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Connelly TM, Ryan J, Foley NM, Earley H, Sahebally SM, O'Brien C, McCullough P, Neary P, Cooke F. Outcomes After Colonic Self-Expanding Metal Stent Insertion Without Fluoroscopy: A Surgeon-Led 10-Year Experience. J Surg Res 2023; 281:275-281. [PMID: 36219939 DOI: 10.1016/j.jss.2022.08.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/10/2022] [Accepted: 08/21/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Colonic self-expanding metal stents (SEMS) can be used to relieve malignant and benign large bowel obstruction (LBO) as a bridge to surgery (BTS) and for palliation. Guidelines suggest the use of fluoroscopic guidance for deployment. This may be difficult to obtain after hours and in certain centers. We aimed to determine the outcomes of stenting under endoscopic guidance alone. METHODS All patients who underwent SEMS insertion in our tertiary referral center between August 2010 and June 2021 were identified from a prospectively maintained database. Patient demographics (age/gender), disease characteristics (benign versus malignant/location/stage), stenting intent (BTS versus palliative), and outcomes (technical success/stoma/time from stenting to resection/death/study end) were analyzed. RESULTS Fifty-three (n = 39, 73.6% male) patients underwent SEMS insertion. Indications included colorectal carcinoma (n = 48, 90.6%), diverticular stricture (n = 3), and gynecological malignancy (n = 2). In five (9.4%) patients (four BTS and one palliative), SEMSs deployment was not completed because of the inability to pass the guidewire. All underwent emergency surgery. In the BTS cohort (n = 29, median 70.4 [range 40.3-91.8] years), 10 patients underwent neoadjuvant chemoradiotherapy. The permanent stoma rate was 20.7% (n = 6). There was no 30- or 90-d mortality. In the palliative cohort (n = 24, median age 77.1 [range 54.4-91.9]), 16 (66.7%) were deceased at the study end. The median time from stenting to death was 5.2 (2.3-7.9) months. CONCLUSIONS SEMS placed under endoscopic visualization alone, palliatively and as a BTS, had acceptable stoma, morbidity, and mortality rates. These results show that SEMS insertion can be safely performed without fluoroscopy.
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Affiliation(s)
- Tara M Connelly
- Department of Colorectal Surgery, University Hospital Waterford, Waterford, Ireland.
| | - Jessica Ryan
- Department of Colorectal Surgery, University Hospital Waterford, Waterford, Ireland
| | - Niamh M Foley
- Department of Colorectal Surgery, University Hospital Waterford, Waterford, Ireland
| | - Helen Earley
- Department of Colorectal Surgery, University Hospital Waterford, Waterford, Ireland
| | - Shaheel M Sahebally
- Department of Colorectal Surgery, University Hospital Waterford, Waterford, Ireland
| | - Carl O'Brien
- Department of Colorectal Surgery, University Hospital Waterford, Waterford, Ireland
| | - Peter McCullough
- Department of Colorectal Surgery, University Hospital Waterford, Waterford, Ireland
| | - Peter Neary
- Department of Colorectal Surgery, University Hospital Waterford, Waterford, Ireland; University College Cork College of Medicine, Cork, Ireland
| | - Fiachra Cooke
- Department of Colorectal Surgery, University Hospital Waterford, Waterford, Ireland
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Miller AS, Boyce K, Box B, Clarke MD, Duff SE, Foley NM, Guy RJ, Massey LH, Ramsay G, Slade DAJ, Stephenson JA, Tozer PJ, Wright D. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery. Colorectal Dis 2021; 23:476-547. [PMID: 33470518 PMCID: PMC9291558 DOI: 10.1111/codi.15503] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/08/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022]
Abstract
AIM There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland. METHODS Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines. RESULTS All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.
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Affiliation(s)
- Andrew S. Miller
- Leicester Royal InfirmaryUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | | | - Benjamin Box
- Northumbria Healthcare Foundation NHS TrustNorth ShieldsUK
| | | | - Sarah E. Duff
- Manchester University NHS Foundation TrustManchesterUK
| | | | | | | | | | | | | | - Phil J. Tozer
- St Mark’s Hospital and Imperial College LondonHarrowUK
| | - Danette Wright
- Western Sydney Local Health DistrictSydneyNew South WalesAustralia
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Keelan S, Foley NM, Healy D, Moneley D, McHugh S, Kheireseid R, Naughton P. Is It Time for a National Awareness Campaign for Peripheral Arterial Disease (PAD)? Eur J Vasc Endovasc Surg 2020. [DOI: 10.1016/j.ejvs.2020.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Tobin R, Barry N, Foley NM, Cooke F. A giant duodenal diverticulum causing Lemmel syndrome. J Surg Case Rep 2018; 2018:rjy263. [PMID: 30349662 PMCID: PMC6189375 DOI: 10.1093/jscr/rjy263] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 09/02/2018] [Accepted: 09/15/2018] [Indexed: 11/18/2022] Open
Abstract
An 80-year-old female, with a known periampullary giant duodenal diverticulum, presented to the emergency department with general deterioration. While not clinically icteric, her laboratory investigations revealed an obstructive jaundice. MRCP demonstrated mild distension of the gallbladder with several calculi. There was intra- and extra-hepatic biliary dilatation to the level of the ampulla. A giant fluid and air filled periampullary duodenal diverticulum measuring ~8 cm in the long axis was noted. The CBD was dilated to the level of this diverticulum and the cause of the patient’s biliary dilatation and obstruction. A rare pancreaticobiliary complication of duodenal diverticula is Lemmel syndrome. Lemmel syndrome is defined as an obstructive jaundice caused by a periampullary duodenal diverticulum compressing the intra-pancreatic portion of the common bile duct with resultant dilatation of the extra- and intra-hepatic bile ducts. Recognition of this condition is important, as delayed diagnosis can result in unnecessary further investigations.
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Affiliation(s)
- Roseanne Tobin
- School of Medicine, University College Cork, College Road, Cork, Ireland
| | - Niamh Barry
- School of Medicine, University College Cork, College Road, Cork, Ireland
| | - Niamh M Foley
- Department of Surgery, University Hospital Waterford, Dunmore Road, Waterford, Ireland
| | - Fiachra Cooke
- Department of Surgery, University Hospital Waterford, Dunmore Road, Waterford, Ireland
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Foley NM, Coll JM, Lowery AJ, Hynes SO, Kerin MJ, Sheehan M, Brodie C, Sweeney KJ. Re-Appraisal of Estrogen Receptor Negative/Progesterone Receptor Positive (ER−/PR+) Breast Cancer Phenotype: True Subtype or Technical Artefact? Pathol Oncol Res 2017; 24:881-884. [DOI: 10.1007/s12253-017-0304-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 09/01/2017] [Indexed: 02/03/2023]
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Chen X, Meng X, Foley NM, Shi X, Liu M, Chai Y, Li Y, Redmond HP, Wang J, Wang JH. Activation of the TLR2-mediated downstream signaling pathways NF-κB and MAPK is responsible for B7-H3-augmented inflammatory response during S. pneumoniae infection. J Neuroimmunol 2017; 310:82-90. [DOI: 10.1016/j.jneuroim.2017.07.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 06/01/2017] [Accepted: 07/03/2017] [Indexed: 01/28/2023]
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Lim MS, Jinih M, Ngai CH, Foley NM, Redmond HP. The utility of the radionuclide probe in parathyroidectomy for primary hyperparathyroidism. Ann R Coll Surg Engl 2017; 99:369-372. [PMID: 28462641 DOI: 10.1308/rcsann.2017.0016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Parathyroidectomy is the definitive treatment for primary hyperparathyroidism but the intraoperative identification of adenomas is challenging. The aim of this study was to evaluate the utility of a radionuclide probe (RNP) in addition to intraoperative parathyroid hormone ( IOPTH) measurement as an intraoperative diagnostic adjunct in patients undergoing parathyroidectomy for primary hyperparathyroidism. METHODS This was a retrospective cohort study of patients treated between 2004 and 2015 in a university affiliated teaching hospital. Patients were grouped into those with RNP use (RNP+) and those without (RNP-). The primary outcome measure was rate of operative failure, which included false positives. The diagnostic sensitivity and positive predictive value of both RNP and IOPTH were also evaluated. RESULTS A total of 298 patients were included in the study, 127 (42.6%) being in the RNP+ group and 171 (57.4%) in the RNP- group. The false positive rate for the RNP+ patients was 1.6% compared with 9.4% for RNP- patients (p=0.006, hazard ratio [HR]: 6.45). The rates of operative failure were 6.3% and 11.7% respectively (p=0.159, HR: 1.97). RNP use had a sensitivity of 92.0% and a positive predictive value of 98.3% compared with 78.6% and 95.2% respectively for IOPTH monitoring. CONCLUSIONS RNP use is associated with fewer false positives and reduced operative failure than IOPTH measurement. It also has a higher sensitivity and positive predictive value. RNP use is recommended in centres that have the required facilities.
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Affiliation(s)
- M S Lim
- Cork University Hospital, Ireland
| | - M Jinih
- Cork University Hospital, Ireland
| | - C H Ngai
- Cork University Hospital, Ireland
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Foley NM, O'Connell EP, Lehane EA, Livingstone V, Maher B, Kaimkhani S, Cil T, Relihan N, Bennett MW, Redmond HP, Corrigan MA. PATI: Patient accessed tailored information: A pilot study to evaluate the effect on preoperative breast cancer patients of information delivered via a mobile application. Breast 2016; 30:54-58. [PMID: 27611236 DOI: 10.1016/j.breast.2016.08.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 08/01/2016] [Accepted: 08/18/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES The information needs of cancer patients are highly variable. Literature suggests an improved ability to modulate personalised stress, increased patient involvement with decision making, greater satisfaction with treatment choices and reduced anxiety levels in cancer patients who have access to information. The aim of this project was to evaluate the effects of a mobile information application on anxiety levels of patients undergoing surgery for breast cancer. MATERIALS AND METHODS An application was developed for use with Apple iPad containing information on basic breast cancer biology, different treatments used and surgical techniques. Content and face validity studies were performed. A randomized control trial was designed, with a 1:2 allocation. Data collected include basic demographics and type of surgery. Questionnaires used included: the HADS, Mini-MAC, information technology familiarity and information satisfaction. RESULTS A total of 39 women participated. 13 women had access to an iPad containing additional information and 26 women acted as controls. The mean age was 54 and technology familiarity was similar among both groups. Anxiety and depression scores at seven days were significantly lower in control patients without access to the additional information provided by the mobile application (p = 0.022 and 0.029 respectively). CONCLUSION Anxiety and depression in breast cancer patients is both multifactorial and significant, with anxiety levels directly correlating with reduced quality of life. Intuitively, information should improve anxiety levels, however, we have demonstrated that surgical patients with less information reported significantly lower anxiety. We advise the thorough testing and auditing of information initiatives before deployment.
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Affiliation(s)
- N M Foley
- Breast Research Centre, Cork University Hospital, Wilton, Cork, Ireland.
| | - E P O'Connell
- Breast Research Centre, Cork University Hospital, Wilton, Cork, Ireland
| | - E A Lehane
- Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - V Livingstone
- Breast Research Centre, Cork University Hospital, Wilton, Cork, Ireland
| | - B Maher
- School of Medicine, University College Cork, Cork, Ireland
| | - S Kaimkhani
- Breast Research Centre, Cork University Hospital, Wilton, Cork, Ireland
| | - T Cil
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
| | - N Relihan
- Breast Research Centre, Cork University Hospital, Wilton, Cork, Ireland
| | - M W Bennett
- Breast Research Centre, Cork University Hospital, Wilton, Cork, Ireland
| | - H P Redmond
- Breast Research Centre, Cork University Hospital, Wilton, Cork, Ireland
| | - M A Corrigan
- Breast Research Centre, Cork University Hospital, Wilton, Cork, Ireland; Royal College of Surgeons, Dublin, Ireland
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Foley NM, Racz JM, Al-Hilli Z, Livingstone V, Cil T, Holloway CMB, Romics L, Matrai Z, Bennett MW, Duddy L, Nofech-Mozes S, Slodkowska E, Mallon EA, Dawson N, Roche T, Relihan N, Hill ADK, Redmond HP, Corrigan MA. An International Multicenter Review of the Malignancy Rate of Excised Papillomatous Breast Lesions. Ann Surg Oncol 2015; 22 Suppl 3:S385-90. [PMID: 26240010 DOI: 10.1245/s10434-015-4773-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Papillary lesions of the breast are a relatively rare, but heterogeneous group ranging from benign to atypical and malignant. Debate exists regarding the optimal management of these lesions. In the absence of more accurate risk-stratification models, traditional management guidelines recommend surgical excision, despite the majority of lesions proving benign. This study sought to determine the rate of malignancy in excised breast papillomas and to elucidate whether there exists a population in which surgical excision may be unnecessary. METHODS A multicenter international retrospective review of core biopsy diagnosed breast papillomas and papillary lesions was performed between 2009 and 2013, following institutional ethical approval. Patient demographics, histopathological, and radiological findings were recorded. All data was tabulated, and statistical analysis performed using Stata. RESULTS A total of 238 patients were included in the final analysis. The age profile of those with benign pathology was significantly younger than those with malignant pathology (p < 0.001). Atypia on core needle biopsy was significantly associated with a final pathological diagnosis of malignancy (OR = 2.73). The upgrade rate from benign core needle biopsy to malignancy on the final pathological sample was 14.4 %; however, only 3.7 % had invasive cancer. CONCLUSIONS This international dataset is one of the largest in the published literature relating to breast papillomas. The overall risk of malignancy is significantly associated with older age and the presence of atypia on core needle biopsy. It may be possible to stratify higher-risk patients according to age and core needle biopsy findings, thereby avoiding surgery on low-risk patients.
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Affiliation(s)
- N M Foley
- Breast Research Centre, Cork University Hospital, Cork, Ireland.
| | - J M Racz
- Department of Surgical Oncology, University of Toronto, Toronto, ON, Canada
| | - Z Al-Hilli
- Department of Surgery, Beaumont Hospital, Dublin, Ireland.,The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - V Livingstone
- Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - T Cil
- Department of Surgical Oncology, University of Toronto, Toronto, ON, Canada
| | - C M B Holloway
- Department of Surgical Oncology, University of Toronto, Toronto, ON, Canada
| | - L Romics
- Departments of Breast Surgery, Radiology & Pathology, Victoria Infirmary, Glasgow, UK
| | - Z Matrai
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary
| | - M W Bennett
- Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - L Duddy
- Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - S Nofech-Mozes
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - E Slodkowska
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - E A Mallon
- Departments of Breast Surgery, Radiology & Pathology, Victoria Infirmary, Glasgow, UK
| | - N Dawson
- Departments of Breast Surgery, Radiology & Pathology, Victoria Infirmary, Glasgow, UK
| | - T Roche
- Department of Surgery, Beaumont Hospital, Dublin, Ireland.,The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - N Relihan
- Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - A D K Hill
- Department of Surgery, Beaumont Hospital, Dublin, Ireland.,The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - H P Redmond
- Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - M A Corrigan
- Breast Research Centre, Cork University Hospital, Cork, Ireland
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Abstract
The incidence of sepsis is increasing over time, along with an increased risk of dying from the condition. Sepsis care costs billions annually in the United States. Death from sepsis is understood to be a complex process, driven by a lack of normal immune homeostatic functions and excessive production of proinflammatory cytokines, which leads to multi-organ failure. The Toll-like receptor (TLR) family, one of whose members was initially discovered in Drosophila, performs an important role in the recognition of microbial pathogens. These pattern recognition receptors (PRRs), upon sensing invading microorganisms, activate intracellular signal transduction pathways. NOD signaling is also involved in the recognition of bacteria and acts synergistically with the TLR family in initiating an efficient immune response for the eradication of invading microbial pathogens. TLRs and NOD1/NOD2 respond to different pathogen-associated molecular patterns (PAMPs). Modulation of both TLR and NOD signaling is an area of research that has prompted much excitement and debate as a therapeutic strategy in the management of sepsis. Molecules targeting TLR and NOD signaling pathways exist but regrettably thus far none have proven efficacy from clinical trials.
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Affiliation(s)
- Niamh M Foley
- Department of Academic Surgery, University College Cork, Cork University Hospital, Cork, Ireland
| | - Jian Wang
- Department of Pediatric Surgery, Affiliated Children's Hospital, Soochow University, Suzhou, 215003 China
| | - H Paul Redmond
- Department of Academic Surgery, University College Cork, Cork University Hospital, Cork, Ireland
| | - Jiang Huai Wang
- Department of Academic Surgery, University College Cork, Cork University Hospital, Cork, Ireland
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Foley NM, Maher BM, Corrigan MA. Social media and tomorrow's medical students--how do they fit? J Surg Educ 2014; 71:385-390. [PMID: 24797855 DOI: 10.1016/j.jsurg.2013.10.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 10/02/2013] [Accepted: 10/15/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVE The main aim of our study was to establish the prevalence of social networking accounts among a group of second-level students (aged 15-18 years), to determine whether they used privacy settings, and to examine their attitudes to various aspects of social media use in medicine. DESIGN A descriptive study design was employed. The questionnaire was constructed specifically to address the attitudes of students to social media. No similar suitable validated questionnaire could be identified. The questionnaire consisted of 20 questions with a mixture of open answer, yes/no, and Likert scale response options. PARTICIPANTS Participation was voluntary and anonymous. Second-level school children interested in studying medicine and aged between 15 and 18 years took part. SETTING An annual open day organized by the School of Medicine in University College Cork, Ireland, formed the setting. The day comprised a mixture of lectures, demonstrations, and practical sessions designed to give the students insight into life as a medical student. RESULTS A total of 96 students attended, and all were handed the questionnaires. Of them, 88 students completed the survey. Overall, 90.9% of students had Facebook accounts and 53% had Twitter accounts. Of those with social media accounts, 14.8% reported having no privacy settings. Most respondents felt that unprofessional behavior on social media sites should be a factor considered in admission to medical schools. CONCLUSIONS Serious consequences can result from lapses in best practice relating to social media behavior. Dedicated reflective learning modules need to be incorporated into undergraduate and postgraduate training programs as a matter of urgency.
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Affiliation(s)
- Niamh M Foley
- Breast Research Centre, Cork University Hospital, Cork, Ireland.
| | | | - Mark A Corrigan
- Breast Research Centre, Cork University Hospital, Cork, Ireland; School of Medicine, University College Cork, Cork, Ireland
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Foley NM. Chronic obstructive pulmonary disease. SAAD Dig 2000; 17:3-12. [PMID: 11404867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
COPD is the most common chronic condition in the UK and it varies in severity from mild through to disabling and severe disease with respiratory failure. The treatment of the disease is tailored to the severity of the symptoms and the cornerstones are stopping smoking, inhaled bronchodilator and inhaled corticosteroid therapy. Preoperative assessment of patients with COPD needs to be thorough; remember that these patients may have concomitant ischaemic heart disease. Patients with severe COPD are at particularly high risk when given intravenous sedatives, opiates or general anaesthetics.
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Armstrong L, Foley NM, Millar AB. Inter-relationship between tumour necrosis factor-alpha (TNF-alpha) and TNF soluble receptors in pulmonary sarcoidosis. Thorax 1999; 54:524-30. [PMID: 10335007 PMCID: PMC1745499 DOI: 10.1136/thx.54.6.524] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The importance of tumour necrosis factor-alpha (TNF-alpha) in the pathogenesis of pulmonary sarcoidosis has remained uncertain because of the paucity of clinical features associated with excessive levels of this cytokine. Increased levels of soluble TNF receptors (TNF-R), which are known to inhibit TNF-alpha activity, were recently described in the lungs of subjects with sarcoidosis. We hypothesised that TNF-alpha bioactivity may be inhibited in sarcoidosis by the presence of TNF-R. A study was therefore undertaken to investigate for the first time the relationship between soluble receptors and TNF-alpha bioactivity in the lungs of subjects with sarcoidosis. METHODS Alveolar macrophages (AMs) from 16 subjects with histologically proven sarcoidosis and 13 healthy controls were cultured in the presence and absence of lipopolysaccharide (LPS). The subjects with sarcoidosis were grouped by radiological assessment into stage I (n = 6) and stage II/III (n = 10). The cell culture supernatants and bronchoalveolar lavage (BAL) fluid were assayed for TNF bioactivity using the WEHI 164 clone 13 assay. Immunoreactive (bound and free) TNF-alpha and free TNF-Rs (p55 and p75) were determined by ELISA. RESULTS Bioactive TNF-alpha was undetectable in the BAL fluid of all the subjects with sarcoidosis and most of the healthy controls. However, there was significantly more immunoreactive TNF-alpha in the BAL fluid from subjects with sarcoidosis than from the controls (median values 0.304 ng/ml and 0.004 ng/ml, respectively, 95% CI 0. 076 to 0.455, p<0.001). The levels of both p55 and p75 in the BAL fluid were higher in both sarcoidosis groups than in the controls (p<0.0005 and p<0.001, respectively). In LPS stimulated AM supernatants reduced TNF-alpha bioactivity was seen in subjects with stage I sarcoidosis compared with those with stage II/III disease and healthy controls (median 0.333 ng/ml vs 1.362 ng/ml and 2.385 ng/ml, respectively, p<0.01). This contrasted with increased p55 levels in the AM supernatants derived from subjects with stage I sarcoidosis compared with those with stage II/III disease and healthy controls (median 0.449 ng/ml vs 0.058 ng/ml and 0.078 ng/ml, respectively, p<0.01). The levels of p75 were increased in unstimulated AM cultures in subjects with stage II/III disease compared with those with stage I disease and healthy controls (median 0.326 ng/ml vs 0.064 ng/ml and 0.102 ng/ml, p<0.05). CONCLUSIONS These results indicate that TNF-alpha bioactivity may be inhibited by increased soluble TNF-R in the lungs of subjects with sarcoidosis, and this inhibition may be greater in patients with stage I sarcoidosis than in those with stage II/III disease. This may represent a homeostatic mechanism which protects the lung from excessive TNF production characteristic of chronic inflammation.
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Affiliation(s)
- L Armstrong
- Lung Research Group, University of Bristol Division of Medicine, Southmead Hospital, Bristol BS10 5NB, UK
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Abstract
The case records of consecutive patients admitted to a specialist HIV/AIDS inpatient unit between 1989 and 1993 with pyrexia of undetermined origin (PUO) were reviewed in order to determine the eventual diagnosis. Seventy-nine episodes occurred in 75 patients; 52 patients had a prior AIDS defining diagnosis. CD4+ lymphocyte counts ranged widely, 0-0.79 (median = 0.04) x 10(9)/l. Infections were found in 63 episodes (79%), including mycobacterial infection in 41 episodes (53%) and bacterial infection in 12 episodes (15%). Tumours were found in 6 episodes (8%), 5 of these were lymphoma. Factitious fever accounted for 2 episodes (3%) and connective-tissue disease for 1 episode (1%); no definite diagnosis was reached in 7 episodes (9%). PUO in HIV positive patients is commonly due to infection or tumour. Unexplained fever in this patient group should not be ascribed to HIV infection itself and should be vigorously investigated to find a cause.
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Affiliation(s)
- R F Miller
- Department of Medicine, University College London Medical School, UK
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Abstract
BACKGROUND Community acquired bacterial pneumonia is increasingly encountered in HIV infected individuals and some patients have a radiographic lobar pneumonia. METHODS A retrospective review of clinical features, microbiological diagnosis, and outcome of community acquired lobar pneumonia was carried out in HIV positive patients admitted to a specialist unit from 1987 to 1993. RESULTS Forty nine episodes occurred in 45 patients, all of whom were men. CD4 counts ranged widely. A bacteriological diagnosis was made in 25 episodes (51%), seven patients had more than one infective cause. The commonest pathogens were Streptococcus pneumoniae (11 episodes), Staphylococcus aureus (six), Pneumocystis carinii (three), Haemophilus influenzae (three), and Pseudomonas aeruginosa (two). Four patients died. Other complications included intrapulmonary cavitation or abscess formation (11 episodes), empyema (three), and pleural effusion (10 episodes). CONCLUSIONS Many different infections cause community acquired lobar pneumonia in HIV positive men. Some patients have co-infections and there is a high complication rate.
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Affiliation(s)
- R F Miller
- Department of Medicine, University College London Medical School
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Churchill DR, Lucas SB, Williams I, Foley NM, Miller RF. Recurrent pseudomembranous colitis due to Clostridium difficile in AIDS. Genitourin Med 1994; 70:51-5. [PMID: 8300102 PMCID: PMC1195181 DOI: 10.1136/sti.70.1.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Abstract
BACKGROUND Infection with Pneumocystis carinii typically results in a pneumonia which histologically is seen to consist of an eosinophilic foamy alveolar exudate associated with a mild plasma cell interstitial infiltrate. Special stains show that cysts of P carinii lie within the alveolar exudate. Atypical histological appearances may occasionally be seen, including a granulomatous pneumonia and diffuse alveolar damage. In these patients the clinical presentation may be atypical and results of investigations negative unless lung biopsies are performed and tissue obtained for histological examination. METHODS The incidence and mode of presentation of histologically atypical pneumocystis pneumonia was studied in a cohort of HIV-I antibody positive patients. RESULTS Over a 30 month period 138 patients had pneumocystis pneumonia, of whom eight (6%) had atypical histological appearances which were diagnosed (after negative bronchoalveolar lavage) by open lung biopsy in five, percutaneous biopsy in one, and at post mortem examination in two. Atypical appearances included granulomatous inflammation in four patients, "pneumocystoma" in two (one also had extrapulmonary pneumocystosis), bronchiolitis obliterans organising pneumonia in one patient, diffuse alveolar damage and subpleural cysts in one (who also had intrapulmonary cytomegalovirus infection), and extrapulmonary pneumocystosis in two patients. CONCLUSIONS Various atypical histological appearances may be seen in pneumocystis pneumonia. Lung biopsy (either percutaneous or open) should be considered when bronchoalveolar lavage is repeatedly negative and evidence of P carinii should be sought, by use of special stains, in all lung biopsy material from HIV-I antibody positive patients.
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Affiliation(s)
- N M Foley
- Department of Medicine, University College London Medical School, Middlesex Hospital
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18
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Pitkin AD, Grant AD, Foley NM, Miller RF. Changing patterns of respiratory disease in HIV positive patients in a referral centre in the United Kingdom between 1986-7 and 1990-1. Thorax 1993; 48:204-7. [PMID: 8497816 PMCID: PMC464354 DOI: 10.1136/thx.48.3.204] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Respiratory illness is a significant contributor to morbidity and mortality in patients with human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS). It has been suggested that Pneumocystis carinii pneumonia is no longer the most frequent cause of respiratory disease in this group because of widespread use of prophylaxis and anti-retroviral drugs. METHODS A retrospective comparison of the diagnoses in HIV 1 antibody positive patients with respiratory illness admitted to a major UK centre in 1986-7 and 1990-1 was carried out to identify changes in patterns of respiratory disease. RESULTS In the 1986-7 period there were 73 patients, of whom none received zidovudine or prophylaxis for pneumocystis pneumonia while in the 1990-1 period there were 122 patients. One hundred and ninety patients (98%) were male homosexuals. Pneumocystis pneumonia remained the commonest respiratory disease, comprising 68% of all diagnoses in the 1986-7 period and 48% in the 1990-1 period. Bacterial infections (bronchitis and pneumonia) were seen more commonly in the 1990-1 period (23%) than in the 1986-7 period (14%), as was pulmonary Kaposi's sarcoma (12% in 1990-1 and 4% in 1986-7). Mycobacterial infection remained uncommon (4% in 1986-7 and 6.5% in 1990-1). CONCLUSION Despite widespread use of zidovudine and prophylaxis, pneumocystis pneumonia remains the commonest respiratory disease in homosexual men.
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Affiliation(s)
- A D Pitkin
- Department of Medicine, University College London School of Medicine, Middlesex Hospital
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19
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Abstract
We have studied the effect of the HIV epidemic on the incidence of tuberculosis in an inner city area of London which has a high incidence of acquired immunodeficiency syndrome (AIDS). During the period 1985-1991, there was a steady increase in the number of new AIDS cases, whilst the numbers of notifications and laboratory isolates of Mycobacterium tuberculosis remained largely unchanged. Before 1990 there were few cases of tuberculosis in HIV-infected individuals but in the past 2 years there has been a marked increase. In 44% of patients, the site of infection was pulmonary, in 39% extrapulmonary and in 17% pulmonary and extrapulmonary. There were no previous manifestations of immunodeficiency in 58% of patients. This is the first study to show an association between tuberculosis and HIV in the U.K. and supports the suggestion that there is an increased incidence of tuberculosis in patients with HIV infection who are not intravenous drug users.
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Affiliation(s)
- N M Foley
- University College and Middlesex School of Medicine, Department of Medicine, Middlesex Hospital, London, U.K
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20
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21
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Foley NM, Millar AB, Meager A, Johnson NM, Rook GA. Tumour necrosis factor production by alveolar macrophages in pulmonary sarcoidosis and tuberculosis. Sarcoidosis 1992; 9:29-34. [PMID: 1344039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
Tumour Necrosis Factor alpha (TNF/Cachectin) is a cytokine produced mainly by macrophages, which has been shown to cause endothelial cell damage, pyrexia and weight loss, clinical features of tuberculosis, but not of sarcoidosis which is in many other respects a similar disease. 1,25 di-hydroxy Vitamin D and gamma interferon, factors which are present in vivo in both tuberculosis and sarcoidosis, enhance the ability of macrophages to release TNF in vitro. We have studied the ability of pulmonary alveolar macrophages (PAM) harvested by broncho-alveolar lavage (BAL) to produce TNF in response to stimulation with E. coli endotoxin lipopolysaccharide (LPS). 25 patients undergoing bronchoscopy and BAL were studied: 9 with sarcoidosis, 7 with tuberculosis (TB) and 9 (non-neoplastic) disease controls. TNF was assayed by Enzyme Linked Immunosorbent Assay (ELISA) in lavage fluid and cell culture supernatants. No TNF was detected in lavage fluid from any of the groups. PAMs from control patients released no detectable TNF spontaneously, but released 59 +/- 31 units after LPS stimulation. Cells from patients with sarcoidosis and tuberculosis released TNF spontaneously in vitro (TB 226 +/- 106 units; Sarcoidosis 293 +/- 176). TNF release by these cells was not increased further by addition of an optimal concentration of LPS. Thus, the pulmonary macrophages of patients with sarcoidosis and tuberculosis released significantly more TNF than those of controls.
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Affiliation(s)
- N M Foley
- Department of Medicine, University College and Middlesex School of Medicine, London
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22
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Millar AB, Miller RF, Foley NM, Meager A, Semple SJ, Rook GA. Production of tumor necrosis factor-alpha by blood and lung mononuclear phagocytes from patients with human immunodeficiency virus-related lung disease. Am J Respir Cell Mol Biol 1991; 5:144-8. [PMID: 1892644 DOI: 10.1165/ajrcmb/5.2.144] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Tumor necrosis factor-alpha (TNF) is a cytokine involved in the pathogenesis of shock and in granuloma formation, tissue necrosis, and fibrosis, in many organ systems, including the lung. It has been suggested that cells from patients infected by the human immunodeficiency virus (HIV + ve) are primed for TNF release. We postulated that TNF release from the alveolar macrophages (AM) of such patients with lung disease might lead to their observed pulmonary dysfunction. We present data confirming that peripheral blood monocytes (PBM) and demonstrating that AM from HIV + ve patients with pulmonary manifestations show significantly greater TNF production than those from HIV-negative (HIV - ve) subjects. In addition, we found sequentially significant increases in TNF production from AM and PBM of HIV + ve patients with no pathogens detected at bronchoscopy (NB), bacterial pneumonia (BP), and those with Pneumocystis carinii pneumonia (PCP). The overall TNF levels were greater from AM than PBM in all groups other than spontaneous production from HIV - ve subjects. Adherent populations of PBM and AM were incubated for 4 h with lipopolysaccharide (10 micrograms/ml) or control medium alone. Cell-free supernatants were examined for the presence of TNF using an immunoassay. The TNF levels (mean +/- SD) in IU/ml from stimulated PBM of the PCP, BP, NB, and control groups, respectively, were 186 +/- 36, 140 +/- 30, 95 +/- 18, and 55 +/- 10 and the spontaneous levels were 123 +/- 25, 100 +/- 22, 75 +/- 24, and 11 +/- 5.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- A B Millar
- Department of Medicine, University College and Middlesex School of Medicine, United Kingdom
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23
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Rook GA, Foley NM, Meager A. What mediates the immunopathological component of the immune response to Mycobacterium tuberculosis? Can it be switched off? Bull Int Union Tuberc Lung Dis 1990; 65:23-6. [PMID: 2124156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- G A Rook
- Department of Medical Microbiology, University College & Middlesex School of Medicine, School of Pathology, London, United Kingdom
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24
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Abstract
Tumour necrosis factor (TNF) concentrations were measured in the bronchopulmonary secretions of 5 patients with the adult respiratory distress syndrome. Each patient underwent fibreoptic bronchoscopy and bronchopulmonary aspiration, and control samples were obtained in an identical manner from 24 patients who underwent bronchoscopy for other reasons (8 had tuberculosis, 6 had sarcoidosis, and 10 had haemoptysis but no abnormal findings). Aspirated fluid was assayed for the presence of TNF by use of an enzyme-linked immunosorbent assay. In the 5 patients with adult respiratory distress syndrome, TNF concentrations exceeded 500 U/ml (12.5 ng/ml), whereas in the control samples no TNF was detected.
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Affiliation(s)
- A B Millar
- Department of Medicine, University College and Middlesex School of Medicine, London
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Foley NM, Coral AP, Tung K, Hudspith BN, James DG, Johnson NM. Bronchoalveolar lavage cell counts as a predictor of short term outcome in pulmonary sarcoidosis. Thorax 1989; 44:732-8. [PMID: 2588210 PMCID: PMC462054 DOI: 10.1136/thx.44.9.732] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Sixty seven patients with biopsy proven pulmonary sarcoidosis were prospectively studied to determine whether single point bronchoalveolar lavage cell counts were a useful indicator of functional outcome and whether repeated lavage helped in management. The mean follow up period was 25 (range 13-37) months. No patient was having corticosteroid treatment at the time of initial bronchoalveolar lavage. "High intensity alveolitis" (lymphocyte count greater than or equal to 28%) was present at the initial lavage in 42 patients. These patients showed a significant improvement in their pulmonary function and chest radiographs over the follow up period whereas patients with "low intensity alveolitis" did not. Of the 42 patients with high intensity alveolitis, 31 had chronic sarcoidosis (duration over two years, mean 80 months). These patients showed a significant improvement in FVC but not in TLCO. Corticosteroids resulted in greater functional and radiological improvement in the patients with high intensity alveolitis than in those with low intensity alveolitis. Repeat bronchoalveolar lavage in 34 patients, mean 8.4 months after the original lavage, showed a weak inverse relation between a reduced lymphocyte count and change in forced vital capacity and isotope uptake on a gallium scan. These correlations were too weak to make repeated cell counts useful in management. Our results suggest that high intensity alveolitis may be a favourable prognostic factor for lung function in pulmonary sarcoidosis, even in patients with chronic disease, but that repeat lavage adds little to the management of the individual patient.
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Affiliation(s)
- N M Foley
- Medical Unit, Middlesex Hospital, London
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