The Ulster medical journal

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A twelve year prospective wound audit was undertaken in an academic surgical unit. Data from 10,000 operations were analysed. Overall, wound infection rates decreased during this time. Infection rates in contaminated wounds in particular fell from 19.2% to 4.7%. This decrease in wound infection may be related in part to a change in the antibiotic prophylactic regimen and in part to the institution of the wound sepsis audit which provided regular information on the unit infection rates. This audit permitted early detection of adverse trends, and may have had a direct influence on surgical techniques.
 
Improved survival of very pre-term infants is a result of advances in obstetric and neonatal medicine. To provide relevant data for a Northern Ireland population group, we evaluated mortality and morbidity of extremely low birthweight (ELBW; < 1000 g) infants from a tertiary referral neonatal unit. Seventy-seven ELBW infants were admitted on the first day of life during the period April 1990 to April 1992. Mean (SD) gestational age (GA) was 26.2 (2.1) weeks and birthweight (BW) was 781 (132) g. The degree of severity of initial illness was high, with a mean (SD) CRIB (clinical risk index for babies) score of 7.4 (4.2). Fifty (65%) babies survived, being discharged home at a mean (SD) age of 95 (34) days. Survivors were more likely to have received maternal steroid therapy or been born in this hospital. Ten (20%) of the survivors had evidence of severe neonatal brain injury or cranial ultrasonography--Papile grade 3 or 4 intraventricular haemorrhage (IVH) or periventricular leucomalacia (PVL). Survival rate of ELBW infants without severe brain injury was 54% overall; this ranged from 0% in ELBW infants born at 23 weeks GA and 33% at 24 weeks GA to 85% at 27 weeks GA.
 
Conventional cytogenetic analysis using G-banded metaphase spreads and interphase FISH analysis from A) unstimulated bone marrow cell suspensions at CMML diagnosis (March 1999) and B) unstimulated bone marrow cell suspensions (conventional cytogenetic analysis only) and a cytospin preparation (interphase FISH only) at transformation to AML (March 2002). Chromosome 13 is highlighted (green) and chromosome 15 (red). 46,XY karyotype indicated in (A). 48,XY,+13,+15 karyotype indicated in (B). 
A 58-year-old man was admitted with symptoms of lethargy and easy bruising for four months duration. Peripheral blood (PB) analysis revealed a white blood cell count (WBC) of 15.9 x 10(9)/l with monocytes 5.4 x 10(9)/l. Bone marrow (BM) was hypercellular with 15% blasts, monocytosis and trilineage dysplasia. Conventional cytogenetic analysis (G-banding) detected an apparently normal male karyotype (46,XY). A diagnosis of chronic myelomonocytic leukaemia (CMML) was made. After 3 years, PB analysis revealed a WBC count of 22 x 10(9)/l and a predominance of blasts. BM aspirate analysis also revealed 89% myeloid blasts and G-banding detected the emergence of an abnormal clone harbouring an extra copy of chromosomes 13 and 15. A diagnosis of disease transformation to acute myeloid leukaemia (AML) was made. Post chemotherapy BM aspirate was very hypocellular and the abnormal +13, +15 clone was still present suggesting primary refractory disease. A second course of chemotherapy was only administered for 24 hours due to complications. The abnormal +13, +15 clone was still present and it was decided that no further treatment apart from palliative care could be offered. The patient died 11 weeks later, five months after AML transformation. This is the first description of a cytogenetically normal CMML patient transforming to AML with the emergence of a unique +13, +15 double trisomy resulting in an adverse outcome.
 
M4Eo acute myeloid leukaemia (AML) patients with the typical chromosome 16 abnormalities have a favourable prognosis. These subtle 16q22 gene rearrangements can be difficult to detect by conventional cytogenetic methods and if missed could lead to the incorrect assignment of prognostic group and hence subsequent treatment strategies. We retrospectively studied 13 patients diagnosed with M4Eo AML for such chromosome 16 abnormalities comparing conventional cytogenetic (G-banding) and molecular (FISH) methods. G-banded analysis detected only 2 patients with definite chromosome 16 abnormalities whereas FISH detected 4 patients, one with the typical inversion and three with the typical chromosome 16 translocation. FISH analysis also confirmed a false +ve G-banded result in one patient and a false -ve G-banded result in another patient. Finally, FISH confirmed a deletion of one chromosome 16 homologue in another patient indicating a poor prognosis. The overall survival of patients with the typical 16q22 rearrangements (n=4) was also significantly better (P=0.007) than patients with normal chromosome 16 homologues or having other numerical and/or structural abnormalities (n=9). This set of data shows that FISH is a more accurate method for the detection of cryptic 16q22 gene rearrangements and because of the prognostic implications has become a mandatory test along with conventional cytogenetics for all newly diagnosed M4Eo AML patients in Northern Ireland. Images Fig 1 Fig 3
 
Osteoporosis results in significant morbidity and mortality for a large number of patients within Northern Ireland. Recombinant PTH (Teriparatide) is one of a growing number of treatment options for the disease. A retrospective analysis was carried out for all patients who had been commenced on Teriparatide since it was first used in the Belfast Health and Social Care Trust (BHSCT) in 2007. Patient demographics, clinical history and prior treatment were recorded prior to an eighteen month treatment protocol. Outcome measures including bone densitometry, bone turnover markers and health status were assessed on commencement and completion. 138 patients have commenced teriparatide therapy since 2007 (9 male, 129 female). At the time of analysis 60 patients had completed treatment, 53 patients were receiving ongoing treatment and 25 patients did not complete the 18 month course. On completion vertebral bone mineral density (BMD) had increased by 8.3% while femoral neck BMD had increased by 3.5%. Bone turnover markers demonstrated a significant increase of bone formation and resorption at 4 months, with a smaller increase at 18 months. Health outcome measures (EuroQoL-5 and patient visual analogue scale) indicated improvement in the quality of life of patients of those who completed the treatment course. Experience in the BHSCT with teriparatide since 2007 demonstrates improvement in BMD comparable to published data, changes in bone turnover markers consistent with increased bone remodeling and better health outcomes for patients.
 
The nephrotic syndrome has emerged over several centuries as the consequence of continued profuse proteinuria, arising in turn from a variety of lesions affecting the glomerulus which impair glomerular ability to retain plasma proteins, in particular, albumin. As a syndrome, it has its own complications and requires its own management irrespective of the underlying lesions. Dissection of these by renal biopsy and by clinical investigation reveals a variety of systemic diseases which affect the kidney, but a majority of primary immune-based diseases appear unique to the glomerulus. Whether the lesion called by Müller and Munk 'nephrosis', and now called minimal change disease and focal segmental glomerulosclerosis is one disease or many, is the subject of intense debate at the moment, as is the relationship between two types of lesion. Only a better understanding of their pathogenesis, and of how the glomerulus normally retains plasma protein, will solve this knotty problem.
 
We report the experience of insulin secreting islet cell tumours at the Royal Victoria Hospital, Belfast. Sixteen cases have been treated between 1960 and 1980, 3 of which were malignant. These were, we believe, the only insulinomas associated with hypoglycaemia diagnosed in Northern Ireland (population 1.5 million) during the past 20 years so that the incidence was approximately 0.5 per million per year. The aim of this paper is to demonstrate the changes in diagnostic techniques which have evolved during the past 20 years, and to assess their value.
 
Fig: Statue of Sir Hans Sloane by John Michael Rysbach in the Chelsea Physic Garden 
Sir Hans Sloane was born in Killyleagh, Co Down, the seventh and last son of Alexander Sloane. His father, who was of Scottish ancestry, had a long association with James Hamilton, Earl of Clanbrassil who had acquired the castle in Killyleagh and extensive estates in east Down. The Hamilton family took an interest in the education of the Sloane children, and much of the early tuition of Hans was conducted within the library of Killyleagh Castle. In 1679 he moved to London to study medicine and botany. In 1683, he continued his studies in Paris and Montpellier, and graduated from the University of Orange. On his return to London, he became a protégé of Thomas Sydenham. In 1687 he was appointed physician to the Duke of Albemarle and surgeon to the West Indies fleet. While in Jamaica he added countless specimens to his collections, continuing a lifetime passion. He also invented milk chocolate there. Following the untimely death of the duke, he returned to London and built up a fashionable medical practice. He married Elizabeth Langley, heiress of a wealthy city alderman, and widow of a sugar planter in Jamaica. They set up house in Great Russell Street. The family home accommodated his burgeoning collections of books, specimens and curiosities. In 1685 he was elected a Fellow of the Royal Society, later becoming the honorary secretary and president. Following his death, his collections were bought for the nation and formed the foundation of the British Museum.
 
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This paper considers the role of county infirmaries in providing health care for the inhabitants of two counties in south-east Ulster. It traces the establishment and management of these institutions from their beginnings shortly after the passing of the Infirmaries Act (1765) to the middle of the nineteenth century. From the available evidence, the accommodation, staff, patient numbers and diet of the infirmaries are considered and an assessment of their efficacy in offering a valuable service to their communities is discussed.
 
Thomas Ferrar was the second professor of surgery in the short-lived (1835-1849) medical school of the Royal Belfast Academical Institution. Appointed on 5 July 1836 he failed to turn up for the winter session and was accordingly discharged on 29 November. He died in Sligo in the following June aged 39. Nothing has been written about Ferrar who survives as a mere foot-note in Belfast medical history. The events leading to his dismissal are, however, unusual, equivocal, and worth recounting. The facts suggest that the Institution was clearly justified in its action but that Ferrar emerges with some credit for a certain if misplaced high-mindedness though overshadowed by his patent derelictions. Images Figure
 
This paper outlines the provision for fever patients, (other than those suffering from cholera during the epidemic of 1832-34), in counties Armagh and Down in the two decades prior to the introduction of the Poor Law to Ireland. Possible causes of fever and the numbers of patients treated are discussed. The establishment and location of fever hospitals and the state of the premises are considered and an assessment of the contribution of these institutions to the development of medical provision in the early nineteenth century is also provided.
 
A world-wide increase in diabetic deaths and a varying rate of increase between one country and another over the past hundred years has long been recognised. During the nineteenth century, the incidence of diabetes was low in Ireland as measured by mortality. Nevertheless, the rising trend found elsewhere was also apparent in Ireland. Recorded deaths were 0.22/100,000 of the population in 1840, rising to 13.2 by 1972. Most of the increase occurred between the 1880s and 1911, but only 15% of this can be accounted for by an ageing population. It is, therefore, necessary to seek other explanations. During the period, sugar and fat consumption in Ireland rose sharply. It has not been possible precisely to relate dietary causes to the incidence of diabetes, but the Irish experience suggests that such a link may exist.
 
Thomas Wrigley Grimshaw was born in Whitehouse, County Antrim, in 1839, and learned his medicine at the Dublin School of Medicine when its reputation was at its highest. If his teachers strayed from the art of bedside medicine into science it was into meteorology that had been revived by Thomas Sydenham, the 'English Hippocrates' in the seventeenth century. When Grimshaw was appointed Registrar General for Ireland in 1879 he diverted attention from the acute epidemics of zymotic diseases to chronic pulmonary affections that numerically were far more deadly. Cartography became an obsession with him, and he used it to show that Ireland was divided by phthisis into east and west. Koch's 'great discovery' in 1882 that tuberculosis is an infection not a 'constitutional' disease made him change his long-held views, and in the decade before his death in 1900 at Carrickmines, County Dublin, he became an active advocate of the new knowledge, distressed by the fact that thriving Belfast and its hinterland had the highest mortality from phthisis in Ireland. His concern for the health of young girls employed in large numbers in the linen factories was matched by his landmark advocacy of young ladies anxious to gain the licence to practise medicine in Great Britain and Ireland.
 
John MacDonnell (1796-1892) was born in Belfast and trained in surgery in Dublin, Edinburgh, London and Paris. In 1829 he became a demonstrator in anatomy at the Richmond Medical School where he was appointed visiting surgeon in 1836, and from 1847 to 1851 he held the professorship of descriptive anatomy at the Royal College of Surgeons in Ireland. He was appointed Medical Poor Law Commissioner until 1872 when the Local Government Board and the Poor Law Commission were merged and he continued to serve. In later years, before his death in 1892, he turned his attention to history, but it is his administration of ether to 18-year-old Mary Kane in January 1847 that shines undimmed in his personal history.
 
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John Alexander Lindsay was born at Fintona, county Tyrone in 1856, and at the age of 23 he graduated in medicine at the Royal University of Ireland. After two years in London and Europe he returned to Belfast to join the staff at the Royal Victoria Hospital and in 1899 he was appointed to the professorship of medicine. He was valued by the students for his clarity and by his colleagues for his many extracurricular contributions to the medical profession in the positions entrusted to him. He published monographs on Diseases of the Lungs, and the Climatic Treatment of Consumption, but his later Medical Axioms show his deep appreciation of studied clinical observation. Although practice was changing in the new century Lindsay displayed an ability to change with the new requirements, as evidenced by his lecture on electrocardiography as president of the section of medicine of the Royal Academy of Medicine in Ireland in 1915. He was impressed by the way the string galvanometer changed attention from stenosis and incompetence of the valves to the cardiac musculature, but rightly suspected that there was more to be told about the state of the myocardium than Einthoven's three leads revealed. His death occurred in Belfast in 1931.
 
Dr Benjamin Moore was the first Professor of Biochemistry in these islands. His life and medical career are described together with his prescient contributions to public health. A man of remarkable vision, his ideas were written more than three decades before the Beveridge Plan for a National Health Service.
 
Among the problems facing Northern Ireland after its foundation in 1920, one of the most daunting was the prevalence of tuberculosis, a chronic communicable disease with highest mortality among young women and men in the prime of life. Over a quarter of a century, legislative changes tardily responded, and in spite of, or because of its magnitude, Brice Clarke (1895–1975) devoted himself to the challenge. After decorated service in the Great War of 1914–19 he returned to finish his medical studies in Queen's University Belfast and held hospital appointments until he became Chief Tuberculosis Officer for Belfast and soon afterwards Director of Tuberculosis Services in Northern Ireland. For twenty years he was an enthusiastic proponent of collapse therapy, and even before the new chemotherapy hastened the natural decline in the tuberculosis epidemic he trumpeted the value of properly equipped chest clinics and generously funded welfare schemes. His garden at Hillsborough could not contain him in retirement; he set off on a slow boat to Japan in 1962, and returned to pen biographical sketches of famous consumptives until his death in 1975 at the age of 80.
 
PET/CT scanning can determine suitability for curative therapy and inform decision making when considering radical therapy in patients with non-small cell lung cancer (NSCLC). Metastases to central mediastinal lymph nodes (N2) may alter such management decisions. We report a 2 year retrospective series assessing N2 lymph node staging accuracy with PET/CT compared to pathological analysis at surgery. Patients with NSCLC attending our centre (excluding those who had induction chemotherapy) who had staging PET/CT scans and pathological nodal sampling between June 2006 and June 2008 were analysed. For each lymph node assessed pathologically, the corresponding PET/CT status was determined. 64 patients with 200 N2 lymph nodes were analysed. Sensitivity of PET/CT scans for indentifying involved N2 lymph nodes was 39%, specificity 96% and overall accuracy 90%. For individual lymph node analysis, logistic regression demonstrated a significant linear association between PET/CT sensitivity and time from scanning to surgery (p=0.031) but not for specificity and accuracy. Those scanned <9 weeks before pathological sampling were significantly more sensitive (64% >9 weeks, 0% ≥9 weeks, p=0.013) and more accurate (94% <9 weeks, 81% ≥9 weeks, p=0.007). Differences in specificity were not seen (97% <9 weeks, 91% ≥9 weeks, p=0.228). No significant difference in specificity was found at any time point. We recommend that if a PET/CT scan is older than 9 weeks, and management would be altered by the presence of N2 nodes, re-staging of the mediastinum should be undertaken.
 
The presence of cutaneous vitellointestinal duct remnants was confirmed histologically in 19 cases in the period 1970-1984. These lesions occurred mostly in males (16 males, 3 females), and 80% in children under the age of five years. One case was identified in an adult, suggesting that these lesions may in some cases cause little inconvenience, and that their true incidence is underestimated.
 
In Northern Ireland 55 patients were shown to be infected with echovirus type 19 between October 1974 and October 1975. The peak incidence was in June 1975 and male children were predominently affected. The patients were widely distributed throughout Northern Ireland. Fifty three patients had meningitis and there were two families where 2 children in each family had meningitis.
 
Top-cited authors
Somaiah Aroori
  • University Hospitals Plymouth NHS Trust
Tom Diamond
  • The Bracton Centre, Oxleas NHS Trust
Mark O'Donnell
  • Belfast Health and Social Care Trust
Maurice B. Loughrey
  • Belfast Health and Social Care Trust
Brendan P Madden
  • St George's Healthcare NHS Trust