Primary hyperparathyroidism causing posterior reversible encephalopathy syndrome: a case report.

Posterior reversible encephalopathy syndrome (PRES) is a reversible leukoencephalopathy characterised by subcortical vasogenic oedema and neurological signs. We present the case of a 64-year-old woman who presented to hospital with symptomatic primary hyperparathyroidism. Her parathyroid hormone (PTH) level on admission was elevated at 1,330ng/l (normal range15-68ng/l) and her serum calcium measured 4.83mmol/l (normal range 2.25-2.54mmol/l). Technectium-99m sestamibi scan demonstrated a focus of radiotracer uptake consistent with a right upper parathyroid adenoma or carcinoma. After commencing appropriate medical treatment, the patient developed intractable seizures necessitating endotracheal intubation. Magnetic resonance imaging of her brain revealed bilateral symmetrical T2 hyperintensities in the posterior circulation consistent with PRES. Following stabilisation and further medical treatment for hypercalcaemia, the patient underwent a parathyroidectomy. Preoperative rapid PTH assay measured 1,021ng/l. Following excision, PTH levels fell to just 10ng/l. She was extubated in the intensive care unit on postoperative day 1 and made an uneventful recovery. At her 6-week follow-up appointment, all neurological symptoms had resolved. PRES is a rare neurological entity more often seen in the setting of hypertension, immunosuppression and renal failure. The development of new neurological manifestations in the setting of known risk factors should raise suspicion for the underlying diagnosis.

A Phase II Toxicity End Point Trial (ICORG 99-09) of Accelerated Dose-escalated Hypofractionated Radiation in Non-small Cell Lung Cancer.

AIMS: The objective of this phase II clinical trial was to prospectively evaluate the safety and efficacy of accelerated hypofractionated three-dimensional conformal radiation therapy (3DCRT) in localised non-resectable/non-operable non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: Sixty patients with stage I-III NSCLC were enrolled in a prospective single-arm All Ireland Co-operative Oncology Research Group (ICORG 99-09) toxicity end point phase II trial. The protocol allocated patients between three radiation schedule dose levels (60, 66 or 72 Gy, in 20, 22 and 24 fractions, respectively, 3 Gy daily, five fractions per week) according to combined lung V25Gy (V25Gy ≤ 30%) with built-in early stopping toxicity rules. The primary end point was toxicity with evaluation of dose-limiting toxicity. The secondary objectives included radiological tumour response rate at 3 months after the completion of radiation therapy and the thoracic progression-free survival time. RESULTS: Sixty patients were recruited from August 1999 to June 2009. Forty-nine patients were included in the primary per-protocol analysis. Eleven patients were not evaluable. In the first 30 evaluable patient cohort, severe oesophageal toxicity was reported in two patients (2/49; 4% experiencing grade 5 oesophageal late toxicity, related to the 97% oesophageal length). The trial was temporarily closed and was then reopened to validate an oesophageal dose volume constraint (DVC) of limiting the length of oesophagus fully encompassed by the 97% isodose to less than 1 cm (applied to 21 patients). The trial prospectively showed the safety of the oesophageal DVC, with no oesophageal toxicity above grade 3 thereafter. Thirty-nine per cent of patients had disease progression at 3-4 months after radiotherapy, 22% had stable disease, 20% had a complete response and 14% had a partial response. The median overall survival was 13.6 months (95% confidence interval 10.5-16.7) and overall survival at 1 and 3 years was 57% and 29%, respectively. CONCLUSION: A strategy using accelerated hypofractionated 3DCRT is feasible and reasonably safe for patients with inoperable NSCLC. It is safe to deliver for centrally located tumours if DVCs are applied to the oesophagus, which is the primary dose-limiting toxicity. Further studies are required to assess the efficacy of hypofractionated regimens for centrally located tumours using an oesophageal DVC and monitoring for oesophageal toxicity.

Stereotactic Radiosurgery (SRS) / Stereotactic body radiotherapy (SBRT): Benefit to Irish patients and Irish Healthcare Economy.

Cancer incidence across Europe is projected to rise rapidly over the next decade. This rising cancer incidence is mirrored by increasing use of and indications for stereotactic radiation. This paper seeks to summarize the exponential increase in indications for stereotactic radiotherapy as well as the evolving economic advantages of stereotactic radiosurgery and stereotactic body radiotherapy.

A study of needle stick injuries among non-consultant hospital doctors in Ireland.

INTRODUCTION: NCHDs are exposed to a great number of blood-borne infections. Needle stick injuries are possibly the main route of acquiring such infections from a non-consultant hospital doctors (NCHDs) perspective. This study examines NCHDs experiences surrounding needle stick injuries. METHODS: A cross-sectional self-administered anonymous questionnaire survey was conducted on 185 NCHDs working in a clinical setting among seven teaching hospitals in Ireland. Implied consent was obtained. The data was analysed using Excel spreadsheets. Ethical approval was received. RESULTS: A response rate of 85.4% (158/185) was achieved. Findings of the study are shown in the manuscript table. CONCLUSIONS: A needle stick injury (NI) history is greater among surgical NCHDs than medical NCHDs. The level of disposable glove usage is worryingly poor. Training in sharps handling and dealing with a NI needs to be addressed. HIV is the blood-borne infection most fear of being contracting as a consequence of a NI.

Characteristics of patients presenting with erythema nodosum and sarcoidosis.

We explored the relationship between erythema nodosum (EN) and sex, age, serum angiotensin converting enzyme (ACE), bronchoalveolar lavage lymphocytosis (BAL-I), interstitial granulomas and radiological stage in patients presenting with pulmonary sarcoidosis in Ireland. Sixty-nine patients diagnosed with sarcoidosis between 2003 and 2006 were studied. Forty one patients (59%) were male. Sixteen patients (23%) presented with EN. Forty one patients of 65 (63%) had transbronchial biopsies demonstrating non-caseating granulomas. Patients with sarcoidosis presenting with EN were more likely to be female (p=0.042), younger (p=0.012) and have earlier stage pulmonary disease (p=0.02). There were no correlations between serum ACE, interstitial granulomas and disease stage. BAL-I did however predict increasing disease radiological stage (p=0.042). In this study, one quarter of patients with sarcoidosis presented with EN among their presenting features. These patients were more likely to be young females with early stage radiological disease.

Globus pharyngeus: long-term follow-up and prognostic factors.

A prospective trial of 80 patients with globus pharyngeus is reported. An in-depth analysis of the typical history at presentation is given. The average follow-up period was 27 months (range, 21 to 42 months). The asymptomatic rate at this interval was 25%, with a further 35% reporting a significant improvement in symptoms. Three independent factors were found to influence prognosis (p less than .05). These were sex, length of history at consultation, and the presence or absence of associated throat symptoms. Male patients having a history of the globus symptom for less than 3 months and not complaining of any associated throat symptoms had the best chance of becoming asymptomatic or symptomatically improved. The presence or absence of heartburn or its treatment had no bearing on outcome.