Publications by authors named "Sean Tierney"

41 Publications

Lower extremity amputations in Ireland: a registry-based study.

Ir J Med Sci 2021 Mar 23. Epub 2021 Mar 23.

Healthcare Outcome Research Centre, RCSI, Dublin, Republic of Ireland.

Objective: To analyse the current provision of lower extremity amputations (LEA) in Irish public hospitals by patient characteristics and assess the potential savings for reducing numbers if a national multi-disciplinary foot protection clinic (MDFPC) was established nation-wide.

Design And Data Sources: Patient characteristics of LEA conducted during 2016-2019 were analysed based on discharge data from the national hospital inpatient enquiry system. Reported consequences from existing literature were used to extrapolate national consequences.

Results: Public hospitals registered 3104 hospital admissions with LEA during 2016-2019. 68% (n = 2099) of these were minor amputations. About 76% (n = 1592) of minor amputations and 52% (n = 525) of major amputations were performed on patients with a diagnosis of diabetes. If the implementation of a national MDFPC programmed could reduce the number of diabetic amputations by 20%, 80 minor and 26 major amputations could be avoided annually. This would avoid nearly 3000 hospital bed days and correspond to a potential annual saving of €3 M.

Conclusion: LEA has severe impact on patients' lives and hospital resources. Potential savings from effective prevention strategies may offer both health improvements and cost-savings.
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http://dx.doi.org/10.1007/s11845-021-02536-zDOI Listing
March 2021

Analysing the Operative Experience of Paediatric Surgical Trainees in Sub-Saharan Africa Using a Web-Based Logbook.

World J Surg 2021 Apr 8;45(4):988-996. Epub 2020 Dec 8.

Department of Surgery, University of Malawi, Blantyre, Malawi.

Background: The expansion of local training programmes is crucial to address the shortages of specialist paediatric surgeons across Sub-Saharan Africa. This study assesses whether the current training programme for paediatric surgery at the College of Surgeons of East, Central and Southern Africa (COSECSA) is exposing trainees to adequate numbers and types of surgical procedures, as defined by local and international guidelines.

Methods: Using data from the COSECSA web-based logbook, we retrospectively analysed numbers and types of operations carried out by paediatric surgical trainees at each stage of training between 2015 and 2019, comparing results with indicative case numbers from regional (COSECSA) and international (Joint Commission on Surgical Training) guidelines.

Results: A total of 7,616 paediatric surgical operations were recorded by 15 trainees, at different stages of training, working across five countries in Sub-Saharan Africa. Each trainee recorded a median number of 456 operations (range 56-1111), with operative experience increasing between the first and final year of training. The most commonly recorded operation was inguinal hernia (n = 1051, 13.8%). Trainees performed the majority (n = 5607, 73.6%) of operations recorded in the eLogbook themselves, assisting in the remainder. Trainees exceeded both local and international recommended case numbers for general surgical procedures, with little exposure to sub-specialities.

Conclusions: Trainees obtain a wide experience in common and general paediatric surgical procedures, the number of which increases during training. Post-certification may be required for those who wish to sub-specialise. The data from the logbook are useful in identifying individuals who may require additional experience and centres which should be offering increased levels of supervised surgical exposure.
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http://dx.doi.org/10.1007/s00268-020-05892-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7921073PMC
April 2021

von Willebrand Factor Antigen, von Willebrand Factor Propeptide, and ADAMTS13 in Carotid Stenosis and Their Relationship with Cerebral Microemboli.

Thromb Haemost 2021 Jan 15;121(1):86-97. Epub 2020 Sep 15.

Department of Neurology, The Adelaide and Meath Hospital, Dublin incorporating the National Children's Hospital (AMNCH)/Tallaght University Hospital, Dublin, Ireland.

Background:  The relationship between von Willebrand factor antigen (VWF:Ag), VWF propeptide (VWFpp), VWFpp/VWF:Ag ratio, ADAMTS13 activity, and microembolic signal (MES) status in carotid stenosis is unknown.

Methods:  This prospective, multicenter study simultaneously assessed plasma VWF:Ag levels, VWFpp levels and ADAMTS13 activity, and their relationship with MES in asymptomatic versus symptomatic moderate-to-severe (≥50-99%) carotid stenosis patients. One-hour transcranial Doppler ultrasound of the middle cerebral arteries classified patients as MES+ve or MES-ve.

Results:  Data from 34 asymptomatic patients were compared with 43 symptomatic patients in the "early phase" (≤4 weeks) and 37 patients in the "late phase" (≥3 months) after transient ischemic attack (TIA)/ischemic stroke. VWF:Ag levels were higher ( = 0.049) and VWFpp/VWF:Ag ratios lower ( = 0.006) in early symptomatic than in asymptomatic patients overall, and in early symptomatic versus asymptomatic MES-ve subgroups ( ≤0.02). There were no intergroup differences in VWFpp expression or ADAMTS13 activity ( ≥0.05). VWF:Ag levels and ADAMTS13 activity decreased ( ≤ 0.048) and VWFpp/VWF:Ag ratios increased ( = 0.03) in symptomatic patients followed up from the early to late phases after TIA/stroke. Although there were no differences in the proportions of symptomatic and asymptomatic patients with blood group O, a combined analysis of early symptomatic and asymptomatic patients revealed lower median VWF:Ag levels in patients with blood group O versus those without blood group O (9.59 vs. 12.32 µg/mL,  = 0.035).

Discussion:  VWF:Ag expression, a marker of endothelial ± platelet activation, is enhanced in recently symptomatic versus asymptomatic carotid stenosis patients, including in MES-ve patients, and decreases with ADAMTS13 activity over time following atherosclerotic TIA/ischemic stroke.
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http://dx.doi.org/10.1055/s-0040-1715440DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855251PMC
January 2021

Simultaneous assessment of plaque morphology, cerebral micro-embolic signal status and platelet biomarkers in patients with recently symptomatic and asymptomatic carotid stenosis.

J Cereb Blood Flow Metab 2020 11 11;40(11):2201-2214. Epub 2019 Nov 11.

Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital/Tallaght University Hospital, Dublin, Ireland.

The relationship between plaque morphology, cerebral micro-embolic signals (MES) and platelet biomarkers in carotid stenosis patients warrants investigation.We combined data from two prospective, observational studies to assess carotid plaque morphology and relationship with cerebral MES and platelet biomarkers in patients with recently symptomatic (≤4 weeks of transient ischaemic attack (TIA)/ischaemic stroke) versus asymptomatic carotid stenosis. Plaque morphology on ultrasound was graded with Grey-Scale Median (GSM) and Gray-Weale (GW) scoring. Bilateral transcranial Doppler ultrasound classified patients as 'MES+ve' or 'MES-ve'. Full blood counts were analysed and flow cytometry quantified CD62P and CD63 expression, leucocyte-platelet complexes and reticulated platelets.Data from 42 recently symptomatic carotid stenosis patients were compared with those from 36 asymptomatic patients. There were no differences in median GSM scores between symptomatic and asymptomatic patients (25 vs. 30;  = 0.31) or between MES+ve vs. MES-ve symptomatic patients (36 vs. 25;  = 0.09). (GSM ≥25) had higher platelet counts (228 vs. 191 × 10/L), neutrophil-platelet (3.3 vs. 2.7%), monocyte-platelet (6.3 vs. 4.55%) and lymphocyte-platelet complexes (2.91 vs. 2.53%) than '' ( ≤ 0.03).Recently, symptomatic carotid stenosis patients with 'GSM-echodense plaques' have enhanced platelet production/secretion/activation compared with their asymptomatic counterparts. Simultaneous assessment with neurovascular imaging and platelet biomarkers may aid risk-stratification in carotid stenosis.
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http://dx.doi.org/10.1177/0271678X19884427DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7585923PMC
November 2020

A systematic review and meta-analysis of comparative studies comparing nonthermal versus thermal endovenous ablation in superficial venous incompetence.

J Vasc Surg Venous Lymphat Disord 2019 11;7(6):902-913.e3

Royal College of Surgeons in Ireland, Dublin, Ireland.

Objective: Endovenous thermal ablation (TA) offers an effective initial treatment option for superficial venous incompetence of the lower limb. These techniques offer lower complication rates with similar efficacy to traditional open surgery. In recent years, nonthermal ablation (NTA) in the form of mechanochemical ablation and cyanoacrylate vein ablation has been suggested to further reduce perioperative morbidity. This study aimed to compare the use of both thermal and nonthermal endovenous ablative techniques in the management of superficial venous incompetence.

Methods: A search of online databases including MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane database was last performed in January 2019. Comparative studies comparing NTA with TA were included. The primary outcome was technical success. Secondary outcomes included operative pain, complications, modification of disease severity, and quality of life.

Results: Six studies describing the outcomes of 1236 participants and 1256 truncal ablations were included for analysis. Follow-up ranged from 6 weeks to 36 months. With regard to overall technical success, 458 of 483 (94.8%) receiving NTA and 521 of 553 (94.2%) undergoing TA had successful truncal ablation on follow-up ultrasound imaging at the study end point (pooled risk ratio, 1.01; 95% confidence interval [CI], 0.99-1.04). Subgroup analysis identified no difference in success between groups during immediate, 6-month, 12-month, or >12-month follow-up periods. Postprocedural pain was generally lower in those undergoing NTA with a mean difference of -18.11 (95% CI, -36.7 to 0.48). Techniques experienced significatly lower rates of ecchymosis (risk ratio, 0.43; 95% CI, 0.23-0.78), with no difference identified with regard to rates of paresthesia, phlebitis, and skin pigmentation. Further assessment of quality of life (mean difference, -0.27; 95% CI, -0.57 to 0.04) and Venous Clinical Severity Score (-0.52; 95% CI, -1.05 to 0.01) revealed no difference between groups. Included data were deemed of moderate methodologic quality.

Conclusions: Nonthermal techniques are as effective as standard TA in the first year and, in some studies, may be associated with less procedural pain. These data suggest that NTA offers an alternative and safe means to treat superficial venous disease. There is, however, a need for further powered trials with larger numbers of patients and longer follow-up to definitively examine this hypothesis.
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http://dx.doi.org/10.1016/j.jvsv.2019.06.009DOI Listing
November 2019

Making all deaths after surgery count.

Lancet 2019 06 27;393(10191):2588. Epub 2019 Jun 27.

College of Surgeons of East, Central and Southern Africa, Arusha, Tanzania.

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http://dx.doi.org/10.1016/S0140-6736(19)31113-4DOI Listing
June 2019

Women in Surgery Africa and research.

Lancet 2019 05;393(10186):2120

Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA.

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http://dx.doi.org/10.1016/S0140-6736(19)31106-7DOI Listing
May 2019

Increased Leucocyte-Platelet Complex Formation in Recently Symptomatic versus Asymptomatic Carotid Stenosis Patients and in Micro-emboli Negative Subgroups.

Thromb Haemost 2019 May 15;119(5):821-833. Epub 2019 Feb 15.

Department of Neurology, Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH)/Tallaght University Hospital, Dublin, Ireland.

Introduction:  Cerebral micro-embolic signals (MES) predict risk of stroke in carotid stenosis patients. However, MES-negative 'recently symptomatic patients' also have a higher stroke risk than 'asymptomatic patients'. Differences in platelet activation status may contribute to this disparity in risk.

Methods:  This prospective, observational study assessed platelet biomarkers and their relationship with MES in asymptomatic versus symptomatic moderate (≥50-69%) or severe (≥70-99%) carotid stenosis patients. Full blood count parameters were measured and whole-blood flow cytometry was used to quantify platelet surface CD62P and CD63 expression and leucocyte-platelet complex formation. Bilateral simultaneous transcranial Doppler ultrasound of the middle cerebral arteries classified patients as 'MES positive' or 'MES negative'.

Results:  Data from 34 asymptomatic patients were compared with those from 43 symptomatic patients in the 'early phase' (≤ 4 weeks) and 37 of these symptomatic patients in the 'late phase' (≥ 3 months) after transient ischaemic attack/ischaemic stroke. There were no differences in %CD62P or %CD63 expression between early or late symptomatic and asymptomatic patients overall ( > 0.05). The percentage of lymphocyte-platelet complexes was higher in early symptomatic than in asymptomatic patients (2.8 vs. 2.16%;  < 0.001). MES were more commonly observed in early symptomatic (31.4%;  = 0.027) but not in late symptomatic (6.7%;  = 0.996) versus asymptomatic patients (7.1%). The percentage of lymphocyte-platelet complexes was higher in early symptomatic than in asymptomatic MES-negative patients (2.7 vs. 2.17%;  = 0.02).

Conclusion: These data add to the evidence that leucocyte-platelet complex formation/platelet activation is increased in recently symptomatic versus asymptomatic patients, and may contribute to the pathogenesis of first and subsequent strokes in carotid stenosis patients, including those who are MES negative.
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http://dx.doi.org/10.1055/s-0039-1678666DOI Listing
May 2019

Extracranial and Intracranial Vasculopathy With "Moyamoya Phenomenon" in Association With Alagille Syndrome.

Front Neurol 2018 29;9:1194. Epub 2019 Jan 29.

Department of Neurology, The Adelaide and Meath Hospital, Dublin, Incorporating The National Children's Hospital (AMNCH)/Tallaght University Hospital, Dublin, Ireland.

Alagille syndrome (AGS) is an autosomal-dominant, multisystem disorder caused by mutations in the JAG1 gene. A 34-year-old man was referred to our service 10 years ago with focal seizures with impaired awareness and transient slurred speech. He had a 5-year history of intermittent left monocular low-flow retinopathy. He has a family history of AGS. General examination revealed mild hypertension, aortic regurgitation, and livedo reticularis. Neurological examination was normal. He had mild hyperlipidaemia and persistently-positive lupus anticoagulant consistent with primary anti-phospholipid syndrome. Color Doppler ultrasound revealed low velocity flow in a narrowed extracranial left internal carotid artery (ICA). MR and CT angiography revealed a diffusely narrowed extracranial and intracranial left ICA. Formal cerebral angiography confirmed severe left ICA narrowing consistent with a left ICA "vasculopathy" and moyamoya phenomenon. Transthoracic echocardiogram revealed a bicuspid aortic valve and aortic incompetence. Molecular genetic analysis identified a missense mutation (A211P) in exon 4 of the JAG1 gene, consistent with AGS. AGS should be considered in young adults with TIAs/stroke and unexplained extracranial or intracranial vascular abnormalities, and/or moyamoya phenomenon, even in the absence of other typical phenotypic features. Gene panels should include JAG1 gene testing in similar patients.
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http://dx.doi.org/10.3389/fneur.2018.01194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6362309PMC
January 2019

Excision of true facial artery aneurysm using facial nerve monitoring.

J Vasc Surg Cases Innov Tech 2018 Jun 27;4(2):126-127. Epub 2018 Apr 27.

Department of Vascular Surgery, Tallaght Hospital, Dublin, Ireland.

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http://dx.doi.org/10.1016/j.jvscit.2017.09.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6012978PMC
June 2018

Mortality rates of patients undergoing emergency laparotomy in an Irish university teaching hospital.

Ir J Med Sci 2018 Nov 15;187(4):1039-1044. Epub 2018 Feb 15.

Department of Vascular Surgery, Tallaght Hospital, Tallaght, Dublin 24, Ireland.

Introduction: Emergency laparotomy (EL) is a commonly performed operation with increased morbidity and mortality. Currently, there is a lack of published outcomes following emergency laparotomy within an Irish population. The aim of this study was to assess our outcomes and compare these to predefined outcomes from NELA.

Methods: A review of a prospectively maintained database of all patients who underwent an emergency laparotomy between January 1st 2015 and October 31st 2016 was performed. Patient demographics, operative indication and procedures, preoperative lactate, time of surgery, admission to high dependency unit (HDU) and mortality (30- and 90-day mortality) were included. Statistical analysis was performed using Minitab V18 with p < 0.05 considered significant.

Results: One hundred twenty-four emergency operations were performed on 120 patients. The median age was 60 years. Indications for surgery included the following (%): peritonitis (32.45%), obstruction (22.5%), complicated hernia (19.1%), mesenteric ischaemia (15%), trauma (4.1%), and acute haemorrhage (3.3%). A consultant surgeon and consultant anaesthetist were present at 79 and 78% of EL carried out, respectively. Reported 30- and 90-day mortality were 6.66 and 11.6%, respectively. Thirty-day mortality was 20% in octogenarians. Index lactate did not correlate with mortality (p = 0.43). A significant proportion of mortalities had procedures carried out between 6 pm and midnight with the highest mortality rate in patients with mesenteric ischaemia (p < 0.05).

Conclusion: EL is associated with high mortality rates. Our mortality figures compare favourably with the NELA data. We support the development of a national database to facilitate improvements in the quality of care delivered to this high-risk cohort.
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http://dx.doi.org/10.1007/s11845-018-1759-4DOI Listing
November 2018

Port insertion for minimally invasive surgery: a report of practices in the Irish Republic.

Ir J Med Sci 2018 Nov 6;187(4):1021-1027. Epub 2018 Feb 6.

Department of Surgery, Midland Regional Hospital Tullamore, Arden Rd, Puttaghan, Tullamore, Co. Offaly, Ireland.

Background: With rapidly evolving surgical technologies, minimally invasive surgery (MIS) has become the mainstay approach for many surgeons worldwide. As laparoscopic surgery was introduced in Ireland over two decades ago, we may be encountering a higher prevalence of related complications.

Aims: This study aimed to gather data pertaining to risk factors for port-site herniation in MIS.

Methods: A 14-point anonymous questionnaire was distributed electronically between January and May 2017 to consultant and trainee laparoscopists in the Republic of Ireland. This survey related to laparoscopic volume and surgical approaches to laparoscopic port-sites.

Results: There were 172 eligible responses nationally. Approaches to peritoneal access included Hasson, veress (blind puncture) and SILS were 66.3, 32.6 and 1.2%, respectively. Senior surgeons and specialists in Obstetrics and Gynaecology (OBGYN) reported significantly higher utilisations of closed peritoneal access (p < 0.05). Of the participants, 119 (69.2%) reported using a bladeless trocar over a bladed type. Fascial closure was utilised in 94.2% of ≥ 10 mm and 2.3% of 5-mm ports using absorbable suture in 76.7%, non-absorbable suture in 14.5% and port closure devices in 8.7%. Perceptions of risk factors for PSH were not congruent with significant variations in responses between levels of expertise.

Conclusions: This study demonstrates significant variations in laparoscopic port-site practices amongst surgeons nationally. The new era of practitioners may benefit from evidence-based technical workshops and guidelines to increase awareness and reduce potential complications.
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http://dx.doi.org/10.1007/s11845-017-1732-7DOI Listing
November 2018

360° Operative Videos: A Randomised Cross-Over Study Evaluating Attentiveness and Information Retention.

J Surg Educ 2018 Jul - Aug;75(4):993-1000. Epub 2017 Nov 6.

Department of Surgical Affairs, Royal College of Surgeons in Ireland, Dublin.

Objective: Although two-dimensional (2D) and three-dimensional videos have traditionally provided foundations for reviewing operative procedures, the recent 360º format may provide new dimensions to surgical education. This study sought to describe the production of a high quality 360º video for an index-operation (augmented with educational material), while evaluating for variances in attentiveness, information retention, and appraisal compared to 2D.

Design: A 6-camera synchronised array (GoPro Omni, [California, United States]) was suspended inverted and recorded an elective laparoscopic cholecystectomy in 2016. A single-blinded randomised cross-over study was performed to evaluate this video in 360º vs 2D formats. Group A experienced the 360º video using Samsung (Suwon, South-Korea) GearVR virtual-reality headsets, followed by the 2D experience on a 75-inch television. Group B were reversed. Each video was probed at designated time points for engagement levels and task-unrelated images or thoughts. Alternating question banks were administered following each video experience. Feedback was obtained via a short survey at study completion.

Setting: The New Academic and Education Building (NAEB) in Dublin, Royal College of Surgeons in Ireland, July 2017.

Participants: Preclinical undergraduate students from a medical university in Ireland.

Results: Forty students participated with a mean age of 23.2 ± 4.5 years and equal sex involvement. The 360º video demonstrated significantly higher engagement (p < 0.01) throughout the experience and lower task-unrelated images or thoughts (p < 0.01). Significant variances in information retention between the 2 groups were absent (p = 0.143) but most (65%) reported the 360º video as their learning platform of choice. Mean appraisal levels for the 360º platform were positive with mean responses of >8/10 for the platform for learning, immersion, and entertainment.

Conclusions: This study describes the successful development and evaluation of a 360º operative video. This new video format demonstrated significant engagement and attentiveness benefits compared to traditional 2D formats. This requires further evaluation in the field of technology enhanced learning.
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http://dx.doi.org/10.1016/j.jsurg.2017.10.010DOI Listing
September 2019

The Brain Drain Myth: Retention of Specialist Surgical Graduates in East, Central and Southern Africa, 1974-2013.

World J Surg 2017 12;41(12):3046-3053

College of Surgeons of East, Central and Southern Africa (COSECSA), Njiro Road, Arusha, Tanzania.

Background: This study assesses the retention of specialist surgical graduates from training programmes across eight countries in East, Central and Southern Africa from 1974 to 2013. It addresses the gap in existing data by analysing retention rates of surgical graduates by comparing graduating institution to current location. Data were assessed by country, region, specialty and gender with a view to informing national and regional healthcare and education strategies.

Methods: Twenty-five institutions train surgeons in the ten countries covered by the College of Surgeons of East, Central and Southern Africa (COSECSA)-24 Universities and the College itself. These institutions were requested in November 2014 to supply details of graduates from their postgraduate surgical training programmes. Complete graduate lists were returned by the College and 14 universities by March 2016. These surgical graduates were compared against the database of current practising surgeons in the region held by COSECSA. Data were cross-checked against medical council registers, surgical society records, and with members and fellows of COSECSA.

Results: Data were incomplete for 126 surgical graduates. Of the remaining 1038 surgical graduates, 85.1% were retained in the country they trained in, while 88.3% were retained within the COSECSA region. Ninety-three per cent (93.4%) were retained within Africa. Of the eight countries, Malawi had the highest retention rate with 100% of surgical graduates remaining in country, while Zimbabwe had the lowest rate with 65.5% remaining.

Conclusion: High surgical graduate retention rates across the region indicate that the expansion of national surgical training initiatives is an effective solution to addressing the surgical workforce shortage in East, Central and Southern Africa and counters long-held arguments regarding brain drain in this region.
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http://dx.doi.org/10.1007/s00268-017-4307-xDOI Listing
December 2017

Objective scoring of an electronic surgical logbook: Analysis of impact and observations within a surgical training body.

Am J Surg 2017 Nov 21;214(5):962-968. Epub 2017 Jul 21.

Department of Surgical Affairs, Royal College of Surgeons in Ireland, Dublin, Ireland.

Background: Historically, evaluating operative-volumes has proven difficult due to mass-variability in operative-complexities and participation. This study aimed to introduce a national scoring interface for residents' operative-logs while forming meaningful observations on specialities, training-institutes and technical competency.

Methods: A weighted-scoring algorithm was applied prospectively to residents' operative volumes since July 8th 2013 with daily web-based quantitative feedback. Pre and post intervention analyses were performed with historical volumes. Operative volumes were correlated with work-based and university technical-skills' assessments.

Results: Ninety-five residents completed two-year preliminary training since 2013 recording 79,490 operations. These residents recorded significant (p < 0.050) increases in mean-score (case-load), total, performed and assisted operations of >16,528 (50%), 234 (45%), 115 (66%) and 113 (33%) respectively. The number of resident-performed operations was a significant predictor of performance in work-based and university technical-skills assessments (p < 0.050). There were no associations between these measures and the volume of assisted-operations.

Conclusions: Open-benchmarking of surgical-volumes stimulates residents to actively pursue operative-opportunities and record those experiences. It provides objective performance data on residents and training-institutes while providing evidence that level of operative participation is significant in technical skills development.
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http://dx.doi.org/10.1016/j.amjsurg.2017.07.028DOI Listing
November 2017

Assessment of 'on-treatment platelet reactivity' and relationship with cerebral micro-embolic signals in asymptomatic and symptomatic carotid stenosis.

J Neurol Sci 2017 05 14;376:133-139. Epub 2017 Mar 14.

Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital, Trinity College Dublin, Ireland; Department of Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital, Trinity College Dublin, Ireland; Department of Vascular Neurology Research Foundation, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital, Trinity College Dublin, Ireland; Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, UK; Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland. Electronic address:

Introduction: The relationship between on-treatment platelet reactivity and cerebral micro-embolic signals (MES) is unknown, and has not been previously simultaneously assessed in asymptomatic and symptomatic carotid stenosis patients.

Methods: Consecutive eligible patients with ≥50% asymptomatic or recently symptomatic carotid stenosis (≤4weeks following TIA/ischaemic stroke) were recruited to this pilot study. Symptomatic patients were followed up to the 'late' phase (≥3months) following symptom onset or carotid intervention; longitudinal data were analysed from symptomatic patients with data available at both time-points. Platelet function/reactivity was assessed with the PFA-100® to measure collagen-ADP (C-ADP) and collagen-epinephrine (C-EPI) closure times in citrate-anticoagulated whole blood. Bilateral simultaneous 1-hour transcranial Doppler ultrasound (TCD) monitoring of the middle cerebral arteries was performed to classify patients as MES +ve or MES -ve.

Results: 31 patients with ≥50% asymptomatic and 46 with early symptomatic carotid stenosis or occlusion were included. 35 symptomatic patients were followed up to the late phase (23 following carotid intervention). Prevalence of 'high on-treatment platelet reactivity' (HTPR) on the C-EPI cartridge did not differ between asymptomatic and symptomatic patients overall, but was lower in 'symptomatic post-intervention' than asymptomatic patients on aspirin monotherapy (10% vs. 50%; p=0.03). The prevalence of HTPR on the C-EPI cartridge decreased between the early and late phases in symptomatic patients (63% vs. 34%; p=0.017), including those on aspirin monotherapy (p=0.016). There were no significant differences in HTPR status between asymptomatic vs. early or late symptomatic MES +ve or MES -ve patients.

Discussion: Carotid interventional treatment, presumably in combination with resolution of the acute phase response, may decrease the prevalence of HTPR in patients with recently symptomatic carotid stenosis over time. Preliminary subgroup analysis suggests that successful intervention may reduce the prevalence of aspirin-HTPR in symptomatic patients to lower levels than asymptomatic medically-treated patients on aspirin monotherapy. Larger, longitudinal studies are warranted to reassess the impact of more intensive secondary preventive treatment on ex vivo platelet function at different levels of shear stress in carotid stenosis patients.
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http://dx.doi.org/10.1016/j.jns.2017.03.015DOI Listing
May 2017

Development and evaluation of a trauma decision-making simulator in Oculus virtual reality.

Am J Surg 2018 Jan 10;215(1):42-47. Epub 2017 Feb 10.

Department of Surgical Affairs, Royal College of Surgeons in Ireland, Ireland.

Background: Consumer-available virtual-reality technology was launched in 2016 with strong foundations in the entertainment-industry. We developed an innovative medical-training simulator on the Oculus™ Gear-VR platform. This novel application was developed utilising internationally recognised Advanced Trauma Life Support (ATLS) principles, requiring decision-making skills for critically-injured virtual-patients.

Methods: Participants were recruited in June, 2016 at a single-centre trauma-course (ATLS, Leinster, Ireland) and trialled the platform. Simulator performances were correlated with individual expertise and course-performance measures. A post-intervention questionnaire relating to validity-aspects was completed.

Results: Eighteen(81.8%) eligible-candidates and eleven(84.6%) course-instructors voluntarily participated. The survey-responders mean-age was 38.9(±11.0) years with 80.8% male predominance. The instructor-group caused significantly less fatal-errors (p < 0.050) and proportions of incorrect-decisions (p < 0.050). The VR-hardware and trauma-application's mean ratings were 5.09 and 5.04 out of 7 respectively. Participants reported it was an enjoyable method of learning (median-6.0), the learning platform of choice (median-5.0) and a cost-effective training tool (median-5.0).

Conclusion: Our research has demonstrated evidence of validity-criteria for a concept application on virtual-reality headsets. We believe that virtual-reality technology is a viable platform for medical-simulation into the future.
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http://dx.doi.org/10.1016/j.amjsurg.2017.02.011DOI Listing
January 2018

The Specialist Surgeon Workforce in East, Central and Southern Africa: A Situation Analysis.

World J Surg 2016 Nov;40(11):2620-2627

College of Surgeons of East, Central and Southern Africa, Njiro Road, Arusha, Tanzania.

Background: In East, Central and Southern Africa accurate data on the current surgeon workforce have previously been limited. In order to ensure that the workforce required for sustainable delivery of surgical care is put in place, accurate data on the number, specialty and distribution of specialist-trained surgeons are crucial for all stakeholders in surgery and surgical training in the region.

Methods: The surgical workforce in each of the ten member countries of the College of Surgeons of East, Central and Southern Africa (COSECSA) was determined by gathering and crosschecking data from multiple sources including COSECSA records, medical council registers, local surgical societies records, event attendance lists and interviews of Members and Fellows of COSECSA, and validating this by direct contact with the surgeons identified. This data was recorded and analysed in a cloud-based computerised database, developed as part of a collaboration programme with the Royal College of Surgeons in Ireland.

Results: A total of 1690 practising surgeons have been identified yielding a regional ratio of 0.53 surgeons per 100,000 population. A majority of surgeons (64 %) practise in the main commercial city of their country of residence and just 9 % of surgeons are female. More than half (53 %) of surgeons in the region are general surgeons.

Conclusions: While there is considerable geographic variation between countries, the regional surgical workforce represents less than 4 % of the equivalent number in developed countries indicating the magnitude of the human resource challenge to be addressed.
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http://dx.doi.org/10.1007/s00268-016-3601-3DOI Listing
November 2016

Experience of plastic surgery registrars in a European Working Time Directive compliant rota.

J Plast Surg Hand Surg 2017 Aug 20;51(4):264-269. Epub 2016 Oct 20.

a Department of Plastic Surgery , St James's Hospital Dublin, Trinity College Dublin , Ireland.

Background: Surgical training requires exposure to clinical decision-making and operative experience in a supervised environment. It is recognised that learning ability is compromised when fatigued. The European Working Time Directive requires a decrease in working hours, but compliance reduces trainees' clinical exposure, which has profound implications for plastic surgery training. The aim of this study was to evaluate plastic surgery registrars' experience of an EWTD-compliant rota, and to examine its impact on patient care, education, and logbook activity.

Methods: An electronic survey was distributed to plastic surgery registrars in a university teaching hospital. Registrars were asked to rate 31 items on a five-point Likert scale, including statements on patient care, clinical and operative duties, training, and quality-of-life. Interquartile deviations explored consensus among responses. Operative caseload was objectively evaluated using eLogbook data to compare activity at equal time points before and after implementation of the EWTD rota.

Results: Highest levels of consensus among respondents were found in positive statements addressing alertness and preparation for theatre, as well as time to read and study for exams. Registrars agreed that EWTD compliance improved their quality-of-life. However, it was felt that continuity of patient care was compromised by work hours restriction. Registrars were concerned about their operative experience. eLogbook data confirmed a fall-off in mean caseload of 31.8% compared to activity prior to EWTD rota implementation.

Conclusion: While EWTD compliant rotas promote trainee quality-of-life and satisfaction with training, attention needs to be paid to optimising operative opportunities.
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http://dx.doi.org/10.1080/2000656X.2016.1241791DOI Listing
August 2017

Experience with botulinum toxin therapy for axillary hyperhidrosis and comparison to modelled data for endoscopic thoracic sympathectomy - A quality of life and cost effectiveness analysis.

Surgeon 2016 Oct 10;14(5):260-4. Epub 2015 Jun 10.

Department of Vascular Surgery, Tallaght Hospital, Tallaght, Dublin 24, Ireland.

Aim: To estimate cost-effectiveness of botulinum toxin therapy for axillary hyperhidrosis compared to the standard surgical intervention of endoscopic thoracic sympathectomy (ETS).

Methods: The validated dermatology life quality index questionnaire was given to patients attending for treatment over a 4 month period, to assess their quality of life (QoL) over the preceding week (n = 44). Follow-up was performed 4-6 weeks later by telephone using the same questionnaire to validate the effectiveness of the treatment. The duration of effect of the botulinum toxin treatment was also recorded and this data was used as the basis for cost effectiveness analysis. Using HIPE data, the baseline cost for single intervention using botulinum toxin and ETS was retrieved. Using figures provided by HIPE and expert opinion of the costs of complications, a stochastic model for 10,000 patients was used to evaluate the total costs for ETS including the complications.

Results: The results from the QoL analysis show that botulinum toxin therapy is a successful therapy for improvement of symptoms. It was revealed that the mean interval before recurrence of original symptoms after botulinum toxin therapy was 5.6 months. The baseline cost for both treatments are €389 for botulinum toxin and €9389 for uncomplicated ETS. The stochastic model yields a mean cost of €11,390 for ETS including complications.

Conclusions: Treatments reached cost equivalence after 13.3 years. However, given the efficacy of the botulinum toxin therapy and the low risk we propose that botulinum toxin therapy for hyperhidrosis should be considered the gold standard.
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http://dx.doi.org/10.1016/j.surge.2015.05.002DOI Listing
October 2016

The impact of a surgical boot camp on early acquisition of technical and nontechnical skills by novice surgical trainees.

Am J Surg 2015 Sep 27;210(3):570-7. Epub 2015 Apr 27.

National Surgical Training Centre, Royal College of Surgeons in Ireland, Dublin, Ireland.

Background: Acquisition of skills early in surgical training represents a significant challenge at present because of training time constraints. The aim of this study was to investigate if an intensive surgical boot camp was effective in transferring skills at the beginning of a surgical training program.

Methods: New core surgical trainees (n = 58) took part in a 5-day boot camp. There were pretest and posttest assessments of knowledge, technical skills, and confidence levels. The boot camp used simulation and senior surgical faculty to teach a defined range of technical and nontechnical skills.

Results: The scores for knowledge (53.8% vs 68.4%, P < .01), technical skills (35.9% to 60.6% vs 50.6% to 78.2%, P < .01), and confidence levels improved significantly during boot camp. Skills improvements were still present a year later.

Conclusion: The 5-day surgical boot camp proved to be an effective way to rapidly acquire surgical knowledge and skills while increasing the confidence levels of trainees.
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http://dx.doi.org/10.1016/j.amjsurg.2014.12.046DOI Listing
September 2015

Kommerell's diverticulum, right-sided aortic arch, and a hypoplastic left vertebral artery arising from the left common carotid artery.

J Vasc Surg 2014 Oct;60(4):1059

Department of Vascular Surgery, Tallaght Hospital, Dublin, Ireland; Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland.

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http://dx.doi.org/10.1016/j.jvs.2013.08.092DOI Listing
October 2014

An assessment of the readability and quality of elective orthopaedic information on the Internet.

Acta Orthop Belg 2014 Jun;80(2):153-60

This study assessed the readability and quality of websites related to; total hip replacement, total knee replacement and anterior cruciate ligament reconstruction using validated instruments. 225 websites were analyzed from Google, Yahoo and Bing. Readability was assessed using the Flesch Reading Ease Score and Flesch-Kincaid grade level. Quality was assessed using the LIDA tool, HON-code status and an original assessment tool. Only 13.7% were set at or below the recommended 6th grade readability level. 27.35% were HON-code certified. There was a wide variation in quality scores between websites and the information relating to the three procedures was inconsistent and generally of poor quality. Given the deficit in information it is important Orthopaedic surgeons provide patients with high quality, readable information or direct them to an appropriate source.
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June 2014

Skills transfer after proficiency-based simulation training in superficial femoral artery angioplasty.

Simul Healthc 2012 Oct;7(5):274-81

Department of Surgical Training, Royal College of Surgeons in Ireland.

Introduction: The purpose of this study was to explore whether basic endovascular skills acquired using proficiency-based simulation training in superficial femoral artery (SFA) angioplasty translate to real-world performance.

Methods: Five international experts were invited to evaluate a preliminary 28-item rating scale for SFA angioplasty using a modified Delphi study. To test the procedural scale, 4 experts and 11 final-year medical students then performed 2 SFA angioplasties each on the vascular intervention simulation trainer simulator. Thereafter, 10 general surgical residents (novices) received didactic training in SFA angioplasty. Trainees were then randomized with 5 trainees receiving further training on the vascular intervention simulation trainer simulator up to proficiency level. All 10 trainees then performed 1 SFA angioplasty on a patient within 5 days of training. The trainees' performance was assessed by 1 attending consultant blinded to the trainees' training status, using the developed procedural scale and a global rating scale.

Results: Four items were eliminated from the procedural scale after the Delphi study. There were significant differences in the procedural scale scores between the experts and the students in the first trial [mean (SD), 94.25 (2.22) vs. 74.90 (8.79), P = 0.001] and the second trial [95.25 (0.50) vs. 76.82 (9.44), P < 0.001]. Simulation-trained trainees scored higher than the controls on the procedural scale [86.8 (5.4) vs. 67.6 (6), P = 0.001] and the global rating scale [37.2 (4.1) vs. 24.4 (5.3), P = 0.003].

Conclusions: Basic endovascular skills acquired using proficiency-based simulation training in SFA angioplasty do translate to real-world performance.
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http://dx.doi.org/10.1097/SIH.0b013e31825b6308DOI Listing
October 2012

Analysing the operative experience of basic surgical trainees in Ireland using a web-based logbook.

BMC Med Educ 2011 Sep 25;11:70. Epub 2011 Sep 25.

National Surgical Training Centre, Colles Institute, Royal College of Surgeons in Ireland, 123 St, Stephen's Green, Dublin 2, Ireland.

Background: There is concern about the adequacy of operative exposure in surgical training programmes, in the context of changing work practices. We aimed to quantify the operative exposure of all trainees on the National Basic Surgical Training (BST) programme in Ireland and compare the results with arbitrary training targets.

Methods: Retrospective analysis of data obtained from a web-based logbook (http://www.elogbook.org) for all general surgery and orthopaedic training posts between July 2007 and June 2009.

Results: 104 trainees recorded 23,918 operations between two 6-month general surgery posts. The most common general surgery operation performed was simple skin excision with trainees performing an average of 19.7 (± 9.9) over the 2-year training programme. Trainees most frequently assisted with cholecystectomy with an average of 16.0 (± 11.0) per trainee. Comparison of trainee operative experience to arbitrary training targets found that 2-38% of trainees achieved the targets for 9 emergency index operations and 24-90% of trainees achieved the targets for 8 index elective operations. 72 trainees also completed a 6-month post in orthopaedics and recorded 7,551 operations. The most common orthopaedic operation that trainees performed was removal of metal, with an average of 2.90 (± 3.27) per trainee. The most common orthopaedic operation that trainees assisted with was total hip replacement, with an average of 10.46 (± 6.21) per trainee.

Conclusions: A centralised web-based logbook provides valuable data to analyse training programme performance. Analysis of logbooks raises concerns about operative experience at junior trainee level. The provision of adequate operative exposure for trainees should be a key performance indicator for training programmes.
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http://dx.doi.org/10.1186/1472-6920-11-70DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3189901PMC
September 2011

Prevalence of lymphoedema and quality of life among patients attending a hospital-based wound management and vascular clinic.

Int Wound J 2012 Apr 13;9(2):120-5. Epub 2011 Sep 13.

FFNMRCSI, Centre for Nursing and Midwifery Research, Royal College of Surgeons in Ireland, Dublin, Ireland.

Lymphoedema is a chronic, incurable, debilitating condition, usually affecting a limb and causes discomfort, pain, heaviness, limited motion, unsatisfactory appearance and impacts on quality of life. However, there is a paucity of prevalence data on this condition. This study aimed to determine the prevalence of lymphoedema among persons attending wound management and vascular clinics in an acute tertiary referral hospital. Four hundred and eighteen patients meeting the inclusion criteria were assessed. A prevalence rate of 2.63% (n = 11) was recorded. Thirty-six percent (n = 4) had history of cellulitis and broken skin, 64% (n = 7) had history of broken skin and 36% (n = 4) had undergone treatment for venous leg ulcers. The most common co-morbidities were hypertension 55% (n = 6), deep vein thrombosis (DVT) 27% (n = 3), hypercholesterolemia 36% (n = 4) and type 2 diabetes 27% (n = 3). Quality of life scores identified that physical functioning was the domain most affected among this group. This study has identified the need to raise awareness of this condition among clinicians working in the area of wound management.
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http://dx.doi.org/10.1111/j.1742-481X.2011.00851.xDOI Listing
April 2012

Beyond consent--improving understanding in surgical patients.

Am J Surg 2012 Jan 8;203(1):112-20. Epub 2011 Jun 8.

Department of Surgery, Adelaide and Meath Hospital, Tallaght, Dublin 24, Ireland.

Background: Little is known of the actual understanding that underlies patient choices with regard to their surgical treatment. This review explores current knowledge of patient understanding and techniques that may be used to improve this understanding.

Methods: MEDLINE and PubMed were searched using the terms "patient understanding," "patient comprehension," "consent," "video," "multimedia," "patient information leaflet," "internet," "test-feedback," "extended discussion," "shared decision making," and "decision aid." All retrieved peer-reviewed studies were included in the review.

Results: Understanding in surgical patients is poor. There is little evidence to support the use of information leaflets, although multimedia appears to be effective in improving patient understanding. The internet is not used effectively as an aid to consent by health care providers. Patients with lower educational levels may gain most from additional interventions. Improving patient understanding does not impact on their satisfaction with the treatment they have received but may reduce periprocedural anxiety.

Conclusions: There is a need for greater awareness of patients' information needs, and novel approaches that may enhance decision making through improved understanding are required.
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http://dx.doi.org/10.1016/j.amjsurg.2010.12.010DOI Listing
January 2012

Enhanced ex vivo inhibition of platelet function following addition of dipyridamole to aspirin after transient ischaemic attack or ischaemic stroke: first results from the TRinity AntiPlatelet responsiveness (TrAP) study.

Br J Haematol 2011 Mar 12;152(5):640-7. Epub 2011 Jan 12.

Department of Neurology, The Adelaide and Meath Hospital/National Children's Hospital, Tallaght, Dublin, UK.

Ex vivo dipyridamole 'non-responsiveness' has not been extensively studied in ischaemic cerebrovascular disease. Platelet surface marker expression, leucocyte-platelet complex formation and inhibition of platelet function at high shear stress as detected by the PFA-100® Collagen-Adenosine-diphosphate (C-ADP) and Collagen-Epinephrine cartridges was assessed in 52 patients within 4 weeks of transient ischaemic attack (TIA) or ischaemic stroke on aspirin, and then 14 d (14 d) and >90 d (90 d) after adding dipyridamole. A novel definition of 'Dipyridamole non-responsiveness' was used. The median C-ADP closure time increased following addition of dipyridamole, remained elevated at 90 d (P ≤ 0·03), and was unaffected by aspirin dose. 59% at 14 d and 56% at 90 d were 'dipyridamole non-responders' on the PFA-100. The proportion of non-responders at 14 and 90 d was similar (P= 0·9). Compared with baseline (4·6%), median monocyte-platelet complexes increased at 14 d (5·0%, P= 0·03) and 90 d (4·9%, P= 0·04). Low C-ADP closure times were associated with increased monocyte-platelet complexes at 14 d (r= -0·32, P= 0·02) and 90 d (r= -0·33, P = 0·02). Monocyte-platelet complexes increased in the subgroup of dipyridamole non-responders on the PFA-100 (P≤ 0·045), but not in responders (P ≥ 0·5), at 14 and 90 d versus baseline. Additional inhibition of platelet function has been detected with the PFA-100 when dipyridamole is added to aspirin. Elevated monocyte-platelet complexes may contribute to ex vivo dipyridamole non-responsiveness.
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http://dx.doi.org/10.1111/j.1365-2141.2010.08539.xDOI Listing
March 2011