 34:2-7.

2. Holdgate A, Morris J, Fry M, Zecevic M. Accuracy of triage nurses in predicting patient disposition. Emergency Medicine Australasia. 2007 Aug: 19(4): 341-5. PMID: 17655637 3. Stover-Baker B, Stahlman B, Pollack M. Triage nurse prediction of hospital admission. Journal of Emergency Nursing.

2012 May; 38(3): 306-10. PMID: 22464226

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JMSG | ABSTRACT Glycosignature in healthy and degenerated human intervertebral disc Joyce, K.1, Mohd Isa, I.L.1,2, Pandit, A.3 School of Medicine, NUI Galway, Ireland 2 Centre for Research in Medical Devices, Ireland 3 Network of Excellence for Functional Biomaterials, NUI Galway, Ireland 1

Introduction

Results

Discogenic low back pain affects 42% of patients with chronic low back pain1. Degenerative disc disease is described as failure in cellular response to external stresses leading to physiologic dysfunction and disc destruction.

Glycosylation patterns of tissues give insights into the spatially and temporally regulated inflammatory and degenerative processes. The degeneration of the human disc is a process never before investigated by lectin histochemistry.

Staining with all lectins showed a lamellar arrangement of binding in ECM of the AF of foetal tissue that was lost in Thompson Grade III/IV tissue. A significant increase in sialylated/ galactosylated motifs was seen in degenerated tissue when compared to healthy tissue. There are significant differences in fucosylation, mannosylation and GlcNAc expression in healthy vs. degenerated tissue and characteristic changes in patterns of binding.

Aim To characterize the glycoprofile of the IVD histochemically using plant lectins in healthy and diseased tissue.

Methods Staining with several lectins (Con A, SNA, MAA, DSA, UEA-I, PNA, WGA and WFA) of formaldehyde-fixed sections of foetal (n=2) and diseased tissue (n=2) was performed with ethical approval.

Conclusion This study has shown that healthy and degenerated human discs present distinct glycosylation trends intracellularly and ECM in AF and NP tissue. The carbohydrate moieties detected may correlate with adhesion molecule/ proteoglycan expression which could play a role in the degenerative process of intervertebral disc disease. This pilot study offers insight into the glycoprofile of the IVD and the alterations in this glycoprofile that occur in a disease model .

References 1. Strine TW & Hootman JM. US national prevalence and correlates of low back and neck pain among adults. Arthritis Rheum, 2007; 57: 656-65.

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JMSG | ABSTRACT Analysis of H2AX protein abundance in luminal breast cancer Kelly, F.1, Passos, J.2, Dodson, H.2 1 School of Medicine, NUI Galway, Ireland 2 Discipline of Anatomy, School of Medicine, NUI Galway, Ireland

Introduction

Methods

H2AX is an abundant variant of the canonical histone H2A. H2AX is an important component of the DNA damage response since its phosphorylation on serine-139 results in formation of Ć&#x201D;-H2AX, leading to the recruitment of many repair proteins to the damage site.

Current work in Dr Dodsonâ&#x20AC;&#x2122;s lab is investigating the role of H2AX in breast oncogenesis. It is evident from the METABRIC dataset that H2AX mRNA expression increases with luminal subtype progression.

Histone proteins were extracted from cultured cell lines using hydrochloric acid and these were run alongside standard curves of known quantities of recombinant H2A and H2AX protein. H2A and H2AX protein abundance was measured by fluorescent western blot.

Aim Our objective is to investigate H2AX protein abundance in luminal breast cancer cell lines and explore the association of this with the mRNA expression (METABRIC dataset). We will analyse the ratio of H2AX to total H2A protein in normal breast MCF10A (control), and in MCF7 (luminal-A), T47D (luminal-A) and BT474 (luminal-B) cancer cell lines.

Results Preliminary results show that T47D has the highest ratio of H2AX to total H2A protein in the cell lines tested (13.8%), followed by MCF10A (12.5%), MCF7 (10.3%) and BT474 (8.5%).

Conclusion Normal-like and luminal-A subtypes have the highest H2AX abundance, while the luminal-B subtype has the lowest H2AX. This result is somewhat unexpected as H2AX mRNA expression is higher in the luminal-B subtype.

This work gives some insight into the potential of H2AX as a biomarker for luminal breast cancer progression.

References 1. Shechter D, Dormann H, Allis C, Hake S. Extraction, purification and analysis of histones. Nature Protocols. 2007;2 (6):1445-1457.

2. Inic Z, Zegarac M, Inic M, Markovic I, Kozomara Z, Djurisic I et al. Difference between Luminal A and Luminal B Subtypes According to Ki-67, Tumor Size, and Progesterone Receptor Negativity Providing Prognostic Information.

Clinical Medicine Insights: Oncology. 2014;8:CMO.S18006

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JMSG | ABSTRACT Apparent treatment resistant hypertension: a feasibility study Kielty, H.1, Casey, M.2, Glynn, L.3, Molloy, G.J.4, Durand, H.4, Newell, J.5, Murphy, A.W.2,6, Hayes, P.2 1 School of Medicine, NUI Galway, Ireland 2 Discipline of General Practice, School of Medicine, NUI Galway, Ireland 3 School of Medicine, University of Limerick, Ireland 4 School of Psychology, School of Medicine, NUI Galway, Ireland 5 Health Research Board Clinical Research Facility, NUI Galway, Ireland 6 Health Research Board Primary Care Clinical Trials Network, Ireland

Introduction Most cases of hypertension can be effectively treated with lifestyle changes together with medications, but within this population lies a group with more difficult to treat hypertension â&#x20AC;&#x201C; those with apparent treatment resistant hypertension (aTRH). The American Heart Association and the UK National Institute for Health and Care Excellence have both highlighted the need for further research into the prognosis of patients with resistant hypertension, both apparent and true.

Methods In sixteen practices affiliated to a university research network, 646 patients had been identified with apparent treatment resistant hypertension. To inform a planned full cohort study of these patients, we conducted a feasibility study within three practices to determine participation of practices and patients, availability of outcome measures and data collection duration time .

Results All three practices fully participated and 205/210 (98%) patients were followed up for a median of 23 months. Thirty-five outcome events of

interest occurred â&#x20AC;&#x201C; the most common was new onset of retinopathy (9 cases). Eight percent (17/210) had the main composite outcome of death or serious incident cardiovascular event.

Of the six patients who died, identification of cause of death was possible from practice records in five; the national General Register Office was successfully used for the final patient.

There were 123 admissions, both day and overnight, recorded in 94 individual patients.

Average manual systolic blood pressure measurements improved from baseline by 5 mmHg to 138 (SD 19) mmHg, diastolic remained the same at 75 (SD 12) mmHg. Average eGFR increased from 60.7 (SD16.3) to 66 (SD19.7) mls /min /1.73m2. The average time for data collection per patient was 12.6 minutes .

Conclusion This study demonstrates that the proposed methodology for a full cohort study within general practice of patients with apparent treatment hypertension is both acceptable to practices and feasible. Importantly, individual patient record review facilitates consideration of adherence, dosing and white coat hypertension.

Further development of the appropriate components of a composite outcome measure is appropriate.

References 1. Myat A, Redwood SR, Qureshi AC, Spertus JA, Williams B. Resistant hypertension. Bmj. 2012;20(345).

2. Calhoun DA, Jones D, Textor S, Goff DC, Murphy TP, Toto RD, et al. Resistant hypertension: diagnosis, evaluation, and treatment. A scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension (Dallas, Tex : 1979). 2008;51(6):1403-19.

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JMSG | ABSTRACT Comparison of the effects of infliximab on IL-1β production Lee, R.1, Mattimoe, D.2, Coralie, M.2, Samhari Afiq, A.2, Costello, R.2, Egan, L.2 1 School of Medicine, NUI Galway, Ireland 2 Lambe Institute for Translational Research, Ireland

Introduction

Results

Infliximab (IFX) is an anti-tumour necrosis factor alpha (TNF-α) monoclonal antibody, which is highly important in the management of Inflammatory Bowel Disease (IBD). However, its mechanism of action in treating IBD remains poorly understood; as does the mechanism by which many patients lose responsiveness to it.

Interestingly, unstimulated IBD-patient samples incubated for twenty-four hours had consistently higher IL-1β concentrations than in four hours (mean=1138pg/mL vs. 73.63pg/mL – P<0.0001).

This did not occur in any healthy controls. The three patients with corresponding pre/post-IFX samples had significantly reduced IL-1β concentrations post-IFX. Mean IL-1β concentration in pre-IFX samples was 783.5pg/ mL, and 525.7pg/mL in post-IFX samples. Paired t-test showed this difference was indeed highly significant (P=0.0009).

Aim This study investigated intracellular Interleukin1β (IL-1β) concentrations in response to bacterial ligands over varying incubation times, and IFX’s effects on those results in the hopes of elucidating IFX’s mechanism of action in treating IBD, and loss of response in the hopes of adding to the understanding of this complication and aiding development of novel pharmacotherapies for this condition.

Methods IL-1β concentrations were determined by enzyme-linked immunosorbent assays (ELISA) of supernatants from whole blood incubations.

Samples from healthy controls (n=7) and IBD patients immediately before/after IFX-infusion (n=7) were obtained after receiving informed consent in each case. Samples were incubated over four/twenty-four hours with bacterial ligands (bacterial cell-surface lipopolysaccharides [LPS - 5ng/mL], Muramyl dipeptide [MDP 6.25ng/mL], Flagellin [1,000ng/mL]), or extra culture-media for unstimulated controls .

Conclusion Twenty-four hour incubations are superior to four hour incubations at eliciting full IL-1β expression in experiments such as these, which will be of significance as this study continues.

Infliximab appears to be significantly antagonistic to IL-1β expression despite its reputation as a specifically anti-TNF-α antibody. Further study is required to examine effects of IFX therapy on production of IL-1β and other cytokines implicated in IBD, to better understand how IFX treats this condition and how patients lose responsiveness to it; with the aim of adding to the understanding of this complication, aiding the development of therapies available to patients, and ultimately improving quality of life in those living with this condition.

References 1. Akiho H, Yokoyama A, Abe S, Nakazono Y, Murakami M, Otsuka Y, et al. Promising biological therapies for ulcerative colitis: A review of the literature. World Journal of Gastrointestinal Pathophysiology. 2015;6(4):219-27.

2. Nielsen OH, Ainsworth MA. Tumor Necrosis Factor Inhibitors for Inflammatory Bowel Disease. New England Journal of Medicine. 2013;369(8):754-62.

3. Rutgeerts P, D&#39;Haens G, Targan S, Vasiliauskas E, Hanauer SB, Present DH, et al. Efficacy and safety of retreatment with anti–tumor necrosis factor antibody (infliximab) to maintain remission in Crohn&#39;s disease. Gastroenterology. 1999;117(4):761-9.

4. Sands BE, Anderson FH, Bernstein CN, Chey WY, Feagan BG, Fedorak RN, et al. Infliximab Maintenance Therapy for Fistulizing Crohn’s Disease. New England Journal of Medicine. 2004;350(9):876-85

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JMSG | ABSTRACT The changing role of prostate specific antigen measurements in the assessment of suspected prostate cancer Moloney, D.1, Mullins, M.1,2, McCarthy, P.1,2 1 Department of Radiology, School of Medicine, NUI Galway, Ireland 2 Department of Radiology, University Hospital Galway, Ireland

Introduction With increasing use of multiparamaetric MRI (mpMRI), and Prostate Imaging Reporting and Data System (PIRADS), the traditional role of prostate specific antigen (PSA) assessment is evolving and is now more likely to be used to triage and stratify risk groups rather than its ‘screening’ role heretofore.

and cancer grades, but this is not sustained for patients with high grade cancers. Adding DRE to the algorithm increases sensitivity and specificity but only marginally in both cases. PIRADS has a higher PPV and NPV than the current screening method of PSA(≥4 ng/mL) and positive DRE.

Aim To assess and quantify risk of cancer at given levels of PSA, PSA density, prostate volume and digital rectal exam (DRE).

Methods A retrospective analysis of 1,000 consecutive TRUS-guided prostate biopsy patients in a 4year period 2012-16. Database searches using PACS and SPSS were used to identify cases and carry out analysis. The patients corresponding Pathology reports were used to record positive biopsies and Gleason Score.

Results Both actual PSA levels and PSA density are highly sensitive in assessing risk in prostate cancer and both are strongly correlated with risk, with specificity rates exceeding 90%, but specificity levels depend on the actual PSA level.

Overall an elevated PSA alone has a PPV of 54%.

Higher PSA/PSAD levels also predict invasion

Conclusion Highly trained radiologists are now fundamentally influencing the traditional role of PSA assessment in prostate cancer. mpMRI has become the mainstay of assessment and increasingly is becoming the first step in triage.

Carrying out an MRI scan as a screening test on every patient is not feasible, however, it can be used with PSA levels to triage and prevent unnecessary repeat biopsies being performed.

PSA still has a role, but its use will change, as despite its high sensitivity levels, specificity is low.

References 1. Hegde, J., Mulkern, R., Panych, L., Fennessy, F., Fedorov, A., Maier, S. and Tempany, C. (2013). Multiparametric MRI of prostate cancer: An update on state-of-the-art techniques and their performance in detecting and localizing prostate cancer. Journal of Magnetic Resonance Imaging, 37(5), pp.1035-1054.

2. Steiger, P. and Thoeny, H. (2016). Prostate MRI based on PI-RADS version 2: how we review and report. Cancer Imaging, 16(1).

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JMSG | ABSTRACT A study of the correlation between the verbal months backwards test and a novel computerised version Mulligan, M.1, Lally, L.1,2, McCarthy, G.1,2, Adamis, D.2, Meagher, D.3 1 School of Medicine, NUI Galway, Ireland 2 Department of Psychiatry, Sligo Mental Health Service, Ireland 3 School of Medicine, University of Limerick, Ireland

Introduction Delirium is a prevalent condition in the inpatient hospital setting (21% of all patients)1. Prevalence is higher in older patients and particularly in those with prior dementia1. Delirium is misdiagnosed, detected late or missed in over 50% of cases2. A major challenge in accurately detecting delirium is the lack of a convenient tool that can be used to assess for impaired attention3. The Months Backwards Test (i.e.

MBTv) is the most sensitive bedside test of attention for identifying delirium in an older patient cohort4. Hospital staff occasionally have difficulty with interpretation of the MBTv scoring system; we hypothesise that employing a standardised test on a handheld electronic tablet will allow ease of interpretation, reduce inconsistency in scoring and lead to quicker and more reliable diagnoses.

Aim To observe if there is significant correlation between patient performance in the MBTc (a novel computerised version) and the MBTv in a cohort with mixed neuropsychiatric conditions.

Methods Participants of Old Age University Hospital.

were recruited from the Psychiatry Consultation Liaison Service at Sligo Hospital and Galway University Participants were subsequently

allocated to four different (>65 yo) cohorts (Dementia and Delirium, Dementia, Delirium, Cognitively Intact) based on prior diagnosis, collateral history (IQCODE), clinical impression, and the rating scales listed: Revised Delirium Rating Scale (DRS-R98), MMSE, MBTv, MBTc, and IQCODE. Agreement between the two versions of the test was investigated.

Results 75 patients, mean age: 80(SD:7.6), 31 male (37.3%). 36 delirium and dementia (DMDL), 7 delirium only (DL), 13 dementia only (DM), 19 cognitively intact. Overall Spearman’s rho=0.772 (p<0.0001). Agreements between the assessments were: DMDL rho=0.666, p<0.0001, DL rho=0.778, p=0.039, DM rho=0.378, p=0.203, cognitively-intact rho=0.143, p=0.559.

Conclusion Overall, there was statistically significant agreement between the MBTc and the MBTv. For the delirious subset (DMDL, DL), statistically significant agreement was present. However, poor inter-test correlation existed in the groups without delirium (DM, cognitively intact). These results would imply that the MBTc is as effective as the MBTv in patients who are clinically suspected to have delirium (DLDM, DL only) and its ease of scoring interpretation may favour its use in the future.

References 1. Ryan, DJ., O’ Reagan, N., O Caoimh, R. Delirium in an acute hospital population: predictors, prevalence and detection. BMJ Open. 2003;3(1).

2. Kean, J., Ryan, K. Delirium detection in clinical practice and research: critique of current tools and suggestions for future development. Journal of Psychosomatic Research. 2008;65(3):255-259.

3. O’Hanlon S, O’Regan N. Improving delirium care through early intervention: from bench to bedside to boardroom. J Neurology, Neurosurg, Psychiatry. 2014;85(2):207-13.

4. O’ Reagan, N., Ryan, D. Attention! A good bedside test for delirium? Journal of Neurology, Neurosurgery & Psychiatry, 2014;85(10):1122-1131.

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JMSG | ABSTRACT Knowledge, attitudes and behaviours of medical students towards sexual health Murphy, M.1, Bourke, L.2, Koltos, A.2 , Field, C.A.2 School of Medicine, National University of Ireland, Galway, Ireland 2 Health Promotion, School of Health Sciences, National University of Ireland, Galway, Ireland 1

Introduction

Results

Sexual health is a key component to a holistic approach to population health and well-being. As medical students are future healthcare professionals, it is critical they understand the importance of sexual health for their own health and that of their future patients.

The mean age of respondents was 21, females accounting for 66% of respondents. 1-3MB had high levels of participation accounting for 85.4% of responses. The majority of respondents (69%) agreed that their future career influenced decisions surrounding sexual health, while levels of knowledge increased as students progressed (p<0.05). A large proportion (86%) of participants agreed they would like to further their knowledge at a preclinical stage.

Aim The aim of this research is to explore the knowledge, attitudes, and behaviours (KAB) of medical students towards sexual health focusing on sexual-activity, contraception and STIs. Methods The study involved both quantitative and qualitative components, carried out by incorporation of a cross-sectional survey of medical students. The questionnaire was based on the findings of a systemic literary review, as well as experience of researchers in the field.

Respondents were invited to participate via a gatekeeper in the School of Medicine. Data derived from the questionnaire was stored and analysed in SPSS. Ethical approval was granted by the College of Medicine Nursing and Health Sciences Research Ethics Committee.

Conclusion Participants displayed levels of sexual activity similar to the wider student population. While the majority of participants felt they had an adequate knowledge and were open to discuss sexual health, they believed enhancing this knowledge at a preclinical stage would be beneficial.

References 1. Cottingham, J., Kismodi, E., Gruskin, F., Miller, AM. (2015) â&#x20AC;&#x153;Sexual Health Human Rights and The Lawâ&#x20AC;? [Available at http://www.who.int/reproductivehealth/publications/rtis/sexualhealth.pdf] 2. Macneela, P., Dring, C., Lente, E., Place, C.,Dring, J., Mccaffrey, J (2012) "Student Lifestyle Survey" [Available at http:// www.nuigalway.ie/student_services/health_promotion/documents/sls_june_2012_2.pdf]

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JMSG | ABSTRACT Neutrophil to lymphocyte ratio in Luminal A breast cancers: relationship with oncotype DX score Ni Mhaonaigh, N.C.1, McAnena, P.F.1, Kerin ,M.J.1, Brown, J.A.L.1 1 Department of Surgery, The Lambe Institute for Translational Research, NUI Galway, Galway, Ireland.

Introduction

Results

Breast cancer is a heterogenous disease that exhibits varying prognoses and responses to treatment. Neutrophil-to-lymphocyte ratio (NLR) has been extensively investigated in recent years as a marker of host immune function. High pre-operative NLR has been shown to negatively impact prognosis in a variety of cancers, including breast cancer1. Our aim was to investigate the relationship between NLR and Oncotype DX score, and examine if NLR could potentially contribute to estimating risk of breast cancer recurrence.

1.2% (4/309) patients died, 3.8% (12/309) had recurrence and the remaining 293 patients were alive with no record of disease progression. We found no correlation between any NLR score and: age at diagnosis (p=0.856), disease-free survival (-0.062), or Oncotype Dx score (p=0.94). However, patients in the low-risk Oncotype score (<18) group (n=159) had a significantly lower mean pre-operative NLR, compared to the intermediate-risk group (18-30, n=123) (2.73 vs. 3.26. p=0.036).

Methods Pre-treatment blood tests from 309 Luminal A breast cancer patients (2006-current) with Oncotype scores treated at a tertiary referral centre (Galway University Hospital) were analysed. NLR score for each patient was calculated and correlated with age at diagnosis, and Oncotype score.

Conclusion No NLR score evaluated correlated to Oncotype score. However, the higher mean NLR score in patients in the intermediate Oncotype suggests that these patients may have a poorer prognosis and are more likely to have a recurrence of breast cancer. Long term follow-up of our cohort is required to investigate the prognostic impact of NLR and Oncotype.

References 1. Chen, J., et al., Prognostic value of neutrophil-to-lymphocyte ratio in breast cancer. FEBS Open Bio, 2015. 5: p. 502-7.

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JMSG | ABSTRACT Transcatheter tricuspid valve intervention: is there a clinical need?

Theva Raj, N.1, Mylotte, D.2 1 School of Medicine, NUI Galway 2 Department of Cardiology, University Hospital Galway

Introduction

Results

Severe tricuspid regurgitation (TR) is a frequently under-treated clinical problem.

Surgical repair of the TR is associated with high mortality and therefore <1% of patients with severe TR undergo surgical intervention.

Among 462 patients, 160 (34.63%) were diagnosed with TR. Most (N=147) patients presented with mild/moderate TR, while 13 (8.13%) had severe TR. Patients with severe TR were more likely to suffer from atrial fibrillation (84.62%, p=0.01) and bundle branch blocks (53.85%, p=0.04), compared to patients with mild or moderate TR. Patients with severe TR also had significantly higher pulmonary artery systolic pressures (50.09±15.87 versus 34.56±12.31, p<0.0001). All 13 patients with severe TR and 95.92% of patients with mild or moderate TR suffered from mitral regurgitation as well. The 13 patients with severe TR were deemed suitable for transcatheter tricuspid therapies.

Aim To assess the prevalence, clinical and echocardiographic characteristics of patients with moderate or severe TR in those with systolic heart failure.

Methods A retrospective review of the clinical notes and echocardiographic data of 462 patients registered with the Heart Failure Clinic at University Hospital Galway was performed.

Echocardiographic criteria were adjudicated according to the recommendations of the European Association of Echocardiography. The data was collected in a dedicated database and standard statistical tests were performed.

Conclusion There exists a significant proportion of patients with significant TR that remains under-treated.

These patients may be suitable for transcatheter tricuspid valve intervention.

References 1. Dreyfus GD, Martin RP, Chan JKM, Dulguerov F, Alexandrescu C. Functional tricuspid regurgitation – a need to revise our understanding. Journal of the American College of Cardiology. 2015 Jun;65(21):2331-6.

2. Lancellotti P, Moura L, Pierard LA, Agricola E, Popescu BA, Tribouilloy C, et al. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. European Journal of Echocardiography. 2010 May 01;11(4):307-32.

3. Taramasso M, Maisano F. Novel technologies for percutaneous treatment of tricuspid valve regurgitation. European Heart Journal. 2017 Sep 21;38(36):2707-10.

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JMSG | ABSTRACT Hippocampal connectivity implicated in sleep disruption in bipolar disorder Oredegbe, A.4, Nabulsi, L.1, McPhilemy, G.1, Martyn, F.M.1, Costello, L.1, Grogan, C.3, Natj, P.2, Ambati, S.2, McDonald, C.2, Cannon, D.2 1 The Centre of Neuroimaging & Cognitive Genomics (NICOG), National University of Ireland, Galway 2 Clinical Neuroimaging Lab, National University of Ireland, Galway 3 NCBES Galway Neuroscience Centre, National University of Ireland, Galway 4 College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway

Introduction Sleep disruption, often experienced by bipolar patients in the euthymic phase1, is associated with increased functional connectivity between the hippocampus and anterior cingulate cortex2.

Abnormalities in graph theoretical global measures have been detected in bipolar disorder3, as well as in local measures in the bilateral hippocampus and anterior cingulate4.

Whether these connectivity disturbances present as structural network abnormalities particular to sleep disturbance in bipolar disorder, remains unknown.

Aim To investigate the relationship between sleep quality and global as well as local measures of structural connectivity in bipolar and control groups.

Methods Seventy participants either psychiatrically healthy (HC, n=35, mean age 38±14 years, 60% female) or meeting DSM-IV-TR criteria for bipolar disorder (BD, n=35, euthymic, 44±13, 51% female) underwent structural and diffusion MRI and sleep quality assessment using the Pittsburgh Sleep Quality Index(PSQI)3, where higher scores indicate worse sleep. Structural connectivity maps were constructed using subject parcellation (FreeSurfer 5.3.0) and constrained spherical deconvolution-based tractography (ExploreDTI

4.8.6). Global network metrics including global efficiency and characteristic path length were derived (BCT1.52, MATLAB R2012b). Local network metrics including local efficiency, clustering coefficient and degree were derived at the bilateral anterior cingulate and the bilateral hippocampus (BCT1.52, MATLAB R2012b). Local and global metric results were compared with PSQI in each group (SPSS v24).

Results These age (T=-1.66, p=0.10) and gender (c2=0.52, p=0.63) balanced groups differed significantly in sleep quality (HC:4.23 ±2.17, BD:7.86 ±4.36, U=269, p=0.00005). Sleep quality did not relate to any global measure of structural connectivity in either group (r=-0.02-0.13, p=0.46 -0.90). Right hippocampal degree increased with PSQI (r=0.41, p=0.02) in the bipolar group. PSQI did not relate to local clustering coefficient or local efficiency of the hippocampus.

Conclusion Sleep quality was moderately disrupted and significantly poorer in bipolar disorder relative to control group. Sleep quality did not relate robustly with global measures or with local hippocampal connectivity in healthy controls.

Sleep disruption may be related to the number of axonal connections (degree) to the right hippocampus in bipolar disorder.

References 1. Cretu J, Culver J, Goffin K, Shah S, Ketter T. Sleep, residual mood symptoms, and time to relapse in recovered patients with bipolar disorder. Journal of Affective Disorders. 2016;190:162-166.

2. Regen W, Kyle S, Nissen C, Feige B, Baglioni C, Hennig J et al. Objective sleep disturbances are associated with greater waking resting-state connectivity between the retrosplenial cortex/ hippocampus and various nodes of the default mode network. Journal of Psychiatry & Neuroscience. 2016;41(5):295-303.

3. Leow A, Ajilore O, Zhan L, Arienzo D, GadElkarim J, Zhang A et al. Impaired Inter-Hemispheric Integration in Bipolar Disorder Revealed with Brain Network Analyses. Biological Psychiatry. 2013;73(2):183-193.

4. O'Donoghue S, Kilmartin L, O'Hora D, Emsell L, Langan C, McInerney S et al. Anatomical integration and rich-club connectivity in euthymic bipolar disorder. Psychological Medicine. 2017;47(09):1609-1623.

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JMSG | ABSTRACT Unplanned re-operation and interventional radiology post-appendicectomy: a meta-analysis Shamsul Badrin, A.1, Kate Bailey, K.1, Kabir, U.1, Lawlor, J.1, Johnston, A.1, Sugrue, M.1 Donegal Clinical Research Academy, Department of Surgery, Letterkenny University Hospital, National University of Ireland Galway

1

Introduction

Results

Optimizing delivery of emergency general surgery is important as not only does it account for over 10% of all surgical care, but it also has significant potential morbidity and mortality. Reintervention is an unexpected outcome following appendicectomy. There is no published metaanalysis on this topic. This meta-analysis evaluated the prevalence and potential predictors of reoperation and interventional radiology drainage post-appendicectomy.

2810 articles reviewed were reduced to 52 qualifying studies for a final analysis of 315,312 appendicectomies. Overall 0.8% (0%-14.2%) underwent some form of re-intervention. The reoperation rate was 0.6% (0%-14.9%) and reintervention radiologic drainage rate 1.5% (0.0%11.1%). Reoperations were significantly reduced where a laparoscopic approach was used, in uncomplicated appendicitis and where a drain was not used. The following did not predict reintervention: single port versus triple port laparoscopy, laparoscopy versus conversion from laparoscopy to open, and the grade of surgeon performing the appendicectomy.

Methods An ethically approved PROSPERO-registered (ID CRD42017069040) meta-analysis following PRISMA guideline using databases, PubMed and Scopus for studies between June 2012 to May 2017 was undertaken. Headings included “reoperation”, “return to operation theatre”, “complication”, “appendicectomy”, “outcome”, “abscess drainage”. Articles scoring ≥ 16 for comparative and ≥ 10 for non-comparative using MINORS criteria were included. P-values of < 0.05 were considered statistically significant.

Conclusion This meta-analysis identified a small but notable reoperation and re-intervention rate, significantly increased by complex appendicitis and open surgery. Strategies promoting for earlier presentation and diagnosis with laparoscopic approaches may improve overall outcomes.

References 1. Scott JW, Olufajo OA, Brat GA, Rose JA, Zogg CK, Haider AH, Salim A, and Havens JM (2016) Use of National Burden to Define Operative Emergency General Surgery. JAMA Surgery 02115:e160480

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JMSG | ABSTRACT Exploring the attitudes and barriers to home haemodialysis in end-stage kidney disease patients Shet, S.1, Clarke, S.2, Durack, L.2, Madden, C.3, Oâ&#x20AC;&#x2122;Connor, P.3, Reddan, D.4 1 School of Medicine, National University of Ireland, Galway 2 Merlin Park Hospital 3 Department of General Practice, National University of Ireland, Galway 4 University Hospital Galway

Introduction

Results

Home Haemodialysis (HHD) has recently become available as an alternative to in-centre Haemodialysis (HD). In addition to being more convenient and being associated with improved clinical outcomes, HHD is more cost-effective than in-centre HD. In spite of these advantages, uptake remains low.

The most common barriers to HHD were fear of needle use, desire to keep home and hospital separate and no security of healthcare professionals. The most common enablers of HHD were increased flexibility (time saved, ability to continue working), as well as reduced need for travel.

Aim

Conclusion

The aim of this study is to gain an understanding of a range of stakeholdersâ&#x20AC;&#x2122; perceived barriers to, and enablers of, HHD. An improved understanding of such perceptions to will help to identify patients that are suitable for HHD, and how these patients can be better supported, and encouraged to opt for HHD.

Although in-centre patients recognised the benefits of HHD, the barriers listed above prevented them from opting for it. Such barriers must be addressed in order to promote higher uptake of HHD. This could be done by devising effective strategies to improve patient knowledge and technical skills, thus reducing associated fears and uncertainty surrounding HHD.

Methods The study utilized qualitative semi-structured interviews from two groups; Home HD patients (n=5) and facility HD patients (n=7). Interviews were transcribed and later thematically analysed.

References 1. Mowatt G, Vale L, Perez J, Wyness L, Fraser C, MacLeod A, et al. Systematic review of the effectiveness and costeffectiveness, and economic evaluation, of home versus hospital or satellite unit haemodialysis for people with end-stage renal failure. Health Technol Assess 2003;7(2) 2. Tong A, Palmer S, Manns B, et al. The beliefs and expectations of patients and caregivers about home haemodialysis: an interview study. BMJ Open. 2013;3(1)

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JMSG | ABSTRACT Cord blood lymphocyte count as a potential screening tool for severe combined immunodeficiency Timon, J.1, Wrafter, A.2, Gilmore, R.2, Moylett, E.1 Academic Department of Paediatrics, NUI Galway 2 Department of Haematology UHG 1

Introduction

Results

Severe Combined Immunodeficiency (SCID) is a group of very rare diseases that are present at birth causing the child to have very little or no immune system.

SCID is commonly characterised by lymphopenia at birth, typically fatal unless corrected. SCID is not screened for in Ireland or the UK.

We report a mean lymphocyte value at birth of 5.51 x10^9L (SD=1.787,Range=10.80), neutrophils a mean of 6.98x10^9L (SD=2.67,Range 11.50 ) and platelets a mean of 276.36x10^9L (SD=65.2, Range=391.00). One newborn had a lymphocyte count below our cut off point (0.9 x10^9), this child was followed up and values normalized within the first few weeks of life.

The aim of our study was to investigate a useful cut-off absolute lymphocyte value (cord blood sample) as a potential screening tool for SCID. Methods Over an 8-week period, cord samples were obtained from 135 healthy term newborns born in UHG. 25 of these samples had to be excluded due to clotting, therefore, in total, 110 samples were analysed. The samples were analysed, focusing on a lower absolute lymphocyte limit of 2 x 10^9 as a predictor for possible SCID. The study was approved by the Clinical Research Ethics Committee; consent was obtained using an â&#x20AC;&#x2DC;opt outâ&#x20AC;&#x2122; format.

Conclusion In conclusion, a lower limit for absolute lymphocyte count of 2x10^9L would be useful in excluding SCID in healthy term infants.

Extending that value to 1.5x10^L would be feasible with only one otherwise healthy infant with a value below that level in our cohort.

References 1. Van der Burg M, Gennery A. Educational paper. European Journal of Pediatrics. 2011;170(5):561-571.

2. A National Model of Care for Paediatric Healthcare Services in Ireland Chapter 45: Universal Child Health Programme. Health Service Executive; 2015.

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JMSG | ABSTRACT Investigations in bone morphometry and bone mineral density distribution among osteoarthritic, osteoporotic, and type 2 diabetic patients Tio, S.W.1, Parle, E.2, Behre, A.3, Carey, J.4, Coleman, C.2, Vaughan, T.2, McNamara, L.M.2 1 School of Medicine, NUI Galway Ireland 2 Biomedical Engineering, NUI Galway Ireland 3 Lehigh University, Pennsylvania, USA, 4 Merlin Park University Hospital, Galway, Ireland

Introduction

Results

Type II diabetes has been known to compromise bone microstructure, increasing patientâ&#x20AC;&#x2122;s fracture risk even with normal bone mineral density (BMD)1. However, mineral heterogeneity in diabetic human bone is still unknown.

Bone morphometry in patients with OP were significantly decreased compared to OA and DB respectively, characterized by significant decrease in bone volume and trabecular volume (-16.3% and -20.7%), trabecular number (-11.0% and 9.9%), trabecular thickness (-6.9% and -11.9%), and significant increase in trabecular space (+9.5% and +11.8%). Additionally, significant decrease in stiffness (-58.7% and -60.8%) and yield stress (54.2% and -60.8%). bone mineral density distribution analysis showed significant increase in OP compared to OA and DB respectively, peak (+5.0% and +6.4%), full width at half maximum (+31.0% and +13.8%). Compared to OA, DB had a significant increase in FWHM (+15.2%).

Aim The aim of this study is to compare human trabecular bone morphometry, stiffness, strength, and mineral heterogeneity in patients presenting either with Type II diabetic patients (DB)(n=5), osteoporosis (OP) (n=10) or osteoarthritis (n=5), focusing mainly on central region of human femoral head (HFH).

Methods 20 HFHS were obtained from consented patients aged 55-90, males (n=6) and females (n=14) undergoing hip replacement surgery in 2 local hospitals. 4-8 bone cores from the central region were scanned using MicroCT to obtain 3Dimensional X-ray images. They were then tested using a Zwick tensile/compression testing machine. T-test was used to determine statistical significance (p<0.05).

Conclusion OP vs OA and OP vs DB are statistically significant. DB vs OA, only significant increase in FWHM, indicating more heterogeneity in DB which might be contributing factor to bone brittleness compared to OA.

References 1. Nyman et al., Clinic Rev Bone Miner Metab (2013) 11:38â&#x20AC;&#x201C;48.

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JMSG | ABSTRACT Development of discrete choice experiment to determine patient’s preferences for the treatment of prostate cancer: a focus group discussion Umar, E.A.M.1, Corcoran, R.2, Sullivan, F.3, Donovan, D.O.1,2 School of Medicine, National University of Ireland, Galway 2 Department of Public Health, Health Service Executive, West.

3 Prostate Cancer Institute, NUI Galway, Galway Clinic 1

Introduction Various treatments are available for Prostate Cancer. To determine patients’ preferences for the various types of treatment we will use a Discrete Choice Experiment (DCE) methodology which revolves around identifying attributes of these treatments and how different levels of those attributes might affect patients’ preferences for particular treatment.

Aim To develop and design a DCE to determine patients’ preferences for the treatment of prostate cancer using focus group discussions.

Chance of cure Chance of reoccurrence Ability to maintain sexual functionality Degree of urinary incontinence Hospital stay after the treatment Doctor’s reputation Influence of peers Ability to pursue leisure activities during and after treatment Table 1: What matters to patients in choosing their treatment.

Methods Conclusion The discussion was divided into four different sections and each section focused on one aspect of the patients’ treatment journey. The focus group was led by an experienced facilitator, recorded and transcribed. Basic analysis was carried out by grouping the transcript into themes or attributes.

Although a small number of participants were involved in our focus group, the concurrent nature of their responses provided us with list of attributes which we can use to design our DCE. Further focus group discussions may be necessary to determine levels of each of these attributes.

Results The focus group transcript identified several interconnecting themes. Some themes related specifically to why the patients chose the treatment they did, their experiences through the treatment phase and the side-effects of the treatment.

References 1. De Bekker-Grob EW, Bliemer MCJ, Donkers B, et al. Patients’ and urologists’ preferences for prostate cancer treatment: a discrete choice experiment. British Journal of Cancer. 2013;109(3):633-640. doi:10.1038/bjc.2013.370.

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JMSG | ABSTRACT The road to consultancy: what it takes to get to the top Van Den Berg, N.1, Hogan, N.2, Joyce, M.1 1 Department of Colorectal Surgery 2 University Hospital Galway, Galway, Ireland

Introduction

Results

Medical and surgical training pathways in Ireland are changing.

110 of 166 consultants at UHG completed the questionnaire (66%). 70.9% were male and 91.8% were Irish. Psychiatry, Pathology, and Dermatology were the only specialties with female consultants in the majority. The specialties with the youngest age at appointment were Geriatrics, Dermatology, Immunology, and Radiology (mean age=34), with Surgery, Oncology, and Cardiology having the (mean age=37). All (100%) consultants in Geriatrics and Dermatology completed higher degrees; as well as 91.0% of surgeons and 86.0% of cardiologists. 85.4% of consultants did not take a break in training; of those who did, 85.0% were female. In Anaesthesia, Radiology, Cardiology, and Oncology all consultants completed a fellowship prior to appointment and 83% of surgeons completed fellowships.

Conclusion

Aim This study set out to determine demographics, training duration and research activities of the current cohort of consultants at University Hospital Galway (UHG) to determine goal posts for which doctors in higher specialty training (HST) should aim.

Methods A single-centre study was conducted by prospectively distributing questionnaires in an interview format. Data was collected and analysed using Excel. The 28-item questionnaire was subdivided into 5 sections: “Demographics”, “Education”, “Training”, “Research” and “Miscellaneous” with an open-ended question at the end for consultant input. The questions were structured as binomial questions, as well as both open and closed ended questions. Survey guidelines were used to maximize response and ensure data accuracy.

Great variation exists in training pathways. As training changes, establishing a guideline for medical students and doctors working towards consultancy in Ireland is imperative.

References 1. Bruce-Brand, R., Broderick, J., Ong, J. and O’Byrne, J. (2012) ‘Diagnosing the doctors’ departure: survey on sources of dissatisfaction among Irish junior doctors.’, Irish Medical Journal, 105(1), pp. 15–18.

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JMSG | ABSTRACT Different forms of resilience: a key predictor of functioning and potential therapeutic target for those with chronic mental illness Conlon, C.1, Liston, A.2, Adamis, D.2 School of Medicine, NUI Galway, Ireland.

2 Dept of Psychiatry, Sligo/Leitrim Mental Health Services, Sligo.

1

Introduction Chronic mental illnesses challenge functioning, with resilience buffering hopelessness. Resilience is central to the new movement of positive psychiatry which refreshingly is a strength based approach to mental health. Understanding resilience better may help identify those with lower functioning and prove an important target for rehabilitation.

Aim To establish which form of resilience (socialsupport, emotional-coping or situational-coping) is most important in attainment of higher functioning for people with Schizophrenia, Schizoaffective-Disorder or Bipolar-Disorder a f ter c on tr ollin g f or f ac t or s lik e psychopathology.

Methods Community-dwelling patients aged 18+ of Sligo/ Leitrim area with Schizophrenia, BipolarDisorder or Schizoaffective-Disorder were approached in this ethically approved crosssectional study. The scales used were Resilience Appraisal Scale (RAS), Global Assessment of Functioning (GAF) and Basic Psychiatric Rating Scale (BPRS). RAS has 12 items scored on a 5point Likert-Scale, it accessed the aforementioned resilience sub-scales with lower scores indicating higher resilience. GAF accessed f u nc t ion in g wh ils t B P R S m e a s u re d

psychopathology. Data analysis involved descriptive and linear regression with SPSS. Results Of 132 approached, 107 agreed to participate, [mean age 47.91, (SD:13.73), 60 (56.1%) males].

The mean GAF was 59.33, (SD:16.12), mean BPRS 38.95 (SD:13.78), and the means of RASsub-scales were: social-support 1.79(SD:0.88), situational-coping 2.12 (SD:0.90) and emotionalcoping 2.35 (SD:1.07). The significant predictors of general functioning were BPRS (t=- 7.776, p≤0.001) and RAS-social-support (t=-3.311, p=0.001).

Conclusion Higher functioning is achieved with lower psychopathology and better social support. The clinical implication is the development and realization of a social-support-network, which builds resilience, offers a promising therapeutic target for people with serious chronic mental illnesses.

References 1. Johnson, J., Gooding, P.A., Wood, A.M., Taylor, P.J., Pratt, D. and Tarrier, N. (2010) ‘Resilience to suicidal ideation in psychosis: Positive self-appraisals buffer the impact of hopelessness’, Behaviour Research and Therapy, 48(9), 883889.

2. Leucht, S., Kane J.M., Kissling, W., Hamann, J., Etschel, E. and Engel, R. (2005) ‘Clinical implications of Brief Psychiatric Rating Scale scores’, The British Journal of Psychiatry, 187(4), 366-371.

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JMSG | CASE REPORT A Case of Foot in Mouth: fibular free flap reconstruction of the mandible using custom virtual surgical planning Aisling Moriarty1 School of Medicine, NUI Galway

1

Summary Our patient was a 65 year old gentleman who presented to the maxillofacial department with a 2 month history of right sided cheek swelling, toothache, and more recent onset of lower lip paraesthesia. Tissue biopsy and imaging revealed the diagnosis of a squamous cell carcinoma, arising from the buccal mucosa, and invading into the right mandibular ramus and body. Our patient underwent tumour resection and fibular free flap reconstruction of the mandible, using custom virtual surgical planning. Based on preoperative virtual reconstructive mapping, a pre bent titanium plate and custom made fibular and mandibular cutting rigs were constructed for a new jawline that closely matched his original facial contour, for optimal functioning and aesthetics. A denervated pec major flap was incorporated into reconstruction for graft protection. Clear surgical margins were obtained and our patient underwent chemoradiotherapy postoperatively as per protocol, as well as oral rehabilitation. Post op surveillance revealed a good response to treatment.

Introduction Custom virtual surgical planning is a relatively new concept in reconstructive surgery. It utilizes preoperative imaging and virtual simulation to construct and print 3D models that are unique to the patient and proposed surgery. The best example of this new technique is in the field of maxillofacial surgery, where precision planned mandibular reconstructions are becoming superior in terms of postoperative functional and aesthetic results, compared to traditional intraoperative manual techniques1.

medications and had no family history of malignancy. He is a truck driver, living at home with his wife, and is a lifelong non smoker. He drank <2 units of alcohol/week.

On external examination, there was a subtle loss of contour to the right lower border of the patients jaw line. On examination of the oral cavity, we could appreciate some right sided buccal swelling, along with erythema of the overlying mucosa. There was no palpable lymphadenopathy or signs of systemic disease.

Differential Diagnosis and Investigations The presentation of such a buccal swelling, progressive in nature and resistant to standard antibiotic therapy, should prompt one to consider the prospect of either a deep seated infective process, or a malignancy. Our investigation was done with this in mind.

Imaging was the first port of call in our investigation, and we first ordered a dental orthopantograph. This is a panoramic view of the patientâ&#x20AC;&#x2122;s mandible, teeth, TMJ, and frontal/ maxillary sinuses. This showed an osteolytic mass in the right mandibular ramus and body, measuring approximately 4.5cm. A biopsy of the lesion came back with signs consistent of a squamous cell carcinoma, arising from the buccal mucosa. MRI and CT imaging of head and neck confirmed this finding, and identified signs suggestive of lymph node involvement, but without distant disease. This gave our patient a radiological stage of a T4aN2b squamous cell carcinoma of the oral cavity2.

Case Presentation This 65 year old gentleman presented with a two month history of toothache, painful swelling of his right cheek, and a new onset paraesthesia of his right lower lip. He was referred in by his dentist after failure of antibiotic therapy. This patient was otherwise healthy, who took no long-term 32

Image 1: Dental OPG showing 4.5cm osteolytic mass destroying right mandibular ramus and body Volume no. 4 | SPRING 2018

JMSG | CASE REPORT Management The core of our therapeutic strategy for this patient was to achieve freedom from both disease and disability. The mainstay of therapy for such a high grade carcinoma would be surgical resection of the tumour and mandibular reconstruction, followed by adjuvant chemoradiotherapy and oral rehabilitation, with close follow up. After some discussion at the MDM for head and neck malignancy, the patient was planned for a bilateral neck dissection as well as tumour resection, due to the presence of radiologically suspicious lymph nodes.

Along with this, our patient was deemed to be an excellent candidate for a fibular free flap reconstruction of the mandible using custom virtual surgical planning.

A CT of the head and leg and lower limb MRA was sent away for virtual surgical planning. They sent us virtual 3D reconstructions,

Image 4: Custom made titanium plate screwed into place with fibular grafts attached posteriorly. Fibular skin forms the floor of the mouth.

Image 2: Virtual surgical planning models detailing tumour extent (red), area to be resected (green), and reconstruction (blue). detailing the extent of mandible to be resected, and the virtual planned reconstruction. This was composed of three specific cuts of fibula, joined to form the shape of the mandible, and anchored together by a titanium plate.

Image 5: Pec major flap being incorporated onto graft site.

These virtual images were sent along with a custom made cutting rig for the fibula and mandible, and a custom titanium plate. The cutting guide was to ensure the osteotomies would match up exactly with the preoperative virtual plan, and the plate acted to anchor the fibular graft to the cut edges of mandible. This plate came pre-bent, removing any need for intraoperative manipulation, providing our patient with an aesthetically and functionally acceptable jawline that resembled the patients original facial contour as closely as possible.

Image 3: Custom made cutting rigs for fibula (left) and right mandibular ramus (right).

Image 6: Post operative x-ray of the head and neck. Note titanium plate in situ with three cuts of fibula attached.

Intraoperatively, two separate teams worked together to prepare the fibular donor site and the mandibular recipient site. The fibular

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JMSG | CASE REPORT

Image 10: En bloc resection of the mandible, lower incisors, lymph nodes and skin island.

Image 7: Hairy skin from fibula forming floor of mouth.

grafts were fixed onto the posterior aspect of the mandibular plate, with soft tissues still attached. A clinical decision was made intraoperatively to incorporate a pec major flap into the reconstruction, for bulk and protection to the underlying graft site and anastomoses. An island of skin from the fibular harvest site was also incorporated to the lateral aspect of the face, again to relieve tension over the graft site.

Histology from the en bloc resection reported an invasive, moderately differentiated squamous cell carcinoma, originating from the oral mucosa. Although some invasion of the perineural space, mandibular bone and skeletal tissue was reported, there was no lymphovascular invasion. 37 lymph nodes were resected as part of the bilateral neck dissection, none of which showed metastatic change. Thus, a pathological stage of T4aN0M0 was given.

Image 8: Pre op inspection of oral cavity showing swelling and erythematous changes to buccal mucosa.

In keeping with national guidelines, our patient underwent adjuvant chemoradiotherapy, due to the high risk of locoregional recurrence associated with oral squamous cell carcinoma3. As well as this, he is receiving oral rehabilitation along with either dental implant or denture fitting. He is being managed by a multidisciplinary team comprising of speech and language therapists, physiotherapists, dieticians and clinical nurse specialists, to assist the patient in his return to baseline functioning.

Reflection

Image 9: Patient 4 weeks post op. Denervated pec major flap will atrophy over time providing a more natural facial contour.

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Mandibular reconstruction with segments of straight bone has long been a challenge in head and neck surgery, with post operative results largely dependent on surgeon experience and intraoperative judgement. Prior to virtual surgical planning, measurements for osteotomies and metal plating were largely done by sight, using intraoperative preplating techniques4. With the increasing accessibility to 3D virtual imaging and printing, virtual surgical planning is now becoming the new standard of care in complex facial reconstructive surgery5. The opportunity to virtually design the resection and reconstruction offers many advantages. One review found improved reconstruction accuracy, facial aesthetics and dental occlusion when virtual surgical planning was implemented6. As well as improved clinical outcomes, the implementation of virtual surgical planning is economically viable, as reduced operation times and Volume no. 4 | SPRING 2018

JMSG | CASE REPORT complication rates translate to reduced costs, even after accounting for the associated expense of using such a program7.

As with any new technology, some drawbacks are to be expected.

In this case, an issue with funding for the virtual program resulted in delays to surgical management, by which time the planned resection margins were in danger of becoming obsolete due to tumour growth. The surgical margins were sufficient to excise the tumour, but with a narrower margin than originally intended.

When managing a progressive disease such as cancer, it is of paramount importance that your surgical plan can adapt to changes in tumour size and character. This is a main pitfall of virtual surgical reconstruction; where all planning is done based on a single snapshot of the tumour in time. Thus, the surgeon must References 1 Kirke DN, Owen RP, Carrao V, Miles BA, Kass JI. Using 3D computer planning for complex reconstruction of mandibular defects. [cited 2018 Mar 4]; Available from: https://cancersheadneck.biomedcentral.com/track/ pdf/10.1186/s41199-016-0019-4?site=cancersheadneck.biomedcentral.com 2 Lydiatt WM, Patel SG, O’Sullivan B, Brandwein MS, Ridge JA, Migliacci JC, et al. Head and neck cancers-major changes in the American Joint Committee on cancer eighth edition cancer staging manual. CA Cancer J Clin [Internet]. 2017 Mar 1 [cited 2018 Mar 3];67(2):122–37. Available from: http://doi.wiley.com/10.3322/caac.21389 3 Keane M. NCCP Chemotherapy Protocol NCCP Protocol: CISplatin 100mg/m 2 with Radiotherapy. 2016 [cited 2018 Mar 4]; Available from: https://www.hse.ie/eng/services/list/5/cancer/profinfo/chemoprotocols/ headandneck/387.pdf 4 Pellini R, Mercante G, Spriano G. Step-by-step mandibular reconstruction with free fibula flap modelling. Acta Otorhinolaryngol Ital [Internet]. 2012 Dec [cited 2018 Mar 4];32(6):405–9. Available from: http://

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balance the desire for tissue preservation in their virtual reconstructions, against the danger of inadequate surgical margins and risking incomplete clearance.

Virtual surgical planning should therefore not be seen as a replacement to good clinical judgement. It is to be implemented as an adjunct; a tool to enhance a surgeon’s efficiency and accuracy 5.

It can be used to communicate the procedure to the patient, and manage patient expectations with virtual simulations of expected results. With this in mind, we should embrace this technology as a valuable aid to clinical decision making and preoperative planning, but ultimately trust our own clinical judgement to guide patient management and preserve patient safety.

www.ncbi.nlm.nih.gov/pubmed/23349561 5 Pfaff MJ, Steinbacher DM. Plastic Surgery Applications Using ThreeDimensional Planning and Computer-Assisted Design and Manufacturing.

Plast Reconstr Surg [Internet]. 2016 Mar [cited 2018 Mar 4];137(3):603e– 616e. Available from: http://content.wkhealth.com/linkback/openurl? sid=WKPTLP:landingpage&an=00006534-201603000-00048 6 Lin H-H, Lo L-J. Three-dimensional computer-assisted surgical simulation and intraoperative navigation in orthognathic surgery: A literature review. J Formos Med Assoc [Internet]. 2015 Apr 1 [cited 2018 Mar 4];114(4):300– 307. Available from: https://www-sciencedirectcom.libgate.library.nuigalway.ie/science/article/pii/S0929664615000686 7 Zweifel DF, Simon C, Hoarau R, Pasche P, Broome M. Are Virtual Planning and Guided Surgery for Head and Neck Reconstruction Economically Viable? J Oral Maxillofac Surg [Internet]. 2015 Jan [cited 2018 Mar 4];73 (1):170–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25443385

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JMSG | CASE REPORT The Dangers of a Rolling Stone MĂ­cheĂĄl Brennan1 1 Surgical Department, Letterkenny University Hospital

Summary Our patient was an 88-year-old male who presented with signs of a small bowel obstruction.

Gallstone ileus was diagnosed, and the patient underwent a lower midline laparotomy with enterlithotomy. Patient recovered well and was discharged home on post-operative day 6.

Introduction This is an important case to illustrate that rarer causes of bowel obstruction need to be considered. Although gallstone ileus accounts for less than 2% of all small bowel obstruction, it is thought to represent up to 25% of nonstrangulated small bowel obstruction in the over 65 age group1. For this reason, it is important to keep it in mind.

Case Our patient was an 88-year-old male who was brought in by ambulance following GP referral. He was complaining of sudden onset bilateral lower abdominal pain which was worse on the left. He described it as a non-radiating continuous pain which he rated at a severity of 7/10. He had associated symptoms of nausea and had 5 episodes of bilious vomiting that day. He also complained of absolute constipation. His symptoms had been ongoing for just under 24 hours. His past medical history was significant for an episode of cholecystitis 9 months previously which had been treated conservatively. His CT from this admission (Image 1) showed a moderately enlarged gallbladder (GB) with a thickwalled collection, and a 4.5cm gallstone was seen in neck of GB causing outflow obstruction He also has a history of atrial fibrillation and NSTEMI. His drugs included warfarin, which was held on admission. He lives at home with his son and is independent in his activities of daily living. He is a retired lorry driver who is a non-drinker and smokes 5 cigarettes per day. His family history was insignificant.

On exam, the patient was sitting up in bed, well orientated to person, place and time. The abdomen was noticeably distended. He was tender in the left iliac fossa with guarding. His abdomen was tympanic to percussion and bowel sounds were noted to be high pitched.

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Image 1: CT Abdomen on first admission At this stage the differential diagnosis included small bowel obstruction, large bowel obstruction, obstruction of a hernia and diverticulitis.

Management in the ED consisted of fluid resuscitation and administration of 50% O2. He was given 40mg esomeprozole IV and 4mg ondansetron IV. Bloods and a CT abdomen were ordered. The most abnormal of his blood results was his INR, which was 5.3. His urea and creatinine were also mildly elevated, but this was attributed to his vomiting and lack of oral intake in the previous 24 hours. The diagnosis was clinched when his CT was performed (Image 2).

Compared to the CT 9 months previously, the GB was no longer distended. However, there was now a direct communication between GB and first part of duodenum and the 4.5 cm gallstone previously identified in neck of GB was now in mid-small bowel causing a mechanical obstruction, and a diagnosis of gallstone ileus was made.

Image 2: CT Abdomen on second admission

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JMSG | CASE REPORT The majority of stones impact in the terminal ileum5 due to the anatomical small diameter and less active peristalsis here.

However, stones can lodge anywhere in the bowel. Bouveret syndrome is a rare entity where the stone causes gastric outlet obstruction6. This can happen if a cholecyto-gastric fistula is formed. Gallstone coleus can also occur where a stone becomes lodged in the colon, either through a cholecyto-colonic fistula or smaller stones which pass through the ileocecal valve can become lodged in diseased parts of colon eg in diverticulitis. Gallstones causing gastric or colonic obstruction may be treated at endoscopy7. There have been cases where colonic stones have been removed at proctoscopy or have passed spontaneously after several days conservative management7.

At this stage the patient had received octaplex, and his INR was brought down to 1.8. He was brought emergently to surgery where a lower midline laparotomy was performed. The stone was found in the mid-jejunum. The stone was milked proximally to a healthier portion of bowel where an enterotomy would be safer.

A longtitudinal enterotomy was performed on the antimesenteric aspect of the jejunum and a 4.5cm gallstone was removed. The bowel was walked proximally and distally to ensure there were no remaining fragments of stone left behind. The enterotomy was closed transversely to maximise bowel diameter at this point and to minimize the risk of future stenosis or obstruction.

The patient spent 3 days in the HDU where his recovery was noneventful. He was moved to the ward and his warfarin was restarted, and he was discharged home on post -operative day 6.

He returned to clinic 6 weeks later without any complaints and had a well healed laparotomy incision.

The main controversy surrounding the management of gallstone ileus is whether to perform cholecystectomy and fistula repair at the time of enterolithotomy. This is known as a one stage procedure. The alternative two stage procedure involves enterlithotomy alone with either expectant management of further biliary problems or elective cholecystectomy and fistula repair. The advantages of the one stage procedure are that there is a lower rate of recurrence of gallstone ileus. As well as this, Bossart et al found there to be a 15% risk of gallbladder cancer in patients who have had gallstone ileus and have not undergone cholecystectomy, versus .8% for the one stage procedure 8.

However, there is a significantly higher mortality associated with the one stage procedure, (7% vs 5%)1. The typical patient who presents with gallstone ileus is an elderly patient with multiple comorbidities, usually with an ASA grade 2 or 3. Proponents of enterolithotomy alone maintain that the one stage procedure is both more technically difficult and exposes elderly comorbid patients to longer more demanding surgeries. This is thought to account for the higher mortality associated with the one stage procedure. Therefore, it is recommended that the one stage procedure be reserved for patients with absolute indications for gallbladder intervention at presentation or younger patients with a good physiological and metabolic reserve.

Reflection Gallstone ileus is a rare complication of cholelithiasis which requires the formation of a cholecystoenteric fistula to allow for the passage of stones directly into the bowel. Fistulas complicate about 2-3% of cholelithiasis with associated cholecystitis. As gallstone disease is more common overall in the female population, the incidence of gallstone ileus is also higher in females. The typical presentation is that of an elderly female, complaining of intermittent â&#x20AC;&#x153;tumblingâ&#x20AC;? pain. This intermittent pain is caused by the stone becoming lodged, causing obstruction, becoming dislodged again and moving further distally until it finally becomes impacted. This can lead to delayed presentation and diagnosis. Mean duration of symptoms before presentation to hospital is 3-5 days2. An association between Mirizzi syndrome and the presence of a cholecystoenteric fistula has been suggested.

When a stone is impacted in the cystic duct it can result in narrowing and damage to the common hepatic duct3. Fistulas are thought to form when pericholecystic inflammation following cholecystitis lead to formation of adhesions between the biliary system and adjacent bowel. Pressure necrosis from the stone against the biliary tree then leads to erosion and fistula formation 4.

Historically gallstone ileus is thought to account for 1-2% of all small bowel obstructions. However, a recent nationwide review of 3,452,536 mechanical bowel obstructions from 2004-09 in US found it to account for <.095%. The authors attributed this to the higher number of cholecystectomies being performed nowadays1.

References 1 Halabi WJ, Kang CY, Ketana N, Lafaro KJ, Nguyen VQ, Stamos MJ, et al.

Surgery for gallstone ileus: a nationwide comparison of trends and outcomes. Annals of surgery. 2014;259(2):329-35.

2 Zuegel N, Hehl A, Lindemann F, Witte J. Advantages of one-stage repair in case of gallstone ileus. Hepato-gastroenterology. 1997;44(13):59-62.

3 Beltran MA, Csendes A, Cruces KS. The relationship of Mirizzi syndrome and cholecystoenteric fistula: validation of a modified classification. World journal of surgery. 2008;32(10):2237-43.

4 Normal H, Keaveny AP, Afdhal NH, Bowers S, Ashley SW, Chopra S, et al.

Gallstone ileus.

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The take home message from this case is not to attribute every small bowel obstruction to adhesions or hernias! Rarer diagnoses do happen, and gallstone ileus is one to bear in mind, particularly in the elderly female.

5

Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases.

The American surgeon. 1994;60(6):441-6.

6 Arya S, Guha S, Kuppuswamy M, Chaggar JG, Ralte L, Chejera R, et al. A rare presentation of gastric outlet obstruction (GOO)â&#x20AC;&#x201C;The Bouveret's syndrome. Annals of Medicine and Surgery. 2015;4(1):67-71.

7 Farkas N, Karthigan R, Lewis T, Read J, Farhat S, Zaidi A, et al. A single centre case series of gallstone sigmoid ileus management. International journal of surgery case reports. 2017;40:58-62.

8 Bossart PA, Patterson AH, Zintel HA. Carcinoma of the gallbladder: a report of seventy-six cases. The American Journal of Surgery. 1962;103 (3):366-9.

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JMSG | EDITORIAL Gardasil Vaccine and Human Papilloma Virus Dr. Edina Moylett 1

School of Medicine, National University of Ireland, Galway

Almost everyone will experience infection with Human Papilloma virus (HPV) at some stage in their lifetime; the virus is the most common sexually transmitted viral infection worldwide, with first infection typically occurring soon after sexual debut. HPV is responsible for a myriad of disease presentations but notably certain serotypes of HPV cause a variety of human cancers.

For the first time in vaccine development and as part of the standard immunisation recommendations, there is an efficacious vaccine that prevents cancer, HPV vaccine.

There are more than 200 types of HPV, which can be subdivided into cutaneous or mucosal classes based upon their tissue tropism. Certain HPV types have high affinity for cutaneous epithelium detectable in plantar, common, flat and butcher’s warts; HPV types associated with plantar and common warts include types 1, 2, and 4; flat warts are most often caused by HPV types 3 and 10, while butcher's warts are most often associated with HPV types 7 and 2. HPV types with a predilection for anogenital keratinized skin and mucous membrane infection also exist. Common sites for infection include the penis, scrotum, perineum, anal canal, perianal region, vaginal introitus, vulva, and cervix. Over 40 mucosal HPV genotypes can infect the genital tract.

 Genital warts (condyloma acuminatum) – are benign anogenital warts, caused most often by HPV types 6 and 11.

 Squamous

intraepithelial

lesions

and/or

carcinoma of the vagina, vulva, cervix, anus, or penis – approximately 15 HPV types are associated with cancer and are known as high risk, carcinogenic, or cancer associated. HPV 16 is the most common and is associated with the highest risk of progression to cancer. HPV type 16 can infect the oral mucosa and has been associated with squamous cell carcinoma of the oral cavity.

Worldwide, cervical cancer is the 4th most common cancer among women with approximately 530,000 cases of invasive cervical 38

carcinoma diagnosed and 260,000 cervical cancer deaths annually. HPV accounts for virtually all cases of cervical cancer; HPV 16 approximately 50% of cases, HPV 18 for 20%; types 31, 33, 45, 52, and 58 an additional 20% of cases.

Additionally HPV is responsible for approximately 90% of anal, 70% of vaginal, 50% of penile, 40% of vulvar, and 13%–72% of oropharyngeal cancers.

Three different HPV vaccines are currently available varying in the number of HPV types they contain and target:

 Quadrivalent HPV vaccine (Gardasil®) targets HPV types 6, 11, 16, and 18 (currently in use, Ireland)

 9-valent vaccine (Gardasil 9®) targets the same HPV types as the quadrivalent vaccine (6, 11, 16, and 18) as well as types 31, 33, 45, 52, and 58 (currently in use, USA)

 Bivalent vaccine (Cervarix®) targets HPV types 16 and 18 Quadrivalent vaccine, Gardasil®, was introduced in 2006. The vaccine is currently approved in over 120 countries and is part of the national immunisation program in over 70 countries worldwide. In excess of 270 million doses have been administered globally, 690,000 doses in Ireland; over 230,000 Irish girls are fully vaccinated. All girls less than 15 years of age at the first dose require two doses of the vaccine given at least 6 months apart. Owing to a paucity of scientific efficacy data in older girls, those aged 15 years and older at the first dose currently require three doses.

“For the first time in vaccine development and as part of the standard immunisation recommendations, there is an efficacious vaccine that prevents cancer.”

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JMSG | EDITORIAL A recent systematic review of 10 years’ real world experience with Gardasil® vaccine was conducted by Garland et al [1].

‘Subsequent to introduction of the Gardasil®, consistent decreases in the prevalence of HPV 6/11/16/18 cervical/vaginal infections, genital warts, low- and high-grade cytological abnormalities, cervical intraepithelial neoplasia (CIN)2, CIN3, and adenocarcinoma in situ were observed among females in their teens and 20s (age groups targeted by national immunization programs).

exposure, this drop will have an unfortunate effect on preventable cervical cancer diagnoses for this cohort of girls in the future. Fortunately well-informed, scientifically based, socially acceptable HPV vaccination campaigns, tirelessly staffed by dedicated personnel, have reversed some of the ill effects.

Uptake figures to date in 2017-2018 are in the 60% range but not yet back to the initial highs following vaccine introduction in 2010.

Decreases were highest in younger birth cohorts, reflecting a lower likelihood of prevalent HPV infection at time of vaccination. Irrespective of study design, declines were detected within 4 years after vaccine availability, even in settings with comparatively low vaccine coverage. Rapid reductions up to approximately 90% in HPV 6/11/16/18 infections and genital warts after introduction of Garadasil® vaccination programs were first demonstrated in young women in Australia, Europe, North America, and New Zealand. Follow up cervical screening in countries with high vaccine coverage, for example Australia and Denmark where programs had achieved high and timely coverage with catch-up vaccination, respective reductions as high as 57% in CIN2+ and 80% in CIN3+ lesions were reported in the youngest cohorts vaccinated shortly after program implementation. The greatest impact has been seen where the vaccine is routinely administered before HPV exposure.

“Given the well documented importance of immunisation prior to first HPV exposure, this drop will have an unfortunate effect on preventable cervical cancer diagnoses for this cohort of girls in the future. “

“HPV vaccination works, is highly effective and ultimately saves lives, the HPV program is one of the most important public health initiatives in recent times.”

HPV vaccination works, is highly effective and ultimately saves lives, the HPV program is one of the most important public health initiatives in recent times. HPV vaccine is a significant step towards prevention in cancer diagnoses. Vaccine efficacy is dependent on delivery of the program. Tragically in recent times in Ireland and other EU countries, concern was expressed regarding HPV vaccine efficacy among the parents of vaccinated girls. Reports of chronic regional pain syndrome (CRPS) and postural orthostatic tachycardia syndrome (POTS) appeared.

Social media enabled incorrect and inflammatory information to be widely disseminated to a non discerning parental audience to the extent that vaccination uptake rates dropped precipitously in this country during 2016-2017. The HPV vaccine uptake figure for 2014-2015 nationally was 86.9% (target >80%); this figure dropped sharply to 51% during 2016-2017. Given the well documented importance of immunisation prior to first HPV

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What of HPV safety? The World Health Organisation has repeatedly validated the safety of HPV vaccines and at no time has expressed concern. The Global Advisory Committee on Vaccine Safety (GACVS), an independent expert clinical and scientific advisory body, provides the WHO with rigorous advice on vaccine safety issues of potential global importance. At a recent GACVS meeting (June 2017) the following statement pertaining to Gardasil® safety was released: “There are now accumulated safety studies that include several million persons and which compare the risks for a wide range of health outcomes in vaccinated and unvaccinated subjects. However, despite the extensive safety data available for this vaccine, attention has continued to focus on spurious case reports and unsubstantiated allegations. The Committee continues to express concern that the ongoing unsubstantiated allegations have a demonstrable negative impact on vaccine coverage in a growing number of countries, and that this will result in real harm”.

Conditions such as CRPS and POTS will continue to occur, it is well recognised that approximately 150 per million young girls between 10 and 19 years may develop CRPS or POTS; the diagnosis of the latter conditions is independent of HPV administration. A recent review of HPV vaccine safety has provided additional reassurance as to vaccine safety [2]. In 109 studies, including 15 population-based studies in over 2.5 million vaccinated individuals across six countries, there was no consistent evidence of an increased risk of any unwanted adverse event, including demyelinating syndromes or neurological conditions such as CRPS or POTS. The authors concluded that the risk–benefit profile for HPV vaccines remains highly favourable.

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JMSG | EDITORIAL HPV vaccine is a public health success phenomenon. In conclusion, I would like to echo the sentiments expressed by all 69 US National Cancer Institute-designated Cancer Centres. “As national leaders in cancer research and clinical care, we are compelled to collectively call upon parents and health care providers to increase vaccination rates so our nation’s children don’t grow up to become cancer patients”.

Dr. Edina Moylett has been in post as Senior Lecturer in Paediatrics at National University of Ireland, Galway/ Consultant Paediatrician at University college Hospital Galway since 2004; she is Director of Student Affairs for the School of Medicine, NUI Galway. Prior to joining the academic staff at NUIG, Dr. Moylett was a member of the paediatric faculty at Texas Children’s Hospital in Houston, Texas where she completed fellowship training in both paediatric infectious diseases and paediatric allergy and clinical immunology. Formerly a graduate of the Royal College of Surgeons, Dr. Moylett is a Fellow of the Royal College of Physicians of Ireland, Faculty of Paediatrics. Dr. Moylett is a current member of the National Immunisation Advisory Committee.

References 1

Garland SM, Kjaer SK, Muñoz N, Block SL, Brown DR, DiNubile MJ, Lindsay BR, Kuter BJ, Perez G, Dominiak-Felden G, Saah AJ. Impact and effectiveness of the quadrivalent human papillomavirus vaccine: a systematic review of 10 years of real-world experience. Reviews of Infectious Diseases. 2016 May 26;63(4):519-27.

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2

Phillips A, Patel C, Pillsbury A, Brotherton J, Macartney K. Safety of Human Papillomavirus Vaccines: An Updated Review. Drug safety. 2017 Dec 26:18.

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JMSG | EDITORIAL NASA, NEEMO and Telemedicine Dr Derek T O’Keeffe Practice makes perfect or rather perfect practice makes perfect1. This is the central tenet of human spaceflight training and to aid perfect practice the world’s space agencies (e.g. NASA, ESA) have developed several space analogue habitats here on Earth2,3. This is because the most important part of any human spaceflight mission is the human. The space analogue training facilities are located in geographically remote and extreme environments around the planet including polar regions, deserts, caves and underwater. These terrestrial space analogues mimic the mental and physical challenges of living and working in space or on another planet (e.g.

Mars) and allow the practice of operational, experimental and safety protocols.

The NASA Extreme Environment Mission Operations (NEEMO) is an annual NASA multiweek mission that sends a group of six astronauts, scientists and engineers to Aquarius, the worlds only undersea research station which is located 6km off Key Largo, Florida, USA (Image 1).

This Aquarius sealab is 13m in length and is situated at a depth of 20m (3 atmosphere pressure) and allows crew to live and work

underwater 24 hours a day. It consists of a kitchen, labs and sleeping quarters. It also has a wet porch, which allows entry/exit from the habitat into the ocean (Image 2).

“Every mission has a wide variety of scientific experiments associated with it, from human psychology to marine biology, using the unique Aquarius habitat as a high fidelity space analogue.”

The sealab team or aquanauts carry out mission work both inside the Aquarius habitat and outside in the sea during Extra Vehicular Activities (EVA’s). A significant advantage of living on the ocean floor is that it enables the Aquanauts to practice saturation diving4. This technique allows crew during EVAs to dive for up to 9 hours without having to worry about decompression sickness (by comparison surface dives usually last < 2 hours).

Mission control is coordinated topside from a high tech hub on shore with live video/audio communications links (with simulated time delay if required) to the crew below sea (Image 3).

Since 2001, every NEEMO mission has a wide variety of scientific experiments associated with it, from human psychology to marine biology, using the unique Aquarius habitat as a high fidelity space analogue. In 2016, as part of its mission brief NEEMO #21 required a state of the art Telemedicine technology implementation.

Image 1: NEEMO Aquarius Habitat

Image 2: Aquarius Habitat Floor Plan Volume no. 4 | SPRING 2018

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JMSG | EDITORIAL Telemedicine is defined by the WHO as “the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities”5.

I have a background in Biomedical Engineering and Medicine and had previously done field work in a remote space analogue extreme environment (MDRS) as well as developing and implementing a medical technology project on the International Space Station. Therefore I was approached to be the telemedicine flight surgeon6 for NEEMO mission #21.

Image 3: NEEMO Mission Control This mission’s international crew was chosen to test advanced technology and techniques for future space exploration by living in simulated spacecraft conditions and conducting simulated spacewalks (EVAs) outside of their undersea habitat mimicking the extreme environment challenges of the Martian / lunar surface.

The NEEMO #21 crew was notable for having the first Irish Aquanaut, Dr. Marc O’Griofa, on-board, who collaborated with me testing next generation telemedicine technology as well as completing experiments with telomere degradation and vestibular function testing. The remaining crewmembers included

“The telemedicine experimental protocol involved monitoring crew health to inform operational decisions. For example if there was an EVA scheduled for the day, the advanced telemedicine technology could give objective data as to which crewmember was suitable or not to participate.”

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2 NASA astronauts (Lt. Commander Reid Wiseman, Dr. Megan McArthur) and an ESA astronaut (Dr. Matthias Maurer) whose experimental brief also included geology, marine biology and genomic projects.

The advanced telemedicine technology chosen for NEEMO #21 was the Equivatel system7. This multi-parameter wireless physiological system records ECG, Respiratory, Tri Axial Accelerometer and temperature signals. The system is notable for very high data quality with low data loss rates. Ergonomically the system’s garment is comfortable to wear and therefore is optimized for long duration use (Image 4).

Image 4: Equivatel Telemedicine System The telemedicine experimental protocol involved monitoring crew health to inform operational decisions. For example if there was an EVA scheduled for the day, the advanced telemedicine technology could give objective data as to which crewmember was suitable or not to participate. Things that might exclude a participant from an EVA include poor sleep patterns, rising temperature, elevated heart rate (Image 5). In addition the telemedicine system could monitor crew movements through it accelerometer systems which provided valuable insight into daily activities.

The extreme environment telemedicine experiment of NEEMO #21 was a complete success. We were able to demonstrate high fidelity real time physiological signal recording of the Aquanauts both from Galway, Ireland and from topside mission control in Florida, USA. Using this information the mission commander was able to make better operational decisions and I as the flight surgeon could objectively monitor, analyse and optimise crew activities such as sleep quality, mobility and on board exercise regimes.

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JMSG | EDITORIAL

Image 5: Physiological monitioring Dr. Derek O’Keeffe holds dual first class honours degrees in Engineering and Medicine as well as a Masters and PhD in Biomedical Engineering from the University of Limerick and NUIG. He has was a Fulbright Scholar at Harvard University and is an alumni of Green Templeton College at Oxford University. He is a graduate of the Endocrinology Fellowship programme at the Mayo Clinic, Rochester, USA and the Irish Endocrinology SpR scheme. As well as multiple academic publications, he holds two biomedical patents and several international research prizes. He has previously worked with NASA and has also done overseas volunteer work in Ghana and Papua New Guinea. He is a Black Belt Taekwondo instructor, qualified pilot and advanced scuba diver. He was awarded the Outstanding Young Person of the World award by JCI. He has travelled in over 110 countries and is looking forward to seeing the rest.

This advanced type of physiological monitoring is usually seen in our intensive care units. However this type of physiological telemedicine equipment is starting to be used by first responders (e.g. hazardous materials firefighters), military (e.g. special operations forces) and in clinical research (e.g. pharmacological trials). In the future, following the projections of Moore’s Law 8, it will no doubt become part of routine patient care.

Abbreviations NASA – National Aeronautics and Space Administration ESA – European Space Agency WHO – World Health Organisation MDRS – Mars Desert Research Station

References 5 1

https://www.quotes.net/quote/1373 2 https://www.nasa.gov/analogs 3 http://www.esa.int/Our_Activities/Human_Spaceflight/Caves 4 http://www.alertdiver.com/Saturation_Diving

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http://www.who.int/goe/publications/goe_telemedicine_2010.pdf https://www.nasa.gov/content/flight-surgeons 7 http://www.equivital.co.uk 8 https://www.intel.com/content/www/us/en/silicon-innovations/moores-lawtechnology.html 6

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JMSG | STUDENT PERSPECTIVE AFMC and AMSI: Acronyms for an Amazing Summer Aisling Bell1 1

School of Medicine, NUI Galway

The advice about how you should spend the summer between fourth year and final year is definitely polarised. Some people say it’s the end of an era before the big, bad, working world hits you in the face with a week of nights on call and you should enjoy it. Others say you need to take every opportunity to get experience in specialties so you can bulk up your CV and figure out what you want to be when you grow up. I was lucky enough to do both.

3 take home points: 1 – Use your weekends wisely so try to book your dates to get as many as you can, and never waste one!

2 – Get your visa, guidebook and currency well before you leave!

programme which closed around the end of November, never in my wildest dreams thinking I would get accepted to both! So a CV, a motivation letter and a video interview later, I was a part of Ireland’s first SCOPE adventure. Thankfully the choices were much more manageable – we got to rank 3 countries from a list of 9. Make sure you look up the countries beforehand, I chose based on language, climate and which ones were already on my bucket-list. Although I’m sure others had much more sophisticated methods. If you get accepted to the exchange then you can rank your preferred region and specialty.

TORONTO My summer began in the land of water-proof money and “Timmy’s” coffee. Between orthopaedic surgery in Toronto-Western Hospital and paediatric plastic surgery in SickKids, I got to see the most amazing surgeries.

3 – See as many things in the hospital as possible, you may never see anything quite like them again (plus, it may or may not be the main reason you’re going abroad but ‘experience’ is definitely how you’ll be justifying that loan…).

The bad news is you need to get started early, the good news is it might be the best summer you’ll ever have. The application process for AFMC, the Canadian electives portal, opens around November for the following summer months so there’s no room for last minute planning. Sadly the places are randomly allocated but, if you’re one of the lucky ones to get through the lottery, then the real fun starts. Canada is a big place with lots of hospitals and even more specialties – so pick a university, pick a province or at least pick a coast to help keep your blood pressure down when you face the list. If that’s not incentive enough you also have to pay an application fee for each university.

No prizes for figuring out why I only applied to one. You find out in December if you’ve been accepted to the university and then you get to choose some specialty options. I went for 2 twoweek electives and you could choose two specialties and they’ll give you one of them in one of their affiliated hospitals.

I also applied for the International Federation of Medical Students’ Association (IFMSA) elective 44

Image 1: City Hall, Toronto One that I will never forget, took 9 hours, 2 consultant plastic surgeons and the beginnings of a smile. A boy with bilateral congenital facial nerve palsy had a gracillus flap harvested and implanted in his cheek, where a nerve graft that was placed weeks earlier was waiting for it. Painstaking microsurgery on minute neurovascular structures later and I was placing the plastic guard he would wear across his cheek to protect the muscle while it healed. In the coming months his brain would rewire and he would begin to use this new muscle and by the end of the year he’d be smiling in his family’s Christmas card. I only wish I could have seen his follow up – one of the down sides to such a short elective all the way across the Atlantic.

With Montreal just a bus ride away, Niagara Falls around the corner and an enormous city to explore you’ll have no shortage of things to do when you’re not in the hospital. It’s so easy to navigate even I only got lost occasionally.

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JMSG | STUDENT PERSPECTIVE CAPE COAST After a week at home and a frantic trip to the Ghanaian embassy for my visa I was on my way again. Cape coast is the Galway of Ghana – it’s a big city but it still has local charms that you won’t get in the capital, Accra.

So no matter where you go in the world or what organisation you go with, an overseas elective will be one of the best undergraduate experiences you could have. It’s not too soon to start thinking about it and it will bring you through the dark days of the 4th med OSCEs – so note the deadlines, google the vaccines and sure you’re halfway there already!

Image 2: Busua Beach, Western Region, Ghana The Head of Surgery in Cape Coast Teaching Hospital met us on our first week and gave me the single best piece of advice I could have gotten – “Always ask yourself how they do so much with so little”. The healthcare system there is very different, patients pay first and we treat later which requires some getting used to.

Doctors manage patients based on their diagnosis, the available resources and what the patient can afford. You will come home with both a deep appreciation for the HSE and a better understanding of the actual cost of healthcare. I saw patients more sick and more stoic than I will ever see in GUH, a perspective I would never get from an elective anywhere else.

There are 10 regions in Ghana and over our 6 week stay we travelled to 7 of them – the journeys could be quite uncomfortable but between safaris, rainforest canopy walks and waterfalls the destinations were invariably worth every mile.

Through the SCOPE programme I met 10 amazing new people who were as excited as I was to explore as much of the country as we could.

Image 4: Kakum National Park, Ghana

Image 3: Wli Falls, Hohoe, Volta Region, Ghana Volume no. 4 | SPRING 2018

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JMSG | STUDENT PERSPECTIVE My WHO Europe Internship Experience Rosemary James1 1

School of Medicine, NUI Galway

It took a gruelling nine months for my application to work as an intern for the World Health Organization (WHO) Regional Office for Europe to be approved. But it was very much worth it.

For as long as I can recall, working in international health governance has been a dream of mine. I am a keen believer that disease prevention and health promotion are the way of the future. I chose the best programme for this – Public Health Services (PHS). PHS is a programme within the Department of Health Systems and Public Health (DSP). My team was comprised of four diverse members – Dr Cichowska, the manager, and a Polish public health physician, Dr Von Krauss, the technical officer and a Canadian engineer, Ms Agnello, the consultant and an American public health fanatic with a Master’s of Global Health, and finally, Ms Olesen, the assistant, originally from Russia. At first, I was intimidated by their extensive experience, however by the end of my internship they were like family to me.

“If you are passionate about having any sort of public health career or special interest, doing an internship with WHO would be very beneficial.

It provides the opportunity to witness first-hand how the health systems of the European Region are governed.”

My tasks were very broad, which was perfect, as my aim was to develop a range of skills in different public health areas. I developed a monitoring and evaluation (M&E) strategy for the Coalition of Partners – a relatively new group of public health professionals working together to tackle issues in the European Region through capacity building. I also helped to draft a book chapter on tackling non-communicable diseases through a health systems approach. Aside from this, I conducted literature searches and gap analyses into two areas: universal health coverage, and public healthprimary care collaboration. I also made sure to attend the numerous regional meetings – including 46

conferences on antimicrobial resistance, data sharing and foreign aid.

My most memorable experience would have to have been assisting with the three-day intensive HIV course - where WHO/EURO funded over twenty infectious disease specialists from Eastern Europe and Russia to travel to Copenhagen for training on the best, most up to date practices for HIV treatment and prevention. It was very eyeopening and inspiring to hear what these physicians endure daily to treat their patients despite political, monetary, and social barriers.

Without a doubt, the best outcome of my internship was to have developed a large network of public health professionals. I am now able to reach lovely people around the world for advice and project collaboration. If you are passionate about having any sort of public health career or special interest, doing an internship with WHO would be very beneficial. It provides the opportunity to witness first-hand how the health systems of the European Region are governed.

You are provided with access to emails, data, and professionals which you would never otherwise have. However, if you are purely interested in clinical medicine, the WHO is not for you. It is certainly a bureaucratic and high-pressure environment. You must be able to see health outcomes as a ‘big picture,’ which was at times difficult. Personally, working with WHO has lit the fire inside me to continue to do public health research.

Image 1: My two brilliant supervisors, Dr Cichowska (programme manager) and Dr Von Krauss (technical officer).

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JMSG | SPONSORS

Special thanks to the School of Medicine, NUI Galway and to Ms. Carmel Malone for sponsoring this publication of the Journal of Medical Students, Galway and for championing student research at NUI Galway.

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ISSN: 2009-728X

Journal of Medical Students, Galway National University of Ireland, Galway

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