National scientific medical meeting 1997 abstracts

NATIONAL SCIENTIFIC MEDICAL MEETING 1997

Abstracts

PLENARY SESSION N E U R O L O G Y / N E U R O S C I E N C E S

(0.2) HUMAN MONOCLONAL ANTI-GM~ GANGLIOSIDE ANTIBODIES CROSS REACT WITH LPS OF

CAMPYLOBACTER JEJUNI STRAINS WITH GBS

M. M. Prendergast*, H. J. Willison, A. J. Lastovica, A. P. Moran*.

*Department of Microbiology, National University of Ireland, Galway, Ireland.

Antibodies reactive with GM~ ganglioside and structurally related glycolipids are frequently observed in the serum of patients with peripheral neuropathies. The precise relationship between these ant i -gangl ios ide ant ibodies and disease pathogenesis remains unknown. However, antecedent infection with certain strains of Campylobacterjejuni has been associated with the development of Guillain-Barre syndrome (GBS). Evidence suggests that anti-ganglioside antibodies arise as a result of molecular mimicry between certain gangliosides and structurally related lipopolysaccharides (LPS) of C. jejuni strains. Using thin-layer chromatography overlay, we tested the reactivity of 4 human anti-GM 1 IgM monoclonal antibodies (Mabs), cloned from multifocal motor neuropathy patients, with phenol-water extracted LPS from GBS-associated C. jejuni isolates. The aim was to determine whether the bacterial LPSs and GM~ ganglioside shared epitopes. The Mabs all reacted with GM~ and reacted to different degrees with 8 C. jejuni LPSs tested. Differences in the fine specificities of the Mabs were observed. Furthermore, the antibody reactions indicated the presence of GM~-like sub-epitopes in the C. jejuni LPSs. Cholera toxin, a GM~ ligand, blocked the binding of the Mabs to GM, ganglioside but also to the previously reactive C. jejuni LPSs. Collectively, these results show the presence of shared sub- epitopes between C. jejuni LPSs and GM~ ganglioside, but also indicate variation between C. jejuni strains in their expression of the epitope.

(0.3) TESTING A NEW TECHNIQUE TO DETERMINE VISUAL ACUITY IN CHILDREN

C. Walsh, I. Flitcroft, P. Eustace. Institute of Ophthalmology, 60 Eccles Street, Dublin 7.

Measurement of visual acuity in young children is the most important part of their ophthalmological assessment. It is difficult because of problems with comprehension and co- operation. There are multiple methods to test visual acuity in children, none of which are perfect. One method is to use the spot target of the Catford Drum. The Catford Drum is easy to use and requires little co-operation from the children, but it was found to be inaccurate and to over-estimate acuity. The aim of this experiment is to keep the advantages and improve on the disadvantages of the Catford Drum. The spot target is replaced by a computer-generated Gabor-Funct ion grating target. Detection of the grating target does not occur unless the target is in focus.

Emmetropes and Myopes were tested in this trial and I compared their visibility of the grating targets with subjective Snellen Acuity. A close correlation was found between Snellen Acuity and target detection indicating that this method will be of benefit in the measurement of visual acuity in young children.

(0.4) SEVERE INHERITED COAGULOPATHY IN CHILDREN: RECENT ADVANCES IN MANAGEMENT

C. McMahon*, J. Smith*, G. Lakshmandass ~ O. P. Smith*. Department of Paediatric Haematology* and Paediatric

Surgery ~ National Children's Hospital, Harcourt St., Dublin 2.

Children with severe inherited coagulopathy due to factor VIII and IX deficiency develop spontaneous haemarthroses early in life leading to significant arthropathy before the teenage yrs. Those with factor X deficiency may develop intracranial bleeds or haemarthrosis resulting in a lifetime of disability.

Prophylactic factor replacement can favourably alter the development of these conditions when commenced early in life. We have 29 children (24 with factor VIII deficiency, 2 factor IX and 3 factor X deficiency) on prophylaxis and have determined the success of the programme by the number of bleeds per yr pre-prophylaxis (40/yr) and post-prophylaxis (5/yr).

Regular venous access can be problematical in these young children, frequently leading to treatment failure. We routinely insert right atrial catheters (RAC) to overcome this problem. We have, to date, inserted 19 RACs in 13 children with no intra or post-operative bleeding or thrombotic episodes.

Some children will d.evelop antibodies (inhibitors) to factor concentrate. This has in the past had devastating consequences. Recently recombinant VIIa (rVIIa) has revolutionised treatment of these children. We have performed 5 operations under cover of rVlla with no bleeding problems and have successfully treated bleeds at home with rVlla. Two children with Inhibitors are now being treated with immune tolerance regimens designed to abolish the production of inhibitors.

(0.5) NATIONAL STUDY OF ASTHMA AND WHEEZE IN 121,000 SCHOOLCHILDREN

M. R. H. Taylor, C. V. Holland, D. Cox, B. Good. Departments of Paediatrics and Zoology (TCD) and The National Children's Hospital, Harcourt Street, Dublin 2.

A questionnaire survey of schoolchildren in all counties of the Republic of Ireland was undertaken to estimate the lifetime prevalence of asthma and the 12 month prevalence of wheeze. One hundred and twenty-one thousand 130 replies from children aged 3-19 yrs in 960 schools were analysed. The lifetime prevalence of asthma was 12.9 per cent and was more common in urban (14.3 per cent) than rural (11.0 per cent) children. The prevalence of wheeze was 14.9 per cent and was more common

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in urban ( 16.3 per cent) than rural (12.6 per cent) children. Both asthma (16.3 per cent) and wheeze (17.2 per cent) were commonest in Wicklow. The countries with the highest asthma prevalence were Wicklow, Cork, Dublin and Galway, and of wheeze Wicklow, Dublin, Cork, and Waterford in that order. Asthma was least common in Donegal (10.0 per cent), and wheeze in Leitrim (10.8%). Logistic regression analysis showed a strong relationship between wheeze and males, a history of geophagia, urban living, and county of residence. There was a weaker association with dog ownership but with no other pet. We have previously reported a rise in asthma prevalence from 4.4 per cent in 1983-4 to 11.9 per cent in 1992-3. The present study shows a continuation in the rise of asthma prevalence and a variation across the country which has not previously been reported.

(0.6) IDENTIFICATION OF THREE GENETIC SUSCEPTIBILITY LOCI FOR HUMAN SLE ON

CHROMOSOME 1

G. M. Kearns, P. Gaffney, K. Shark, M. Frauenshuh, W. Ortmann, R. Messner, R. King, S. Rich,* T. Behrens.

University of Minnesota Medical School, and *Bowman Gray Medical School, U.S.A.

Systemic lupus erythematosus (SLE) is an autoimmune disease of unknown etiology. Family and twin studies strongly suggest a genetic component to the disease. In order to identify genetic susceptibility loci for SLE, we are performing a genome- wide screen on a large, well-characterised cohort of sibling pair families with SLE, using analysis of microsatellite markers. Here we report the results of a 26 marker screen of chromosome 1 in 105 SLE sibling pair families (372 individuals with 114 evaluable affected sibling pairs). All patients fulfill the 1982 ACR revised criteria for SLE. Patient DNA was amplified uti l ising PCR with fluorescent primers, and analysed on automated sequencing gels. Using the GENEHUNTER analytical package for multipoint mapping of affected relative pairs, 3 distinct candidate SLE susceptibility loci were identified on chromosome 1. The first region corresponds to cytogenetic position lp36 with a non-parametric lod (NPL) score of 2.52 (p=0.0056). The second region includes the centromeric region and a portion of the proximal long arm including lq20, with a NPL of 2.38 (p=0.0084). The third region maps to 1q41-42, NPL=l.82 (p=0.03). These results suggest several potential susceptibility loci for SLE on chromosome 1.

REGISTRAR'S PRIZE G A S T R O E N T E R O L O G Y

(0.7) HOMOZYGOSITY FOR METHYLENE REDUCTASE C677T VARIANT IS ASSOCIATED WITH LOW FOLATE AND HYPERHOMOCYSTEINAEMIA INFLAMMATORY BOWEL DISEASE PATIENTS: IMPORTANT CLINICAL

IMPLICATIONS

N. Mahmud, A. Molloy, J. McPartlin, J. M. Scott, D. G. Weir. Departments of Clinical Medicine and Biochemistry, Trinity

College and St. James's Hospital. Dublin.

The pathogenetic mechanisms underlying the increased incidence of thrombo-embolic events in inflammatory bowel disease (IBD) is still poorly understood. Hyperhomo-

cysteinaemia is now known to be associated with an increased thromboembolic events. Raised tHcy could be the cause of such complications in patients with IBD. We studied plasma homocysteine levels and its relationship with serum and red cell folate serum vitamin BI2 in IBD patients and to the presence or absence of the 5-10 thermolabile methylenetetrahydrofolalte reductase (MTHFR C677T) genotype.

We studied 163 patients with established IBD [ulcerative colitis (n=87): Crohn's disease (n=76)]. DNA samples were genotyped for the MTHFR (C677T) mutation by PCR and restriction analysis in IBD patients and age and sex matched healthy controls.

Seventeen point 5 per cent of the IBD patients were homozygous (q~I') for MTHFR (C677T) variant compared to healthy controls 8.7 per cent: Odds Ratio=2.01:95 per cent C1 0.68 to 4.05: p=0.04. Plasma tHcy levels were significantly higher in IBD patients who were TT homozygous compared to (CT) heterozygous [mean + SE (~tmol L): 14.86 + 2.17 vs 9.99 + 0.48: p<0.002] and (CC) wild-type homozygous (10.02 + 0.95: p<0.05). The mean red-cell folate and serum vit BI2 levels in IBD patients were lower in TT homozygous variant compared to CT heterozygous or CC wild-type. The homozygous state of the MTHFR (C677T) variant and hyperhomocysteinaemia was not associated with the type of IBD severity, extent or longevity of the disease.

Conclusions: The C677T variant of MTHFR in our patients with IBD is associated with significantly higher tHcy and lower folate and vit Bt2 levels in the TT carriers. The raised tHcy found in this study would appear to be an excellent candidate to explain the presence of these complications in IBD. We believe that all IBD patients should receive low dose folic acid therapy to protect them from the thrombo-embolic complication of raised tHcy.

(0.9) VIRAL KINETICS TO PREDICT EARLY RESPONSE TO ALPHA INTERFERON IN CHRONIC HEPATITIS C

K. M. Walsh, *T. Good, *S. Cameron, D. Thorburn, *E. A. B. McCruden, P. Mills, A. J. Morris.

Departments of *Virology and Gastroenterology, University of Glasgow.

NIH guidelines advise qualitative assessment of hepatitis C virus RNA (HCV RNA) by RT-PCR after 12 weeks interferon therapy. Only PCR negative patients should continue therapy. Earlier assessment of efficacy would reduce the need for prolonged therapy.

The aim of the study was to determine if change in quantitative HCV titre at 4 weeks can predict outcome of interferon therapy earlier than after the standard 12 weeks.

HCV RNA titres were quantified using branched chain DNA (bDNA) assay in 26 responders to interferon (RT-PCR negative after 12 weeks) and 11 matched non-responders. All 37 patients were RT-PCR positive pre-therapy and received alpha interferon 6 m.i.u thrice weekly for 12 weeks. Quantitative HCV RNA titres and qualitative RT-PCR for HCV RNA were measured pre-therapy and at 4 weeks. The change in quantitative HCV RNA titre between pre-therapy and after 4 weeks was compared in the 2 groups.

Seventeen of the 26 responders had become RT-PCR negative at 4 weeks (early responders), of the 9 delayed responders (RT- PCR positive at 4 weeks but negative by 12 weeks), 8 had an undetectable quantitative HCV RNA titre at 4 weeks. The other patient was RT-PCR negative at 12 weeks but became RT-PCR

IJ.M.S. National Scientif ic Medical Meet ing 3 April, May, June 1998

positive again at 24 weeks despite continuing interferon therapy. In contrast all the non-responders still had a detectable quantitative titre at 4 weeks.

Conclusion: Change in quantitative HCV RNA titre at 4 weeks predicts early response to interferon allowing early cessation of treatment in non-responders.

I M M U N O L O G Y

(O.10) APOPTOTIC DEPLETION OF TUMOR- INFILTRATING LYMPHOCYTESB ASSOCIATED WITH

FAS LIGAND EXPRESSION BY HUMAN OESOPHAGEAL CARCINOMA

M. W. Bennett*, J. O'Connell*, G. C. O'Sullivan'l, C. Brady*, D.Roche*, J. K.Collins*,

F. Shanahan*. *Department of Medicine, Cork University Hospital, National

University of Ireland, Cork and 1"Department of Surgery, Mercy Hospital, National University of Ireland, Cork.

Various cancer cell lines express Fas ligand (FasL) and can kill lymphoid cells by Fas-mediated apoptosis in vitro. FasL expression has been demonstra ted in several human malignancies. We sought to determine if human oesophageal carcinomas express FasL, and whether FasL expression is associated with increased apoptosis of tumor-infiltrating lymphocytes (TIL) in vivo, thereby contributing to tumour immune pr ivi lege. Using in s i tu hybr id iza t ion and immunohistochemistry respectively, FasL mRNA and protein were colocalized to neoplastic oesophageal epithelial ceils in all oesophageal carcinomas (squamous, n=6; adenocarcinoma, n=2). FasL expression was variable, with both FasL-positive and -negative neoplastic regions occuring within tumors. TIL were detected by immunohistochemical staining for leukocyte common antigen; CD45. FasL expression was associated with a mean four-fold depletion of TIL when compared with FasL- negative areas within the same tumors (range 1.6-12.0-fold, n=6 p<0.05). Cell death of TIL was detected by dual staining of CD45 (immunohistochemistry) and DNA strand breaks (TUNEL, terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling). There was a mean two-fold increase in cell death among TIL in FasL-positive areas compared to FasL-negative areas (range 1.6-2.4-fold, n=6, p<0.05).

In conclusion, we demonstrate a statistically significant, quantitative reduction of TIL concomitant with signilicantly increased TIL apoptosis within FasL-expressing areas of oesophageal tumours. Our findings provide the first direct, quantitative evidence to support the "Fas counterattack" as a mechanism of immune privilege in vivo in human cancer.

R E S P I R A T O R Y

(O.11) MATRIX METALLOPROTEINASES AND THEIR INHIBITOR IN THE DEVELOPMENT OF PULMONARY

FIBROSIS

M. Henry, S. Koston, K. McMahon, W. MacNee, M. X. FitzGerald, C. M. O'Connor,

Department of Medicine and Therapeutics/Lung Fibrosis Unit, University College Dublin.

The development of pulmonary fibrosis is thought to reflect an aberrant response to wound healing within the extracellular

matrix (ECM). Matrix metalloproteinases (MMPs) are a group of proteases which can cleave most of the constituents of the ECM, Elevated levels of collagenase in BALF of sarcoidosis patients have previously been shown to indicate those patients who will subsequently need treatment. The aims of this study are (a) to determine whether neutrophil collagenase (MMP-8) or inters t i t ia l col lagenase (MMP-1) is responsible for collagenolytic activity associated with the evolution of pulmonary fibrosis, (b) to assess the role of gelatinase B (MMP- 9) in the pathogenesis of pulmonary fibrosis and (c) to investigate the role that the natural inhibitor of metalloproteinase activity (TIMP) may play in the development of pulmonary fibrosis. We evaluated BALF of 16 stage 1 sarcoidosis, 14 stage 2 sarcoidosis, 14 stage 3/4 sarcoidosis patients, 15 idiopathic pulmonary fibrosis (IPF) patients and 15 control subjects. Each sample was assayed for the following: collagenase and gelatinase activity along with MMP-1,-8,-9 and T1MP-1 protein levels using a newly available ELISA assay.

Results. Table I. p<O.Ol* p<O.O01** p<O.O001*** Mean~.+SEM Controls Sarcoid Sarcoid Sarcoid I.P.F.

Stage 1 Stage 2 Stage 3/4 Collagenase 0 16.73+5. 19.67+7.3 81.0+18.3 79.7+27.7 mU/ml *** *** *** ***

MMP-8 0.03_+0.01 1.66_+0.18 1.13_+0.54 10.6+3.57 13.8+6.32 ng/ml ** * *** **

GelatinaseB 6.67+6.67 71.0-226.6 60.7+_13.8 164.6+_33 196.4+64 U/ml * * *** ***

MMP-9 3.18_+0.88 3.95+1.6 4.62+_1.5 18.54+6.0 40.1+26.7 ngJml

TIMP-1 33.11+_3.4 7.6+_1.12 16.48+_1.6 33.86_+5.3 43.29_+5.2 ng/ml *** **

Our results demonstrate that neutrophil collagenase and gelatinase B are involved in the gradual progression to pulmonary fibrosis in sarcoidosis/I.RF. Increasing levels of TIMP may an attempt to control rising levels of gelatinase B activity.

Abstract funded by: EU-Biomed 2/Urolung project.

R H E U M A T O L O G Y & R E H A B I L I T A T I O N

(o.12) A NEW PATHOLOGICAL CLASSIFICATION OF EARLY ARTHRITIS WITH PROGNOSTIC IMPLICATIONS

D. McGonagle, W. Gibbon, P. O'Connor, R Emery. Department of Rheumatology, 36 Clarendon Road, The

University of Leeds, LS2 9NZ

The aim of the study was to use magnetic resonance imaging (MRI) in early arthritis to test the hypothesis that early synovitis could be classified as either primarily synovial based or joint capsule/enthesis associated.

Knee MRI using a 1.5T scanner was performed in 30 patients (17 early spondyloarthropathy (SPA) and 13 early RA, MR1 of the hand was performed in early RA patients (25), early SpA (11), benign polyarthritis (7) and 3 3 normal controls. 14 patients with PMR and 12 with RA had MRI of the shoulder performed (20 and 16 shoulder joints respectively). Scans were assessed blindly by 2 radiologists for sites of bone and soft tissue change.

Sixteen of 17 patients with early SpA knee disease but only 4/13 early RA had abnormalities at the joint capsule (p=0.002). Ten patients with SpA but only 1 RA patient had knee capsule associated bone oedema (p=0.01). In the hand, only 5 patients with RA had soft tissue oedema prominent outside the joint cavity but 6/7 of the benign polyarthritis group (p=0.01) and 6/

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10 patients with SpA had oedema at the joint capsule. 12/25 RA patients had bone oedema within the joint cavity but this was seen in only 2 patients from the non RA groups (p=0.03). Four patients (2 SpA, 2 benign arthritis) but no RA patients had capsular bone oedema (p=0.04). Ten of 20 shoulder scans performed in PMR, but only 2/16 in RA, showed soft tissue oedema outside the synovial cavity, related to the capsule (p= 0.03).

Conclusions: In comparison to RA, the prognosis of SpA, PMR and benign polyarthritis is generally good. The common pattern of capsular associated disease in the latter arthropathies suggests a new classification of arthritis as either primarily intrasynovial (RA-like; poor prognosis) or primarily capsular associated (SpA-like; good prognosis).

POSTER PRESENTATIONS D E R M A T O L O G Y

(P.1) PYODERMA GANGRENOSUM - ADJUNCTIVE TREATMENT WITH SPLIT SKIN GRAFTS

M. Murphy. E. Casey*, E. Naidu*, R. Watson. Departments of Dermatology, Rheumatology* and Plastic

Surgery**, St. James's Hospital, Dublin.

Skin grafting for the ulcers of pyoderma gangrenosum (PG) has not been recommended due to the risk of pathergy.

We report a 65 yr old woman with seronegative rheumatoid arthritis who suffered 2 episodes of pyoderma gangrenosum (PG). On the first occasion she developed 2 painful ulcerated areas on her lower limbs. She was initially treated with prednisolone and cyclosporin. This brought about considerable improvement in the inflammatory component of the ulcers but they were slow to heal, requiring 6 weeks hospitalisation and 4 further months of dressings. Two yr after the initial episode of PG she presented again with more extensive rapid ulceration. Predniso lone and cyc lospor in were introduced. The inflammatory component resolved but the patient was left with four painful deep ulcerated areas, 1 of which extended to tendon fascia. Split skin grafting was performed. Review at 1 month showed complete healing of the ulcers and the patient had regained full independence.

This report illustrates that split skin grafting may have a role to play in the treatment of PG. When the inflammatory component has been controlled by immunosuppressive therapy, deep ulcerated areas may remain. Treatment of these with split skin grafting in our patient's case lead to a shorter in-patient stay and a marked reduction in morbidity.

(P.2) GREEN FINGERS

M. Murphy +, S. McCann*, R. Watson +, L. Barnes +. Departments of Dermatology+ and Oncology*, St. James's

Hospital, Dublin.

The dermatology department was consulted regarding a 50 yr old female inpatient with a 2 day history of a rash on her hands and feet. She had 2 weeks previously, following priming with busulphan, received a bone marrow transplant for chronic myeloid leukaemia. One day post transplantation she developed

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a pyrexia and her liver function tests were noted to be elevated. Her bilirubin continued to rise reaching a maximum of 107 mmols/1 (normal 1-17) 4 days before the appearance of the rash.

On examination erythematous plaques were noted on the dorsa of both hands and feet. Superimposed on the plaques were green patches which appeared vesicular. Flecks of green were noted on the creases of the palms and soles and around the nail cuticles.

Histology of the skin lesions showed individual cell necrosis and abnormal cell nuclei of the sweat glands consistent with chemotherapy induced acral erythema. The proposed mechanism for this is high fever and sweating leading to increased delivery of water-soluble bilirubin to the sweat glands where it is deposited in the horny layer and oxidised to green-coloured biliverdin.

Cutaneous green pigment is rarely encountered in practice. It can occur in association with chloroma, pseudomonas infection and Well's syndrome. There have been a few reports of green pigment occurring with hyperbilirubinemia I but, to our knowledge, it has not been reported in association with acral erythema previously.

Reference 1. Kanzaki, T., Tsuda, J. Bile pigment deposition at sweat pores of patients with liver disease. J. Am. Acad. Dermatol. 1992; 26: 655-6.

(P.3) SEBORRHOEIC KERATOSES IN A DERMATOLOGY CLINIC: REASONS FOR PRESENTATION AND

ACCURACY OF DIAGNOSIS

M. Murphy, R. Watson, E. Sweeney*, L. Barnes. Departments of Histopathology* and Dermatology, St.

James's Hospital, Dublin.

Seborrhoeic keratoses (SK) are a frequent cause for presentation at dermatology clinics. The vast majority of patients presenting with SKs simply require reassurance or if requested, cryotherapy or curettage. Diagnostic accuracy is therefore essential. All previous studies of diagnostic accuracy in SKs have been retrospective and based on histological databases. Diagnostic accuracy of dermatologists has been found to be 61 per cent and 66 per cent by studies using these methods.

In this study we altered our clinical practice and sought to biopsy all consecutive patients who presented with what appeared clinically to be banal SKs. A total of 115 patients were seen over a 7 month period. Details of the lesions and the referring doctors' diagnoses were noted. Over 80 per cent of the lesions were <l.5cm in diameter and 76 per cent were noted to be highly pigmented. A history of change was reported by 72 (62 per cent) of patients. Thus it would appear that smaller, more pigmented, changing lesions are more likely to lead to a referral. Only 15 (13 per cent) of referrals from GPs were accompanied by a letter with an accurate diagnosis. Of the 103 lesions biopsied, 101 were confirmed histologically to be SKs, 1 specimen contained just keratin and 1 lesion was a SCC in situ. The diagnostic accuracy at the dermatology clinic was therefore greater than 98 per cent. This study, unlike other studies was a prospective one and showed an high diagnostic accuracy for dermatologists and thus justifies the common clinical practice of merely reassuring patients or of employing a destructive method of removal once a confident clinical diagnosis of SK is made. A biopsy should be performed in cases where there is any diagnostic doubt.

I.J.M.S, April, May, June 1998

E N D O C R I N O L O G Y (P.4) EXTERNAL QUALITY ASSESSMENT OF HbA1 c

MEASUREMENT IN IRISH HOSPITAL LABORATORIES

E. J. Barrett, H. Graham*. Clinical Biochemistry Laboratory, Regional General Hospital, Dooradoyle, Limerick and *Irish External Quality Assessment

Scheme, P.O. Box 4157, Dublin 14.

The Diabetes Control and Complications Trial (DCCT) confirmed the direct relationship between blood glucose control, as measured by HbAlc, and the risk of developing the longterm complications of Type 1 diabetes. Difficulties in the measurement of HbAlc have been compounded by the variety of analytical techniques, the analytical variation inherent in these methods, the variation between laboratories and the lack of international standardisation.

The Irish External Quality Assessment Scheme (IEQAS) has commenced a detailed evaluation of the status of HbAlc measurement in Irish hospital laboratories with a particular emphasis on the standard of performance required to support intensive diabetes management.

Thirteen hospital laboratories have participated in the study. Blood specimens are provided by a panel of volunteer donors, formed in partnership with the Irish Diabetes Federation. Five different analytical techniques are in use by the participating laboratories. The majority of participants have exceeded the maximum analytical error of 2.1 per cent recommended by IEQAS. Some methods in use do not support transfer of results from laboratory to laboratory.

The analytical performance of HbAlc assay requires improvement in the majority of participating laboratories. There is need for on-going external quality assessment and the adoption of agreed reference ranges and target values.

(P.5) EMBOLISATION OF CARCINOID TUMOURS RESULTS IN ALTERED POST-TRANSLATIONAL

PROCESSING OF CHROMOGRANIN A

R. T. Cunningham, C. E Johnston, W. J. Curry, K. D. Buchanan.

Department of Medicine, The Queen's University, Belfast.

Chromogranin A (CgA) is a recognised gold standard for the identification of neuroendocrine tumours including the so-called 'silent tumours' which are not associated with any known bioactive peptide. The protein has a number of highly conserved dibasic residues and a number of bioactive peptides are generated by proteolysis at these sites. One such peptide is vasostatin (VST), an inhibitor of vasoconstriction. A radioimmunoassay was developed to a fragment of VST. Plasma was collected from a patient with a carcinoid tumour pre- and post- embolisation and this was subjected to chromatography on Sephadex G-150. Fractions collected were analysed for VST-immunoreactivity (IR). A dramatic difference was recorded in the elution profiles as determined by VST-IR with an increase in circulating whole molecule CgA after embolisation. This may reflect total cell lysis with a sudden release of all CgA, Pre-embolisation, there appeared tobe little whole molecule CgA but a large peak of IR corresponding to a molecular weight of approximately 40kD. This may represent partially-processed CgA which has been secreted by the tumour cells.

National Scientific Medical Meeting 5

(P.6) SYNACTHEN TESTING COMPARED WITH INSULIN TOLERANCE TESTING IN EARLY POSTHYPOPHYSECTOMY ASSESSMENT

C. H. Courtney, A, S. McAllister, D. R. McCance, D. R. Hadden, E M. Bell, H. Leslie, B. Sheridan, A. B. Atkinson.

Sir George E Clark Metabolic Unit, Royal Victoria Hospital, Grosvernor Road, Belfast,BT12 6BA.

The insulin tolerance test (ITT) remains the gold standard for determining the integrity of the hypothalamic-pituitary- adrenal axis but has certain limitations, The standard dose short synacthen (250ktg) (SDS), and more recently low dose (l~tg) (LDS) synacthen test have been suggested as indirect alternatives. Preliminary reports indicate that the LDS is more sensitive and specific than the SDS but there is concern over the validity of both tests in the early post-operative period.

Twenty-four patients (age 29-65; 11M/13F) underwent assessment with all 3 tests 4 to 6 weeks after transsphenoidal hypophysectomy (Cushing's disease excluded). A peak cortisol of 550 nmol/l during ITT was considered normal. Normal ranges for the synacthen tests (30 min cortisol) were derived from 16 normal controls (8M/SF): LDS >494 nmol/1; SDS >504 nmol/1 (mean _+ 2SD).

Nineteen patients had a normal cortisol response to ITT. Two of these had a subnormal response to the SDS, and l of the same patients to the LDS. Of the 5 with an inadequate response to ITT, 4 had a subnormal response to the SDS, and 3 to the LDS. The predictive value of the SDS to identify a normal pituitary-adrenal axis is 94.4 per cent with a sensitivity of 89.5 per cent and a specificity of 80 per cent. Likewise the LDS has a predictive value of 90 per cent with a sensitivity of 94.4 per cent and specificity of 60 per cent.

In summary, both the standard and low dose synacthen tests will in some cases incorrectly categorise the integrity of the hypothalamic-pituitary-adrenal axis in patients after pituitary surgery. The low dose synacthen test offered no advantage over the standard dose in this setting.

(P.7) IDENTIFICATION OF A THYROID PEROXIDASE IN THE HUMAN BREAST

M. T. Kilbane, D. E Smith, M. J. Murray, S. G. Shering, E. W. M. McDermott, N. J. O'Higgins, E E A. Smyth.

Endocrine Laboratory, Department of Medicine and Therapeutics, Department of Surgery (St. Vincent's Hospital),

University College Dublin,

Circulating autoantibodies to Thyroid Peroxidase (TPO. Ab) have been described in serum from patients with breast carcinoma asymptomatic for thyroid disease. The underlying cause for this association remains unknown but recent studies using a specific radioimmunossay have demonstrated the presence of TPO in human breast tissue. In order to confirm that the detection of TPO protein truly reflected its localization in the breast, TPO mRNA expression was investigated in extracts of human breast tissue. Total RNA was isolated from freshly frozen breast tumours by simple single step guandine thiocyanate based lysis procedures. RNA preparations from thyroid tissues similarly prepared served as positive controls. Fragments were separated on a 2 per cent agarose gel. Bands corresponding to the full length TPO transcript (472 bp) as well as the 342 bp fragment resulting from alternative splicing at exon 16 were found to be present in 7/9 breast cancer tissues studied. Both


forms of TPO were expressed in mRNA extracts prepared from 2 thyroid specimens. These studies represents the first demonstration of extrathyroidal TPO expression and suggest a pathway for iodide organification in the breast which is supportive of the hypothesis that elemental 12 plays a role in the control of breast tumour growth. In addition TPO expression in the human breast may, in part, offer an explanation for the presence of circulating TPO.Ab in patients asymptomatic for thyroid disease.

(P,8) RAPID ISOLATION OF VLDL SUBFRACTIONS: COMPOSITION AND SUSCEPTIBILITY TO COPPER

MEDIATED OXIDATION

J. McEneny, E. R. Trimble, I. S. Young. Cardiovascular Research Group, School of Clinical Medicine,

The Queen's University of Belfast and the Royal Group. of Hospitals, Belfast.

The dyslipidaemia associated with diabetes and renal failure is characterised by elevated levels of VLDL cholesterol. Lipoprotein oxidation is known to be an important early stage in atherogenesis; LDL oxidation has been extensively studied, but little information is available with regard to VLDL oxidation. We have therefore developed a rapid ultracentrifugation method which enables us to isolate 4 subfractions of VLDL in less than 3.5 h. Application to healthy subjects (n=6) indicated that subfraction A, the largest VLDL, was triglyceride rich and cholesterol depleted when compared with the other subfractions; Subfraction A 84 per cent (+ 2.2) trig/16 per cent (+ 2.2) chol: Subfraction B 77 per cent (+ 1.3) trig/23 per cent (+ 1.3) chol: Subfraction C 74 per cent (+ 1.0) trig/26 per cent (+ 1.0) chol: Subfraction D 64 per cent (+ 3.8) trig/36 per cent (+ 3.8) chol. Subfraction A was also the most resistant to copper mediated oxidation, as measured by the lag time prior to the onset of conjugated diene format ion. Subfract ion A 227 rain*: subfraction B 180 min: subfraction C 180 min: subfraction D 177 min (*p<0.05). However, subfraction A also had the greatest capacity to produce conjugated dienes as measured by the change in absorbance at 234nm; Subfraction A 0.280nm* (+ 0.04); subfraction B 0.204nm(+ 0.03); subfraction C 0.201nm (+ 0.03); subfraction D 0.194mn (+ 0.03) (p<0.05). Therefore although subfraction A is the most resistant to oxidation, once oxidised it has the potential to produce a more atherogenic particle. This methodology may be applied to patient groups with known hypertriglyceridaemia and premature atherosclerosis enabling detection of changes in the subfraction profile and the susceptibility of VLDL to oxidation.

(P.9) EFFECTS OF MODERATE CONSUMPTION OF RED WINE OR VODKA ON SERUM LIPIDS AND

APOLIPOPROTEINS

P Sharpe, C. Mercer, D. McMaster, I. S. Young, A. E. Evans. Cardiovascular Research Group, School of Clinical Medicine,

The Queen's University of Belfast and The Royal Group of Hospitals, Belfast.

Moderate alcohol consumption is associated with a reduced risk of cardiovascular disease. However, it is not known whether all types of alcoholic drink are equally beneficial. Fifty men


participated in a crossover trial comparing the effects of 3 units of red wine or vodka per day for 2 weeks on serum lipids. Each period of alcohol consumption was preceded by a 2 week alcohol free period.

Vodka Red wine

Before After Before After Chol 5.14 (0.17) 5.32 (0.17)* 5.21 (0.16) 5.34 (0.16) HDL 1.15 (0.04) 1.19 (0.04)* 1.15 (0.03) 1.18 (0.04) LDL 3.38 (0.16) 3.46 (0.16) 3.44 (0.14) 3.53 (0.15) Trigs 1.35 (0.10) 1.47 (0.12) 1.33 (0.08) 1.41 (0.10) Apo A1 143.7 (2.6) 156.4 (2.9)* 148.0 (2.4) 154.5 (3.1)* Apo A2 40.3 (0.9) 43.4 (1.1)* 41.4(0.8) 42.7(1.0) Apo B 104.0 (4.0) 111.2 (4.0)* 105.6 (3.4) 109.8 (3.7)* Lp (a) 15.3 13.5" 15.1 13.6" (geom mean)

Results expressed as mean (SEM), n=50. *p<0.05

Both drinks produced modest rises in apoA1, apoB and a fall in Lp(a). Vodka alone gave a small rise in total cholesterol, apoA2 and HDL, but overall there was little evidenee of differenees between the 2 forms of alcohol. These results suggest that moderate consumption of either red wine or vodka produces mainly beneficial ehanges in serum lipids and apolipoproteins.

(P.10) CHANGES IN PARAOXONASE ACTIVITY FOLLOWING WEIGHT REDUCTION ARE INFLUENCED

BY PARAOXONASE GENOTYPE

I. S. Young, J. Cundick, O. Hasselwander, D. McMaster, J. McGeough, D. Savage, A. P. Maxwell, A. E. Evans, F. Kee.

Cardiovascular Research Group, School of Clinical Medicine, The Queen's University of Belfast and the Royal Group of

Hospitals, Belfast.

Paraoxonase is an A-esterase closely associated with an HDL population also containing apoJ (clusterin). Recent evidence indicates that paraoxonase is a major contributor to the antioxidant properties of HDL and may hence help to protect against cardiovascular disease. The aim of this study was to assess the effect of weight reduction on paraoxonase activity in overweight subjects with hypercholesterolaemia. Subjects (n=96) with a BMI > 27.0 kg/m 2 and serum cholesterol >7.0 retool/1 were put on a low fat diet with a target weight loss of 10 per cent over a 3 month period. Diet was associated with a significant reduction in total cholesterol, LDL cholesterol, VLDL cholesterol, HDL cholesterol, triglycerides, apoA, and apoB, and a small but significant rise in Lp(a). Paraoxonase activity fell significantly following diet, although this change disappeared after correction for the fall in HDL. Subjects were also genotyped for the 192 and 55 polymorphisms in the paraoxonase gene. Both polymorphisms had signif icant associations with paraoxonase activity, with the Q/R (192) and L/M (55) alleles associated with increased activity. In the case of arylesterase activity, genotype for the 192 polymorphism was significantly associated with change in activity following diet, with a 6.5 per cent fall in activity for QQ, a 1.6 per cent fall for QR and a 5.3 per cent rise for RR. In conclusion therefore, weight loss in hyperlipidaemic individuals is associated with a fall in paraoxonase activity, and these results provide the first evidence for a possible interaction between paraoxonase genotype and an environmental factor.

I.J.M.S. April, May, June 1998

G A S T R O E N T E R O L O G Y

(P.11) POST-TRANSLATIONAL PROCESSING OF CHROMOGRANIN A

C. J. Larkin, R. G. P. Watson, C. Johnston, J. E. S. Ardill, K. D. Buchanan.

Department of Medicine, Queen's University, Belfast.

The primary source of circulating Chromogranin A (CgA) is from ECL cells. Plasma CgA and gastrin increase in ECL cell hyperplasia. CgA is a precursor of peptides including vasostatin, pancreastatin (PST) and WE-14. Carcinoid tumours display altered CgA processing, with increased expression of PST, vasostatin and WE-14. The aim was to investigate post- translational processing of CgA in ECL cell hyperplasia in the gastric corpus. Forty-two patients were recruited (36 on PPls and 6 with autoimmune gastritis).

Biopsies were taken at OGD. Immunocytochemistry was done with antisera to CgA and its fragments. Fasting serum gastrin was measured. Eighteen patients had normal ECL cells, 9 had simple hyperplasia, 9 had linear hyperplasia, and the 6 autoimmune subjects had micronodular hyperplasia. Mean gastrin was 66 ng/1 in the normals, 55 ng/1 in the simple and 178 ng/1 in the finear hyperplasia groups, and 1644 ng/1 in the micronodular group. CgA processing was minimal in normal and simple hyperplasia. It was increased in the linear and markedly so in the micronodular groups, with increased expression of PST and WE-14.

Thus, CgA processing is minimal in normal and simple ECL cell hyperplasia. In micronodular hyperplasia, processing is markedly increased and there is a significant increase in PST and WT-14 expression. This difference may be a reflection of underlying genetic differences in autoimmune gastritis.

(P.12) EVALUATION OF GASTRIC MOTILITY USING ELECTROGASTROGRAPHY

D. A. McNamara, T. N. Walsh, D. J. Bouchier-Hayes. RCSI Department of Surgery, Beaumont Hospital, Dublin.

Surface electrogastrography (EGG) is used to quantify propagation of the gastric slow wave. Recent developments have improved its diagnostic capabilities. Omeprazole has previously been shown to delay gastric emptying. The aim of this study was to assess the effect of omeprazole on EGG gastric motility patterns. Healthy adult volunteers were fasted for 12 h. Each volunteer acted as their own control to prevent variability due to gender and age. Baseline pre- and post-prandial EGG was performed, using an identical test meal (320 kCal) Omeprazole 20 mg/day was administered orally for 48 h. A second EGG was then performed. Data was analysed using the Synectics Medical microdigitrapper computer system with Gastrosoft software. The normal response to a meal (baseline EGG) was an increase in the frequency of the gastric slow wave, with a mean of 62.5 per cent of gastric contractions occurring at a frequency of<3 per minute prior to the meal whereas only 27.75 per cent of contractions following the meal were of this low frequency (p<0.05). In contrast, following omeprazole there was no significant difference between the percentage of pre-prandial (51.9 per cent) and post-prandial (55.6 per cent) waves of frequency <3 per minute. In conclusion, omeprazole impairs the normal, response of the slow gastric wave to a meal by preventing the increase in wave frequency which normally occurs. This may explain, in part, the means by which omeprazole delays gastric emptying.


(P.13) COMPARISON BETWEEN VIDEOFLUROSCOPY AND MILK-SWALLOW ENDOSCOPY IN THE ASSESSMENT OF SWALLOWING FUNCTION

C. Madden, C. Timon. Department of Otorhinolaryngology - Head and Neck

Surgery, St. James's Hospital, Dublin.

Aspiration is a major source of morbidity in patients with neurological disease or following head and neck surgery. The purpose of our study was to compare flexible nasendoscopy and videofluroscopy in the assessment of swallowing function. We also wished to determine if there were any prognostic factors seen at endoscopy that could predict swallowing outcome.

A pilot study of twelve sets of videofluroscopic and endoscopic assessments of swallowing function was carried out on a prospective basis over a 6 month period. The presence of laryngeal elevation, pooling, reflexive cough and aspiration was noted and compared on both types of assessment.

We found that videofluroscopy was more sensitive in assessing laryngeal elevation and in detecting the quality of the reflexive cough. Endoscopy was better able to assess the presence or absence of pooling and aspiration in our patients. The ability to assess subglottic sensation is only available at endoscopy and we found the presence of reduced or absent subglottic sensation was a poor prognostic factor in predicting swallowing outcome. This has not been noted in the literature before.

In conclusion, we feel that the 2 procedures are not exclusive but are in fact complementary.

H A E M A T O L O G Y

(P.14) MONITORING OF DONOR LEUKOCYTE INFUSION THERAPY FOR LEUKAEMIA RELAPSE POST

BONE MARROW TRANSPLANT

N. Gardiner, M. Lawler, J. O'Riordan, C. Duggan, S. R. McCann.

Department of Haematology, St. James's Hospital, Dublin.

Allogeneic Bone Marrow Transplantation (BMT) is the most successful treatment for chronic myeloid leukaemia (CML) however, a relapse rate of 10-15 per cent remains a clinical problem. It has been shown in CML that donor leucocyte infusions (DLI) mediate a graft versus leukaemia (GvL) effect which has been shown to induce haematological and molecular remission in patients with relapsed CML. The aims of this study included (i) establishing of the degree of chimaerism prior to DLI therapy, (ii) monitoring changes in chimaerism during the aplastic phase and (iii) identifying the earliest response indicator. We report on 4 patients who relapsed post BMT for chronic phase CML and were treated with DLI. At the time of relapse, short tandem repeat PCR (STR-PCR) indicated 1-40 per cent donor cells in all 4 patients. A clinical and molecular response was seen in 4/4 patients following a short period of cytopenia and all patients remain in clinical remission with a follow-up of 6 months-3 yr post DLI. Lineage specific STR-PCR of the cellular response to DLI indicated that a change in the ratio of donor: recipient ceils in the PB CD2 positive fraction was the earliest molecular indication of an anti-leukaemic response. Lineage specific STR-PCR permits detailed monitoring of subtle changes in donor/recipient cell dynamics following DLI during the crucial pancytopenic phase and is a useful predictor of haematological response to DLI therapy.


(P.15) CAN ULTRAVIOLET LIGHT PREVENT GRAFT- VERSUS-HOST DISEASE FOLLOWING ALLOGENEIC

BONE MARROW TRANSPLANTATION

H. Gowing, E. Braakman, M. Lawler, C. Byrne, A. C. M. Martens, A. Hagenbeek, S. R. McCann.

Department of Haematology, St. James's Hospital/TCD; Erasmus University, Rotterdam, The Netherlands.

A major complication when using al!ogeneic BMT for the treatment of leukemia is Graft-versus-Host Disease (GvHD) when donor T-cells mount an immune attack on "foreign" recipient tissue (skin, liver, gut). Removal of donor T cells from the graft prior to BMT can prevent GvHD but is associated with an increase in leukemia relapse, indicating that donor T- cells also mediate a graft-versus-leukaemia (GvL) effect. Ultraviolet-B (UVB) light is known to diminish T-lymphocyte activation in the skin. Therefore w e investigated the possibility of using UVB light to prevent GVHD, while maintaining the GvL activity of the T-cells. In vitro studies showed that a dose of 4000J/m 2 UVB abolished all immune response mediated by donor T-cells. In vivo studies were performed in a histo- incompatible rat BMT model where T-cells induced lethal GvHD in all control animals. Pre-treatment of the BM inoculum (containing T-cells) with intermediate dose UV-B (2,500 or 3,000J/m 2) was ineffective; 21/24 animals died with GvHD by day 40 post BMT. In contrast, 4,000J/m 2 UVB protected >85 per cent of animals at risk of GvHD. But this dose of UVB also abolished the GvL effect. In vitro and in vivo studies showed that UVB also damaged BM stem cells so that the number of BM cells required in a transplant was increased. This study shows that UVB treatment of bone marrow innocula can prevent GvHD, but in so doing, there is some damage to BM stem cells, T-cell mediated GvL activity is also abrogated making it unsuitable as a general GvHD prophylaxis regimen in leukaemia patients although it may have benefit in non malignant disorders where an antileukaemia effect is not required.

(P.16) MOLECULAR MEDICINE IN HAEMATOLOGY, THEORY INTO PRACTICE

2: THE HAEMOSTASIS THROMBOSIS SETTING

N. Kinsella, S. Cusack, M. Lawler, H. Baker, B. White, O. E Smith.

Department of Haematology, Haemostasis and Thrombosis Unit, St. James's Hospital and TCD.

Hypercoagulation is a multifactorial disorder which results in significant morbidity and mortality worldwide. Contributing environmental factors include surgery, trauma, pregnancy and use of the oral contraceptive pill (OCP). Molecular defects in antithrombin, Protein S, and Protein C are implicated but only account for 5-10 per cent of patients with venous thromboembolism (VTE). Recently mutations in genes such as Factor V Leiden (associated with an higher risk of thrombosis due to activated protein C resistance), Prothrombin (Pro ~2~176 and the thermolabile variant of the methylenetetrahydrafolate reductase gene (TL-MTHFR) have been associated with increased risk of developing VTE ranging from 2.8-80 fold. We have developed molecular assays for each of these mutations (including a novel assay for Pro C2~176 to (1) determine their contribution to risk of thrombosis, (2) aid in clinical management of "at risk" patients. In a pilot programme to provide molecular testing of thrombophilic traits as part of a routine hypercoagulation screen


we have tested for Factor V Leiden (FVL A/G) in 533 patients referred from a variety of Irish hospitals in the last 17 months. Patient characteristics and FVL A/G results are: proven VTE (n=253) A/G = 50 (19 6 per cent), A/A=I (0.39 per cent); family history of VTE (n=31) A/G=0 (0 per cent); family history of FVL (n=45) AIG=26 (57 per cent); arterial disease n=64) A/ G=5 (7.8 per cent); pregnancy loss (n=70) A/G = 4 (5.0 per cent), inflammatory bowel disease (n=39) A/G 1 (2.5 per cent). These results indicate the high prevalence of the Factor V Leiden mutation in proven VTE cases and the high specificity of the assay warrants its use as part of a routine hypercoagulation screen.

(P.17) MOLECULAR MEDICINE IN HAEMATOLOGY, THEORY INTO PRACTICE: 1. THE BONE MARROW

TRANSPLANT SETTING

M. Lawler, N. Gardiner, K. Molloy, H. Gowing, A. Wogan, S. R. McCann.

Department of Haematology, Sir Patrick Dun's Research Laboratory, St. Jarnes's Hospital and TCD, Dublin.

Bone Marrow Transplantation (BMT) is the treatment of choice for many haematological malignancies. Therapeutic efficacy relies on the ability of the conditioning treatment pre BMT to ablate the recipient's marrow and the propensity for the donor marrow to engraft and suppress recipient malignant cells. Like any therapy, it is vital to have a suitable assay to (i) evaluate the success of the procedure, (ii) act as an "early warning" for disease recurrence. We have developed a robust and sensitive assay which has now been applied to assess the degree of engraftment post BMT in 255 recipients of allogeneic BMT; aplastic anaemia (AA) (n=134), acute leukaemia (n=65), chronic myeloid leukaemias (CML) (n=32) and assorted haematological malignancies (n=24). The assay relies on the ability to distinguish recipient and donor cells based on their DNA profiles. Serial analysis post BMT allows us to investigate the association between different degrees of haemopoietic chimerism (HC) (the presence of donor only, recipient only or mixed populations of cells post BMT) and disease relapse, graft rejection, and overall survival. Mixed HC without evidence of relapse/rejection was a common finding (20-50 per cent) particularly in unrelated BMTs (90 per cent). Donor or stable mixed HC was a marker of disease free survival. Increasing levels of recipient cells heralded relapse (CML) or graft rejection (AA). Prospective monitoring post BMT can indicate therapeutic intervention (donor T cell infusion for CMLs at risk of relapse; immunosuppression maintenance for AAs at risk of rejection). Thus chimerism testing is a powerful technique which can aid in patient management.

(El8) ANTISENSE OLIGODEOXYNUCLEOT1DES (ODNs) AS IN VITRO PURGING AGENTS IN CHRONIC

MYELOID LEUKAEMIA

S. McElwaine, M. Lawler, D. Hollywood, S. R. McCann. Department of Haematology/Oneology, Sir Patrick Dun's

Research, St. James' Hospital, Dublin 8.,

Following allogeneic Bone Marrow Transplantation (BMT) for chronic myeloid leukaemia (CML), re-emergence of recipient leukaemia cells is associated with disease relapse. Elimination of this refractory cell population is a therapeutic goal for

LJ.M.S. National Scientific Medical Meeting 9 April, May, June 1998

maintaining patients in remission. CML has a defined acquired genetic change, the t(9;22) translocation which we are studying as a target for gene specific anti-leukaemia therapy, t9;22 generates a disease specific chimeric gene (BCR-ABL) which produces a protein (p210) that makes CML cells resistant to chemotherapy induced cell death. Antisense ODNs are short DNA sequence specific "drugs" which can be designed to bind to and potentially downregulate any mRNA molecule in the cell. In CML, downregulation of BCR-ABL expression may increase CML cell susceptibility to chemotherapy induced apoptosis. We have selected the translational start site of the BCR gene as a target for antisense ODNs. Experiments have been performed in 4 CML cell lines to investigate (1) stability of ODN backbone chemistry, (2) stability of ODNs inside CML cells, (3) uptake of fluorescently labelled ODNs by microscopy and FACScan. Results indicate that phosphoro-thioate(PS) ODNs are nuclease resistant when compared to the phosphodiester(PO) chemistry and will not be degraded in the CML cells. Fluorescently labelled PS ODNs have been shown to enter the CML cell lines and localise predominantly in the cytoplasm (where the mRNA is also located). We are currently investigating the ability of the ODN drug to downregulate BCR-ABL and thus sensitise leukaemia cells to chemotherapy induced apoptosis. The success of this approach could lead to the use antisense ODNs as purging agents in vitro.

for t ransplantat ion in the treatment of haematological malignancy, it has recently become clear that mobilisation of stem cells into the peripheral blood by treatment with growth factors provides a rich alternative source of progenitors for transplantation. Rigorous in vitro and in vivo testing is required to validate this peripheral blood stem cell (PBSC) approach as a credible alternative to bone marrow transplantation. We have serially analysed hemopoietic chimerism at times ranging from 1-18 months post BMT as a direct test of stem cell repopulating ability in 15 patients receiving allogeneic PBSCs. Seven patients (4 chronic myeloid leukaemia (CML), 3 acute leukaemias (AL)) received unmanipulated PBSC while in the remaining 8 patients (5 AL, 2 CML, 1 chronic lymphocytic leukemia), PBSC was subjected to CD34+ selection for stem cell enrichment prior to transplant. Complete donor chimerism (CDC) was observed at all timepoints in 13-15 patients while 2 patients showed increasing levels of recipient cells which led to relapse. The overall degree of CDC in this patient group (87 per cent) compares well with percentages achieved for conventional bone marrow transplantation (55-100 per cent). A high degree of CDC was achieved in the CD34 § selected group (75 per cent) when compared to other methods which result in T cell depletion (50- 70 per cent), probably reflecting the higher number of progenitor cells administered. Thus al logeneic PBSC (selected or unselected) is a viable approach for the t reatment of haematological malignancy.

(P.19) PROTEASE INHIBITOR THERAPY IN HIV POSITIVE HAEMOPHILIACS

C. Mcmahon, C. Merry, M. Ryan, O. Smith, F. M. Mulcahy. Department of G.U. Medicine, St. James's Hospital National

Haem0philia Centre, St. James's Hospital, Dublin.

The protease inhibitors (PI) are an effective treatment for HIV infection. There is concern that there may be an increased bleeding tendency in haemophiliac patients on PI therapy. We prospectively studied the effect of introducing PI therapy to 20 HIV positive haemophiliacs. The mean increase in CD4 cell count was 80 cell per cubic ml and there was a mean 2 log drop in viral load. There was no statistically significant increase in factor requirements or treatment episodes for bleeding in the 6 months after the introduction of PI therapy. However 2 patients with severe factor VII deficiency reported unusual bleeds. One patient on SQV developed a forearm bleed while rollerblading and the bleed only settled after 17 treatments with factor VII. Another patient on ritonavir had a bleed on the dorsum of his foot which settled quickly with treatment. However he never previously had a bleed at this site. In view of the significant benefits observed and the fact that only 2 patients had any increase in bleeding tendency, we recommend that concerns about bleeding should not preclude PI therapy in these patients.

(P.20) MOBILISED ALLOGENEIC PBSC TRANSPLANTS; MOLECULAR ASSESSMENT OF ENGRAFTMENT

POTENTIAL

C. Murphy, J. Briones, N. Gardiner, S. R. McCann, M. Lawler. Department of Haematology, St. James's Hospital and TCD,

Dublin. Department of Haematology, Hospital Clinic University of Barcelona, Spain.

Although the bone marrow is the primary source of stem cells

(E21) ELEVATED FACTOR VIII:C AND RECURRENT FETAL LOSS; IS THERE A LINK?

B. White ~, P. Lavin 2, M. Lawler ~, S. Cusack ~, N. Kinsella ~, M. McCaffrey 2, P. Gillen 2, O. P. Smith.

Thrombosis & Haemostasis Unit, St. James's HospitaP and Department of Obstetrics, Rotunda Hospital 2, Dublin

A normal uteroplacental vasculature is essential to maintain a viable fetus to term. Recent evidence suggests that hereditary thrombophilic traits may predispose to recurrent fetal loss. We investigated the prevalence of thrombophilic traits (including 2 novel defects; Prothrombin c2~176 and elevated FVIII:C) in patients with >2 unexplained miscarriages. Clotting assays were used to determine FVIII:C, APCr, APCrV, protein C, Protein S and ATIII. Restriction enzyme digestion analysis of the PCR amplified DNA was used to determine the presence of FV Leiden (FVL) and Prothrombin G2~176 Sixty-five patients were enrolled in the study, median age 35 yr (21-44). Elevated FVIII:C (> 150 1U/ml) was present in 19/57 (33 per cent) of women in comparison to 10 per cent of a reference control group. In all patients with elevated FVIII:C the sample was taken at least 3 months after the fetal loss at a time when coagulation parameters should have returned to normal. No pat ient had the prothrombin ~2~176 polymorphism. There was no increased frequency of protein C (0/65), protein S (1/65) or ATIII (0/65) deficiency. Antiphospholipid antibodies were present in 11 per cent (7/65) of patients. We conclude that there is a probable association between elevated circulating plasma FVIII levels and recurrent fetal loss, however, there appears to be no association with the prothrombin G2~176 polymorphism. The precise role played by high levels of FVIII:C in the pathogenesis of recurrent fetal loss has yet to be determined.


(E22) WISKOTT-ALDRICH SYNDROME: LINKING GENOTYPE TO PHENOTYPE

B. White ~, L. Thompson 2, M. Lalloz 2, M. Layton 2, O. E Smith I.

Department of Haematology, National Children's Hospital, Dublin j and Department of Haematological Medicine, King's

College Hospital, London 2.

Wiskott-Aldrich syndrome (WAS) is a rare X-linked trait occurring at a frequency of 4 per million male births. Two thirds of cases have a family history and the remaining third result from spontaneous mutations. The disorder is characterised by thrombocytopenia, a defect in humoral and cell mediated immunity and obstinate eczema. Not all patients however have this classic triad. Until recently laboratory confirmation of WAS involved demonstrating surrogate markers of the condition such as small platelets coated with IgG, inability to form antibodies to polysaccharide antigens and an abnormal immunoglobulin profile. The recent isolation of the WAS gene (WASP) has greatly facilitated the diagnosis of this condition. We describe 5 patients with thrombocytopenia, 3 of these were young children with a suspected diagnosis of WAS while the remaining 2 were adults with a diagnosis of idiopathic thrombocytopenia. Using single stranded conformational polymorphism followed by direct sequencing we identified WASP gene mutations in all 5 and determined carrier and disease status in the remaining family members. One patient had a novel mutation resulting in a large deletion and severe clinical phenotype. WASP gene mutation analysis should be considered in all patients with unexplained thrombocytopenia.

H I S T O R Y

(P.23) JACOB'S ULCER: "AN ULCER OF PECULIAR CHARACTER"

L. Barnes. City of Dublin Skin and Cancer Hospital and St. James's

Hospital, Dublin.

As Celtic ancestry is considered to be the strongest indicator of susceptibility to non-melanoma skin cancer, it is appropriate that the first description of a basal cell carcinoma is credited to an Irish physician ~. Arthur Jacob trained in the College of Surgeons, Dublin where he was a pupil of Abraham Colles. He also studied in Edinburgh and London, returning to Dublin in 1814 to work as an ophthalmic surgeon and anatomist,

Better known for his research into anatomy of the eye, he described one Layer as "the most beautiful specimen of a delicate tissue which the human body affords". This became known as membrana Jacobi and ultimately, the retina.

In 1827 he described "an ulcer of peculiar character which attacks the eye lids and other parts of the face" now known as a basal cell carcinoma but referred to as Jacob's ulcer in the 1800s. Proud of his description, Jacob drew it to the attention of writers who failed to mention his work.

His original description still holds true "the extraordinary slowness of its progress, the peculiar condition of the edges", "smooth and glossy" having "veins ramifying over it". He distinguished it clearly from a squamous cell carcinoma "the ulcer with cauliflower-like fungus growth, which occasionally attacks old cicatrices", noted its locally destructive nature and its tendency to "spare contaminating the neighbouring lymphatic

glands". He considered the only cure was "by the knife" and emphasised that the tumour "bids defiance to all remedies short of extirpation".

Reference I. Jacob, A. Observations respecting an ulcer of peculiar character which attacks the eyelids and other parts of the face. Dublin Hospital Reports 1827; 4: 232-9.

N U T R I T I O N

(P.21) UNDERNUTRITION IN DUBLIN HOSPITALS

C. Corish l, P. Flood 2, S. Mulligan 3, N. P. Kennedy ~. ~Department of Clinical Medicine, Trinity College Dublin, 2Department of Clinical Nutrition, St. James's Hospital,

Dublin and 3Department of Nutrition and Dietetics, Meath Hospital, Dublin.

This study aimed to assess the prevalence of undernutrition among patients admitted to all specialities of 2 Dublin hospitals, using the criteria for definition as in a recently reported study from Dundee I.

Data were collected from 594 patients on admission and from 189 of those with a minimum stay of 7d on discharge.

The mean prevalence of undernutrition was 11 per cent by comparison with 40 per cent in the Dundee study. Contrary to expectation, prevalence was not significantly higher in the elderly, female or lower socio-economic groups. Unintentional weight loss of more than 10 per cent in ihe 6m before admission occurred in 11 per cent of Dublin, but only 13 per cent of Dundee patients.

Weight loss occurred in 62 per cent of patients reassessed. Of the sixty-two undernourished patients, 40 per cent were referred for nutritional support. Twenty-two undernourished patients were reassessed on discharge, 10 gained weight (6 referred), 3 remained a stable weight (none referred) while 9 lost weight (6 referred).

A lower prevalence of undernutrition was observed in this study by comparison with the Dundee study. Exist ing anthropometric reference data may not be appropriate for defining underhutrition in different population groups.

Reference 1. McWhirter, J., Pennington, C. R. Incidence and recognition of malnutrition in hospitals. British Med. J. 1994; 308: 945-948.

(P.25) A PROFILE OF PATIENTS DISCHARGED FROM A LARGE TEACHING HOSPITAL ON ENTERAL FEEDING

E. McNamara 1, E Flood 2, N. P. Kennedy I. ~Department of Clinical Medicine, Trinity Centre for Health

Sciences, St. James's Hospital, Dublin 8, 2Department of Clinical Nutrition, St. James's Hospital, Dublin 8.

Home enteral nutrition (HEN) is now recognised as an important therapeutic procedure. Little is known about patients on HEN in Ireland. An estimated prevalence of HEN in Ireland would be 348, based on an extrapolation of UK figures.

The medical and dietetic notes of 143 patients discharged on enteral feeding from St. James's hospital since 1993 were reviewed in this survey.

Fifty-three per cent of the patients were male and 47 per cent female. Eleven per cent were aged less than 50 yr, 25 per cent were 81+ yr of age, and the remainder were aged between 51

I.J.M.S. National Scientific Medical Meeting 11 April, May, June 1998

and 80 yr. Forty-one per cent of the sample were discharged to their own home in the community, 42 per cent were discharged to nursing homes, 11 per cent were sent to other hospitals, and the remainder (6 per cent) were discharged to hospice care. Seventy-seven per cent of patients were discharged into the Dublin area,

The main indications for enteral feeding were CVA (35 per cent) and cancer (34.3 per cent). Other indications included Parkinson's disease, Alzheimer's disease, cerebral palsy, multiple sclerosis, and other neurological swallow impairments. The main method of feeding was via percutaneous endoscopic gastrostomy (83 per cent), while nasogastric (7 per cent) and jejunostomy feeding (7.7 per cent) were also employed.

(P.26) THE INVOLVEMENT OF IRISH DIETITIANS IN THE MANAGEMENT OF PATIENTS ON HOME ENTERAL

NUTRITION (HEN)

E. McNamara ~, P. Flood 2, N. R KennedyL ~Department of Clinical Medicine, Trinity Centre for Health

Sciences, St. James's Hospital, Dublin 8.2Department of Clinical Nutrition, St. James's Hospital, Dublin 8.

Irish dietitians play a dominant role in educating patients requiring HEN. Questionnaires, designed to determine current practices in managing patients on HEN, were sent to 105 dietitians, with a 73 per cent response rate.

Results show that the average number of HEN patients discharged yearly was 11.5 per dietitian, with a large SD of 19.7. Dietitians in paediatric hospitals discharged significantly more HEN patients. Paediatric dietitians constituted 11 per cent of the respondents, but they discharged 42 per cent of HEN patients.

Dietitians are responsible for most of the tasks necessary before the HEN patient is discharged. Nursing staff are involved with teaching psychomotor tasks (e,g. teaching to operate pumps, flush feeding tubes etc.).

Nearly all (98.6 per cent) of respondents received telephone calls regarding patients on HEN after they are discharged home, suggesting; that dietitians play a significant role in managing HEN patients even after discharge. Thirty-three per cent of respondents received calls from patients/carers, 76 per cent received calls from public health nurses and 11 per cent received calls from GP's.

Ninety-eight per cent of dietitians consider the process of discharging patients on HEN, and the nutritional care available to them, could be improved. Given 7 options which could improve the current situation, the majority of respondents felt that the provision of community dietitians would be the best approach.

(P.27) GROWTH IN CHILDREN WITH HUMAN IMMUNODEFICIENCY VIRUS - 1 INFECTION IN

ROMANIA

P. M. Mathias t, E. BaW, D. Duiculescu 2, P. Calistru 2. ~Department of Biological Sciences, Dublin Institute of Technology, Kevin Street, Dublin, Ireland, 2"Dr. Victor Babes", Hospital for Infectious and Tropical Diseases,

Bucharest, Romania.

The aim of the present study was to evaluate growth in HIV-1 infected children. Twenty-six children, 15 male and 11 female, mean age 7.4 (SD 0.86) yr, were studied over 12 months. They

were relatively healthy with non-progressive disease and minor opportunistic infections. None were on anti-retroviral therapy. Children were fed a mixed diet providing 8.4 MJ per day plus a 1.05 MJ supplement of Nutrifil, a nutritionally complete food shown to be effective in the early management of HIV infection 1. Weight, height, mid-arm muscle circumference (MAMC) and triceps skinfold thickness (TSF) were measured.

Baseline (n 26) 6 months (n 26 ) 12 months (n 26) Mean SE Mean SE Mean SE

Weight (kg) 19.5 0.78 20.6 0.83 21.2* 0.95

Height(m) l.ll 0.19 1.12 0.21 1.15" 0.20

TSF (mm) 5.9 0.4 5.9 0.3 6.0 0.6

MAMC (ram) 134 3.0 136 2.7 139 3.0 Significantly different from baseline, P<0.05, (paired tests).

Mean values for all variables, shown in the Table, were below the 10th percentile with respect to standards 2 throughout the study. At baseline stunting was more prevalent than wasting. Twenty (77 per cent) children were less than 90 per cent height for age, compared with 19 (73 per cent) who had normal weight for height 3. There were significant increases in weight and height although not commensurate with normal growth 2. Low values for TSF and MAMC indicated that body composition remained abnormal with respect to both fat and lean tissue during the study. Anti-retroviral therapy and more aggressive nutrit ional management may correct these abnormalities.

References 1. Mathias, P. M. Bakeine, G. J., Mugyenyi, R N. Nutrition, 1997; 13, 275. 2. Tanner, J. M., Whitehouse, J. M. Archives of Diseases of Childhood 1976; 51: 170. 3. Waterlow, J. C. British Med .I. 1972; 3: 566-569.

(P.28) DIETARY COMPLIANCE IN DERMATITIS HERPETIFORMIS (DH)

N. O'Gorman ~, M. Abuzakouk 2, N. P. Kennedy ~, C. Feighery 2. 1Department of Clinical Medicine, Trinity Centre for Health

Sciences, St. James's Hospital, Dublin 8, 2Department of Immunology, St. James's Hospital, Dublin 8.

Over two-thirds of patients with DH have an enteropathy indistinguishable from that of coeliac disease (CD). The enteropathy and skin lesions respond to a strict gluten-free diet (GFD) and many patients can reduce their dapsone dosage ~.

This study aimed to evaluate if DH patients a~tendmg St. James's Hospital adhered to a GFD and their level of dietary compliance. Twenty-eight out of 37 patients responaed to a postal questionnaire. Seventy-one per cent indicated they were following a GFD, although only 20 per cent always complied strictly. Twenty-two per cent controlled their symptoms with dapsone alone.

Twenty respondents had a dietary assessment, distal duodenal (D2) biopsy and measurement of antiendomysial antibodies (EmA). Fifty-five per cent of patients had an enteropathy, of which 63 per cent had a severe gut lesion. EmA was positive in 86 per cent of those with a severe gut lesion. Seventy-five per cent of respondents were following a GFD although dietary assessment indicated that 47 per cent were poor compilers.

Many DH patients do not adhere strictly to a GFD, preferring to use dapsone to control skin lesions, although dapsone does not improve gluten-sensitive enteropathy. All newly diagnosed DH patients should undergo a D 2 biopsy and if an enteropathy


is present, a GFD should be instigated. This will improve both the gut and skin lesions, reducing the risk of lymphoma.

Reference 1. Garioch, J., Lewis, H., Sargent, S., Leonard, J., Fry, L. Twenty-five years experience of a gluten-free diet in the treatment of dermatitis herpetiformis. British J. Dermatol. 1994; 131: 541-45.

ONCOLOGY (P.29) LIVER METASTASES IN PATIENTS WITH

UNKNOWN PRIMARY TUMOURS. IS EXTENSIVE INVESTIGATION NECESSARY?

M. Brannigan, S. Pender, E Keeling, J. Varghese, M. Lee. Radiology Department, Beaumont Hospital, Dublin 9.

Patients presenting with multiple liver metastases employ considerable resources in an effort to identify the primary tumour site. For many of these patients there is no prospect of curative treatment and expensive investigations may not be warranted. The aim of the study was to review the investigation and clinical course of patients who present de novo with hepatic metastases from an unknown primary tumour site and to answer which if any investigations are warranted:

Fifty patients (M:F, 33:17, Age range 47-86) who presented with biopsy proven hepatic metastases were reviewed. The primary tumour site was unknown at the time of liver biopsy. Investigations, identification of primary tumour sites, treatment and survival data were recorded from clinical data.

Liver biopsy histology showed metastatic adenocarcinoma in 38, non small cell cancer in 2, small cell cancer 4, poorly differentiated carcinoma in 5 and neuorendocrine in 1. All patients underwent extensive investigation in pursuit of a primary tumour site. Investigations included 75 plain X-rays, 35 CT scans, 26 barium studies, 12 radioisotope scans, 44 endoscopies, 6 bronchoscopies and 2 laparotomies. A primary tumour was identified in 8 patients (16 per cent). Thirteen patients received t reatment with either chemotherapy, radiotherapy or both. Overall survival ranged from 4-545 days (mean 126 days). Mean survival for treated patients was 170 days versus 65 days for untreated patients.

Conclusion: Patients in this series underwent extensive diagnostic tests but the primary tumour was identified in only 16 per cent. Overall mean survival was short and extensive investigation of these patients is not warranted. Treatment with a non toxic chemotherapy protocol may be beneficial in selected c a s e s .

(P.30) SCHWANNOMA OF THE HEAD AND NECK - THE DUBLIN PERSPECTIVE 1986-996

M. Colreavy, R. Gaffney, S. Hone, M. Herzig, M. Walsh. Department of Otolaryngology and Head and Neck Reconstructive Surgery, Beaumont Hospital Dublin.

Schwannomas account for a very small percentage of head and neck neoplasms. Experience of their diagnosis and treatment is thus limited.

We present our experience of 8 Schwannomas diagnosed and treated over a l0 yr period, among 4 major teaching hospitals in Dublin. Post-op Homers in the benign group is a problem often encountered. Combined chemoradiotherapy is advised for the malignant group. New diagnostic histopathologic techniques have ensured more accurate typing and possible pre-operative diagnosis.


(P.31) AN ANTI-ONCOGENE APPROACH AS A NOVEL THERAPEUTIC STRATEGY FOR BREAST CANCER

C. Dolan, A. Wogan, M. Lawler, S. R. McCann, D. Hollywood.

Department of Hematology, St. James's Hospital and TCD; Department of Radiology, St. Luke's Hospital, Dublin.

Genetic abnormalities play a key role in the pathogenesis of breast cancer. If we could target these abnormalities and deregulate their expression, then we could have a powerful new therapeutic strategy against breast cancer. One gene that is aberrantly expressed in breast tumour tissue is the c-erbB2 oncogene. We aim to downregulate expression of this gene by interfering with the transcriptional machinery of cerbB2. Specifically we have synthesised and tested a novel antigene oligodeoxynucleotides (ODNs) directed against the promoter region of the c-erbB-2 oncogene. These triple helix-forming ODNs (TFOs) are small molecules designed to bind to the double helix of DNA in a specific manner and disrupt binding of proteins (transcription factors) which promote gene expression. The antisense TFO we have designed is 28 base pairs in length and is complimentary to a purine rich region in the erbB-2 promoter. Specific binding of the antisense TFO (when compared to nonsense or scrambled sequence TFOs) to the target promoter region has been achieved at physiological pH. EIectromobility shift analysis has indicated that this binding is strong and not easily reversible while DNase I Footprinting analysis has confirmed the exquisite specificity of binding to the erbB-2 promoter. The use of antigene TFOs represents a highly specific method to target genes that play a role in the pathogenesis of breast cancer.

(P.32) TGFB-1 UPREGULATION OF VEGF IN BREAST CANCER CELLS IS INDEPENDENT OF GROWTH

INHIBITION

D. Donovan, J. Harmey, D. J. Bouchier-Hayes. Department of Surgery, Royal College of Surgeons in Ireland,

Beaumont Hospital, Dublin 9.

Transforming growth factor B-1 (TGFB-1) can inhibit the growth of tumour cells and endothelial cells. However many tumour cells carry mutations enabling them to escape this negativeregulation. TGFB-1 has been shown to indirectly promote angiogenesis. Vascular endothelial growth factor (VEGF) is one of the most potent angiogenic factors identified to date.

Breast cancer cell lines, BT474 and MDA-MB-231, were treated with 0-10 ng TGFB-1. Supernatants were removed and assayed for VEGF by ELISA. Total cellular protein was measured to standardise VEGF production. Cell proliferation was measured by direct cell counting and by staining with propidium iodide and flow cytometry.

Five ng/ml TGFB-1 significantly increased VEGF production in BT474 cells over untreated cells (6.04 4- 0.68 vs 4.09 4- 0.69 pg/I.tg protein, p = 0.03). TGFB-.1 increased VEGF production by MDA-MB-231 cells (21.24 4- 2.26 vs 12.1 4- 2.4 pg/~g protein, p = 0.03 at 7.5 pg/lag protein and 25.25 _+ 5.5 vs 1'2.1 4- 2.4 pg/ ~tg protein, p = 0.007 at 10 pg/p.g protein). TGFB- 1 did not inhibit the growth of either cell lines.

Our results indicate that TGFB-1 induction of VEGF occurs independently of growth inhibition.

I.J.M.S. April. May, June 1998

(P.33) HYPOXIA UPREGULATES IL-6 PRODUCTION

A. Haverty, J. H. Wang, J. H. Harmey, H. P. Redmond, D, J. Bouchier-Hayes.

R.C.S.I., Department of Surgery, Beaumont Hospital Dublin 9.

Solid tumours are comprised of tumour cells, endothelial ceils, and immune cells. Hypoxic conditions exist within regions of these tumours. We have previously shown that the proinflammatory cytokine, Interleukin-6 (IL-6) is significantly elevated in breast tumours, compared to normal tissue. We hypothesised that hypoxic growth conditions increase IL-6 production.

Human monocytes were isolated from peripheral blood, matured to macrophages in vitro, for 3 days and activated with 800U/ml IFN-g. Endothelial cells (HUVEC), monocyte derived macrophages (MDM's) and MDA-MB231 breast tumour cells were cultured under normoxic and hypoxic (2 per cent oxygen) conditions at 37~ for 24 h. Culture supernatant IL-6 was measured by ELISA.

IL-6 production by MDM's and endothelial cells was significantly elevated (p<0.01, p<0.05 respectively) following culture in hypoxic conditions compared to normoxic controls.

Conclusions: Hypoxia s ignif icant ly upregulates IL-6 production in vitro. Hypoxic conditions in solid tumours may account for the high levels of IL-6 previously identified in breast tumours.

(E34) ADJUVANT RADIATION THERAPY (RT) FOR BREAST CARCINOMA AND THE THYROID

G. McGreal, S. G. Shering, M. J. Moriarty, A. Shortt, M. T. Kilbane, D. F, Smith, E. W. M. McDermott, N. J. O'Higgins,

E E A. Smyth. University College, St. Luke's and St. Vincent's Hospitals,

Dublin.

Although the target of radiation for breast cancer is often a distance from the neck, some scatter inevitably occurs giving measurable doses of radiation to distant organs, including the thyroid. The aim of this study was to investigate an association between RT for breast carcinoma and possible changes in thyroid volume and function. Thyroid volume (TV) was measured by ultrasound scanning and serum TSH and thyroid peroxidase autoantibodies (TPO.Ab) by immunoassay in breast cancer patients without evidence of previous thyroid disease. Three groups were studied: Patients treated by (a) surgery alone (n=100). (b) adjuvant RT to the chest wall (4500 cGy, n=51). (c) adjuvant RT to the chest wall and the supraclavicular lymph nodes (9000 cGy, n=26). Serum TSH was above the upper limit of the reference range (>4.0mu/1) in 18.0 per cent of irradiated patients (Groups b+c) compared to 5 per cent in group (a) p<0.05. The median TV of 13.8 ml in irradiated patients was significantly < that of 17.5 ml in the non-irradiated breast cancer patients (p<0.01) but was not significantly different from that of 12.0 ml in normal female controls. The findings suggest that adjuvant RT for breast carcinoma may extend to the thyroid gland, induc ing in some pat ients a mild compensated hypothyroidism. RT also appears to mask the increase in thyroid volume observed in a significant proportion of breast cancer patients.


(P.35) TAMOXIFEN IS ANTI-ANGIOGENIC IN VITRO AND ATTENUATES VEGF-MEDIATED ANGIOGENESIS

IN VIVO

D. A. McNamara, J. Harmey, J. H, Wang, D. Donovan, E. Kay*, T. N. Walsh, D. J. Bouchier-Hayes.

RCSI Departments of Surgery and Pathology*, Beaumont Hospital, Dublin.

Angiogenesis is crucial for tumour growth. Tumours secrete promoters and inhibitors of angiogenesis including vascular endothelial growth factor (VEGP), a potent pro-angiogenic cytokine. We have shown that tamoxifen reduces serum VEGF in cancer patients. We hypothesised that tamoxifen inhibits VEGF-mediated angiogenesis. The effect of tamoxifen on angiogenesis was assessed in vitro and in vivo,

Human microvessel endothelial cells (HMEC) and human umbilical vein endothelial cells (HUVEC) were grown in vitro and treated with tamoxifen in DMSO (100 ng/ml - 2.5 ~tg/ml) or DMSO alone. Endothelial cell proliferation was quantified using 5-bromo-2'-deoxyuridine labelling. Adult male Sprague- Dawley rats were pre-treated with po tamoxifen or placebo for 3 days, then injected with Matrigel containing VEGF to elicit new vessels. Tamoxifen or placebo was continued for 5 further days. Gels were excised and microvessel density was quantified.

Human microvessel , but not human umbi l ica l vein, endothelial cell proliferation was inhibited by tamoxifen in vitro at 2.5 I.tg/ml (p=0.001). In vivo, tamoxifen reduced VEGF- elicited angiogenesis with a mean microvessel count in treated gels of 52.6 per high power field (hpf) versus 63.3 per hpf in controls (p<0.05). Therefore, tamoxifen is anti-angiogenic in vitro and inhibits VEGF-mediated angiogenesis in vivo. This effect merits further evaluation to assess the potential role of tamoxifen in dormancy therapy of micrometastases.

(P.36) LIPOPOLYSACCHARIDE INCREASES VEGF PRODUCTION BY MACROPHAGES AND TUMOUR

CELLS

G. Pidgeon, J. Harmey, D. A. McNamara, D. J, Bouchier-Hayes. Royal College of Surgeons in Ireland, Department of Surgery,

Beaumont Hospital, Dublin 9.

Vascular endothelial growth factor (VEGF) is a potent angiogenic factor, stimulating the growth and differentiation of endothelial cells. In addition to its role in tumour biology, VEGF plays a role in angiogenesis-dependent processes such as wound healing. Lipopolysaccharide (LPS) is a bacterial cell wall constituent and is ubiquitously present in air. We have previously shown that LPS injection resulted in increased serum levels of VEGF in a murine tumour model. We hypothesised that LPS stimulates VEGF production by both tumour cells and inflammatory cells.

Human monocytes were isolated, matured to macrophages in vitro for 5 days and activated with 1000 U/ml interferon-T. Monocyte-derived macrophages (MDMs) and murine 4Tl mammary carcinoma cells were incubated with LPS for 24 h. VEGF protein production was assayed by ELISA and VEGF mRNA was assessed by reverse transcriptase-polymerase chain reaction (RT-PCR).

VEGF protein production by 4Tl turnout cells (n=3) was significantly increased (p<0.05) by treatment with l0 ng, 100 ng, 1 ~tg and 10 I.tg/ml LPS (Stats: ANOVA), VEGF mRNA


levels in MDMs were increased in response to 1 ng, 10 ng, 50 ng and 100 ng/ml LPS. Conclusion: LPS increases VEGF at both the mRNA and protein levels. LPS induction of VEGF production by inflammatory and tumour cells may play a role in wound healing, inflammation and turnout biology.

P A T H O L O G Y / C Y T O L O G Y

(P.37) OESTROGEN RECEPTOR STATUS IN BREAST CARCINOMA: STANDARDISATION OF HEAT INDUCED

EPITOPE RETRIEVAL (HIER)

P. Dunne, H. Lambkin, Department of Biological Science, Dublin Institute of

Technology, Kevin St., Dublin.

Oestrogen receptor (OR) status is an important factor in the administration of endocrine therapy to patients diagnosed with invasive breast carcinoma. These tissue receptors are assayed either by cytosolic enzyme immuno-assay or in-situ tissue localisation using immunohistochemistry. At present much variation exists with regards to the superheating protocols used to unmask the OR from paraffin embedded tissue for immunohistochemistry. In this study standardisation of the superheat ing procedure used in many his topathology laboratories today has been performed.

All aspects of HIER were assessed using the microwave as a means of superheating. Hot air oven was also examined as a method of superheating. The optimum HIER protocol for immunohistochemical staining of OR was: (1) Section drying at 60~ prior to immunostaining, (2) 450 ml of antigen retrieval buffer, I0 mM EDTA (disodium) at pH 8.0, (3) Superheating in a microwave for 15 min. at 100~ and (4) Allowing sections to incubate at room temperature in the hot buffer for 20 rain following microwaving. Heating at 70~ overnight in a hot air oven instead of microwaving yielded similar immuno-positivity. However, the level of background staining was substantial in these sections, this served to make counting of positive cells more difficult. No background staining was observed in optimally microwaved slides.

(E38) EXPRESSION OF THE ABL ONCOPROTEIN 1N THE NEOVASCULATURE DURING ENCHONDRAL OSSIFICATION AND IN TUMOUR ANGIOGENESIS

J. M. RusselP, A. J. O'Neill 2, B. M. Dunne 3, M. O'Donovan 3, J. E. Gillan 4, T. G. Cotte:, M. Lawler 3, E. E Gaffney 3. St. James's Hospital t.2.3, Rotunda Hospital 4 and U.C.C:

The Abl family of oncogenes, encoding intracellular protein tyrosine kinases, play important roles in cell cycle regulation and inhibition of apoptosis. Our previous immunohistochemical study demonstrated that the Abl protein is weakly or focally expressed in many different normal tissues, and that certain cell types (chondrocytes and adipocytes) showed consistent strong staining. In this study, we extended our observations on Abl expression in angiogenesis during enchondral ossification and in tumour angiogenesis. Sections from 24 paraffin blocks of fetal rib (16-42 wks gestation), 8 signet ring carcinomas of stomach, 8 l iposarcomas and 10 breast carcinomas were stained immunohistochemically for the c-Abl/BCR-Abl oncoprotein (Serotec, UK), using appropriate controls.


Abl immunoreactivity was not seen in normal blood vessels in adult tissues. In the fetus, there was s t r iking Abl immunoreac t iv i ty in osteoblasts and their associated neovasculature in sites of enchondral ossification from 17 weeks. In signet ring carcinoma, breast carcinoma and liposarcoma moderate to intense Abl expression was obscrvcd, to a variable extent, in angiogenic tumour microvessels as well as in tumour cells These findings strongly suggest a previously unidentified role for he c-abl oncogene in angiogenesis. In on-going studies we are confirming the validity of these observations by determining expression of c-abl mRNA using RT-PCR and IS- RT-PCR

~Supported by the Health Research Board and 2by IACR and CRAB.

R E N A L M E D I C I N E

(P.29) AETIOLOGY OF HYPERKALAEMIA IN ELDERLY PATIENTS

J. Horan, D. Jones, S. K. Biswas, H. Brady*, J. O'Donnell**, E. C. Mulkerrin.

Department of Medicine for the Elderly, University College Hospital, Galway, *Department of Medicine and

Therapeutics, Mater Hospital, Dublin, **Endocrin61ogy Department, U.C.H., Galway.

Elderly people are prone to the deve lopment of hyperkalaemia. Sustained hyperkalaemia usually indicates a defect in renal potassium (K+) secretion and can be due to impairment of glomerular filtration and/or impairment of tubular K+ secretion. The transtubular potassium gradient (TTKG) provides an index of tubular K+ secretion ~. Normally TTKG rises in patients with significant hyperkalaemia. TTKG was assessed at baseline and repeated 3 hr following oral ingestion of 0.5 mg of fludrocortisone in 3 groups: an older group (n=6, mean age 76 yr) with unexplained hyperkalaemia (HK), a group of old (n=8, mean age 79 yr) (OC) and young (n=9, mean age 31 yr) control subjects (YC). GFR was assessed or calculated in all patients at baseline. Mean (_+ sere) baseline TTKG were similar in all 3 groups. At +3 h TTKG had risen significantly from baseline levels in the young subjects only (form 7.5 _+ 8.89 to 11.6 _+ 1.1 p<0.05). No significant change was noted in either elderly group at +3 h. The GFR of the HK group was significantly lower than that of the OC group (40.06_+2.31 vs 55.58_+6.1, p=0.045) they were both significantly lower than those of the YC group (101.66-+6.96, p=0.0001, p=0.02). The inappropriately low baseline TTKG in the HK group as well as the absence of a response to Fludrocortisone indicate tubular insensi t iv i ty to aldosterone. The associated subcl inical impairment of GFR combined to result in overt hyperkaleamia in this subgroup.

Reference I. Kamet et al. Am. J. Kid. Dis. 1994; 24: 597-613.

(P.40) FACTORS INVOLVED IN DEVELOPMENT OF IgA NEPHROPATHY

J. Neary, E. Healy, A. Watson, B. Keogh, M. Ryan. Department of Pharmacology, University College Dublin and Departments of Nephrology, St. Vincent's and Meath Hospitals.

IgA nephropathy (IgAN) is a common form of


glomerulonephritis world-wide which may lead to chronic renal failure (CRF) in up to 30 per cent of patients. The underlying mechanisms in the pathophysiology and reasons why some patients progress to CRF are not established. In this study, We established a database of Irish patients with biopsy-proven IgAN. In addition, we carried out some studies exploring the possible involvement of the cytokines IL-6 and EGF in the disease. From the database study, correlations with progression to CRF included age, male gender, hypertension, raised serum creatinine, nephrotic range proteinuria. In the cytokine study, IgA patients were compared to a control group but also subdivided into IgA active and IgA stable subgroups. While there was a tendency for both serum and urinary IL-6 and EGF to be raised in the IgA active subgroup, these did not reach statistical significance. Serum magnesium and urinary 132-microglobulin were significantly increased in IgA patients. These studies provide some indicators for more accurate predictors of IgA disease progression to CRE

R H E U M A T O L O G Y & R E H A B I L I T A T I O N

(P.41) REHABILITATION IN A RHEUMATOLOGY UNIT - PRELIMINARY FINDINGS OF AN AUDIT OF

OUTCOME

C. Cassidy, S. Ward, E. Stokes. School of Physiotherapy, Faculty of Health Sciences,

University of Dublin, Trinity College, Dublin 2.

The rheumatic diseases represent a major chronic health problem in terms of their prevalence, associated disability and multidimensional impact on patients' lives.

Increasing constraints in health care expenditure and a growing emphasis on accountability are forcing the re-evaluation of patient care. The Health Strategy "Shaping a Healthier Future" stresses the importance of measuring outcome in terms of social and health gain. Intervention may be evaluated by undertaking clinical audit which can be directed at the structure, process or outcome of health care.

The aim of this study was to investigate the effect of a period of rehabilitation on patients with rheumatic diseases. Outcome was measured at the level of impairment (pain, strength), disability (transfers, mobility, hand function) and handicap (quality of life). The Health Assessment Questionnaire (HAQ) was used to identify the self-reported impact of disease on function. Patients admitted to St. Joseph's Rehabilitation Unit, Harold's Cross from October to December 1997 were considered for inclusion. Pre and post intervention assessments were undertaken on 29 patients.

Eighty to ninety per cent of subjects demonstrated an improvement in timed functional tasks. Grip strength improved in 65 per cent of subjects. Eighty per cent of subjects reported a decrease in pain on discharge. Self-reported functional abilities improved in 7:2 per cent of participants. However only 36 per cent of subjects reported an improvement in quality of life (QOL) following intervention. Initial results demonstrate the benefits of rehabi l i ta t ion . Further review of in te rven t ion and implementation of changes, if necessary, would allow the completion of the audit cycle.

(P.42) COMPARISON OF TRADITONAL AND ISOKINETIC EXERCISE PROGRAMMES FOR OA OF KNEE

F. Keoghan, A. Barrett, P. O'Connell. Departments of Physiotherapy and Rheumatology, Beaumont

Hospital, Dublin

Weakness of the quadriceps muscle is a feature of osteoarthritis (OA) of the knee, and quadriceps strengthening exercises are part of treatment. However, the ideal method of strengthening the quadriceps is unknown. In this study 20 OA patients were randomised to either a traditional free weight exercise programme (Trad) or an isokinetic exercise programme (IsoK) using a Kin-Corn dynamometer at a velocity of 30~ Both groups exercised under supervision 3 days/week for 6 weeks. We recorded measures of pain, function and strength at week 0 (WO), week 6 (W6), and at 6 weeks post study (W12). At W6, significant (p<0.01) improvements in muscle strength were seen in both groups in concent r ic torque, Trad W0=16.8+10.2nm, W6=32.8+15.7; IsoK W0=16.9+8.9nm, W6=22,2+8.9, and similarly in eccentric torque. Improvement in visual analogue scores for activity pain was seen only in IsoK group (WO=4.8+2.0, W6=2.2+2.4, p<0.02). Lequesne functional index improved significantly (p<0.05) in both groups, Trad WO=10.6+2.4, W6=7.8+3.7; IsoK W0=9.9+3.0, W6=l 6.9+3.1. Improvements in 50' walk times were also seen in both groups (p<0.05). A trend towards greater improvement was seen in the IsoK group. At W12, improvements were better maintained in the IsoK group. Isokinetic exercise is feasible and compares well with traditional exercise programmes for OA.

(P.43) ANALYSIS OF GAIT IN ANKYLOSING SPONDYLITIS

N. Ryall, P. A. O'Connell, A. Jenkinson, T. O'Brien, P. G. O'Connell.

Department of Rheumatology, Beaumont Hospital, Dublin 9, and Gait Laboratory, Central Remedial Clinic,

Clontarf, Dublin 3.

We undertook this pilot study to evaluate how the gait of subjects with ankylosing spondylitis (AS) differed from normal. Five AS subjects with mild to severe spinal disease without peripheral joint involvement were compared to 5 normal (N) controls. Following a standardised physical examination, all subjects underwent analysis of posture and gait while walking barefoot at a self-selected speed, using a CODA MPX30 system A representative sample gait cycle was analysed for each subject.

Statistically significant differences were seen between N and AS groups on multiple measures. During stance, differences in pelvic obliquity (AS 1.6 ~ degs, N 3.4~ knee flexion (AS 7.7 ~ N 0.9 ~ and ankle flexion (AS 5.8 ~ N 3.6 ~ were seen (p<0.5). During gait, AS walking speed was slower (AS 1.1 m/sec, N 1.3), stride length was shorter (AS 1.12m, N 1.36), while cadence was preserved (AS 58.6 step/min, N 58.0). Differences in hip, knee and ankle motion and ground reaction forces were seen.

In general, AS subjects stood and walked with increased hip, knee and ankle flexion, walked more slowly with reduced stride length and velocity due to these angular differences. The differences increased with the severity of AS and in pattern were consistent across subjects. It appears that there is a characteristic pattern of gait abnormalities in AS which has not previously been described in detail.


GENETICS (P.44) ABSENCE OF DAZ (DELETED IN AZOOSPERMIA)

GENE IN A FERTILE MAN AND HIS INFERTILE SON

T. Barrett L2, D. M. D. Bailey 2, A. Butler 2, R. Harrison ~, D. E. Barton 2.3.

~Human Assisted Reproduction Unit, Department of Obstetrics and Gynaecology, The Rotunda Hospital, Parnell

Street, Dublin 1. 2National Centre for Medical Genetics, Our Lady's Hospital for Sick Children, Crumlin, Dublin 12.

3Department of Medical Genetics, University College Dublin.

Deletions of the AZF regions of the Y chromosome are known to be associated with azoospermia and oligospermia. To investigate the contribution of Y chromosome deletions to infertility, 238 infertile karyotypically normal men presenting for IntraCytoplasmic Sperm Injection (ICSI) were tested by PCR for the presence of 33 Y chi'omosome STS markers, 5 were shown to bear microdeletions around the AZF loci in interval 6 of Yq. DNA samples were available from the fathers of 2 of these patients. One father had all markers present, indicating a de novo deletion had been transmitted to his son, while the other father bore apparently the same deletion as his son. This man (67 yr) has 5 children, while his infertile son has severe oligospermia, with a sperm count of < 1 million/ml. The deletion interval in both runs from DYS153 (just distal to YRRM2) to DYS157 and includes 14 STS loci tested so far indicating that the entire DAZ locus is absent.

The absence of DAZ and surrounding regions in both the fertile father and his infertile son is intriguing. We are currently fine-mapping the deletion endpoints in both men, and plan to assess semen quality and deletion status in the man's other sons.

(P.45) CHEMILUMINESCENT DETECTION SYSTEMS - A VIABLE SUBSTITUTE TO ISOTOPES IN MOLECULAR

RESEARCH?

C. Byrne, S. McElwaine, S. R. McCann, M. Lawler. Department of Haematology/Oncology, Sir Patrick Dun

Research, St. James's Hospital, Dublin 8.

Radioisotopes are extensively used for detection of nucleic acids and proteins in scientific research. Their obvious advantage lies in the sensitivity of detection, particularly when the target is at low concentration. Recent advances in non-radioactive methods may overcome the hazards associated with radioisotope use without loss of sensitivity. We evaluated the use of a variety of enzyme labelling methods and have chosen a horse radish peroxidase (HRP) labelling system combined with a chemiluminescence detection assay. In the area of DNA diagnostics, Short Tandem Repeat polymerase chain reaction (STR-PCR), incorporating a radiolabelled nucleotide into the assay, is used routinely in our laboratory to investigate engraftment following bone marrow transplantation. We have recently adapted the ECL (enhanced chemiluminescence) system for STR-PCR and results indicate sharper resolution on film compared to the radioactive technique with equivalent sensitivity (0.01 per cent in the detection of the minor cell population post BMT. We have also evaluated ECL for detection of gene expression at a protein level using western blotting with specific antibodies to monitor levels of expression of oncogenic proteins (specifically the P210 protein in chronic myeloid leukaemia) in cell lines and primary material as part of an antisense programme to evaluate sequence specific downregulation of P210. The technique is considerably


faster thafa existing protocols and has comparable sensitivity. Our studies indicate that ECL is a safe, fast and sensitive method for DNA and protein detection and provides a viable option to current radioactive methods.

(P.46) PROTHROMBIN~2~176 A NEW PLAYER IN VENOUS THROMBOEMBOLIC DISEASE?

S. Cusack, M. Lawler, B. White, O. E Smith. Department of Hematology, Haemostasis and Thrombosis

Unit, St. James's Hospital and TCD.

Venous thromboembolic disease (VTE) is associated with significant morbidity and mortality. While the pathogenesis of VTE is not fully understood, both inherited and acquired factors are implicated. A mutation in the Factor V gene (Factor V Leiden) mutation which results in increasedactivated protein C resistance is the major predisposing genetic factor to VTE. More recently, a novel mutation in the 3' untranslated region of the prothrombin gene (Pro ~2~176 has been described which also predisposes to deep vein thrombotic events. This genotype was found in 18 per cent of VTE patients studied in contrast to 2.3 per cent of control subjects. We have developed a novel polymerase chain reaction and restriction enzyme digestion based protocol to identify the mutation in subjects with'a strong familial or personal history of VTE. This assay allows detection of the mutation and controls for false negative results by simultaneously assaying for a second restriction enzyme site which is present in all individuals in the population. Using this assay we have examined 239 consecutive patients attending the Haemostasis and Thrombosis unit at St. James's Hospital. The G > A mutation was detected in 7 of these 239 subjects (2.9 per cent). Testing of a control population with no history of VTE indicated a mutation frequency <1 per cent. While this study requires expansion before conclusive results are established, initial data indicate a strong case for the routine screening of patients with a strong familial or personal history of VTE prior to events such as surgery, pregnancy or prescription of the oral contraceptive pill.

(P.47) CONFIRMATION OF ASSOCIATION BETWEEN ATTENTION DEFICIT HYPERACTIVITY DISORDER

AND THE DOPAMINE TRANSPORTER (DAT1)

G. Daly, M. Gill, S. Heron, Z. Hawi, M. Fitzgerald. Departments of Psychiatry and Genetics, Trinity College Dublin.

Child and Family Centre, Ballyfermot Road, Dublin 10.

Attention deficit hyperactivity disorder (ADHD) is a common condit ion of childhood the symptoms of which include ina t tent ion , excessive motor act ivi ty, impuls iv i ty and distractability. It is strongly familial and twin and adoption studies suggest that the familiarity is due, at least in part, to shared genes. Concordance rates of 81 per cent and 29 per cent, respectively, were found in ADHD for MZ and DZ twins. Stimulant drugs (eg, methylphenidate) are effective in the treatment of ADHD and inhibit.the dopamine transporter. This has led to the development of a hypodopaminergic hypothesis for the disease. Others have examined a 3' vari~ible number of tandem repeats (VNTR) polymorphism at the dopamine transporter gene (DAT1) in a sample of 49 ADHD patients and their parents, using the haplotype relative risk (HRR) method. A significant association (X 2 =7.29, 1 d.f., P=0.007) between

tJ.M.S. National Scientific Medical Meeting 17 April, May, June 1998

ADHD and the 480-bp DATI VNTR allele was found. We achieved independent replication in a study of 40 probands and their parents,using the same robust HRR method. We found that the 480-bp allele was preferentially transmitted to ADHD probands (Z2 = 6.07, ld.L, P=0.014).

(P.48) CAG TRINUCLEOTIDE REPEAT POLYMORPHISM AT IL9: ASSOCIATION WITH BIPOLAR AFFECTIVE

DISORDER IN MALES

Z. Hawi, L. Mynett-Johnson, D. Shiels, R. Straub ~, K. Kendler, D. Walsh 2, E McKeon, M. Gill.

Departments of Psychiatry and Genetics,Trinity College, Dublin 2. ~Departments of Psychiatry and Human Genetics,

MCV. 2HRB, Dublin.

The aetiology of the recurrent psychoses (schizophrenia and bipolar affective disorder) is not known, though it is likely to be multifactorial. However, the disorders are familial, and twin and adoption studies support the hypothesis of inherited risk factors for these illnesses. Gender influences many aspects of the major psycfioses. In schizophrenia, the disease onset is earlier and the outcome is worse in males. In manic depression apparent X-linked transmission is seen in some pedigrees. Recently, anticipation has been reported in both disorders. A molecular basis in expansion of trinucleotide repeat sequences has been suggested. We identificd a polymorphic CAG repeat in the pseudoautosomal region (a candidate region for psychoses) and examined the a l l e l e f requenc ies of this repeat in 94 schizophrcnic, 95 bipolar affective disorder and 134 ethnically matched controls. We found no evidence of repeat expansions in the disease samples and allele frequencies were similar in patients and controls. However, when divided by sex, a significanlly increased frequency of the allele 2 was observed in the bipolar males compared to controls (patients 54.7 per cent vs controls 38.7 per cent, X2=6.4, p=0.01) implicating this region in the aetiology of bipolar affective disorder. Larger samples are required to confirm these observations.

cent) have 1 expanded allele and 5 (6.5 per cent) have no expansion. Of the atypical-cases 12 (25.5 per cent) have 2 expanded alleles, 1 (2.1 per cent) has 1 expanded allele and 34 (72 per cent) have no expanded alleles. Point mutation screening is in progress. These results indicate that "typical" FA can exist even in the absence of expansions. There is a significant possibility of false negative results if expansions are the only diagnostic criteria utilised. Similarly, patients with atypical ataxias should be tested for expansions.

(P.50) A SIB-PAIR BASED PEDIGREE PANEL FOR LINKAGE ANALYSIS OF BIPOLAR AFFECTIVE

DISORDER

R. Segurado, T. Mulcahy, B. Larson, C. Comerford, R. O'Connell, E. O'Mahony M. Gill.

Departments of Psychiatry and Genetics, Trinity College Dublin.

Bipolar Affective Disorder (BAD), or manic depression, is a psychiatric condition with a morbid risk of 0.5-1 per cent. Family, twin and adoption studies demonstrate that there is a strong genetic component to this disorder, however the specific aetiology remains unknown. The aim of our study is to carry out a genome-wide scan for susceptibility loci for the disorder using non-parametric sib-pair analysis. At this time, half way through the c l in ical col lect ion we have ascer ta ined and diagnosed 100 affected sibling pairs and their 1st degree relatives. Clinical methods include the use of the SCAN interview to make operational diagnoses according to DSM IV and ICD10 and the polydiagnostic OPCRIT checklist. We are using a split sample design and following preliminary validation of the pedigrees using candidate gene markers we will conduct a genome wide screen in the present pedigrees followed by a process of grid tightening and replication in the second pedigree set currently being ascertained. Using this design we will greatly improve the power to detect linkage due to reduced ethnic diversity and large sample size, in addition to the use of non- parametric analysis.

(P.49) FRIEDREICH ATAXIA WITHOUT GAA EXPANSIONS / EXPANSIONS WITHOUT FRIEDREICH

ATAXIA

F. Ryan ~, D.McCabC, R. Murphy ~, D. E. BartonL ~National Centre For Medical Genetics, Our Lady's Hospital

For Sick Children, Crumlin, Dublin 12. 2The Adelaide Hospital, Peter St., Dublin 8.

Friedreich Ataxia (FA) is the most common autosomal recessive ataxia. Major neurological findings are progressive ataxia, areflexia of the legs, pyramidal weakness and impaired sense of vibration. Cardiomyopathy and diabetes are seen with variable penetrance. In 98 per cent of cases FA has been associated with the homozygous expansion of a GAA triplet repeat in the first intron of the X25 gene. Normal range is 7 to 22 repeats and abnormal range >200 repeats. Rare point mutations have also been seen. To date, no FA patients without an expansion have been reported.

We report the findings of a study of 77 Irish patients. Fifty- six patients have symptoms satisfying the diagnostic criteria for FA and 47 have atypical symptoms. Of the patients with typical symptoms 49 (87.5 per cent) have 2 expanded alleles, 2 (2.5 per

GERONTOLOGY (P.51) USING A PRESSURE-SORE RISK ASSESSMENT AS A SCREENING TEST FOR FUNCTIONAL IMPAIRMENT

J. Donnelly, E Minahan, D. O'Neill. Age-Related Health Care, The Adelaide & Meath Hospital,

Dublin incorporating The National Children's Hospital, Dublin 8.

Medical staff often fail to recognise functional disabdity in the elderlyl.L If not identified, reversible causes are not detected and appropriate treatments and rehabilitation is not instituted. We assessed the accuracy of the Norton Pressure Sore Risk Assessment (PSRA) as a screening toot tbr functional disability, as PSRAs are carried out routinely by of the nursing staff on all hospital admissions.

We assessed 52 consecutive admissions to the geriatric units in the Meath and St. James's Hospitals. In total there were 36 female and 16 male patients. Their ages ranged from 6t to 9a with an average age of 78. A Barthel Acti vlties of Daily Living index (BADL) and a Norton Pressure Sore Risk Assessment Index were completed on each patient on admission. A BADL


of<15/20 indicates significant functional impairment. A Norton of 14 or below indicates a significant risk of developing pressure sores. Our study showed that a score of 14 or less on the Norton had a sensitivity of 42 per cent and a specificity of 100 per cent for functional disability.

This study indicates that everyone detected as being at risk of pressure sores has a very high probabil i ty of being functionally impaired. The Norton missed 58 per cent of the people identified as being impaired on the BADL. However in a clinical setting, the 100. per cent specificity may enable automatic referral to other members of the rehabilitation team.

References I. Ryall, N. et al. lr. J. Med. Sci. 1994. 2. Dickinson, E. J. Lancel 1990: 778-9.

(E52) ATTITUDES OF NURSING STAFF TO BEING INVOLVED IN SCREENING PATIENTS FOR DISORDERS

IN AN ACUTE CARE SETTING

Z. Farrell*, D. O'Neill**. *Speech & Language Therapy Department & **Age-Related

Health Care, The Adelaide & Meath Hospital, Dublin incorporating The National Children's Hospital, Dublin 8.

An increased awareness in swallowing disorders, particularly in the elderly population, has led to an increased demand for services. Speech and language therapists can help minimise risks of aspiration and feeding problems. Many referrals received by our SLT department were inappropriate, thus wasting valuable clinical time in assessment. Some patients at risk were not being detected and developed complications unnecessanly. A swallow screening form was devised to be used by nursing staff to assess swallow status of certain patient groups on admission to hospital, to improve appropriate detection of swallow problems.

A screening form was adapted and staff nurses on 2 wards were trained in its use. A questionnaire was circulated to 8 staff nurses to determine their attitude towards the screening test, after using it for 3 months.

All staff nurses indicated that they liked being involved in swallow screening. It was felt to benefit earlier detection of swallow problems on.admission. All felt that initial training was adequate but would have liked more follow up supervision by the SLT. The numbers of referrals to SLT from the 2 wards decreased, and those received were more appropriate in nature. Overall trained nursing staff demonstrated a good awareness and understanding of swallowing problems.

Conclusion: Training nursing staff in screening swallowing disorders does appear to improve earlier detection of problems, and allows the team to make earlier decisions regarding feeding if the SLT is unavailable. Research is ongoing to establish test sensitivity, specificity and inter-rater reliability.

(P.53) HYPONATREMIA IN THE ELDERLY: EVIDENCE OF AUTONOMIC NEUROPATHY?

D. Jones, J. Horan, C. Glynn, S. K. Biswas, H. Brady*, E. Mulkerrin.

*Department of Medicine & Therapeutics, Mater Hospital, Dublin, Department of Medicine for the Elderly University

College Hospital, Galway.

Hyponatremia (HN) is the most common electrolyte disorder in elderly patients. The reasons for this predisposition are not fully understood. We assessed the haemodynamic and hormonal


responses to postural challenge in a group of older patients with HN, having attempted to normalise serum sodium by fluid restriction, and compared this to age and sex-matched controls.

Fifteen patients (age 77 y _+ 8) with HN (130 mmol/L _+ at recruitment) were compared with 15 controls (age 75 y _+ 7) with normal serum sodium levels (138 mmol/L_+2). Blood pressure (BP) and pulse rate (PR) were assessed during 0 to +60 mins in the supine position, and from +61 to 90 mins in the standing position.

There was no significant difference in BP between the 2 groups. A significant increase in PR within the HN group occurred at +62 mins (from 71_+4 to 86_+5 p<0.01), and this difference persisted until +90 mins. PR in the HN group was also significantly higher than that in the control group from +63 mins to +90 mins (87_+5 vs 69_+4, p<0.01).

Evidence of altered control of heart rate following postural change has been demonstrated in older patients with HN. This may represent evidence of autonomic dysfunction in this group which could explain their predisposition in HN.

(P.55) DIETARY VALUES FOR 100 ELDERLY SUBJECTS MEAN AGE 87 YEARS IN THE BELFAST STUDY

S. E. Lennox l, A. Murphy x, H McNulty 2, I. M. Rea ~. Department of Geriatric Medicine, The Queen's University of

Belfast, UK x. Northern Ireland Centre for Diet and Health, University of Ulster, Coleraine UK 2.

Sparse information is available regarding Dietary Reference Values (DRV's) for people older than 80 yr. As part of an on going Belfast Elderly Longitudinal Free-living Ageing Study (BELFAST), dietary intakes of 100 very elderly subjects (33 males, 67 females) were collected using the 24 h dietary recall method. Subjects were apparently well, mentally alert, free- living, with a mean (sd) age of 87 (7) yr and BMI 24.5 (3.7). Mean intakes for energy and micronutrients were compared with official DRV's set for adults aged 50+{ 1 }. Total energy intake was well below the estimated average requirement (EAR) both for males at 1551_+422 kcals (EAR 2100) and females at 1537+481 kcals (EAR 1810). Substantial numbers of subjects fell below the lower reference nutrient intake (LRNI) values for a range of micronutrients: Fe (14 per cent), Ca (17 per cent), Zn (33 per cent), riboflavin (20 per cent), folate (21 per cent), vitamins B6 (4 per cent), B12 (15 per cent), C (7 per cent) and A (11 per cent). This is of concern since the LRNI is the amount estimated to be sufficient to meet the needs of the bottom 2.5 per cent of the population only. Since these >80 yr old subjects were apparently well, these findings may suggest that current DRV's are inappropriate for the 'oldest old', but this would need to be confirmed by biochemical data on nutrient status. This study highlights the need for a review of standards for this rapidly expanding sector of our population.

Reference 1. Department of Health. Report on Health and Social Subjects No. 41. HMSO, London (1991).

(P.56) INCONTINENCE PREVALENCE ON ACUTE GERIATRIC MEDICAL WARDS

H. McEvoy*, C. McMeel, D. O'Neill. Age-Related Health Ca~'e, The Adelaide & Meath Hospital,

Dublin incorporating The National Children's Hospital, Dublin 8 & *MedE1, St. James's Hospital, Dublin 8.

Incontinence is a major cause of distress to older people and


is frequently overlooked. It is also a marker of poor prognosis in diseases such as stroke. The prevalence of urinary incontinence in an Irish hospital setting is unknown although reported surveys in the United Kingdom suggest prevalence rates of 40 per cent. We studied the prevalence of urinary incontinence in consecutive medical admissions to 2 acute geriatric medical wards.

There were 64 patients, 37 women and 27 men .with a mean age of 80.4 + 7.5 yr [standard deviation]. The pattern of incontinence was: Stress Urge Mixed Unware

0 8 6 18

The prevalence of incontinence was 50 per cent and of the incont inent patients 26 were incont inent by day and 32 incontinent by night. Cognitive impairment was more common in the incontinent group with 20 scoring <7 on the Abbreviated Mental Test Score. Among the precipitating factors, 14 were on diuretic therapy and 12 had bacteruria but only 2 of these had accompanying pyuria.

This pilot study demonstrates that urinary incontinence is prevalent and often undetected by medical staff among older people in acute medical wards. A second phase of the study would establish the extent of remediable factors present and what proportion of this incontinence can be deemed to be transient after appropnate therapy.

(P,57) THE PREVALENCE OF HYPOVITAMINOSIS D AND SECONDARY HYPERPARATHYROIDISM IN AN ACUTE

GERIATRIC UNIT

R. Freaney, M. J. McKenna, M. Crowe, D. Keating. Departments of Medicine for the Elderly and Metabolism, St.

Vincent's Hospital, Elm Park, Dublin 4.

Hypovitaninosis D predisposes to the developnent of osteomalacia and has more recently been shown to influence bone turnover in elderly osteoporotic patients. An intermediate and reversible stage in hypovi taminosis D osteopathy is the accelerated bone loss associated with secondary hyperparathyroidisn. We have previously reported a high prevalence of hypovitaminosis D in patients in an acute geriatric unit . This study assesses the prevalence of secondary hyperparathyroidim in association with hypovitaminosis D in 30 patients admitted to an acute geriatric unit. Mean (+ SD) serun 25 hydroxyvitamin D [25(0H)D] was 10.8 + 4.9 nnol/L. Ninety- three per cent of values were less than 50 nnol/L. Serun parathyroid hormone was increased in 9 patients (30 per cent) and was associated with normal serum ionised calcium levels in 8 of these patients. One patient had parathyroid-mediated hypercalcaemia. Elderly residents (n=l 2) in a nursing home who were receiving low dose Vitanim D supplementation had a mean serum 25(0H)D of 81_+28 nnol/L, and all but one value was >50 nmol/L. Low dose vitamin D supplementation is a safe and effective method of treating hypovitaminosis D. Maintenance of PTH within the range for young healthy adults may prevent bone loss from increased bone turnover. C.

(P.58) THE ROLE OF VESTIBULAR FUNCTION ASSESSMENT IN THE DIZZY PATIENT

M. Colreavy, S. Hone, G. Norman, S. Widda, L. Viani. Department of Otoneurology, Beaumont Hospital, Dublin.

Frequently doctors are challenged with diagnosis and management of patients experiencing dizziness. Apart from the

medical examination, routine investigations may include vestibular function assessment by electronystagmography (ENG). During 1996, the Audiolog3~ Department at Beaumont Hospital performed 200 ENG assessments on patients referred for vestibular investigations. The purpose of this paper was to audit the vestibular assessment service by means of a postal questionnaire sent to 100 patients who had attended for ENG assessment during 1996.

This paper will discuss the results in terms of: 1. Consumer aspects of the service. 2. The implications for management of patients with dizziness.

(P.59) THE INSULIN-LIKE GROWTH FACTOR FAMILY IN SKELETAL MUSCLE DIFFERENTIATION

Galvin ~ C. M, Nolan t, O. Hardiman s. tDepartment of Zoology, University College, Belfield,

Dublin 4. IBeaumont Hospital, Beaumont Ave, Dublin 3.

Insulin-like growth factor I (IGF-I) and insulin-like growth factor II (IGF-II) are structurally related polypeptides with diverse biological properties. They, along with 10 soluble binding proteins (IGF-BP1 to IGF-BP10) and 3 membrane bound receptors (IGF-I receptor, IGF-II receptor and insulin receptor), comprise the IGF signaling family of proteins that affect the growth and development of many cells. In myoblasts, IGF-I and IGF-II have been shown to enhance both proliferation and differentiation, depending on the intracellular pathway activated. In particular it has been shown that IGF-II is produced by mouse skeletal myoblasts as an early event in their differentiation and acts as an autocrine differentiation factor. We have used C2C 12 myoblasts, an in vitro model of myoblast fusion and myotube formation, to examine the changes that occur in IGF binding protein production and in cell surface expression of IGF receptors during the differentiation process. We have observed up-regulation of the IGF-I receptor and changes in IGF binding protein production, as the cells fuse. Since the immortalised C2C12 cell line may not be completely representative of the fusion process in vivo, we are currently using primary mouse myoblasts to investigate whether changes occur in the IGF signaling system during their differentiation.

(P.60) THE MULTIDISCIPLINARY EVALUATION OF MITOCHONDRIAL DYSFUNCTION

O. Hardiman, F. Brett, O. Droogan, P. Gallagher, M. Harmey, M, King, J. Murphy, R. Perryrnan, S. Sukumaran, J. Walsh,

M. A. Farrell. Irish Institute of Neurology and Neurosurgery; School of

Biological Sciences UCD; Dublin Institute of Technology.

We have established a national multidisciplinary research unit to analyse mitochondral dysfunction in patients with suspected mitochondrial disease. We have studied a total of 60 patients in the past 12 months. Following clinical and biochemical evaluation, all patients undergo a muscle biopsy. Each muscle is divided into 3 portions: for b iochemical studies, histopathologic analysis and tissue culture. Fresh mitochondria are extracted for oxidative phosphorylation studies and evaluation of in organello protein synthesis. The individual activity of all 5 complexes of the respiratory chain is also analysed. Histopathologic evaluation includes combined staining

20 National Scientific Medical Meeting VoL 167 Supplement No. 6

with succinic dehydrogenase and cytochrome oxidase, and electron microscopy. Mitochondrial DNA is extracted from harvested mitochondria, and subjected to mutational and deletional analysis. Using these techniques, we have identified 8 patients whose phenotype and genotype are consistent with the common deletion. In addition, we have identified 6 patients with novel phenotypes, 2 of whom have the common deletion, 1 of whom has the MELAS mutation, and 3 of whom have a disorder of in organello protein synthesis.

Our multidisciplinary approach facilitates the generation of an extensive database that correlates clinical, biochemical, his topathological and genetic features of patients with mitochondrial disease.

(P.61) ADMISSION FACTORS PREDICTING NEED FOR SUBSEQUENT PEG TUBE INSERTION IN DYSPHAGIC

STROKE

G. Hughes, C. Cunningham, M. Hurson*, P. Flood*, J. B. Walsh, D. Coakley, D. O'Neill.

Mercers Institute for Research on Ageing and *Department of Clinical Nutrition, St. James's Hospital, Dublin 8.

Approximately 16 per cent of stroke patients will require enteral feeding. A proportion of these will not recover their swallows within the subsequent month and will progress to percutaneous endoscopic gastrostomy (PEG) insertion. It would be of practical benefit if these patients could be identified on admission though whether this is possible is unknown. This report looks at admission factors predicting need for PEG tube insertion.

Forty-seven patients admitted to a teaching hospital in a 14 month period, with acute stroke complicated by severe dysphagia (defined as needing all foods supplied by enteral feeding) were identified by comparing HIPE records with Department of Clinical Nutrition records. Their charts were then reviewed in detail. Patients who, subsequent to nasogastric feeding, required PEG tube insertion were compared to those who recovered their swallows. A multiple logistic regression was used to identify admission factors which predicted need for PEG.

All patients were initially treated with a nasogastric (NG) tube and 13 (28 per cent) had a PEG tube inserted subsequently. Sixteen patients (34 per cent) recovered the ability to swallow and did not need PEG insertion. Eighteen (38 per cent) died within a few weeks of admission and therefore did not receive a PEG tube. Only pre-existing ischaemic heart disease (I.H.D.) [odds ratio 2.6 (95 per cent confidence interval 1.1-6.1)] was independently predictive of need for subsequent PEG tube insertion on the regression analysis.

This initial work suggests that dysphagic stroke patients with pre-existing i.h.d, are twice as likely to need PEG tube insertion. This may indicate a worse prognosis for swallow recovery in cardioembolic stroke though this will need to be confirmed in a larger series.

(P.62) FRIEDREICHS ATAXIA PRESENTING AS LATE- ONSET SPINOCEREBELLAR ATAXIA

E McMonagle ~, E Ryan 2, O. Hardiman I. ~Department of Neurology, Beaumont Hospital, 2Department

of Clinical Genetics, Our Lady's Hospital, Crumlin.

Friedreich's Ataxia (FA) is the commonest autosomal recessive ataxia, classically associated with onset in childhood and death prior to age 30. It is characterised by progressive ataxia,

limb areiflexia, extensor plantar responses, limb weakness and sensory loss, pes cavus and scoliosis. Most patients with FA are homozygous for an unstable GAA trinucleotide expansion in the first intron of the gene frataxin. Disease severity strongly correlates with the length of the GAA repeat. Recently, atypical presentations of FA have been described, with late onset and slow progression. We present a patient who presented at age 26 with a spinocerebellar syndrome, brisk deep tendon reflexes, and slow progression. At age 30, he remains ambulatory, with moderately severe ataxia. There is a family history of neurologic disease in both paternal and maternal kindreds. DNA analysis revealed a small expansion of both alleles, (184 repeats in 1 allele). Although most patients with FA have repeats in excess of 200, a small number of affected patients have been described with shorter expansions. The findings in this patient demonstrate that atypical presentations of FA can occur with onset in adulthood, and that this diagnosis should be considered in all patients presenting with familial ataxia.

(P.63) ANTI-ACETYL CHOLINE RECEPTOR ANTIBODIES IN HIV POSITIVE PATIENTS

S. O'Sullivan, C. Merry, P. Dodd, J. Redmond, E M. Mulcahy.

Department of G.U. Medicine, St. James's Hospital, Dublin.

Myasthenia gravis is an acquired disorder of the neuromuscular junction characterised by muscle weakness and fatiguability. Fatigue is a common symptom in HIV positive patients and recent work suggests that there may be a myasthenic contribution. In this study, we assessed the prevalence of fatigue, weakness and serum acetylcholine receptor antibodies in HIV positive patients attending our clinic. One hundred consecutive patients attending the service participated in the study. Patients were interviewed about symptoms of fatigue and assessed clinically for any evidence of weakness or fatiguability. Blood was drawn for serum receptor antibodies. Ninety per cent of patients admitted to symptoms of fatigue but there was no objective evidence of same. Four patients had acetylcholine receptor antibodies but on further evaluation had normal EMG and CT thorax examinations. In our study, myasthenia gravis was not a significant factor in patient-reported fatigue.

P S Y C H I A T R Y

(P.69) OPIATE ADDICTION: EARLY AGE OF ONSET OF IV ABUSE ASSOCIATED WITH CHILDHOOD SEX

ABUSE

R. Browne, S. Keating, J. O'Connor. National Drug Treatment Centre Board, 30/31 Pearse Street,

Dublin.

The reasons behind opiate addiction are poorly understood. The aetiology has been variously attributed to social deprivation, peer pressure and familial factors. This study endeavours to establish the role of 3 easily identified and potentially destructive early life experiences in the evolution of opiate addiction in a sample of patients attending the Drug Treatment Cerltre, Dublin.

Fifty-two patients were interviewed. Demographic details, a detailed drug history and a history of exposure to sexual abuse, violence or parental alcohol abuse were all taken. Of the 52 patients interviewed 53.8 per cent were male and 46.2 per cent


were female. The mean age of patients was 27 yr (sd 8.9 yr). Sixty-three point 5 per cent were on detoxification programs and 36.5 per cent on maintenance programs. The mean age of first abusing opiates was 19.1 yr (sd 5.15 yr) and the mean duration of opiate abuse was 8.4 yr (sd 1.59 yr). The mean age of leaving school was 14.9 yr (sd 1.59 yr). Twenty-one point 2 per cent of the sample had experienced sexual abuse.(n=l 1) and 23.1 per cent had been subjected to violence as a child (n=12). Thirteen point 5 per cent described significant parental alcohol abuse (n=7).

The mean age of starting opiate abuse of those with a history of sexual abuse differed significantly from the total sample 16.7 yr (sd 2.3 yr) p=0.01. There were no such differences in those with a history of violence or parental alcohol abuse.

Early school leaving correlated with length of drug abuse R E 0.34 p=0.01 and those with a longer history of opiate abuse showed more co-abuse of benzodiazepines R 2 0.51 p=0.01.

This study demonstrates a significantly younger age of onset of opiate abuse in those with a history of sexual abuse in childhood. Acceptance of the need to address underlying issues of abuse as part of the overall strategy to help patients overcome their addiction needs to be stressed.

(P.70) THE SAMARITANS AND PARASUICIDE

B. E Cassidy% R. Smyth ~, N. E Sheppard% aKildare Psychiatric Services, Naas General Hospital, bEastern Health Board, City Gate, Dublin 8 and "Waterford Psychiatric

Services, Waterford Regional Hospital.

The object was to assess the level of knowledge of and contact with the Samaritans in a series of parasuicidal subjects. All patients presenting to a general hospital with self-harm over a 12-month period were interviewed.

Two hundred and thirteen subjects were assessed, resulting in 221 episodes (41% male, 59% female). 36.6% had a history of parasuicide. 87.8% employed self-poisoning and 12.2 per cent self-injury. Males were significantly more likely to use self- injurious methods (P<0.05). Ninety-eight point 1 per cent were aware of the role of the Samaritans. Seven point 5 per cent had considered contacting them and 1.9 per cent contacted them within a week of presentation. A further 2.8 per cent had contacted the Samaritans previously. Those with a past history of parasuicide (P<0.05) and of an older age (P<0.05) were significantly more likely to have contacted the Samaritans.

Conclusions: There was a high level of knowledge of the Samaritans present yet few contacted the service. Some considered contacting but the majority of these did not and of those with previous contact the majority did not re-establish contact. Those who did contact were significantly older and more likely to have a history of self-harm. These results highlight the difficulties faced by all agencies and professionals in attracting and accessing those at risk of suicidal and parasuicidal behaviour.

patients develop psychological problems while coping with diagnosis and treatment. As the sadness and distress they experience can be considered to be an appropriate response, rather than due to psychiatric morbidity, low levels of psychotropic drug use might be expected. It was decided to investigate this by looking at its use in patients referred to a psycho-oncology service.

The use of psychotropic medication in all patients referred to the service over a six month period was examined prospectively, using a proforma. Details recorded included class of psychotropic medication used and by whom it was prescribed. Demographic details and clinical diagnosis were also recorded.

Sixty-three patients were referred over 6 months, 48 women and 15 men, the majority of whom had metastatic disease (62 per cent). Clinically 44.5 per cent had some form of major psychiatric disorder - 39.7 per cent had an adjustment disorder. Surprisingly, 55.5 per cent were already on psychotropic medication at referral, mainly minor tranquillisers (51 per cent) and antidepressants (24 per cent), 22 per cent were on more than one drug. Following psychiatric review, further medication was prescribed in 30 per cent leaving a total of 68 per cent on some form of psychotropic drug.

While such extensive prescribing of minor tranquillisers may require monitoring, the high rate of use of psychotropic medication suggests psychological distress is recognised and pharmacotherapy a commonly used strategy in this group.

(P.72) LATE LIFE DEPRESSION - THREE YEAR PROGNOSIS

A. Denihan, I. Bruce, A. Radic, D. Coakley, B. A. Lawlor. Mercer's Institute for Research on Ageing, St. James's

Hospital, Dublin 8.

The prognosis of late life depression remains controversial. The aim of this study was to determine the 3 yr prognosis of depression in a sample of community-dwelling elderly Irish subjects.

In 1993-1994, 108 cases of depression (78 female, 30 male) were identified by AGECAT in subjects aged 65 yr and over living in the community. The subjects were followed up 3 yr later, 1996- 1997, and AGECAT diagnosis was obtained where possible.

Thirty-three (30 per cent) subjects were lost to follow up (changed address, refused interview, etc.). Follow up information was obtained on 75 (70 per cent) subjects.

Twenty-three (21.3 per cent) subjects had died in the 3 yr period. Thirty-two (43 per cent) subjects remained depressed at 3 yr, 28 of whom had comorbid anxiety symptoms, reaching cases level in 10 subjects. One (1.3 per cent) subject had evolved into an anxiety disorder, and 1 (1.3 per cent) subject was diagnosed as an organic disorder (dementia). Eight (10.7 per cent) subjects reported persistent symptoms (depression and anxiety) which did not reach full diagnostic case level.

This study suggests that depression in the elderly has a poor prognosis, with high rates of mortality and chronicity.

(E71) THE USE OF PSYCHOTROPIC MEDICATION IN PATIENTS REFERRED TO A PSYCHO-ONCOLOGY

SERVICE

R. Cullivan, J. Crown, N. Walsh. Departments of Oncology and Psychiatry, St. Vincent's

Hospital, Elm Park, Dublin 4.

It is well recognised that a significant number of cancer

(P.73) PSYCHOSURGERY: A RETROSPECTIVE REVIEW OF REFERRAL PATTERNS OVER A FIVE YEAR PERIOD

M. O'Doherty*, E K. Bridges. St. Vincent's Hospital, Fairview, Dublin, *lately of Geoffrey

Knight National Unit for Affective Disorders, Maudsley Hospital, London.

The Geoffrey Knight National Unit for Affective Disorders


(GKU) specialises in the operation of stereotactic subcaudate tractotomy (SST), offered nationally and internationally to a small number of patients suffering from severe treatment resistant affective disorders or obsessional compulsive disorders (OCD). The aim of the study was to analyse the patterns of referrals over a 5 yr period.

All referrals to the GKU for 1989 to 1993 inclusive were analysed by age, sex, psychiatric diagnosis, the referring Regional Health Authority, or country, and outcome of assessment.

A total of 218 patients, (133 females and 85 males) with a mean age of 46 yr, were referred for psychosurgery; 208 from Great Britain, 6 from Ireland and 4 from elsewhere. Three quarters of women and half of men referred suffered from affective disorder; 20 per cent of women and 40 per cent of men referred had OCD. Some 40 per cent of all referred patients proceeded to have SST. Women were more likely than men to be accepted for psychosurgery, and this applied to both affective disorders and OCD. Reasons for failing to proceed to SST included: under-treatment (26 per cent); inappropriate diagnosis (15 per cent); withdrawal of consent (6 per cent); recovery (4 per cent).

Conclusions: SST remains in demand as a treatment for severe, treatment resistant affective disorder and OCD. Of particular interest and meriting further study are: the large proportion of patients who were under-treated prior to referral; and those patients, who although accepted by the clinical team, did not proceed to surgery.

(P.74) THE OFFICIAL VERSUS THE REVEALED RATE OF SUICIDES AMONG OPIOID ADDICT DEATHS

M. O'Doherty*, A. Farrington. St. Vincent's Hospital, Fairview, Dublin. *Herbert Hone Drug

Dependency Unit, Brighton.

Officially, suicide accounts for 6-10 per cent of deaths annually among "controlled drug" users notified to the Home Office (Coroners' verdicts in England & Wales). The aim of this study was to investigate the proportion of opioid addict deaths that were definitely or likely to be due to suicide based o n :

(i) circumstantial evidence by the inclusion of opioid verdicts;

(ii) clinical judgement following examination of the coroner's records.

The inquest records of a South Thames District Health Authority of a population of approximately 250,000 were examined for evidence of deaths among opioid addicts (treated and untreated) over a 6 yr period 1986-1991.

A verdict of suicide was returned in 2 of all opioid addict deaths (n=60). This 3 per cent rate of suicide among all opioid addict deaths compared with 9 per cent for the general population of the same age range and over the same time period. Inclusion of open verdicts increased this figure to 18 per cent (compared to 14 per cent for the general population); while inclusion of likely suicides based on clinical judgement identified 30 per cent of all opioid addict deaths as suicide. Twenty-four dead addicts who died by using their drug of abuse, had a verdict of drug dependence/abuse.

Conclusions: The proportion of suicides among dead opioid addicts was found to be 3 times that for the general population and may be twice that identified by coroner's verdicts; but this

figure may be much higher in view of the "hidden suicides" not readily identified among the 40 per cent of dead addicts in which a coroner's verdict of drug dependence was returned.

(P.75) THE CHARACTERISTICS OF LONGTERM PATIENTS ATTENDING TWO PSYCHIATRIC DAY

CENTRES

B. Farragher, S. Fahy, R. Kelly, T. Carey, J. Owens. St. Davnet's Hospital, Monaghan.

Day care forms a vital component of contemporary community-orientated psychiatric service. The aim of this study is to provide a comprehensive description of a patient group (N=67, 33 males, 34 females) attending a catchment areas day centres and to outline the care provided for them. Data was collected on sociodemographic backgrouiad, psychiatric diagnosis, history of contact, material conditions and physical status. Patients ' current mental state and behaviour were assessed using the Present State Examination (PSE 10) and the MRC Social Behaviour Schedule. The predominant psychiatric diagnosis was schizophrenia (42, 63 per cent). The overall mean age was 60 yr (SD _+ 11.5 yr). Fifty-one (76 per cent) were single and 36 (54 per cent) lived in sheltered accommodation. Fifty- two (78 per cent) attended full-time. The average number of yr of contact was 26.6 (SD _+ 11.7 yr). The average length of day centre attendance was 6.5 yr (SD _+ 3.8 yr). Only 6 patients were not on psychotropic medication and only 1 patient had never been an in-patient. The assessments revealed that 42 (62 per cent) patients had significant clinical and behavioural problems and 31 (46 per cent) had social and personal skill problems in the previous 2 yr. Despite prolonged contact with the psychiatric service, this group of patients continues to have on-going difficulties and remains highly dependent on the care being provided.

(P.76) NEEDS ASSESSMENT OF TWO PSYCHIATRIC DAY CENTRE POPULATIONS

B. Farragher, S. Fahy, R. Kelly, T. Carey, J. Owens. St. Davnet's Hospital, Monaghan.

Health care planning for the mentally ill in the community necessitates an estimate being made of the need for items of care. The aim of this study was to assess the needs for care of community based long-term psychiatric patients and to determine the extent to which these needs were met. A needs assessment was carried out on all patients (N=67) attending 2 day centres using the MRC Needs for Care Assessment Schedule. Twenty areas of clinical and social need were assessed. Of 320 identified needs, 249 (78 per cent) were met, 60 (19 per cent) were unmet and 11 (3 per cent) were unmeetable. One hundred and 69 (53 per cent) were clinical needs. Of the unmet needs, 43 were for assessment and 17 were for treatment. Patients with the most contact had the greatest level of need (p<0.05). There were no statistical associations between unmet need, sex, psychiatric diagnosis, length of contact and level of attendance.

Patients attending this service had unidentified needs which were remediable by treatment. The use of a systematic and standardised method of needs assessment proved successful in identifying definite areas of need.

I.J.M.S. National Medical 23 April, May, June 1998 octenttJtc ~vleetlng

(P.77) HOMELESS PEOPLE ATTENDING GALWAY CITY PSYCHIATRIC SERVICES: A SURVEY

O. Gallagher, D. Sloan. Department of Psychiatry, University College Hospital,

Galway.

The prevalence of severe mental illness among .homeless people has been estimated at 25-45 per cent. The purpose of this survey was to obtain a socio demographic profile of the homeless psychiatrically ill in Galway.

A list of homeless people attending the psychiatric services was compiled for a 6 month retrospective period, following liaison with voluntary and psychiatric services. A review of patient records was subsequently completed.

The total number of homeless patients attending the Galway Psychiatric Services for this study period was 14. The average age was 46 yr. The majority, 57 per cent (n=8) had placements with voluntary organisations. Fifty-seven per cent (n=8) had a diagnosis of schizophrenia 3 of which had a comorbid diagnosis of alcohol dependence syndrome (ADS). Twenty-eight point 6 per cent (n=4) had a primary diagnosis of ADS. Of note 28.6 per cent (n=4) had failed to manage in placements supervised by the psychiatric services. One case had a significant forensic history (7 per cent). The age and gender distribution corresponds to those found previously in Britain. The dearth of positive forensic histories is in contrast to the high prevalence in British cohorts.

(P.78) PREVALENCE OF AND RISK FACTORS FOR DEPRESSIVE DISORDERS IN URBAN AND RURAL

SETTINGS IN IRELAND

C. McDonough, P. Casey, A. Horgan, A. Elneihum. Department of Adult Psychiatry, Mater Misericordiae

Hospital, Dublin 7,

The aim of this study is to provide data on the prevalence of and risk factors for depressive disorders in urban and rural settings in Ireland.

Dublin City is selected as the urban and Co. Laois as the rural area using agreed criteria. The sampling frame is adults aged 18-64 identified via primary care data bases. Potential cases of depressive disorders are identified by postal questionnaire using the Beck Depression Inventory (BDI) with a score of 13 and above as cut-off. Following this, Scan II and other validated measures are used at clinical interview to: assign caseness against DSMIV and ICD10 criteria; and assess risk factors and utilization of local health care services.

The results to date 13.1.98: Dublin 1066 urban screening questionnaires sent 328 screening questionnaires returned completed. 36 cases identified to date. Cases/questionnaires returned (%) = 10.97 per cent

baois 498 rural screening questionnaires sent Screening questionnaires returned completed. 6 cases identified to date Cases/Questionnaires returned (%) = 5.43 per cent

As fieldwork is still in progress conclusions are as yet provisional. There appears to be a greater incidence of depression in the urban centre. The figures are in keeping with the European average of 4.6-8.8 per cent point prevalence for depression.

This study is part of "The Outcomes of Depression International Network" (ODIN) with research centres in Britain, Ireland, Norway, Finland and Spain. Funded in part by the EU (Biomed 2 program).

(P.79) HYPNOTIC PRESCRIBING PRACTICE: 10 YEARS AGO AND NOW

C. O'Neill, T. McMonagle. St. Loman's Hospital, Dublin 20.

The purpose of the study was to compare hypnotic prescribing practices in psychiatric inpatients in 1987 with those in 1997 in order to ascertain whether the introduction of newer agents with lower abuse potential and enhanced awareness of the risks associated with benzodiazepines have affected prescribing practice during this period.

Case notes of 50 patients admitted to a Dublin psychiatric hospital during February and March of the 2 yr studied were examined and hypnotic medications on admission, those prescribed during hospital stay, and those prescribed at discharge were collated and compared.

Results: 1987 1997 Number of patients 50 50 % on hypnotics on admission 18 44 % prescribed hypnotics in hospital 50 70 % discharged on hypnotics 30 54 Benzodiazepines as % of prescriptions 100 83

Conclusions: Hypnotic prescribing practices have not improved in the past 10 yr on the basis of this sample. A further study involving larger patient numbers is proposed to further evaluate this, and using the complete audit cycle to attempt to improve this practice.

(P.80) INVOLUNTARY MOVEMENTS IN SCHIZOPHRENIA: GENERIC VULNERABILITY WITH

FRONTAL LOBE DYSFUNCTION

J. Quinn ~, D. Meagher ~, P. Murphy z, A. Kinsella 3, J. Mullaney 4, J. L. Waddington s.

ISt. Davnet's Hospital, Monaghan; 2St. Loman's Hospital, Mullingar; 3DIT; 4St. Ita's Hospital, Co. Dublin; 5RCS1,

Dublin 2.

In schizophrenia, the emergence of involuntary movements (IM) is presumed to be a late-onset side effect of antipsychotic drug treatment. We have examined cognition and medication history in 128 patients to identify predictors of IM. The prevalence of IM increased with age, such that in those aged >75 vulnerability approached 100 per cent: prevalence 93 per cent [95 per cent CI 81-98 per cent]. Using regression modelling, poor performance on a frontal lobe test (P<0.001) and lower current dosage of antipsychotic (P<0.05) were the only variables to independently predict IM; this association held for orofacial rather than for limb-truncal movements, which were predicted by general cognitive impairment. These data indicate the prevalence of IM to approach 100 per cent over a lifetime of schizophrenia, and relate IM int imately to frontal lobe dysfunction within the disease process.

These studies were supported by the Stanley Foundation.


(P.81) PSYCHOTHERAPY IN IRELAND

S. Rooney. Southern Representative of Trainees in Psychotherapy,

National Drug Treatment Centre, Pearse Street, Dublin 2.

The aim of the study was to assess the experience and satisfaction of psychotherapy training in members of the Psychotherapy Section of the Irish Division of the Royal College of Psychiatrists. A questionnaire was compiled and sent to 100 members of the section. Results were compared between Northern and Southern Ireland and between consultants and non consultant hospital doctors.

There was a 46 per cent response rate. Proportionally more doctors in Southern Ire land had obtained mandatory psychotherapy, exper ience in cogni t ive-behavioura l psychotherapy while doctors in Northern Ireland had more mandatory psychotherapy experience in Balint groups, psychoanalytical, family and group psychotherapy. Over 50 per cent of doctors from Northern and Southern Ireland were receiving 1 hr or less supervision per month in cognitive- behavioural, group, family and brief focus psychotherapy. Consultants clearly had more psychotherapy experience and were significantly more satisfied with their psychotherapy training and level of supervision. Significantly more non consultant hospital doctors believed they needed further training in psychoanalytical, cognitive-behavioural, group and brief focus psychotherapy.

Conclusions: 100 per cent of the sample felt there should be improvements in the training of psychotherapy in Ireland.

(P.82) CO-ABUSE OF HEROIN AND BENZODIAZEPINES

S. Rooney, L. Bamford, D. Sloan, J. J. O'Connor. National Drug Treatment Centre, Pearse Street,

Dublin 2.

The objective of the study was to assess what differences exist between ind iv idua l s dependent on opiates and benzodiazepines and compare to those who are dependent on opiates.

A questionnaire was compiled and administered to patients who had been consecutively admitted to an inpatient drug treatment unit. Thirty-four treatment episodes required a benzodiazepine detoxification programme and the remaining 29 treatment episodes constituted the control group. The prevalence of benzodiazepine dependency was 54 per cent (n=34). Significantly more in the benzodiazepine detoxification group were older, had been admitted for a methadone stabilisation programme and were more likely to have been prescribed methadone maintenance programme prior to admission. This group were significantly more likely to have had a depressive illness and an episode of deliberate self harm in the past. They had used heroin longer and tended to use more drugs in general. The three most popular benzodiazepines used were diazepam, flunitrazepam and flurazepam. These were used more frequently, at larger doses and for a longer duration of time. Significantly more of this group were discharged to the National Drug Treatment Centre to continue treatment.

Conclusions: Dependency on heroin and benzodiazepine indicates a more severe and chronic pattern of drug misuse.

(P.83) ANAESTHESIOLOGY CANCELLATIONS IN ELECTIVE SURGERY - AN AUDIT

R. Franklin, K. O'Brien, G. Fitzpatrick. Dept. of Anaesthesia, Adelaide Hospital, Peter St., Dublin 8.

The purpose of this study was to quantify the incidence of cancellations in an elective surgical practice and to determine the reasons for such cancellations. The study was carried out prospectively over a 4 month period in an elective surgical suite. Data was collected on all patients scheduled for surgery at 4 pm the previous day and subsequently cancelled. During the study period 1149 patients were scheduled for surgery. Of these 107 (10.7 per cent) were cancelled. Thirty-two patients (30 per cent of cancellations) failed to show for surgery. Thirty-nine patients (36 per cent) were cancelled by the anaesthetist because of an in tercurrent medical condi t ion requir ing t reatment or optimization. Of these 14 had a chest infection, 8 had unstable cardiac condition, 8 had unacceptable high blood pressure and 5 were taking oral contraceptives. Eighteen (15 per cent) were cancelled by the surgeon because original symptoms had disappeared or because of uncertainty about diagnosis and 15 patients (14 per cent) were cancelled because of scheduling errors. In conclusion a 10 per cent cancellation rate represents significant waste of theatre resource. This could be improved by better patient education, and by shifting preoperative assessment into the preadmission phase of care.

(P.84) ANTIEMETIC PROPHYLAXIS DURING PATIENT CONTROLLED ANALGESIA - CYCLIZINE VS

DROPERIDOL

J. G. Laffey, J. F. Boylan. St. Vincent's Hospital, Elm Park, Dublin 4.

Patient controlled analgesia (PCA) is frequently complicated by PONV and the optimum method of prophylaxis is unknown t. Cyclizine and droperidol are superior to placebo in PONV prophylaxis, but their relative efficacy and side effect profile have not been compared. We assessed antiemetic sequelae, pain and sedation in patients receiving PCA following gynaecologic surgery in a double-blind, randomised trial.

After IRB approval and writ ten consent, 25 women undergoing abdominal hysterectomy entered the study. Patients received a standardised anaesthesia technique and underwent surgery via a transverse incision. Each was assigned to receive either cyc l iz ine (group C) or droperidol (group D) perioperatively. Intravenous morphine sulphate 0.15mg/kg was administered prior to skin incision. Patients received cyclizine 0.7mg/kg or droperidol 0.04mg/kg intravenously 15 mins before abdominal closure, followed by PCA containing morphine sulphate (1 mg bolus) with cyclizine 2mg or droperidol 0.05mg per demand. Blinded observers scored nausea, sedation (Treiger test) and pain (visual analogue scores, PCA use) for 48 h. Nausea was scored using a 5 point ordinal scale. Data were analysed by unpaired t tests and Mann-Whitney U test.

Demographics, pain scores and PCA usage were comparable in both groups. Two patients in each group developed refractory PONV.

Cyclizine and droperidol are equally effective' in antiemetic prophylaxis during PCA, with similar side-effect profiles. A significant minority of patients have refractory PONV despite prophylaxis and treatment.

Reference 1. CanAnaesth. Soc. 1984; 31: 178-87.


(P.85) PATIENT KNOWLEDGE OF PERIOPERATIVE CARE IN AN IRISH TEACHING HOSPITAL

J. Laffey, M. Coleman, J. Boylan. Department of Anaesthesia, St. Vincent's Hospital, Dublin 4.

Recently the public has taken an increasing interest in medicine. However, its percept ion of medical terms, perioperative care and the role of anaesthetists remains limitedk This may limit the validity of informed consent and compromise the preoperative anaesthetic visit. We examined patient knowledge and attitudes concerning perioperative care and the role of the anaesthetist and determined what, if any, improvement in patient knowledge occurred during an elective inpatient stay.

Following ERB approval, 300 patients answered a multiple choice questionnaire. Patient groups were surveyed either before their perioperative visit, after the visit, or after surgery.

Knowledge of commonly used terms and their functions was limited. Twenty-five per cent patients believed that oxygen was an analgesic or antiemetic. These deficits were not improved by preoperative visiting or postoperative ward exposure. Patients' understanding of the role of the anaesthetist was similarly limited, with only 49 per cent of patients surveyed prior to preoperative assessment knew that anaesthetists were medically qualified. This increased to 72 per cent after the visit but declined to 64 per cent postoperal~ively, demonstrating the transience of the knowledge acquired. Thirteen per cent of postoperative patients did not know what procedure they had undergone and 25 per cent did not know the name of their surgeon�9 Comparable proportions of patients admitted to fear of surgery, postoperative pain, awareness, and death. In general, female, younger, higher SE group patients had greater knowledge and expectations.

Patient knowledge concerning perioperative care remains limited and improves only marginally during hospital stay. If increased patient participation is to be realised it will require novel approaches to patient education.

Reference 1. Klafta, J. M., Roizen, M. F. Anaesth Analg. 1996; 83: 1314-21.

(P.85) CAN A NEURAL NETWORK ENHANCE PREDICTION OF RESIDUAL NEUROMUSCULAR

BLOCKADE?

J. G. Laffey, A. J. McShane, J. F. Boylan. St. Vincent's Hospital, Elm Park, Dublin 4.

Residual neuromuscular blockade [RNMB] following surgery is common and its detection has a high error rate, especially in training ~. Artificial neural networks (ANN) are increasingly used to examine complex data z. We hypothesized that ANNs would enhance prediction of RNMB.

In 40 patients, neuromuscular function, relaxant/reversal usage and time intervals were recorded throughout anaesthesia until tracheal extubation by an observer uninvolved in patient care. RNMB was defined as significant "fade" (train of 4 < 0.7) at extubation. Using a jackknife method, a back-propagation ANN model (Neuralyst 1.40, Cheshire) provided probability values from 0 to 1 for predicted RNMB (Poro~) and compared it to the occurrence of observed RNMB (P,,h)" Successful prediction was defined as P h-PpF,j < 0.1. Based on previous data j the network was trained examining the impact of (i) degree of

spontaneous recovery and (ii) time since pharmacological reversal. Data were analyzed by Z 2 test.

Clinical pre-extubation detection of RNMB had a sensitivity of zero and specificity of 1. ANN-based prediction had a sensitivity of 93 per cent (Z 2 = 46.6, P < 0.0001) and specificity of 79 per cent (P = 0.66).

Clinicians' assessment of pre-extubation neuromuscular function is poor. The sensitivity of ANN-based prediction is substantially better than that of human judgment; this enhanced sensitivity is obtained without an excessive decrease in specificity. Although neuromuscula r moni to r ing is semiquantitative, our data may suggest that failure to detect RNMB is related to human factors rather than monitoring limitations.

References 1. Anesthesiology 1995; 83: A1077. 2. Lancet 1995; 346: 1203-7.

(P.87) PATIENT POSTURE AND EPIDURAL CATHETER INSERTION

J. P. R. Loughrey, J. Gardiner. Department of Anaesthesia, Rotunda Hospital, Dublin.

The posture of patients at epidural insertion is usually determined by the preference of the anaesthetist. A previous study concluded that the determining factor in terms of ease of insertion lay in the previous experience of the anaesthetist ~.

A prospective audit of 254 parturients was carried out, examining patient preference for posture at epidural insertion (lying vs sitting), investigating ease and complications (vessel puncture, dural tap) of insertion�9 The epidurals were inserted by a single anaesthesia trainee, thus reducing bias from personal preference or experience. Analysis of data was with Students' T-test, Chi-squared test and 95 per cent confidence interval.

The 2 groups were comparable in terms of age and body mass index. Of the primigra~,idas (n=130), 62 per cent opted for the sitting posture. Overall, 56 per cent of parturients opted for a sitting posture. This was associated with greater ease of insertion (86 per cent first pass, 95 per cent C1 - 0.06-0.26). There was no significant difference in complication rates during insertion between the 2 postures�9

Reference 1. Stone, P. A., Kilpatrick, A. W. A., Thorburn, J. Posture and epidura! catheter insertion. Anaesthesia 1990; (45): 920-923.

(P.88) ATTENUATION OF BRADYCARDIA DURING GYNAECOLOGICAL LAPAROSCOPY USING

GLYCOPYRROLATE

J. McGinley, I. Leonard, M. Carey. Department of Anaesthesia, Coombe Women's Hospital,

Dublin 8.

Dysrhythmias may complicate gynaecological laparoscopy. In our unit, we noted a recurring incidence of bradycardia (heart rate <50 beats per min) during insufiation of pneumoperitoneum


at laparoscopy. Such bradycardias respond to anticholinergic administration however some may lead to asystolic cardiac arrest. Glycopyrrola te , a quaternary amine muscarinic antagonist, avoids the central cholinergic side effects often seen with atropine. The goal of our study was to evaluate the attenuation of bradycardia during gynaecological laparoscopy using pre-emptive glycopyrrolate (0.2rag IV).

Sixty females (ASA I and II) scheduled for gynaecological laparoscopy were studied. In a randomized, double blind, placebo controlled trial, 30 females received glycopyrrolate 0.2mg IV and 30 received saline, immediately prior to induction of anaesthesia. Bradycardia < 50 bts. per mm. was treated with atropine 0.6mg IV. Parametric data was analyzed using the Student t-test.

Nine patients in the placebo group required atropine, 1 of these patients developed a brief asystolic cardiac arrest. No patient in the glycopyrrolate group required atropine. Heart rates were significantly higher in the glcopyrrolate group at intub~ition (P<0.05) and remained higher for up to 4.5 mins after insuflation of pneumoperitoneum (P<0.05). There were no significant differences in MAP at intubation or initial insuflation of pneumoperitoneum. Glycopyrrolate confers cardiovascular stability and avoids the unwanted effects of atropine (blurred vision, dry mouth and confusion) in this patient population.

We recommend the use of pre-emptive glycopyrrolate in elective gynaecological laparoscopy.

(P.89) SPINAL HEADACHES: HOW LITTLE WE KNOW !

P. Neligan, J. O'Rourke, A. Cunningham. Beaumont Hospital, Dublin.

Headache is a well recognised complication of lumbar puncture. The incidence of post dural puncture headache (PDPH) has been shown to be reduced by using fine gauge and pencil tipped spinal needles. Treatment of a PDPH is with fluids, bed rest, NSAIDs, caffeine and, if persistent, an epidural blood patch. The purpose of this study was to demonstrate that many doctors are unaware of these facts.

One hundred non consul tan t hospital doctors were interviewed, including 20 anaesthetic trainees. Each was asked how many LPs they had performed, to select (from a display case) the spinal needle which they routinely used, what they knew about PDPH and its treatment, and if they were familiar with pencil tipped needles.

Ninety per cent of anaesthetists interviewed routinely used 25G pencil tipped spinal needles. Of the non anaesthetist group (NAG) 86 per cent routinely used 22G or larger cutting needles (only 1 used 25G or smaller). Only 12.5 per cent of the NAG had heard of pencil tipped needles; 95 per cent (of the NAG) suggested PDPH as a complication of LP; 37.5 per cent (vs 100 per cent of anaesthetists) knew to treat PDPH with fluids 69 per cent (vs 85 per cent) with NSAIDS, and 46 per cent (vs 100 per cent) with a blood patch; 57 per cent had heard of epidural blood patches but only 18.75 per cent knew how they were performed.

Conclusion: this study suggests that most doctors are unaware of well described methods of preventing and treating post dural puncture headache.


CARDIOVASCULAR (P.90) TAURINE RESTORES ENDOTHELIAL

DEPENDENT BUT NOT INDEPENDENT DYSFUNCTION IN YOUNG HEALTHY CIGARE'VI'E SMOKERS

F. Fennessy, C. Kelly, D. Bouchier-Hayes. Royal College of Surgeons in Ireland, Beaumont Hospital,

Dublin.

Abnormal vasoactivity in response to physiological stresses is a feature of established cardiovascular diseases. It manifests as reduced vasodilatation or paradoxical vasoconstriction in response to increased blood flow or cold pressor stimulation. Flow-dependent dilatation (FDD) is known to depend on intact endothelial function, and the cold pressor test (CPT) on both endothelial dependent and independent functions. Using B-mode ultrasound, we examined the effects of smoking on FDD and the CPT. We postulate that cigarette smoking impairs endothelial dependent and independent functions. We also investigated the effects of taurine, an anti-oxidant which also upregulates nitric oxide production, on the responses of smokers. Flow-mediated dilatation was observed in control subjects, but was impaired in smokers (*p<0.005). Oral supplementation of taurine restored dilatation (**p=0.005). Cold pressor induced vasodilatation was present at 1 minute in controls, in contrast to smokers in whom a vasoconstriction was induced (***p=0.02). After taurine supplementation cold pressor induced vasoconstriction was reduced (****p=0.05), but vasoactivity was not restored to that of controls.

Flow-dependent dilatation (mm) non-smo smo* srno tx. taurine** 0.37+0.09 0.025+0.01 0.36+0.04 Cold Pressor vasoactivity non-smo smo*** smo tx. taurine**** 4.22+5.04% di la ta t . 4.04+1.34% const. 0.5+1.9% const.

These data confirm the presence of abnormal endothelial dependent and independent vasoactivity in otherwise healthy young smokers. Taurine treatment can restore endothelial dependent function. Treatment of smokers endothelium does not completely restore normal haemodynamics underscoring the need to eschew cigarette smoking.

(E91) SMOKING AND SHEAR STRESS INDUCED ENDOTHELIAL CELL ANOIKIS MAY BE PREVENTED

BY THE AMINO ACID TAURINE

E Fennessy, J. H. Wang, C. Kelly, D. Bouchier-Hayes. Beaumont Hospital, Royal College of Surgeons in Ireland,

Dublin.

Vascular endothelial cells (ECs) require attachment to the extracellular matrix (ECM) for growth and survival. Loss of this anchorage dependence by disruption of the ECM results in anoikis, or apoptosis from lack of anchorage. Anoikis may be the result of either mechanical or chemical stresses. Cigarette smoking increases shear stress (SS) and oxidant-mediated EC damage. We hypothesise that 1) increases in SS in vivo result in increases EC death by apoptosis and that 2) taurine treatment of young smokers may prevent the increase in apoptosis induced by smoking. We studied 7 healthy smokers with a self-reported smoking history of 2-pack yrs; and 11 control non-smoking subjects. Circulating endothelial cells were isolated from a peripheral blood sample and counted. On 2 occasions


fluorescein-labelled anti-human factor VIII related antigen mAb was used to confirm the identity of these ceils. Apoptosis was confirmed with the terminal deoxynucleotidyl transferase- mediated dUTP nick end labelling (TUNEL) technique using the In Situ Cell Death Detection Kit (Boehringer Mannheim). Samples were also taken before and after inflation and subsequent deflation of a cuff to 240mmHg for 4.5 rains. (n=8), and before and after treatment of smokers with taurine, 1.5gms/ day/5 days (n=7).

No. of apoptotic cells/0.9 microlitre chamber Non-smo Smokers Tau. Tx. smokers Baseline Increase SS 0.93_-t-0.42 3.295:1.43" 1.11:L--0.59'* 1.06_+0.29 2.4+-0.77*** p=0.02 vs non-smo; **p=0.006 vs smo; ***p=0.002 vs baseline

This study reveals that increases in SS acutely, and cigarette smoking chronically induce anoikis. The amino acid taurine has the capability to prevent EC apoptosis and may play an important role in endothelial cell functioning and survival, which in turn may modify the progression of atherogenesis and cardiovascular disease.

(P.92) TAURINE PREVENTS SMOKERS MONOCYTE- CONDITIONED MEDIUM DOWNREGULATION OF NO ~

AND UPREGULATION OF ENDOTHEL1N-1

F. Fennessy, J. H. Wang, C. Kelly, D. J. Bouchier-Hayes. Department of Surgery, R.C.S.I., Beaumont Hospital, Dublin.

Cigarette smoking is a major risk w for cardiovascular disease and increased monocyte-endothelial interactions have been implicated in the pathogenesis. We investigated the effect of monocyte-conditioned medium (MCM) of young smokers on endothelial nitr ic oxide (NO ~ and Endothe l in- l (ET-1) production, and if MCM of taurine-treated smokers would normalise these responses. Peripheral mononuclear cells were isolated and medium was conditioned. Endothelial cells were co-cultured with MCM, ET-1 and NO production was measured and the experiment was repeated post supplementation of taurine. 1. Endothelin-1 production (picograms/ml supernatant) Groups 24 hr. incubation 48 hr. incubation smoker 78.87+8.6 66.77+13 non-smoker 32.9+3.9* 37.25+5.5* tau. tx. smoker 31.5+6.98 33.40+-9.5" 2. Plasma Nitrite production (ktM nitrite/ml supernatant) Groups 24 hr. incubation 48 hr. incubation smoker 0.17+0.16 0.38_+0.18 non-smoker 1.40-2_0.24* 1.90+_0.42* tau. tx. smoker 1.89+_0.31 * 3.80+_0.80*

These data provide conclusive evidence that monocyte functioning and its interaction with the endothelium is abnormal in smokers, and suggest that the effects of monocytes may be mediated through soluble factors. Monocytes of smokers treated with taurine can restore NO and ET-1 released from endothelium to control non-smoking levels, suggesting that modification of monocyte as well as endothelial functioning is important in the prevention and management of cardiovascular disease.

(P.93) PERFORMANCE OF A PREDICTIVE INSTRUMENT OF ACUTE MYOCARDIAL INFARCTION MORTALITY

J. Kellett. Nenagh General Hospital, Nenagh, County Tipperary, Ireland.

The performance of a predictive instrument of acute


myocardial infarction (AMI) mortality, based on clinical and ECG findings available immediately at the bedside was assessed on 250 consecutive patients. The clinical data and ECG findings used by the instrument to predicted mortality were prospectively entered into a computer data base. Patients were placed in ascending order of predicted mortality, and then divided into 5 equal quintiles. The predicted and observed mortality rate for each quintile were:

Quintile Age (years) O b s e r v e d Predicted Mortality Mortality

I 57.1+9.5 1 (2%) 2.8% II 62.8+9.4 3 (6%) 7.2%

Ili 69.9+10.2 6 (12%) 12.7% IV 73.6+7.1 12 (24%) 22.7%

V 74.8+7.5 19 (38%) 49.8%

Mortality rate from AMI can, therefore, be predicted accurately within minutes of patient presentation using readily available clinical and ECG data. This prediction enables high risk patients, likely to benefit from thrombolytic therapy to be quickly distinguished from those patients for whom the hazards of thrombolysis may not be justified.

(P.94) COST BENEFIT ANALYSIS OF SPINAL CORD STIMULATION IN INTRACTABLE ANGINA PECTORIS:

A WIN-WIN SCENARIO?

J. Laffey, D. Murphy, J. Regan, D. O' Keeffe. Department of Anaesthesia, St. Vincent's Hospital, Dublin.

Spinal cord stimulation (SCS) is well established in the management of patients with intractable pain and has more recently been applied to patients who suffer from incapacitating angina ~. This is the first report in these Isles to highlight both improved quality of life and favourable cost/benefit profile in such a patient.

A 61 yr old ma/a had intractable angina which remained refractory to maximal an t iangina l therapy and 6 revascularisation procedures (CABGX3 PTCA X3). Coronary angiography revealed diffuse distal coronary arterial disease, unsuitable for revascularisation. In view of his ongoing anginal pain, functional limitation, and lack of response to medical therapy, a SCS device was inserted.

At 1 yr post insertion, this man has experienced a marked improvement in his quality of life, with decreased frequency and severity of anginal attacks. A stress ECG demonstrated increased exercise duration, time to onset of angina, and maximal heart rate.

Costs in the 3 yr prior to insertion total over s This includes 140 inpatient days, a coronary angioplasty, and 2 coronary angiograms. Inpatient costs alone in yr prior to insertion of the SCS amount to s Costs in the yr post insertion of the SCS total s including device and its insertion costs of s and repositioning and reprogramming costs of s This represents a saving to the health service of at least s in the first yr.

SCS implantation for the treatment of intractable angina may not only improve quality of life but is cost effective.

Reference I, Barolat, G. Neurosurg. Quarterly 1995; 5(2): 98-124.


(P.95) SMOKING MAY INFLUENCE THE VASCULAR RESPONSE TO GLYCERYL TRINITRATE

A. Mahmud, L. Hemeryck, J. Feely. Department of Pharmacology and Therapeutics, Trinity

Centre for Health Sciences, St. James's Hospital, Dublin 8.

Nitrates such as glyceryl trinitrate (GTN) through release of endogenous nitric oxide (NO) produce vascular dilatation. In patients with coronary heart disease and high oxygen free radical activity there may be paradoxical vasocontrictor response to released NO. We compared vascular effects of GTN in hypertensives on treatment and normotensive controls.

A single sublingual dose of GTN 400 }.twas given to 10 hypertensives (mean age 56+11) and l0 normotensive controls (mean age 44+10). Measurements were taken by Finapress | before and at frequent intervals up to 30 minutes after GTN. Headache was noted in 4 hypertensives. Results (mean, SD) were analysed by the Wilcoxon's Rarrk Sum test and Anova, p*<0.05 compared with baseline.

Variable Baseline 30 minutes Control Hypertension Control Hypertension

Systolic BP 1 1 1 + 1 0 146+13 126+11" 143+21 Diastolic BP 59+6 76_+13 63_+2 78_+13 Mean Arterial Pressure 76+7 99-+18 83-+3 99_+14 Pressure 51_+6 68_+23 63_+12" 73_+ 13 Pulse per min 69_+11 70-2_13 70-+9 73+13

There was no significant change in blood pressure responses in hypertensives. In contrast, there was a steady rise from 15 rain, reaching significance at 30 min in normotensives associated with a larger pulse pressure. The rise in systolic BP was most marked in normotensive smokers (n=5, p<0.05). This late rise in systolic BP in normotensives may indicate an abnormal vascular responsiveness to GTN in those who smoke.

(P.96) EVIDENCE OF IMPAIRED ARTERIAL COMPLIANCE AND ENDOTHELIAL DYSFUNCTION IN

HYPERTENSION

A. Mahmud, L. Hemeryck, M. Hall, J. Feely. Department of Pharmacology and Therapeutics, Trinity

Centre for Health Sciences and Hypertension Clinic, St. James's Hospital, Dublin 8.

Pulse wave velocity (PWV) is a measure of compliance (C) of large arteries and prolonged PWV may be related to increased cardiovascular risk. The response to glyceryl trinitrate (GTN) which causes release of endothelial derived relaxing factor, NO, is a measure of endothelial function. To further investigate vascular reactivity in hypertension we compared PWV in 8 hypertensives (age, mean + S.D. 54+12) to 8 normotensive controls (49+6 yr), PWV was measured from the delay of foot wave between the carotid and femoral artery with the Complior | and taken as measure of arterial C. Blood pressure responses were measured s imul t aneous ly with the Finapress | Measurements were made before and at 10 min following sublingual GTN (400~tg). Results (mean + SD) were analysed by Student's 'F test and paired T test.

The aortic PWV (cm/sec) was prolonged (p<0.05) in the hypertensives (13.3_+3) compared to normotensives (10.9+1), There was no significant change in PWV in response to GTN in the hypertensive group at 10 min (13.6+3) while the PWV was reduced in the control group (9.94_+2, p<0.05). There was no

significant change in blood pressure and heart rate in either group.

Our results indicate that hypertension is accompanied by increased arterial stiffness and decreased C. The lack of response of PWV to GTN in the hypertensive group may also suggest a role of endothelial dysfunction (possibly relative NO deficiency) in the pathogenesis of hypertension.

(P.97) RELIABILITY OF QUANTITATIVE TROPONIN I MEASUREMENT

I. B. A. Menown, T. E Mathew, G. S. Nesbitt, M. Syme, I. S. Young, A. A. J. Adgey.

Regional Medical Cardiology Centre & Department of Biochemistry, Royal Victoria Hospital, Belfast.

Elevation of Troponin I (TnI) within 12 h of admission for acute cardiac chest pain has been shown to be of independent diagnostic and prognostic value. However some concern has been raised regarding immunoassay imprecision and stability of whole blood/serum samples prior to separation/freezing.

Inter-batch imprecision (n=10) was determined for TnI at 2 levels. TnI stability was assessed at room temperature on samples obtained from 7 patients <12 h following admission with acute myocardial infarction. Stability in whole blood was assessed by measuring TnI following increasing delays from venesection to separation (0.5-24 h). Stability in serum was assessed by measuring TnI following increasing delays from separation to freezing at -20~ (0.5-24 h). Freeze/thaw serum stability was assessed by measuring TnI following each of 4 freeze/thaw cycles. Data were compared by repeated measures analysis of variance (ANOVA).

Inter-batch coefficient of variance was 10.3 per cent at a mean TnI of 1 5.43ng/ml, and 4.7 per cent at a mean TnI of 20.45ng/ ml. No significant linear trend in mean TnI (ng/ml) was observed with increasing delays in either separation of whole blood or freezing of serum (see table), nor following each of 4 freeze/ thaw cycles.

TnI stability 0.5h lh 2h 3h 4h 5h 6h 12h 24h wholeblood 32.9 32.9 32.5 33.5 31.9 32.5 29.4 34.0 32.3 serum 32.3 31.8 34.3 34.3 32.7 33.4 32.3 34.4 35.0

In conclusion, whole blood or serum samples remain stable for at least 24 h at room temperature, and for at least 4 freeze/ thaw cycles.

(P.98) IMPROVING ELECTROCARDIOGRAPHIC DETECTION OF RIGHT VENTRICULAR AND

POSTERIOR WALL INVOLVEMENT IN ACUTE INFERIOR MYOCARDIAL INFARCTION

I. B. A. Menown, E Turtle, J. Allen, J. Anderson, A. A. J. Adgey.

Regional Medical Cardiology Centre, Royal Victoria Hospital & University of Ulster, Belfast.

Right-ventricular (RV) or posterior wall involvement in acute inferior myocardial infarction (MI) has important therapeutic and prognostic implications. However, RV and posterior chest leads in addition to the 12-lead ECG are required for accurate detection. Body surface mapping (BSM) has greater spatial sampling and may thus further improve infer ior MI classification.

We studied 479 consecutive patient (pt) admissions with chest

I.J.M.S. April, May, June 1998 National Scientific Medical Meeting 29

pain <12 h. Pts were included if > lmm ST elevation (ST'I') was present in >22 contiguous inferior leads (II, III, aVF) of the 12- lead ECG. Pts with bundle branch block or left ventricular hypertrophy were excluded. A 12-lead ECG, RV leads (RV2, RV4), posterior chest leads (P-V7, P-V9) and an 80-lead BSM (64 anterior and 16 posterior electrodes) were recorded. From each BSM, regional RV and posterior isopotential maps (J point+60ms) were calculated. Infarct size was estimated by serial cardiac enzymes.

Acute MI occurred in 173/479 pts and 62 met the inclusion criteria for inferior MI. Presence of ST'I" in RV or posterior chest regions was detected more frequently by regional maps than by RV or posterior chest leads (p<0.01). Pts with ST$ on RV and/ or posterior regional maps had a trend towards larger infarct size (mean Peak CK 1789+226 vs 1546+392 p=ns).

ST'I'_>0. I mV STI"_~.05mV _>0.1 mV RV2 10 (16%) PV7 4 (6%) 1 (2%) RV4 26 (42%) PV9 5 (8%) 0 (0%) RV2orRV4 26 ( 4 2 % ) PV7orPV9 6 (10%) 1 (2%) RV-map 36 (58%) Posterior map 22 (36%) 17 (27%)

In conclusion, when compared with RV or posterior chest leads, BSM provides improved classification of pts with acute inferior MI.

(P.99) INVASIVE CARDIOVASCULAR PROCEDURES ON A DAY BASIS IN IRELAND - IS THE POTENTIAL BEING

REALISED?

R. O'Hanlon, M. B. Codd, S. Walkin, H. A. McCann, D. D. Sugrue.

Departments of Epidemiology/Cardiology, Mater Misericordiae Hospital, 71 Eccles Street, Dublin 7.

Investigation and treatment on a day basis has been shown to be a safe, efficient and cost effective alternative to hospital admission for certain conditions and patients. The proportion of coronary angiography carried out on a day basis varies widely (17-100 per cent) depending on country, time period, facilities and physician preference. Performance of day percutaneous transluminal coronary angioplasty (PTCA) is considerably less common. This study examined the performance of day coronary angiography and day PTCA at the Mater Hospital (MMH) and nationally. MMH and National Hospital In-Patient Enquiry (HIPE) data (1993-96) were reviewed using relevant ICD codes. On average, 1,500 diagnostic coronary angiograms are performed annually at MMH; 6,500 are performed nationally. At MMH, 60 per cent are done on a day basis; nationally, 42 per cent are day cases. If the MMH contribution to the national figure is removed, then 36 per cent of the remainder are day cases. This potentially represents an opportunity for change. In relation to PTCA, of the 800 carried out nationally in 1996, 344 (43 per cent) were done at MMH. The overall proportion done as day cases is small (3 per cent). Day based PTCA has not yet developed in Ireland. This may change with advances in coronary stenting.

(P.100) HOMOCYSTEINE-MEDIATED VASCULAR INJURY AS A PUTATIVE MECHANISM OF INFLAMMATORY BOWEL DISEASE ASSOCIATED ATHERO-THROMBOSIS

A. M. Rasheed, G. Chert, C. Kelly, D. J. Bouchier-Hayes, A. Leahy.

RCSI Department of Surgery, Beaumont Hospital, Dublin.

Mesenteric microvascular thrombosis and hyperhomo-

cysteinemia are recognised findings in inflammatory bowel disease (IBD) patients. We hypothesise that IBD induced hyperhomocysteinemia damages the mesenteric microvascular endothel ium render ing it dys func t iona l and ini t ia tes atherothrombogenesis. To test this hypothesis we studied the effect of homocysteine (Hcy) on blood flow velocity and leukocyte-endothelial interaction by intra-vital microscopy.

Mesenteric postcapillary venules (2.8 gtM ) of Sprague- Dawley rats were superfused with sterile isotonic pathological and physiological solutions of homocysteine (Hcy) respectively, group (A) 0.1 mM solution (N=8); group (B) 0.01 mM solution (N=8),; group (C) representing the control had 0.00 mM concentration of Hcy (N=8). Leukocyte-endothelial interaction was monitored by counting the number of adherent and migrated leukocytes. RBCs velocity and leukocytes rolling velocity was also measured by intravital microscopy at baseline, 10, 60 and 90 minutes post Hcy superfusion. Expression of CD1 la, CD1 lb and CD18 was determined by flow cytometry. Groups were compared using ANOVA and student's t test.

Administration of Hcy induced microvascular thrombosis but did not induce leukocyte adherence or migration. Hcy did not alter expression of CD 11 a, CD 11 b or CD 18 on neutrophils.

We report the first ever visual ev idence of Hcy's thrombogenecity in the mesenteric microvasculature. This may be mediated through platelet-endothelial interaction rather than leukocyte-endothelial interaction.

(P.101) HYPERHOMOCYSTEINEMIA FAILED TO EXACERBATE EXPERIMENTAL INTIMAL HYPERPLASIA

A. M. Rasheed, E. Kay, S. Jina, I. McDowell*, D. J. Bouchier-Hayes, A. Leahy.

RCSI Departments of Surgery and Pathology, Beaumont Hospital, Dublin. Department of Clinical Chemistry*, UWH,

Cardiff.

Intimal hyperplasia is the rate limiting factor determining longterm patency fo l lowing bal loon angioplas t ies and revascularisation procedures. Vitamin deficiency induced hyperhomocysteinemia is identified as an important risk factor for vascular stenosis and atherosclerosis. This study assessed the effect of vitamin deficiency induced hyperhomocysteinemia on an experimental model of intimal hyperplasia (IH).

Three month old Sprague-Dawley rats weighing (300g) each were randomised into 4 groups; Group 1 (n=15) fed normal rat chow for 12 wks; Group 2 (n=20) fed vitamin B6, B 12 and folate deficient diet for 12 wks; and Group 3 (n=15) fed vitamin B6, B12 and folate deficient diet for 8 weeks, then switched to normal rat chow for another 4 wks. At 8 weeks animals in the 3 groups underwent standardised balloon de-endothelialisation injury of the carotid artery using size 2 Fogarty catheter. Group 4 (n=5) were non-operated controls fed normal rat chow for 12 wks. At 12 wks, carotid arteries were perfusion fixed, histologically prepared and digitally analysed to measure cross sectional areas of int ima, media and lumen. Plasma homocysteine (Hcy) was measured using HPLC fluorimetric method. Groups were compared using ANOVA and student's t test.

Hyperhomocysteinemia failed to exacerbate experimental intimal hyperptasia in this rodent model. Deficiencies of foiate and BI2 inhibit cellular DNA synthesis and hence modulate Hcy's mitogenic potential providing a putative explanation for these unpredicted observations.


(P.102) ENDOTHELIAL CELL DYSFUNCTION AS A PUTATIVE MECHANISM Of HOMOCYSTEINE'S

ATHEROGENICITY

A. M. Rasheed, J. H. Wang, Q. Wo, C. Kelly, D. J. Bouchier-Hayes, A. Leahy

RCSI Department of Surgery, Beaumont Hospital, Dublin.

Despite recognition of homocysteine as an independent risk factor for atherosclerosis, the mechanism of its atherogenecity remains unclear. This study assessed the effect of homocysteine (Hey) on endothelial cell (EC) reparative capacity by measuring EC proliferation and apoptosis. Endothelial cell function was also assessed by measuring production of nitric oxide (NO) and endothelin- 1 (ET- I~ '

Human umbilical vein endothelial cells (HUVECs) at passage 2-3 were exposed to increasing concentrations of d,l-Hcy for 24 h. Endothelial cell proliferation was assessed using 5-bromo- 2'deoxy-uridine labelling and detection kit. Apoptosis was assessed using cell death detection ELISA kit. Nitric oxide concentration was measured using the Griess reaction after 24 and 48 h. Endothelin-1 production was measured at 24, and 48 h using human ET-1 ELISA kit. Constitutive nitric oxide synthase (EC-NOS) expression was assessed by western blotting using anti-human EC-NOS antibody. Groups compared using ANOVA and student's t test.

Hey inhibited HUVEC proliferation, induced apoptosis and decreased nitric oxide concentrations independent of EC-NOS expression. It increased endothelin-I concentrations up to 1 mM Hey concentration and declined thereafter suggesting EC toxicity.

Impairment of EC reparative capacity and induction of endothelial cell dysfunction are recognised early events in atherogenesis. These events are seen secondary to exposure to Hey and may therefore provide a mechanism for its atherogenecity.

(P.103) DELAYED CARDIAC TAMPONADE AFTER OPEN HEART SURGERY

M. N. Shuhaibar, E. McGovern. Department of Cardiothoracic Surgery, National Cardiac Unit,

Mater Misericordiae Hospital, Dublin.

Delayed cardiac tamponade after open heart surgery is uncommon, occurring in 0.1 - 0.2 per cent of cases.

We report 3 cases of delayed tamponade occurring in a single practice in I yr period. All were males aged 29, 48 and 60 yr. The cardiac surgical procedure was aortic valve replacement in 2 cases and closure of atrial septal defect in 1. All were on warfarin therapy post operatively. The presentation was at 14, 28 and 35 days post surgery, 1 acutely and 2 with subacute symptoms and signs. The diagnosis was conf i rmed by echocardiography and pericardiocentesis was carried out promptly with 650-1300 millilitres of serosanguinous fluid aspirated. One patient had a cardiac arrest prior to aspiration but all 3 survived and were discharged well.

Delayed cardiac tamponade is often insidious in onset resulting in delayed diagnosis and treatment. It occurs 5-10 times more frequently in patients who are anticoagulated and echocardiography is the definitive diagnostic procedure. Prompt aspiration is mandatory and recurrence is uncommon.

Reference 1. Breyer et al. Late postoperative tamponade following coronary artery bypass grafting in patients on antiplatelet therapy. Am. Thorac. Surg. 1985; 39(1): 27-29.


(P.104) USE OF ST/HEART RATE SLOPE DURING DIAGNOSTIC EXERCISE ELECTROCARDIOGRAPHY IN

WOMEN

E Turtle, I. B. A. Menown, G. Manoharan, R. Kirkpatrick, N. P. S. Campbell.

Regional Medical Cardiology Centre, Royal Victoria Hospital, Belfast.

It has been suggested that use of ST/heart rate slope (ST/ HRs) may improve the sensitivity and specificity of exercise ECG for diagn6sis of ischaemic heart disease (IHD), particularly in women. However, its role has not been clearly established.

We studied 58 women undergoing exercise ECG (Cornell protocol) who had stress and rest Perfusion (P) imaging. One independent physician, who was unaware of the P result, documented clinical and ECG data. P scans were reported as normal or abnormal. ST/HRs was calculated using a Marquette Max I Stress System. Clinical, ECG and ST/HRs data were correlated with P-imaging and correlations of independent significance were determined by multiple logistic regression.

Of the 58 patients (pts), mean age was 58 yr (range 31-76), 56 pts had a history of chest pain (typical 41 pts, atypical 15 pts), and 15 had a previous myocardial infarction (MI). At the exercise ECG, 15 pts remained on beta-blockers, mean peak exercise was 6.1 METS (+ 2.1 SD), 28 pts achieved HR >85 per cent predicted maximum, exercise was limited by chesi pain in 8 pts, and significant ST depression occurred in 20 pts. P- imaging was reported abnormal in 26 pts. Age, history of IHD, previous MI, abnormal resting Q or Twaves, exercise duration, METS, HR>85 per cent predicted max, limitation by chest pain, and a ST/HRs>3.2 /,tV/bpm all correlated with abnormal P- imaging. Independent significance was only found with Q waves (positive correlation) and exercise duration, HR>85 per cent predicted max, METS (negative correlation).

In conclusion, ST/HRs correlated with an abnormal finding on diagnostic P-imaging, but was not of independent predictive value over and above standard clinical and ECG data.

(P.105) COMPLICATIONS FOLLOWING 'ELECTIVE' VERSUS 'COMBINED' PTCA

S. Walkin, M. B. Codd, R. O'Hanlon, C. McCarthy, H. A. McCann, D. D. Sugrue.

Departments of Cardiology/Epidemiology, Mater Misericordiae Hospital, 71 Eccles Street, Dublin 7.

Percutaneous transluminal coronary angioplasty (PTCA) can be performed as a planned procedure following coronary angiography ( ' e l ec t ive ' ) or at the t ime of angiography ('combined'). The latter may be used in part as a cost-saving exercise, but may also be beneficial in reducing radiation exposure and contrast volume. This study was designed to examine complications following PTCA as an 'elective' versus PTCA as a 'combined' procedure at the Mater Hospital, Dublin. Data from the Mater Hospital PTCA registry (1986-present) were accessed to review clinical and procedural details, immediate and longterm outcome and complications. The following data were examined in 651 patients; age, gender, myocardial infarction (M1) <3 months, unstable angina, number of vessels involved, number of stenoses attempted, procedural success, acute occlusion, death during/within 24 h of PTCA, MI during/within 24 h of PTCA, emergency CABG and groin complications. There were no significant differences in the


patient groups with respect to clinical or procedural variables. A higher proportion of patients in the 'combined' group had a successful outcome to the procedure (p=0.06). There were no differences between the groups with respect to complications. These data suggest that 'combined' PTCA may be beneficial to patients and may have cost-saving implications for this expensive procedure.

(P.106) VITAMIN E SUPPLEMENTATION AND LDL OXIDIZABILITY IN HYPERLIPIDEMIA: DOSE-

RESPONSE STUDY

Y. Wen, S. Killalea, M. Hall, L. Hemeryck, J. Feely. Department of Therapeutics, Trinity Centre for Health

Sciences, St. James's Hospital, Dublin 8.

Vitamin E inhibits the free radical mediated oxidation of low- density lipoprotein (LDL), a crucial step in the initiation of atherosclerosis. Trials to date of vitamin E in the prevention of cardiovascular events including death have yielded contradictory results which may in part be attributed to different dosages. We therefore studied the dose-response effect of vitamin E supplementation on oxidation of LDL in hyperlipidaemic patients.

The vitamin E group (n=20) took vitamin E 100 IU daily and the dose was doubled at 6-weekly intervals to 1600 IU daily. The control group (n=17) received placebo in the same fashion. Blood samples were obtained at baseline and each visit thereafter from all subjects to measure vitamin E status and susceptibility of LDL to copper ion-promoted oxidation, assessed as lag phase of conjugated dienes production.

A significant rise in a-tocopherol levels was seen in the vitamin E group after 1 week of supplementation (100 IU/day) with a significant increase in the lag phase. This continued to rise in a dose-dependent fashion with a doubling of the lag phase on 1600 IU daily.

The close correlation between the dose of vitamin E supplementation and the increase in resistance to LDL oxidation presented in this study suggests that although a relatively low dose i.e. 100 IU daily, may significantly inhibit the in vitro oxidation of LDL, higher doses of vitamin E may have a much greater protective effect.

Supported by Irish Heart Foundation.

C R I T I C A L C A R E

(['.107) AN INFECTIOUS CAUSE OF FACIAL WEAKNESS - A CASE STUDY

C. J. Fahy, A. Griffith. Department of Anaesthesia, Mercy Hospital Cork.

A 57 yr old man was transferred from another institution following a 2 day history of headache, nausea and vomiting. On admission he was init ial ly pyrexic and ataxic which progressed to unilateral facial numbness and dysarthria. On examination he was alert and orientated but pyrexial. However neurological examination revealed left facial weakness, a left extensor plantar response and an absent gag reflex. He was distressed, tachypnoeic and cyanosed. Respiratory examination suggested bilateral consolidation and radiography confirmed this. An initial diagnosis of a brain stem lesion was suggested.


His worsening respiratory status necessitated intubation and ventilation one day following admission. No abnormalities were seen on CT scan of the brain. CSF examination revealed no organisms on Gram stain, however white cell count was 79/cmm, predominantly polymorphonuclear. He was commenced on metronidazole, ceforoxime and ampicillin. Two days after admission Listeria Monocytogenes was isolated from blood cultures and encephalitis was diagnosed. He remained sedated and ventilated and eventually required a tracheostomy. He was weaned from ventilation over the following 2 weeks and began mobi l is ing. Three months fol lowing admission he was discharged having made an excellent recovery although slightly ataxic.

Listeria monocytogenes is a hemolytic gram positive coccobacillus. Infection to humans is rare and can be linked to the consumption of unpasteurised milk. Treatment is with the appropriate antimicrobial and must last longer than 3 weeks.

(El08) HASHIMOTO'S ENCEPHALOPATHY: A CAUSE OF STATUS EPILEPTICUS

J. McGinley, D. McCabe, A. Fraser, E. Casey, T. Ryan, R. Murphy.

Intensive Care Unit, St. James's Hospital, Dublin.

A 42 yr old female was admitted to our unit in status epilepticus. There was no significant meningism and no localising neurological signs were evident. The seizures were resistant to initial therapy with benzodiazepines and phenytoin. Due to the pat ient 's depressed level of consciousness , endotracheal intubat ion was performed and mechanical ventilation was initiated. Seizure control was achieved with anaesthetic doses of sodium thiopentone.

Investigations revealed normal cerebrospinal fluid, absence of any structural lesion on computed tomography or magnetic resonance imaging and an electroencephalogram consistent with the presence of an encephalopathy. The patient was noted to have a soft goitre. As a result of her thyroid function tests (low serum thyroxine) and the absence of any focal signs, a presumptive diagnosis of Hashimoto's encephalopathy was made. This diagnosis was later conf i rmed by a high antimicrosomal antibodies. The patient was commenced on intravenous triiodothyronine and corticosteroids. No further seizures occurred. The patient showed signs of wakening on the fourth day and was extubated on the fifth day after admission. The patient made an uneventful recovery. In conclusion, Hashimoto's encephalopathy, should be considered a as possible cause of status epilepticus when standard investigations are negative. This diagnosis requires the addition of intravenous steroids to the standard medical therapy for status epilepticus.

E . N . T .

(P.109) EPISTAXIS: A RETROSPECTIVE REVIEW OF HOSPITALIZED PATIENTS

M. Browne, J. Fenton, J. Hughes, C. I. Timon. ENT Department, St. James's Hospital, Dublin 8.

A 3 yr retrospective study analyzes the medical records of 127 hospitalized patients with epistaxis. This review represents the first Irish hospital study of patients hospitalized with

epistaxis.

32 National Scientific Medical Meeting VoL 167 Supplement No. 6

This study evaluated multiple factors associated with epistaxis: demographics, underlying medical diseases, use of anti coagulation medication, site of epistaxis and month of hospital admission. Blood transfusion requirement, length of stay, treatment and local/systemic complications were studied as well.

The month of hospital admission was evenly distributed without a wintertime predominance and the mean length of stay was 5 days. Eighty-three per cent of those patients studied responded to packing, balloon placement, local cautery or a combination thereof. Eighteen patients underwent surgical endoscopic cautery, 3 required formal surgical arterial ligation and 1 underwent arterial embolization.

This review identified a 3 yr complication rate of epistaxis and its treatment. No deaths were directly attributable to epistaxis or its treatment.

This study indicates that epistaxis continues to be an important indication for hospital admission and can present a difficult challenge in its management.

(P.110) THE MANAGEMENT OF OTOSINOGENIC BRAIN ABSCESS

J. Fenton, A. Curran D. Smyth, L. Viani, M. Walsh. Department of Otolaryngology, RCSI, Beaumont Hospital,

Dublin.

Otolaryngologic infection has been reported as the most common source of brain abscess. Traditionally otolaryngologic intervention has followed abscess drainage either as a combined procedure or as a follow-up operation at varying intervals. The aim of this study was to attempt to develop a management protocol for otosinogenic brain abscess by assessing the clinical course of such patients treated during an 8 yr period at Beaumont Hospital. A retrospective chart review of 50 consecutive brain abscesses revealed that 50 per cent of the infective sources were either in the paranasal sinuses or ears. The clinical features, bacteriology, radiological findings, treatment modalities and outcome were recorded and assessed. Results demonstrate that there was a lack of uniformity in the timing and form of management in these cases. Analysis revealed that combined ENT/neurosurgical intervention at the first procedure reduced the need for revision surgery. It is proposed that a formal assessment of the paranasal sinuses and the temporal bone should be included in the original radiological examination of patients presenting with an idiopathic brain abscess. It is concluded that the optimum treatment is a combined approach of abscess drainage and surgical management of the paranasal sinus or ear disease at the same sitting.

(P.111) LOGISTIC REGRESSION ANALYSIS DETERMINATION OF MALIGNANCY PREDICTIVE VALUES IN THE ADULT NECK MASS PRESENTING

POPULATION; A PRACTICAL STATISTICAL EXERCISE

J. P. Hughes, J. Fenton, P. Lee, A. Kelly, C. 1. Timon. Department of Otolaryngology, St. James's Hospital,

Dublin 8. Department of Community Health and Statistics, Trinity College, Dublin.

The definitive assessment and management of patients presenting with cervical masses contributes significantly to otolaryngology workload. Our ongoing prospective study of over

190 patients displays the range of pathology encountered, and aims to critically evaluate the significance of basic clinical factors raising the clinicians' index of suspicion. The clinical details and pathological diagnoses of 194 patients presenting over 16 months have been entered on a computer database ("Excel") for corre la t ion/s igni f icance testing. Logist ic regression analysis based "models" are generated to provide predictive values of malignancy, for single and grouped clinical factors. "Protective" odds ratios / percentage likelihood ranging from x 3 - 5.5 are recorded for female sex, < 40 yr of age and lengthier duration subgroups. (P=<0.01). The educational usage of time-honoured "rules-of-thumb" e.g. "The rule-of-sevens" and the "80 per cent rule" is critically evaluated. This useful statistical exercise details a 39.7 per cent rate of malignancy diagnosis confirming the cautionary axioms of evaluation in patients presenting with a neck mass.

(P.112) THE ROLE OF THE OTOLARYNGOLOGIST IN EMERGENCY MANAGEMENT OF ACE-INHIBITOR

INDUCED ANGIOEDEMA

J. P. Hughes, J. Fenton, N. Shine, A. Blayney, D. P. McShane, C. I. Timon.

Departments of Otolaryngology, Mater Misercordiae Hospital and St. James Hospital, Dublin.

The widespread use of angiotensin converting enzyme inhibitors (ACE-I) in the treatment of hypertension and heart failure has been mirrored by increasingly encountered cases of ACE-I induced angioedoma. Predilected sites in the upper aerodigestive tract necessitate immediate airway management. The reported incidence of all ACE-I "events" is approximately 0.1 - 0.2 per cent and appears to understate occurrence rates. ACE-I induced angioedoma is now the most likely cause of angioedema requiring emergency admission for airway management in the United States of America.

A series of 7 such patients managed at our Departments is presented. The age range was from 17-66 yr. Angioedema onset post ACEI commencement occurred up to 48 months. Two female patients suffered episodes post-cessation of implicated ACEI's. Six of 7 patients had experienced more moderate episodes occas ional ly mul t ip le , prior to these severe presentations. Three patients required emergency surgical in te rven t ion compris ing 2 t racheostomies and 1 cricothyroidotomy. Two patients died during directly related ACEI induced angioedema admissions.

The exact pathophysiology remains poorly understood but clearly ACE-I induced angioedema warrants close attention and monitoring particularly in light of our relatively large series and increasingly sporadic reporting in the literature.

OBSTETRICS & G Y N A E C O L O G Y

(P.U3) BACK PAIN IN PREGNANCY

J. Hussey, M. Howlett, A.. Langton, A. McEvoy. School of Physiotherapy, Faculty of Health Sciences,

University of Dublin, Trinity College, Dublin 2.

Back pain has been recognised as a common accompaniment of pregnancy. Reported incidence is around 50 per cent and appears to depend on factors such as parity, weight gain and occupation.


The objectives of this study included: identifying incidence of back pain in pregnancy; the onset, location and management of back pain; and the relationship of back pain to anthropometric values, parity, epidural anaesthesia for previous labours and occupation. In patients with pain, the effect this pain had on activities of daily living was also investigated.

The study was undertaken in Dublin and Limerick. Maternity Units. Two hundred and ninety-nine women within 72 h of delivery were surveyed by means of an author-administered questionnaire.

Sixty-six per cent of women complained of onset of back pain in pregnancy. It would appear from preliminary results that height, weight, parity, history of epidural anaesthesia for pain management in previous labours and smoking history are not associated with the onset of back pain during pregnancy. However women with occupations that required manual handling, lifting or a physically heavy workload had a higher incidence of the onset of back pain in pregnancy than those involved in lighter work.

(P.114) OBSTETRICAL FACTORS RELATING TO THIRD DEGREE TEARS

J. Slevin, C. Fitzpatrick, M. J. Turner. Coombe Women's Hospital.

The aim of this study was to evaluate obstetrical factors associated with third degree tears. Over a period of 41 months a total of 22,265 women were delivered greater than or equal to 500 grms; 100 third degree tears were recorded (incidence: 0.45 per cent). Of these, 38 (38 per cent) had involvement of the ano-rectal mucosa and 62 (62 per cent) had sphincter involvement alone. Seventy-three were nulliparous (73 per cent); 24 were para 1 (24 per cent) and 3 were para 2 (3 per cent); 5 of the parous patients had no previous vaginal delivery. Twenty- five nulliparae (34.2 per cent) and 13 multiparae (48.1 per cent) had involvement of the ano-rectal mucosa. Three patients (3 per cent) had a history of a previous third degree tear. The mean gestation was 40.8 weeks; 60 (60 per cent) were <40 weeks. There was no association between third degree tears and induction or acceleration of labour or epidural analgesia. The incidence of instrumental delivery in nulliparae was 36 (49.3 per cent) and in multiparae 3 (11.1 per cent); hospital rates: 26 per cent and 5 per cent. Eighteen (48.6 per cent) nulliparae and 9 (37.5 per cent) multiparae, having a spontaneous vaginal delivery had an episiotomy (hospital rates: 44.6 per cent and 10.2 per cent). Fifteen nulliparae (20.5 per cent) and 16 multiparae (59.2 per cent) had infants > 4 kg; hospital rates >11.3 per cent and 17.1 per cent third degree tears are associated with nulliparity, parity >4 kg in multiparae, the strongest association being with parity. Among women delivering spontaneously, episiotomy was not protective.

P A E D I A T R I C S

(P.115) POST-OPERATIVE ACNE & STRIAE - AN UNUSUAL COMPLICATION OF CARDIAC SURGERY

F. Enright, N. Goggin, C. Costigan, D. Duff, P. Osizlok, F. Wood, R. Watson

Our Lady's Hospital for Sick Children, Crumlin, Dublin.

A 13 yr old girl with complex congenital heart disease developed an acneiform eruption and extensive striae 21 days


post-cardiac surgery. Her post-operative course was complicated by pulmonary embolus and recurrent life threatening arrhythmias.

Investigations revealed increased endogenous production of cortisol - am 757 nmol/l; pm 646 nmol/1 (normal < 300 with circadium rhythm) - in the absence of other endocrine abnormality. Serum and urinary cortisols returned to normal in 4 months.

We report a unique example of excessive endogenous cortisol production in response to stress resulting in striae and an acneiform eruption.

(P.116) BRACHIAL PLEXUS INJURY AND CLAVICULAR FRACTURE OF THE NEWBORN

R. B. Fitzsimons. Department of Paediatrics, Tralee General Hospital, Tralee,

Co. Kerry,

Recently reported incidences of brachial plexus injury (BPI) and clavicular fracture (CF) vary from 1-5/1000 for BPI and 2.2-32/1000 livebirths (LB) for CF ~3.

Data on these 2 conditions has been recorded between 1985 and 1997 on all newborn infants under the care of 1 of the 2 paediatricians at TGH. Charts were retrospectively reviewed for confirmation of birth details and duration of labour.

There were 12 BPI, 11 being transient Erb-Duchenne and 1 full plexus which was persistent. There were 17 CF. 15,586 LB delivered during the period which would give 7,793 to each paediatrician allowing for an even distribution. This gives an incidence of 1.55/1000LB for BPI and 2.18/1000 for CF. The BPI infants were slightly heavier (75 per cent over 4 Kg birthweight) than the CF group (47 per cent over 4 Kg).

Seventy-five per cent of CF were on the left, presumably reflecting delivery of the anterior shoulder. Left and right were equal in BPI. The 3 Breech deliveries were in the BPI infants. Assessment of these conditions should form part of regular audit. References 1. Mami, C. et al. Minerva Ginecologia. 1997; 49: 203-6. 2. Ecker, J. et al. Obstetrics and Gynecol. 1997; 89: 463-7. 3. Walle, T. et al. Acta Obstet. Gynecol. Scand. 1993; 72: 450-4.

(P.117) SPINA BIFIDA - ASSOCIATION WITH INCREASED LOWER LIMB NAEVI

N. Flanagan. F. Enright, L. Barnes, R. Watson. Departments of Dermatology, Our Lady's Hospital for Sick

Children, Crumlin and St. James's Hospital, Dublin.

Evidence that melanocyte growth may be under neural control has previously been reported. Three spina bifida (SB) patients were noted to have increased numbers of naevi on the lower limbs on routine dermatological consultation. The following study was performed to test the hypothesis that SB may be associated with increased numbers of melanocytic naevi on the lower limbs. We prospectively examined 42 patients with SB and 42 age- and sex-matched controls (24 female, 18 male, age range 3-19 yrs, mean 10.6 yrs) seen consecutively at Our Lady's Hospital Crumlin from January to March 1996. When compared to the Vancouver Mole Study both males and females with SB demonstrated increased mean number of naevi on the lower limbs and this difference was most marked in females aged 13 and over (18.4 vs 5). When compared with Irish age- and sex-

34 National Scientific Medical Meeting Vot 167 Supplement No. 6

matched controls, SB patients had similar mean total number of naevi. In females with SB the mean number of naevi on the lower limbs was over double that seen in controls (8.4 vs 4.1) whereas in males with SB it was less than that seen in controls (5.2 vs 6.2). Fourteen of 42 SB patients had naevi measuring over 5 mm in diameter compared with 4 controls (p<0.05) Eight of 42 SB patients had congenital naevi (outside the paraspinal area) compared with 2 controls (p=0.09). A small number of patients were found to have clinically atypical naevi. This study supports an association between SB and increased numbers of naevi on the lower limbs.

(P.118) NEONATAL ABSTINENCE SYNDROME, ARE MOTHERS BEING SCREENED EFFECTIVELY FOR

INFECTIOUS DISEASE?

E. Molloy, E. Griffin, P. F. Deasy, M. Sheridan, M. J. White. Department of Paediatrics, Coombe Women's Hospital,

Dublin 8.

To assess antenatal screening for Hepatitis B, C and HIV infection in an obstetric population based in an urban maternity hospital and to ascertain symptoms, length of stay for infants born with neonatal abstinence syndrome.

A total of 42 mothers and 43 infants' records were reviewed from July 1996 to June 1997 with maternal history of drug abuse and neonatal drug withdrawal.

Maternal prenatal screening revealed the fol lowing prevalence. Hepatitis B, 32/42 (76 per cent) were screened, 1 mother tested Hep. B positive. Hepatitis C, 32/42 were screened, 15/42 (36 per cent) tested Hep. C positive. HIV, 25/42 (59 per cent) were screened, 1 mother tested positive and was treated prenatally. Forty-three infants (average birth weight 2.79kg, 33 term, 10 preterm) were admitted to the Special Care Baby Unit. The average length of stay was 23.4 days, 41/43 received phenobarbitone (average course 47.8 days), 10/43 received oral morphine (average course 10.2 days).

More successful antenatal screening procedures for hepatitis and H1V are needed, particularly for HIV to determine if antenatal treatment with AZT is indicated. Neonatal abstinence syndrome accounts for a significant number of bed days in the Special Ca,'e Baby Unit.

(P.119) PATHOGENESIS OF REYE SYNDROME: EFFECTS OF ASPIRIN METABOLITES ON ENZYME KINETICS OF

HYDROXYACYL DEHYDROGENASES OF MITOCHONDRIAL BETA-OXIDATION

R. Moore, A. Gray, J. Hill, B. Middleton*, J. F. T. Glasgow. Department of Child Health, The Queen's University of Belfast and Department of Biochemistry, University of

Nottingham.

Inhibition of mitochondrial beta-oxidation by aspirin (ASA) metabolites has been suggested as a link between ASA and Reye Syndrome (RS). Using intact skin fibroblasts from RS survivors and controls we have reported inhibition of palmitate flux by salicylic acid (SA) and hydroxyhippuric acid (HHA), which is concentration related (max. 50 per cent) -the probable site of action being hydroxyacyl dehydrogenases (HAD). The inhibition was further investigated using specific assays for long and short- chain HAD (LCHAD and SCHAD) in - a) homogenised cells

from the 2 groups and b) purified enzymes (human trifunctional enzyme (TFE) as source LCHAD; porcine SCHAD).

Results show a) No difference in enzyme activity between the groups; both enzymes are inhibited by SA and HHA (conc related); no detectable increase in LCHAD activity at low SA conc; b) Kinetics of inhibition (SA & HHA) were studied i) in the anti-physiological direction by specific assay of LCHAD and SCHAD; ii) in the physiological direction using TFE. Results show i) inhibi t ion of SCHAD is reversible and competit ive but that of LCHAD is complex, being both competitive and uncompetitive; ii) mostly uncompetit ive inhibition, not reversed by increasing substrate concentration. Conclusion - ASA metabolites are potent, complex inhibitors of SCHAD and LCHAD (probably the rate limiting step in beta- oxidation). For TFE, Vm, ~ was reduced to 30 per cent in the presence of ASA metabolites, equivalent to residual activity in LCHAD deficiency. Such effects may contribute to the metabolic disturbance in RS.

(P.120) VALIDATION AND QUANTIFICATION OF HIP ULTRASOUND AS A SCREENING TEST FOR INFANTS AT RISK OF CONGENITAL DISLOCATION OF THE HIP (CDH)

D. Slattery, V. Donoghue, A. McMahon, J. Murphy. Department of Neonatology, The National Maternity Hospital,

Holies St., Dublin.

This study aims to validate hip ultrasound (u/s) as a reliable tool, quantify its effectiveness in detecting abnormalities in infants at risk of CDH and compare its reliability with that of x- ray.

One hundred infants whose hips were clinically normal but were at increased risk because of breech, positive family history or persistent clicks were identified. Hip u/s was performed at 3 weeks, 6-8 weeks and then compared with hip x- ray at 4 months. Subsequently 13,700 infants were clinically screened for CDH. 1,137 (8.3 per cent) high risk infants were identified and had u/s scanning at 6-8 weeks. A research nurse explained the study recruited patients and ensured follow-up. The consultant radiologist who performed all the ultrasounds trained in the Graf technique. Special equipment was purchased (G~'af locating device).

One hundred and 31 (11 per cent) infants had abnormal ultrasounds and 6 (0.5 per cent) had frank dislocation. Hip u/s at 6-8 weeks was superior to u/s at 3 days because the latter picked up immature hips that later normalised. The reliability of the later scan was similar to the 4 month hip x-ray.

In conclusion, hip u/s is effective at identifying clinically undetectable hip dislocation. Ultrasound permits safe follow up.

(P.121) TRANSCATHETER OCCLUSION OF PATIENT DUCTUS ARTERIOSUS (PDA) WITH A RASHKIND

UMBRELLA DEVICE - EARLY AND MEDIUM TERM FOLLOW UP

D. Slattery, A. McCarthy, P. Oslislok, D. Duff. The Cardiology Department, .Our Lady's Hospital, Crumlin.

The aims of the study were to determine the success of the Rashkind umbrella device to occlude a PDA, assess the frequency of complications of the device and establish the frequency of residual shunting at early and medium term follow up.

Intervention involved insertion of a Rashkind umbrella device


under radiographic control into a PDA via the transvenous route. Ninety-six devices were delivered. Methods of evaluation included angiography, clinical examination and ECHO with doppler colour flow (DCF). Follow up was at day 1, 3 months, 6 months, and annually or biannually thereafter.

Our results were disappointing. Most closures occurred within 1 yr of the procedure. Forty-seven per cent of patients had occluded their PDA on angiography, 51 per cent on ECHO with DCF and 87 per cent on clinical examination by day 1 post procedure. Further closures occurred with time. Five per cent of patients experienced complications including arrythmias, malposition and embolisation of the device. We documented the reopening of some PDAs on follow up with ECHO with DCF.

In conclusion, this is a safe procedure. Clinical examination alone is not sufficient follow up, ECHO with DCF is mandatory. Insertion of a second device or a coil is required in some patients to fully occlude the PDA.

R E S P I R A T O R Y

(I'.122) NITINOL STENTS - THE MATERIAL DIFFERENCE

M. Colreavy, I. Keogh, S. Hone, M. Walsh. Department of Otolaryngology, Beaumont Hospital RCSI,

Dublin.

Tracheobronchial stenting poses one of the most challenging and difficult clinical dilemmas facing otolaryngologists. All too often these patients suffer extreme distress and some ultimately die of asphyxiation.

Recently due to the advent of the new "Super Elastic Alloys", a new dedicated tracheobronchial stenting system has been devised and is currently undergoing clinical trial at our dept.

We prospectively have inserted 6 stents in 4 patients over the past 12 months. The indications included life threatening tracheal obstruction secondary to mediastinal Hodgkin's disease, lung metastases causing L main branch bronchus obstruction, obstructive subglottic extension of laryngeal tumour and tracheomalacia.

We present our experience with these stents that we have followed up for almost 1 yr. We have found them to be remarkably well tolerated by both airway and patient and hope they will add to our battery of treatment for these difficult problems.

(P.123) MATRIX METALLOPROTEINASES AND THEIR INHIBITOR IN EMPHYSEMA

M. Henry, S. Koston, K. McMahon, W. MacNee, M. X. FitzGerald, C. M. O'Connor.

Department of Medicine and Therapeutics/Lung Fibrosis Unit, University College Dublin.

Emphysema is a slowly progressive disease characterised by progressive destruction of the alveolar extracellular matrix (ECM). Most studies to date have focused on neutrophil elastase as the major effector of this destruct ion. Matrix metalloproteinases (MMPs) are a family of endopeptidases in the lung capable of destruction of most of the components of the ECM. We have previously reported that collagenase activity in BALF of emphysema patients may be a better indicator of disease than elastase activity. The aims of this study were, firstly to determine whether neutrophil collagenase (MMP-8) or interstitial collagenase (MMP-1) was predominantly responsible for the excess collagenolytic activity noted previously, secondly to review the type of gelatinolytic activity in BALF of emphysema

patients and thirdly to assess BALF of emphysema patients for TIMP, the natural inhibi tor of MMP. Ten patients with emphysema and 15 control subjects underwent BAL. Lavage fluid (BALF) was assessed for the following; collagenase and gelatinase activity and protein concentrations of MMP-1,-8,-9 and TIMP-1 using a newly available ELISA assay.

Results: p<0.00l* p<0.0001** Table I Controls Emphysema Mean + SEM (N=I 5) (N=10) Collagenase (mU/ml) 0 55.0 + 5.43** MMP-8 (ng/ml) 0.03 + 0.01 3.03 _+ 1.06"* Gelatinase (U/ml) 0.07 + 0.07 2.03 + 0.87* MMP-9 (ng/ml) 3.18 + 0.88 24.55 + 11.76 TIMP-1 (ng/ml) 33.11 + 3.36 53.92 + 2.3*

Collagenase activity was detected in all 9/10 emphysema samples and no controls. MMP-8 levels were detectable in all emphysema samples and no controls. Negligible amounts of MMP-1 were found in 3/10 emphysema and 1/15 control samples. Our results indicate that the source of collagenolytic activity noted in emphysema BALF samples was neutrophil collagenase. Higher levels of TIMP found in emphysema samples may be another useful reflection of ECM damage in emphysema

Abstract funded by: EU Biomed 2 / Eurolung.

(P.124) COMPARISON OF RESPONSIVENESS OF CIRCULATING NEUTROPHILS FROM CYSTIC FIBROSIS

AND BRONCHIESTASIS PATIENTS

K. J. Russell, M. Henry, M. X. Fitzgerald, C. M. O'Connor Department of Medicine and Therapeutics, University College

Dublin, and St. Vincent's Hospital, Dublin 4.

Neutrophil migration is a multistep process involving the sequential roiling of the neutrophil along the endothelium (using L-selectin) and firm adhesion to the endothelium (mediated by Mac-l). Stimulation of the neutrophil triggers the shedding of L-selectin and upregulation of the Mac-1 complex (CD18/ CDllb) . In a recent study, we have shown that circulating neutrophils in cystic, fibrosis (CF) patients have a blunted response to stimulation with respect to L-selectin, and are less likely to shed this adhesion molecule from their surface upon stimulation I. This effect is most noticeable during acute infections. However, it was not possible to conclude from this study whether the blunted responsiveness was due to infection alone or a combination of the CF defect and infection. The aim of this study was to investigate if the blunted responsiveness of neutrophils observed in CF patients also occurs in neutrophils from non-CF bronchiestasis patients. Blood samples (n= 13) from 11 acutely infected CF patients (6F, 5M), 16 chronically infected CF patients (8F, 8M), 15 non-infected controls (8F, 7M), 5 acutely infected bronchiestasis patients (3F, 2M) and 5 stable bronchiestasis patients (4F, 1M) were analyzed for surface expression of L-selectin and Mac-l. Upon stimulation with interleukin-8 (IL-8) and n-formylmethionylleucylphenylalanine (fMLP), both groups of non-CF bronchiestasis patients shed significantly more L-selectin than CF patients, with levels of shedding in the bronchiestasis group similar to that observed in the control group. These results may indicate that the response of CF neutrophils to stimulation differs from that of neutrophils from individuals without a defective CFTR gene. This work was funded by the Health Research Board, Ireland.

Reference 1. Russell, K. J. et al. AJRCCM, 1998, in press

36 National Scientific Medical Meeting w~L 167 Supplement No. 6

D R U G M E T A B O L I S M

(P.126) ISOLATION AND CHARACTERISATION OF A URINARY METABOLITE OF THE REVERSE

TRANSCRIPTASE INHIBITOR NEVIRAPINE IN MAN

P. V. Kavanagh, S. M. McNamara, J. Feely, M. Barry*, J. E. O'Brien**.

Department of Pharmacology & Therapeutics, Trinity College, Dublin 2. *Department of Pharmacology &

Therapeutics, University of Liverpool, Britain. **Department of Chemistry, Trinity College, Dublin 2.

Nevirapine is highly selective non-competitive inhibitor of HIV-1 reverse transcriptase. It is widely used in combination therapies t. In this study, the urinary excretion and metabolism of nevirapine was profiled. Post-administration urines were collected after a single 200 mg oral dose.

Analysis by gas chromatography/mass spectrometry indicated that the major urinary metabolites were 3 mono- hydroxylated derivatives. Minor amounts of di- and tri- hydroxylated derivatives were also observed. The mono- hydroxylated metabolites were observed for up to 48 h after administration.

The predominant mono-hydruxylated metabolite was purified by preparative thin layer chromatography and fully characterised by mass spectrometry, and 1H nuclear magnet resonance spectroscopy. It was shown to be 4-hydroxynevirapine produced by oxidation of the methyl group in the molecule 2.

Such information regarding the metabolism of nevirapine is vitally important for clinical monitoring and will also allow us to develop a specific immunoassay test targeting the metabolites.

References 1. Havlir et al. J. Infect. Diseases, 1995; 171: 537-545. 2. Proudfoot et al. Org. Chem. 1992; 57: 4023-4025.

G E N E R A L P R A C T I C E

(P.129) PATIENTS' BEHAVIOUR, ATTITUDES AND KNOWLEDGE CONCERNING ANTIBIOTICS FOR SORE

THROATS: A QUALITATIVE STUDY

P. McCormick. Sligo General Practice Training Unit, Sligo General Hospital,

Sligo, Ireland and Department of Community Health & General Practice, Trinity College, Dublin 2.

Sore throats are usually due to a viral infection. Nevertheless, up to 80 per cent of patients who present with sore throat are treated with an antibiotic without laboratory investigation.

A qualitative research method employing semi-structured interview with parents of young families in the Sligo town area.

Thir ty-e ight parents represent ing 20 famil ies were interviewed. Patients tended to consult their doctor with sore throat if symptoms are severe or when a child is affected. In these instances, antibiotic treatment is generally expected and frequently obtained. This is despite an acknowledged change in attitudes towards antibiotic use. Many expressed concerns about "immunity" regarding frequent antibiotic use but this had a variety of meanings. Although people tended to endorse easier access to antibiotics through a pharmacist, the keeping of antibiotics at home was not favoured. Other factors influencing the expectation of antibiotics included cost (for private patients), personal convenience and the sense of security when taking antibiotics. Few of the respondents were knowledgeable about

the cause of sore throats and the role of antibiotics in treating them.

Conclusion: Although attitudes towards routine antibiotic use are changing, a significant patient-led expectation for antibiotic treatment of sore throat remains. Patients have l imited knowledge in the area of antibiotic use.

(P.130) CURRENT PRACTICES IN INFLUENZA VACCINATION

C. Molony, R. M. Doyle, J. B. Walsh, D. Coakley. Department of Medicine for the Elderly and Mercers Institute

for Research on Ageing, St. James's Hospital, Dublin 8.

Influenza vaccination is a widely available service carried out by general practitioners (GP's). Uptake rates of greater than 80 per cent are required in order to achieve maximum benefits. A postal questionnaire of prescribing practices for influenza vaccination was administered to GP's referring to St. James's Hospital. Questions asked included;

(1) The cohort of patients selected for vaccination. (2) Side-effects due to vaccination (3) The economics of vaccination from the GP's perspective. (4) Where responsibility for vaccination should lie. The questionnaire response rate was 70/125 (56 per cent).

(1) The majority of patients selected for vaccination had chronic obstructive pulmonary disease followed by diabetes mellitus. Sixty-eight of 70 (97 per cent) of GP 's selected patients on an opportunistic basis with only two GP's using a computerised database to identify patients. Most GP's did not have designated vaccination clinics.

(2) Side-effects were not commonly reported, however the most frequently reported side-effect was flu-like illness. The presence of side-effects did not appear to affect the uptake of subsequent vaccinations.

(3) The majority of GP's felt a vaccination fee should be charged for non - GMS card holders. The current rate is s - s

(4) Most GP's felt they were best suited towards achieving a high uptake rate, however half of all GP's expressed some difficulty in acquiring the vaccine.

Factors mitigating against effective uptake of the vaccine include lack of an appropriate database for identification of patients requiring the vaccine.

H E A L T H S E R V I C E S

(P.131) CHANGES IN DAY ACTIVITY IN ACUTE HOSPITALS IN IRELAND OVER TWO DECADES,

1977-1996

M. B. Codd, P. R. O'Connell. Departments of Epidemiology/Health Services Research & Surgery, Mater Misericordiae Hospital, 71 Eccles Street,

Dublin. 7.

The acute hospital service consumes 50 per cent of annual non-capital expenditure on healthcare in Ireland. Wi~h increasing emphasis on efficiency and reduction in waiting lists, numbers of day cases have increased in all acute hospitals. Activity data are reported from hospitals in 2 ways: (a) the Integrated Monthly Return (IMR), compiled into Annual Health Statistics Reports


and (b) HIPE data from which the HIPErformance bulletin is compiled. These data sources were reviewed from 1977-1996 to document inpatient, day case and acute bed numbers. In 1977, 44 patients were treated as day cases, <1 per cent of non- outpatient care. By 1996, 233,908 patients (30 per cent of non- outpatient care) were treated as day cases. Over this period, inpatient numbers remained remarkably constant (~500,000/yr); acute bed numbers decreased by 37 per cent from 18,878 to 11,937. Thus, average length of stay has decreased (10.9 days in 1977 vs 6.7 days in 1996). Due to advances in anaesthesia and technology, treatment on a day basis is now possible in virtually every speciality. The UK Audit Commission has set targets for the proportion of selected procedures which could be carried out on a day basis. These provide guidelines with which to compare existing practice in Ireland.

IMMUNOLOGY (P.132) MEASUREMENT OF URINARY NEOPTERIN AND LUNG FUNCTION IN PATENTS WITH CYSTIC FIBROSIS

L. C. Dowey ~, S. J. Elborn 2, H. McGlynn ~, D. I. Thurnham ~. 1Northern Ireland Centre for Diet and Health, University'of Ulster, Coleraine, BT52 ISA. 2Adult Cystic Fibrosis Unit,

Belfast City Hospital, Belfast, Northern Ireland.

Pulmonary disease is responsible for over 90 per cent of deaths in cystic fibrosis (CF) patients. These patients suffer chronic bacterial infection, which, along with the host's own immune response leads to lung damage. Interferon-gamma (IFN-'f) is a major proinflammatory cytokine. Blood and urinary neopterin has been shown to be elevated in a number of disease states. It is released from activated monocytes/macrophages when stimulated by IFN-'L Neopterin is excreted in the urine and is measured easily using HPLC. In this study urinary neopterin and pulmonary function tests were measured in 13 CF patients (range 18-37 yr, mean 27.9) and age-sex matched control subjects (range 18-40 yr, mean 26.6). Urinary neopterin levels in CF patients were considerably greater than controls subjects (p<0.01). Pulmonary function tests, FEVI, FVC and VC were all decreased in CF patients compared to controls (p<0.05). There was an overall trend for a positive correlation between elevated neopterin levels and decreased lung function in CF patients, although 'n ' was not great enough to show a statistical significance. These results suggest that urinary neopterin has the potential as a good quantitative and qualitative parameter and may be useful to monitor disease severity in patients with CF.

(P.133) MENSTRUAL CYCLE ASSOCIATED CHANGES IN ENDOMETRIAL LYMPHOCYTE SUBSETS

L. Flynn, J. Carton, B. Byrne, *R Kelehan, #C.O'Herlihy, C. O'Farrelly.

Education & Research Centre, St. Vincent's Hospital, Dublin. *Department of Pathology, National Maternity Hospital,

Dublin. #Department of Obstetrics & Gynaecology, University College Dublin.

Relative proportions of lymphocyte populations within the human uterus are reported to be important for successful pregnancy. Their function, in this instance is hypothesised to be

the generation of specific tolerance to an immunologically foreign fetus. Strong evidence now exists advocating hormonal control of several components or both the humoral and cellular components of the immune system within the female reproductive tract. The aim of this study was to phenotypically characterise, and investigate the changes in the lymphocyte subsets in non-pregnant endometrium over the menstrual cycle. This would provide a means to indirectly measure responses to cyclically dependent endocrine hormone fluctuations.

Endometrial tissue was obtained from hysterectomy samples by sharp curettage from 31 women, and single cell suspensions suitable for flow cytometry were prepared using enzymatic disruption. Cell suspensions were then stained with labelled mAbs specific for anti-CD3, CD4, CD8, CD56, CD45 & CD14, and analysed by flow cytometry.

Within the leukocyte population, NK cells (CD56+) increased dramatically between late proliferative and late secretory phases (28.16 per cent to 83.12 per cent; p=0.0027). In contrast, T- cells (CD3+) markedly decreased within the same timeframe (56.34 per cent to 5.64 per cent; p=0.0027). Further characterisation within the CD3+ populations demonstrated that relative proportions of conventional CDS+ T-cells and CD4+ T- ceils are essentially stable over the entire cycle, although, unconventional natural T-cells (CD3+CD56+), and double positive T-cells (CD3+CD4+CD8+), increased in the latter stages of the cycle (5.36 per cent to 9.71 per cent; p=0.046, and 2.47 per cent to 4.44 per cent; p=0.043). The fluctuation or lymphocyte subsets, concomitant with menstrual cycle hormonal changes is suggestive or temporal immunosurveillant and immun0regulatory functions, particularly at a time when implantation or the fertilised embryo would putatively take place.

(P.135) RELEASE OF BACTERIAL LIPOPOLYSACCHARIDES BY SERA FROM COMPLEMENT DEFICIENT INDIVIDUALS

A. M. O'Hara ~, A. R Moran ~, B. A. Fernie 2, A. Orren ~. ~Department of Microbiology, National University of Ireland,

Galway, Ireland. 2Centre for Veterinary Science, Cambridge, Britain.

The membrane attack complex, comprising the terminal complement components, C5b-C9, disrupts the outer membrane of target cells leading to the release of lipopolysaccharides (LPS). LPS are important mediators of the pathogenesis of gram- negative sepsis. Hereditary deficiency of terminal complement components C5 through C8, are associated with increased susceptibility to Neisseria meningitidis infections. This increase is less apparent in subjects with C9 deficiency (C9D). We assessed the ability of terminal complement deficient sera to release LPS from Escherichia coli JS, a galactose epimerase mutant used previously in other LPS release investigations. The mutant incorporates galactose specifically into LPS. We report investigations of patients deficient in C7 and C8 who had suffered recurrent meningococcal infections, and of 2 elderly Irish subtotal C9D (C9SD) subjects with no history of the infection. LPS release was monitored using E. coli J5 radiolabelled with tritiated galactose. Incubation of 3H-labelled E. coli J5 with C7D and C8D sera brought about minimal LPS release. The C9SD sera induced moderate LPS release. Comparison of LPS release by C9SD serum and C9D serum lacking functional C9 haemolytic activity, showed the C9SD


protein to have both LPS releasing and haemolytic activity. These results suggest that the terminal complement components not alone contribute to bacteriolysis but also to LPS release. This may be important in gram-negative pathogenesis.

I N F E C T I O U S D I S E A S E S / G U M E D I C I N E

(P.136) TRIPLE THERAPY IN HIV POSITIVE INTRAVENOUS DRUG USERS

C. Merry, S. Clarke, G. Courtney, C. deGascun, F. M. Mulcahy.

Department of G.U. Medicine, St. James's Hospital, Dublin.

Combinat ion ant i re t rovi ra l therapy in HIV posit ive intravenous drug users (IDU) raises the issues of compliance and drug interactions. The aim of this study was to assess uptake, efficacy and safety of triple therapy in IDU attending our service. We prospectively recorded the change in CD4 cell count, HIV plasma RNA, compliance and drug interactions. Sixty-two of the 550 IDU attending the service were commenced in PI therapy over a 6 month period. There was a 1.9 log drop in HIV viral RNA and a mean increase in CD4 cells of 70. We noted that 90 per cent of the patients were compliant with the medication and no drug interactions were noted throughout the study period. PI therapy was effective, safe and well tolerated in the IDY population. IDU who commit to triple therapy were compliant with their medication.

(1'.137) PHARMACOKINETICS AND EFFICACY OF RITONAVIR 300 mgs QID

C. Merry, M. Ryan, M. Barry, F. M. Mulcahy. Department of G.U. Medicine, St. James's Hospital, Dublin.

Department of Pharmacology & Therapeutics, Liverpool University, Liverpool.

Ritonavir (RIT) 600 mg twice daily is a potent protease inhibitor, but it is poorly tolerated. Many patients indicate the onset of symptoms 2 h after each dose and lasting for approximately 4 h suggesting a possible relationship between peak plasma concentration and adverse effects. In this study we firstly determined the kinetics of RIT 600 mg bd versus 300 mg qid in 6 HIV+ male patients who wished to discontinue RIT 600 mg 12 hourly because of adverse effects. Secondly, we prospectively studied the changes in the surrogate markers of disease progression. Steady state RIT profiles were following administration of ritonavir 600 mg 12 hourly and RIT 300 mg 6 hourly.Blood samples were obtained at times 0, 1, 2, 3, 4, 5 & 6 h post dosing. RIT concentrations were determined by HPLC. Both the maximum plasma concentration and the AUCo_6h were significantly lower following ritonavir 300 mg 6 hourly (Cm, ~ 11.15 + 1.77 vs 22.31 + 3.17 I.tg.ml~; AUC0.~h 49.37 + 8.16 vs 89.76 + 14.40 t.tg.h.ml-'; mean + sem). RIT 300 mg 6 hourly enabled all 6 patients to continue with therapy and maintained trough levels above the 90 per cent effective plasma concentration (EC9o) of 2.1 ktg.ml". The mean increase in CD4 count was 105 cells per cubic ml at 6 months. There was a mean 1.5 log reduction in HIV plasma RNA noted. A change in dosing regimen from RIT 600 mg 12 hourly to 300 mg 6 hourly improved tolerability, maintained antiviral efficacy.

%'ol. 167 Supplement No. 6

(P.138) SUBTHERAPEUTIC PLASMA SAQUINAVIR LEVELS IN HIV- 1 POSITIVE PATIENTS

C. Merry, M. Ryan, M. Barry, E M. Mulcahy. Department of G.U. Medicine, St. James's Hospital, Dublin.

Department of Pharmacology & Therapeutics, Liverpool University, Liverpool.

Saquinavir (SQV) is a potent in vitro inhibitor of the HIV-1 and HIV-2 proteinase enzyme. However in vivo this drug has a bioavailability of only 3-5 per cent. This is thought to be partly due to extensive first pass metabolism of SQV by cytochrome p450 3A4 and countertransport of the drug by the transporting protein, p glycoprotein. We have previously demonstrated marked inter patient variability in plasma SQV levels. In this study, we prospectively assessed trough plasma SQV levels in 23 HIV positive patients attending our clinical. All patients were at steady state SQV. The patients attended the dayward following an overnight fast and had blood drawn for SQV assay. The samples were centrifuged without delay and analysed using high performance liquid chromatography. The mean trough plasma SQV level was 81.6 ng/ml which is above the recommended ECg0 for SQV of 30 ng/ml. The range of trough plasma SQV noted was 19 ng/ml - 305 ng/ml. Six of the patients studied (26 per cent) had trough plasma SQV levels below the recommended EC90 and consequently SQV was of limited antiviral benefit to these patients. We would therefore suggest that therapeutic drug monitoring may be of value in monitoring patients on SQV therapy.

(I'.139) EMERGENCE OF TEICOPLANIN RESISTANT STAPHYLOCUCCUS EPIDERMIDIS IN A PAEDIATRIC

HOSPITAL

C. Nourse*, M. Byrne, E. Moylett, H. Murphy, K. Butler. Department of Paediatrics, University College Dublin and Our Lady's Hospital for Sick Children, Crumlin, Dublin.

The recent emergence of teicoplanin resistant Staphyloccus Epidermidis (TRSE) among blood cultures in a paediatric hospital prompted an investigation. Teicoplanin disc sensitivity tests were carried out on isosensitist agar using a 30mcg disc and MIC is determined by E test on isosensitest agar without additives. When TRSE were isolated, patient charts were reviewed with attention to patient age, sex, location, underlying diagnosis, duration of hospitalisation, prior antibiotic exposure, and colonisation or infection status with TRSE. From July 1996 to May 1997, TRSE were recovered from 34 blood cultures from 15 patients (MICs 8 to 32 mcg/ml) representing 6.6 per cent of positive blood cultures and 11.4 per cent of CoNS recovered from blood cultures during that period. Of the 10 males and 5 females, median age was 1 month (range one week to 8 yr). Ten patients were located in ICU at the time of the positive culture. Median length of hospitalisation was 10 days. Patients were exposed to a median of 12 antibiotic days (range 0 to 61 days) with no patient having previous courses of teicoplanin (5 had received vancomycin). Three cases had systemic infection with TRSE and 1 case had central catheter colonisation. In the remainder, recovery of TRSE was considered to represent skin contamination. Pulsed field gel elect.rophoresis (PFGE) revealed that there were 2 pairs of patients with similar strains; both housed in the ICU. TRSE are rapidly emerging among blood culture isolates and can cause significant clinical infection. Teicoplanin therapy may fail to resolve these infections. There is a need for surveillance of nosocomial isolates of CONS to determine resistance to glycopeptides.

LJ.M.S, National Scientific Medical Meet ing 39 April, May, June 1998

(P.140) LEMIERRE'S SYNDROME IN IRELAND

H. Thaker, C. Barry, J. Russell, G. Sheehan. Department of Infectious Diseases, Mater Hospital, Eccles

St., Dublin 7.

A 15 yr old boy presented with fever, dysphagia, a dry cough, right sided chest and abdominal pains for 1 week. He had a temperature of 39~ an inflamed pharynx, an altered "Donald Duck" speech and trismus, He had a tender left internal jugular vein with a fluctuant abscess in the supra-clavicular fossa. There was a right pleural effusion. Chest X-ray showed multiple lung abscesses and a right lower lobe collapse with effusion. CT of the neck demonstrated internal jugular vein thrombosis and parapharyngeal abscess. A diagnosis of Lemierre's syndrome was made. The patient was commenced on penicill in G, metronidazole and cefotaxime intravenously. A white cell scan revealed no other abscesses.- Emergency surgical exploration of the neck led to drainage of the abscess involving the carotid sheath and the parapharyngeal space and the necrotic internal jugular vein was excised. Gram negative anaerobic bacilli were isolated from the abscess. The patient was heparinized and maintained on IV penicillin G and metronidazole for 1 week followed by oral antibiotics for 6 weeks. He made a complete recovery with resolution of the cavitating lesions in the right lung parenchyma. Our case thus illustrates the successful management of Lemierre's syndrome.

cause of hospital acquired infection. Methicillin resistance (MR) is encoded on the mec gene. Recognition of MR by disk diffusion methods can be difficult. Addition of salt to the culture medium, and incubation of plates at 30~ are used to facilitate detection of MR. We have compared the performance of the methicillin (5ug) and oxacillin (lug) disk diffusion tests and the methicillin Etest strip on (Mueller-Hinton Agar, MHA, with 2 per cent NaCI at 37~ with the performance of these methods on Diagnostic Sensitivity Test agar (DST) and Isosensitest agar (IST) incubated at 30~ Twenty-five strains Staphylococcus aureus and 26 strains of coagulase negative staphylococci (CNS) isolated from blood cultures were studied. For S. aureus strains there was complete categorical agreement between all methods. There was significant variation in the results obtained for CNS. On MHA there was complete agreement for the oxacillin and methicillin disk diffusion tests. Results with the Etest method differed from those with disk diffusion method for 2 of 26 CNS strains. On DST and IST at 30 ~ 1 and 2 strains respectively failed to grow. False sensitive results occurred on IST (2 strains) and on DST (1 strain). Results of testing for the mec gene by PCR are available for 15 (of 26) CNS strains and coincide with the results obtained by the reference method. Any of the methods studied appears to work satisfactorily for S. aureus strains however there are significant problems with testing CNS on DST or IST.

MICROBIOLOGY (P.141) Q FEVER ENDOCARDITIS REVISITED

B. Boyle, R. Hone. Department of Microbiology, Mater Misericordiae Hospital,

Eccles Street, Dublin 7.

Q fever endocarditis accounts for from 1 to 6 per cent of blood culture negative endocarditis and was first reported in Ireland in 1960. In previous series it was associated with a mortality of up to 50 per cenP. We review 7 cases presenting to our hospital between 1994 and 1997.

Four patients were male, mean age of all cases was 53 yr (range 39-62). Underlying heart lesions were: mitral valve disease in 6 cases (2 had prosthetic valves) and 1 aortic valve disease. The average durations of symptoms prior to diagnosis was 7 months (range 1-12). Occupational risk was noted in 3 patients. On presentation clinical and laboratory features typical of Q fever endocarditis (fever, anaemia, elevated liver enzymes) were present in the majority of cases. All had raised titres to Q fever phase I antigen. Notable, in 5 cases, was the absence of thrombocytopenia. Antibiotic treatment alone was successful in 2 patients. Five patients required surgical excision of the infected valve. All patients are currently well.

Increased recognition and earlier diagnosis of Q fever endocarditis has lead to a significant reduction in mortality. Reference 1. Tobin et al. The American Journal of Medicine; 1982; 72: 396-400.

(P.142) DETECTION OF METHICILLIN RESISTANCE IN STAPHYLOCOCCI

B. Conboy, C. Butler, D. Moris, M. Cormican, J. Flynn. Department of Bacteriology, Clinical Science Institute,

National University of Ireland, Galway.

Methicillin resistant staphylococci (MRS) are an important

(P.143) INVESTIGATIONS OF THE RELATIONSHIP BETWEEN CHLAMYDIA PNEUMONIAE AND

ATHEROSCLEROSIS

O. McCormack, N. Corbally, A. Murray, S, Kirrane, C. O'Keane, R. Hone.

Department of Pathology, Mater Misericordiae Hospital, Eccles Street, Dublin 7.

Chlamydia pneumoniae, a human respiratory pathogen, has been associated with coronary heart disease and been detected in atherosclerotic lesions of coronary arteries and aorta.

This study aimed to examine the relationship between C. pneumoniae and atherosclerosis in an Irish population.

Sixty-four atheromatous plaques from coronary arteries (36), carotid arteries (25) and other (3), were examined by polymerase chain reaction for C. pneumoniae specific DNA. Histological examination was also carried out.

Sixty-five serum samples obtained from patients undergoing surgery for coronary artery disease were examined for lgG and IgM antibody to C. pneumoniae.

Results showed seroprevalance of C. pneumoniae was low and there was no evidence of C. pneumoniae within atheromatous plaques in this population.

This study supports the view that the role of C. pneumoniae in coronary heart disease may vary in different populations ~.

Reference 1. Weiss, Robin et al. I. Infect. Dis. 1996; 173: 957-62.

(P.145) ROTAVIRUS IN IRELAND

S. M. Lynch, B. Cryan, D. Whyte. Microbiology Department, Cork University Hospital.

On behalf of INFOSCAN

Infectious diarrhoea in the developing world has been estimated to result in at least 5 million deaths annually. The very young are particularly susceptible to infection and suffer the highest mortality. Rotavirus is the most common enteric


pathogen in young children in both tropical countries and in the developed world. Quarterly rota-virus notifications from the Southern area (Munster) are available from 1992. In this presentation, they will be represented graphically and compared to Campylobacter spp. and Salmonella spp. notifications during the same period. Significantly rotavirus was more common than either of the 2 bacterial pathogens in the 3 yr studied. There has been an increase in rotavirus notifications from 361 in 1992 to over 700 in 1997. Males were infected more often than females, 54 per cent versus 46 per cent. Winter/Spring peaks are obvious and conform to the expected seasonal pattern. Rotavirus vaccines are being developed and some have undergone field trials with promising results. It is likely that such vaccines will become available for general usage in the short to medium term future. To accurately determine the requirement for a rotavirus vaccination programme in Ireland the true incidence and epidemiology of rotavirus needs to be defined. This aim can only be achieved b y setting up a national laboratory based surveillance system.

(P.147) ANTIBIOTIC RESISTANCE IN SALMONELLA ENTERICA ISOLATES FROM THE REPUBLIC OF IRELAND

D. Morris, C. Butler, M. Cormican, J. Flynn, G. Corbett-Feeney.

Department of Bacteriology, Clinical Sciences Institute, University College Galway, Galway, Ireland.

Antimicrobial resistance is recognised with increasing frequency in clinical isolates of Salmonella enterica from European countries. Of particular importance is the epidemic of Salmonella typhimurium definitive type 104 (DT104) which possesses chromosomally encoded resistance to A,C,S,Su,T- Ampicill in (A), Chloramphenicol (C), Streptomycin (S), Sulphonamides (Su), and Tetracycline (T). We have studied 181 clinical isolates of S. enterica collected from 7 centres in the Republic of Ireland. This collection contained the following serovars: S. enteritidis (53), S. typhimurium (51), S. derby (15), S. virchow (13), S. bredeney (13), S. schwarzengrund (11), S. agona (6) and others (19). In accordance with NCCLS- recommended methods for disk-diffusion testing, susceptibility to A,C,S,Su,T, Trimethoprim (Tri), Cefotaxime (Ctx), and Ciprofloxacin (Cip) was determined. Data analysis was perfonned using WHONET4 software. All strains were sensitive to cefotaxime and ciprofloxacin. The percent of isolates resistant to at least one of the antimicrobials were as follows: S. enteritidis (4 per cent), S. typhimurium (94 per cent), S. derby (100 per cent), S. virchow (31 per cent), S. bredeney (38 per cent), S. schwarzengrund (27 per cent), S. agona (33 per cent). Thirty- seven (73 per cent) of the S. typhimurium isolates exhibited the A,C,S,Su,T phenotype of resistance and 9 (18 per cent) also expressed resistance to trimethoprim. All strains of S. derby were resistant to S,Su,T. In contrast to data from England and Wales, no resistance to ciprofloxacin was noted.

(P.148) RAPID DETECTION OF MYCOBACTERIUM TUBERCULOSIS BY TWO MOLECULAR METHODS

A. Murray, N. Corbally, R. Hone. Department of Microbiology, Mater Misericordiae Hospital,

Eccles Street, Dublin 7.

In the Republic, of Ireland the notification of tuberculosis is


15.4/100,000 population. In the Mater Misericordiae hospital 3000 samples per yr are processed for tuberculosis. These samples have a positivity rate of 3.5 per cent of these 59 per cent are positive by microscopy. With 41 per cent microscopy negative samples in mind two molecular systems for the rapid detection of Mycobacterium tuberculosis have been evaluated. Ligase chain reaction (LCx Abbott Laboratories) and Amplicor MTb). Both systems contained the 3 standard steps in extraction amplification and detection.

The Amplicor system is based on amplification of the target using 2 biotinylated oligonucleotide primers followed by hybridisation of the amplified product to a specific nucleic acid probe. This is detected colorimetrically in a microwell plate using avidin-horseradish peroxidase. The LCx system depends on amplicification of the target using 4 oligonucleotide probes. Detection of the amplified product is by micropartiele enzyme immunoassay. All of these reactions take place in a 1 tube format.

Results from both systems suggest they have a role in increasing the speed of detection of Mycobacterium tuberculosis particularly in high profile smear negative patients. For smear positive patients both these systems lend themselves to the rapid identification of Mycobacterium tuberculosis.

O C C U P A T I O N A L M E D I C I N E

(P.149) JUNIOR DOCTORS: A WEIGHTY PROBLEM

T. Mackle, M. Colreavy. Department of Otolaryngology, Beaumont Hospital, Dublin 9.

There has been increasing publicity in the popular press about the weight of school bags carried by children. However other groups such as junior doctors may carry large weights with them on duty. The aim of the study was to ascertain the average weight of white coats and contents carried by junior doctors and to examine any differences between speciality and grade.

Fifty-two of 60 consecutive junior doctors were enrolled in the study and had their white coats and contents weighed.

There were 20 females and 32 males. The average weight was 1.6 kg and 1.6 kg respectively. Surgical specialities on average carried less than medical specialities (1.48kg vs 1.75kg). More senior doctors divested themselves of extra weight. Registrars carried an average of 1.2kg while interns carried and average of 1,8kg Average body weight did not differ between the groups

Conclusions: Junior doctors carry the equivalent of almost 2 bags of sugar while on duty. This may have important implications with regard to energy expenditure, stamina, response time and tiredness through prolonged periods on call.

O P H T H A L M O L O G Y

(P.150) AN INFRA-RED OCCULOGRAPHIC STUDY OF EXTRA-OCULAR EYE MOVEMENTS IN ALZHEIMER'S

DISEASE

J. Perkins, C. Saidlear, A. Young, M. Wrigley *, E,Eustace. Institute of Ophthalmology, 60 Eccles St., Dublin 7.

*Department of Old Age Psychiatry, 61 Eccles St., Dublin 7.

The aim of this study was to assess whether a specific strategy of eye movements during reading exists in Alzheimer's Disease

IJ.M.S. National Scientific Medical Meeting 41 April, May, June 1998

(AD). S t r a t e g i e s of r e a d i n g hav.e been found in o the r neurological disorders e.g. sixth nerve palsies and particularly homonymous hemianopia. Previous studies of eye movements in AD have shown defici ts , charac ter i s t ica l ly in saccadic accuracy, velocity and latency as well as impersistence of gaze and an inability to suppress anticipatory saccades or to ignore visual stimuli (an attentional grasp reflex). Since. reading is purely saccadic, it is likely to be an effective way of testing eye movements in AD. AD is often a diagnosis of exclusion and it is hoped that if a specific strategy of reading was isolated it would help make the diagnosis more definitive.

The patients ' visual acuity, pupillary responses, visual field and intra-ocular pressure were first examined. Cognitive ability was assessed with a Mini Mental State Examinat ion and a func t iona l s tage of demen t i a was also es tab l i shed . Eye movements were measured using the IRIS system. This method is based on the reflection of Infra-red light from the corneo- scleral junction (limbus) of the eye. The results, presented in graph form, show abnormalities in the refixation complexes of the affected patients.

P H A R M A C O L O G Y / THERAPEUTICS

(P.151) BEHAVIOURAL RESPONSIVITY TO THE D1-LIKE AGONIST A 68930 IN MICE WITH DjA DOPAMINE

RECEPTOR ' K N O C K O U T '

J. Clifford I, O. Tighe 2, D. T. Croke 2, J. Drago 3, D. R. Sibley 4, J. L. Waddington I.

Departments of ~Clinical Pharmacology & 2Biochemistry, R.C.S.I, Dublin 2; 3Monash University, Australia; 4NINDS,

Bethesda, USA.

Among D~-like dopamine receptors it is the adenylyl cyclase- coupled DIA r e c e p t o r that has been a s sumed to play a fundamental role in the regulation of psychomotor behaviour, however, there is indirect evidence which indicates a functional role for another Dr-like receptor that may be coupled to a transduction system other than/additional to adenylyl cyclase. D 1A 'knockout ' mice were challenged with A 68930, a selective Dl-like agonist and assessed by direct visual observation. In wildtypes [D~A/-], A 68930 dose-dependently induced sniffing, sifting rearing, grooming and intense grooming. Relative to wildtypes, 'knockouts ' [DIANA-/ ] evidenced unaltered sniffing and sifting responses to the highest dose of A 68930, with only rearing being attenuated significantly [P<0.001]; grooming was not altered, while intense grooming to the highest dose was attenuated [P<0.05] but still occurred to significant excess relative to vehicle controls [P<0.05]; there was a prominent increase in locomotion to the highest dose of A 68930 [P<0.001]. Mice with targeted gene deletion of the Di^ receptor showed preservation of several behavioural responses to the highly potent and select ive full efficacy D l - l i k e agonist A 68930. Grooming is the most widely accepted behavioural index of Dr-like receptor activation and this response was not abolished in D~A/ mice. These findings suggest either that several elements of behavioural responsivity to Dr-like stimulation involve at least in part not the DtA but rather some other Dl-like receptor, or that compensa tory processes consequent to developmenta l absence of Dzg receptors can mediate these responses.

Supported by RCSI. We thank Abbott for A 68930.

(P.152) THE IMPACT OF MAJOR TRIALS ON THE USE AND CHOICE OF LIPID LOWERING DRUGS

J. Feely, A. Kelly, M. Carvalho. Departments of Pharmacology & Therapeutics and

Community Health, Trinity College, Dublin 2.

Two landmark studies established the statins as drugs of choice in the management of hyperlipidaemia. The 4S Study (simvastatin 20-40 mg, patients aged 35-70 yr, 82 per cent male) repor ted on the benef i t s of secondary p r even t i on ~ whi le WOSCOPS (pravastatin 40 mg, male only 45-64 yr) reported the benefits of primary prevention of coronary heart disease 2. To determine the possible impact of these studies on the use of LLD in the community, particularly in relation to drug choice, dosage, gender and age we examined prescribing in the General Medical Services (GMS patients, approx. 150,000) Eastern Health Board area in selected months before and fol lowing publication of these studies. From 1994 to Sept. '96 the use of LLD increased 3 fold, largely statins, particularly more with pravastatin than simvastatin. The use of clofibrate plateaued and there was a small increase in the use of cholestyramine and gemfibrozil. The percentage increase was greatest in the 75+ age group followed by the 65-74 age group. Growth in use was also more marked in female than male population. Similarly for dosage less than half the patients are on the dosage of statin used in the seminal trials.

Based on trial results one would predict increased use of statin 20-40 mg in middle age subjects especially male. In practise LLD was increased 3 fold, appropriately with statins but in elderly patients, particularly female but in lower dosage. There appears to be selective application of evidence based medicine in relation to the use of LLD.

References 1. Lancet, Nov. 1994; 344: 1383. 2. NEJM, Nov. 1995; 353: 1301.

(P.153) POOR RECORDING OF DRUG HYPERSENSITIVITY IN PATIENT RECORDS

M. Hennessy, M. Kelly, J. Feely. Department of Pharmacology and Therapeutics, Trinity

Centre for Health Sciences, St. James's Hospital, Dublin 8.

Fa i l u r e to a c c u r a t e l y r eco rd drug h y p e r s e n s i t i v i t y , particularly allergies, to antimicrobials may place a patient at risk of severe toxicity if re-exposed to the same or related m e d i c i n e s . To d e t e r m i n e the ex t en t to wh ich drug hypersensitivity was recorded we reviewed some 271 in-patients (147 female) from General Medical and Surgical wards. Initially patients were interviewed and almost 20 per cent (52) reported that they had suffered allergic reactions. However, we believe that only 36 or approximately two-thirds of these are truly allergic in nature - characteristic clinical features, anaphylaxis, angioedema, urticaria; onset in relation to dosing and response to antihistamines and steroids. Of the 36 reactions 23 were attributable to antimicrobials (21 to penicillins). These included anaphylaxis, Steven Johnson's syndrome angioedema as well as rashes. Only 2 were recorded on the cover of the chart, l 0 on the drug prescription sheet and there was no record anywhere in 6 cases. With regard to the other adverse react ions to cyclosporin, penicillamine, gold, codeine, metoclopramide etc. there was a similarly poor level of recording adverse reaction in the patient records.


In summary the majority of patients at risk of further drug hypersensitivity do not have this documented in designated sites where it would be of practical importance - drug prescription chart, cover of patient case record. Further action needs to be taken to ensure all known drug hypersensitivities, which seem to affect over 10 per cent of the patient population, are documented in appropriate positions.


inhibitors indicated a role for the p42/p44 Mitogen Activated Protein Kinase (MAPK) signal transduction pathway in the CsA- induced TGF-B production. CsA also induced an increase in the cyclic AMP response binding element (CREB) in LLC-PK~ cells indicating a role for altered gene transcription. These novel findings provide evidence that CsA nephrotoxicity may be mediated at least, in part, by overproduction of TGFB in renal cells leading to fibrosis.

(P.154) UTILISATION OF THE NATIONAL MEDICINES INFORMATION CENTRE (NMIC) RESOURCES BY

DOCTORS IN IRELAND C. Hughes, M. Hanlon, J. Feely, K. Sabra.

National Medicines Information Centre and Department of Pharmacology & Therapeutics, St. James's Hospital, Dublin 8.

We reported previously that when doctors in Ireland prescribe new medicines the pharmaceutical industry is the dominant source of informationL The NMIC established in September 1994 provides independen t informat ion to heal thcare professionals in Ireland on all aspects of drug use. We were interested to determine (by "DI-scan") the utilisation of the NMIC resources by doctors.

From October 1994 to October 1997 10,767 enquiries were received with general practitioners (GPs) accounting for 13.5 per cent and hospital doctors for 11.69 per cent. Information was most frequently sought on adverse drug reactions (ADR), 32.19 per cent and 41.8 per cent respectively. Fifteen point 6 per cent of GP enquiries concerned choice of therapy compared with hospital doctors (10 per cent) possibly because hospital doctors are more likely to be familiar with the limited therapeutic options within their specialty. On the other hand enquiries for information on pharmaceutical aspects of medicines e.g. intravenous compatibilities, came predominantly from hospital doctors (11 per cent) compared to GP's (0.8 per cent).

When available an independent medicines information centre will be used extensively by prescribers. The needs however of GP's and hospital doctors differ considerably. Whether the information provided, including bulletins, influences the choice of medicine remains to be established.

Reference 1. Clin. Pharm. Ther. 1997; 61: 214.

(P.155) CYCLOSPORINE A ENHANCES TGF-B EXPRESSION IN A RENAL CELL MODEL

T. Keane, D Egan, M. Ryan. Department of Pharmacology, University College Dublin and

Tallaght Regional Technical College.

Cyclosporine A (CsA) is a very effective immunosuppressive drug whose use is limited by development of nephrotoxicity. CsA nephrotoxicity is associated with establishment of renal fibrosis. TGF-B is a cytokine with potent fibrogenic properties and may therefore play a role in renal fibrosis. The aims of this study were to investigate the effects of CsA on TGF-B expression in renal cells. The established proximal tubular LLC-PK, renal cell was used as the model system. Cells were exposed to CsA (50-500 nM) for varying times. CsA increased the release of TGF-B as measured by ELISA into the medium. In addition, CsA increased the expression of the TGF-13 receptor in LLC- PKI cells as measured by Western Blot analysis. Use of specific

(P.156) THE PHARMACOKINETIC INTERACTION BETWEEN SAQUINAVIR AND NELFINAVIR

C. Merry, M. Ryan, M. Barry, F. M. Mulcahy. Department of G.U. Medicine, St. James's Hospital, Dublin

and Department of Pharmacology & Therapeutics, Liverpool University, Liverpool.

Saquinavir (SQV) is a potent protease inhibitor in vitro. However in vivo this drug has a low bioavailability of 3-5 per cent due to first pass metabolism by cytokine P450 3A4. Nelfinavir (NFL) is a new protease inhibitor which inhibits the activity of Cytochrome -450 3A4. Therefore combination therapy with SQV plus NFL is an attractive therapeutic option due to this pharmacokinetic interaction. In this study, we evaluated the effect of NFL on plasma SQV levels in 6 HIV positive patients. All 6 patients were at steady state SQV. The patients attended the dayward following an overnight fast and had blood drawn for SQV assay at 0, 1, 2, 3, 4, 6 and 8 h post dosing. The patients were then prescribed NLF 750 mg tid in addition to their usual medications for 2 days. Patients returned for pharmacokinetic study on day 3. There was marked inter patient variability in plasma SQV levels on both study days. The SQV C .... increased from 253 ng/ml to 1204 ng/ml in the presence of NFL. The area under the time-concentration curve (AUC0.sh) increased from 1106 ng/ml/h to 5472 ng/ml/h in the presence of NFL. The variability in the baseline SQV levels noted suggest that there may not be a single dosing schedule for all patients and that the dosing may best be adjusted using individual

(P.157) AN AUDIT OF ADVERSE DRUG REACTIONS IN PATIENTS ON PROTEASE INHIBITOR THERAPY

C. Merry, M. Ryan, M. Barry, F. M. Mulcahy. Department of G.U. Medicine, St. James's Hospital and Department of Pharmacology & Therapeutics, Liverpool

University, Liverpool.

Many adverse drug reactions have been described for all 3 commonly prescribed protease inhibitors (PI) namely, saquinavir (SQV), ritonavir (RIT) and indinavir (IND). We prospectively studied the tolerability of PI in patients over a 6 month period. One hundred and 91 HIV positive patients were prescribed PI therapy during the study period representing 241 evaluable patient drug exposures. The RIT treated group had the highest incidence and most severe adverse drug reactions. Twenty-eight per cent of patients on RIT (n=20) discontinued therapy due to adverse drug reactions compared with I 0 per cent (n= 11) and 5 per cent (n=3) for SQV and IND respectively., Nausea and vomiting were the most frequent side effects in all 3 treatment groups n=60 (25 per cent). The second most common side effect was diarrhoea n=32 (13 per cent). Perioral and peripheral paraesthesia were the third most frequently documented side


effects and only occurred in the RIT treated group n=24. Three patients on PI therapy (2 on IND and 1 on RIT) developed otherwise unexplained hypokalaemia. Three patients on IND therapy developed nephrolithiasis. The PI constitute a valuable addition to the anti-retroviral armamentarium. However from this study it is evident that tolerability is a problem for many patients.

(158) WHAT'S IN TRADE NAME WHEN ASPIRIN DOSE IS THE SAME?

S. C. Sharma. Department of Pharmacology and Therapeutics, Trinity

College, Dublin 2.

While the oral absorption of a drug is improved when taken with some liquid it is not clear if the absorption of a water soluble aspirin tablet is different from the tablet which is not marketed as water soluble. We have compared the amount of salicylate excreted in urine following the intake of 2 doses, each of the five commonly used aspirin preparations in their tablet form. These included Dispirin, Nu-seals, Caprin, Aspro clear and Bayer aspirin. The effect of aspirin on bleeding time was also studied. Following an informed consent 16 healthy volunteers (8 males, 8 females) with a median age of 21 (19-25) yr participated in the study. They were divided into 2 groups. One group was given 300 mg and the other 600 mg of aspirin on every second day, 1 h after the mid-day meal or a standard sandwich and following the emptying of bladder which also provided a control sample. The amount of urine excreted at 45 and 90 minutes was then collected, measured and estimated for its salicylate content. The results shown in the table indicate that the excretion of salicylate is considerably higher fol lowing the ingestion of Aspro, Bayer aspirin and Dispirin compared with Caprin and Nu-seals aspirin, perhaps indicating their pattern of absorption from the G.I.T.

Urinary salicylate after the intake of various aspirin preparations (mg/100 ml+SEM )

Dose 300 mg 600 mg 45 min 90 min 45 min 90 min

Dispirin 4.14+ 1.84 10.78+2.91 9.69+3.03 21.84+4.1 Nu-seals 0.32 + 0.02 0.83 + 0.23 0.77 + 0.24 1.43 + 0.30 Caprin 0.27_+0.01 0.64_+0.19 0.69+0.45 1.39+0.66 Aspro 7.41 + 1.21 19.89 + 1.92 11.45 + 2.56 26.43 + 3.20 Bayer 6.66+2.09 10.91+_2.60 9.77+-2.79 21.56+-2.98

There was an increase in bleeding time with both the doses of aspirin but the increase in subjects treated with 600 mg aspirin was not significantly different from the group treated with 300 mg of aspirin. The increase in bleeding time occurred despite the administration of aspirin on every second day indicating that alternate day aspirin intake may be as good as its daily intake.

(P.159) EVIDENCE OF GOOD QUALITY OF PRESCRIBING WITHIN THE GENERAL MEDICAL

SERVICES (GMS) SCHEME

D. Williams, A. Kelly, M. Carvalho, J. Feely. Departments of Pharmacology and Therapeutics and

Community Health, Trinity College, Dublin 2.

Hitherto pharmacoepidemiology was concentrated more on the quantity than quality of prescribing. To develop an index of quality of prescribing we investigated the incidence of potential drug in te rac t ions with warfar in wi th in the GMS scheme. Evidence of good prescribing practice can be inferred from choice

within a particular drug group where the use of an interacting drug can be compared with that of a non-interacting drug.

A list of theoretical drug interactions with warfarin was der ived from the Brit ish 'National Formulary list of drug interactions. We studied the number of prescription items, which were co-prescribed with warfarin for the month of May 1996. We compared the use of the interacting drug cimetidine and the non-interacting drug ranitidine in warfarin and non-warfarin users.

A total of 24,481 prescription items were co-prescribed with warfarin of which 2,740 (11 per cent of total) were identified as p o t e n t i a l l y i n t e r a c t i n g p r e s c r i p t i o n s (e .g . a n t i b i o t i c s , carbamazepine, mefanamic acid, piroxicam).

The ratio of cimetidine to ranitidine use in the warfarin-users was 0.26 compared to 1.49, (both statistically significant) in the non-warfarin-users.

That prescribers are almost 6 times more likely to choose non-interacting ranitidine for patients on warfarin requiring a H 2 antagonist provides evidence of good prescribing practice within the GMS. We bel ieve that the GMS data is a useful measu re of the qua l i ty of drug p r e s c r i b i n g and can be extrapolated to other therapeutic areas subject to cl inical ly important drug interactions.

The assistance of the GMS Board is acknowledged.

(P.160) SWITCH IN USE AND CHOICE OF ORAL CONTRACEPTIVES IN IRELAND FOLLOWING UK PILL

SCARE

D. Williams, A. Kelly, M. Carvalho, J. Feely. Departments of Pharmacology & Therapeutics and

Community Health and General Practice, Trinity College, Dublin 2 and St. James 's Hospital, Dublin 8.

On Oct. 18, 1995 the UK Committee of Safety of Medicine (CSM) issued a warning about the safety ( thromboembolism disease) of third generation oral contraceptive steroids (OCS) recommending a switch to older agents except where women were intolerant of first and second generation OCS. This pill scare lead to some users stopping OCS mid-cycle and a rise subsequently in abortions and pregnanciesL Advice in Ireland did not recommend such a switch. To determine whether the local or UK advice was followed we obtained data from the General Medical Service (GMS) on the use of combined oral contraceptives prescribed before and after the CSM's warning, as shown in Table.

1st Gen. 2nd Gen. 3rd Gen.

Jan '95 n = 12,516 8% 34% 58% Sep '95 n = 12,651 8% 34% 58% Dec '95 n = 10,717 10% 47% 43% Jan '96 n = 11,070 11% 49% 40% Nov '96 n = 9,996 10% 53% 37%

It is clear that prescribers and pill users were influenced more by the UK scare than by advice from the Irish Regulatory Authority with a marked switch from 3rd generation products. A similar response has been noted in other European countries. We have also recorded a marked fall in the overall use of OCS a trend that was not noted in the UK. There is now a centralised European mechanism to licence drugs in the EU. We need to develop a European perspective to these issues of drug safety as constituent nations are no longer isolated islands.

Reference

1. BMJ, 1996, 313;363

44 National Scientific Medical Meeting wq 167 Supplement No. 6

P U B L I C H E A L T H

(P.161) TRENDS IN MORTALITY FROM ISCHAEMIC HEART DISEASE IN IRELAND, 1961-1995

M. B. Codd, N. G. Mahon, H. A. McCann, D. D. Sugrue. Departments of Epidemiology/Cardiology, Mater

Misericordiae Hospital, 71 Eccles Street, Dublin 7.

International comparisons of age-standardised mortality rates from ischaemic heart disease (IHD) indicate that IHD mortality in Ireland continues to rank among the highest in the world. IHD is recorded as the cause of death in 25 per cent of all deaths in Ireland (CSO 1993). This study reviews mortality from IHD in Ireland over a 35 yr period (1961-95 inclusive). Data were collated from Annual Vital Statistics reports using relevant International Classification of Diseases (ICD) codes. Between 1961 and 1995, the 1CD system underwent 2 revisions with significant changes to IHD codes. In ICD-8 (1968) a separate code was assigned for acute myocardial infarction (AMI). ICD- 9 (1978) introduced a modification to the coding of both IHD and AMI. Denominator information for this review was derived from census data. Rates were adjusted to the 1991 population of Ireland. IHD mortality increased from 1961-1974 in both men and women. A plateau was maintained thereafter until 1985. Since 1985, IHD mortality has decreased by 24 per cent (272/ 100,000 to 207/100,000); AMI mortality has decreased by 33 per cent (215/100,000 to 144/100,000). While this trend is encouraging, the burden of care required for IHD has changed to a lesser degree due to demographic changes taking place in the population.

(P.162) NEURAL TUBE DEFECTS - PROFILE FROM HIPE

G. M. Sayers, Z. Johnson. The Health Information Unit, Dr. Steevens Hospital, Steevens

Lane, Dublin 8.

The prevalence rate of 27/100,000 for neural tube defects (NTDs) at birth in Dublin for the period 1980-1992 is one of the highest in Europe ~. The purpose of this study was to draw up a profile of those with NTDs using data from the Hospital Enquiry System (HIPE) information system. Data relating to those living in the Eastern Health Eoard only for 1996 was used. The data was anlysed using the SAS statistical package.

In 1996, there were 413 discharges relating to NTDs. Fifty- one per cent were repeat admissions. Males were slightly in the majority (50.5 per cent). Almost 25 per cent of the patients discharged were under 5 yr of age. Forty-two per cent were aged ~'rom 5-19 yr, 27 per cent were aged 20-39 yr with the oldest patient being aged 62 yr. The median age was 13 yr.

A wait!ng list was the source for 44 per cent of admissions

with 40 per cent being an emergency admission. The vast majority (97 per cent) were discharged home following their hospital discharge. Almost three quarters (75 per cent) stayed for 0-6 days with 7 per cent staying over 21 days in hospital. This data shows that this population is a young population, the majority of whom spend relatively short periods in hospital.

Reference 1. Eurocat Central Register. Registration of congenital anomalies and multiple births. Report No. 6. Brussels: Eurocat 1992.

T O X I C O L O G Y

(P.163) A GAS CHROMATOGRAPHY/MASS SPECTROMETRY METHOD FOR THE DETERMINATION

OF 7-AMINOFLUNITRAZEPAM, THE MAJOR METABOLITE OF FLUNITRAZEPAM, IN URINE

S. M. McNamara, P. V. Kavanagh, J. Feely. Department of Pharmacology & Therapeutics, Trinity

College, Dublin 2.

The benzodiazepine class of drugs (e.g. diazepam, temazepam etc.) occupy an important part in the treatment of anxiety and sleeping disorders. Unfortunately, certain members of this family are widely abused. Flunitrazepam (Rohypnol+M), known as the 'date rape drug', has been used to incapacitate unsuspecting victims leading to sexual assaul0. This prompted us to establish a sensitive, reliable and reproducible method for the detection of the drug in urine. Flunitrazepam is converted to 7-aminoflunitrazepam in the body and this anaiyte was targeted for analysis by gas chromatography/mass spectrometry 2.

Previous methods which have used trimethylsilyl (TMS) derivatives, acid hydrolysis or no derivatisation at all proved unworkable in our hands, giving unreproducible results. The method developed here is based upon a simple solvent extraction followed by mild der ivat isa t ion with methyl - ( -b is - trifluoroacetyl) amine (MBTFA), giving a trifluoroacetyl (TFA) derivative. 7-Amino-l-methylclonazepam was used as an internal standard.

Analysis of the derivatised extracts by gas chromatography/ mass spectrometry with selected ion monitoring (SIM) gave a lower limit of detection of I ng/ml for 7-aminoflunitrazepam with a working linear range of 1-500 ng/ml.

The method has been found to he reproducible and has allowed us to ~rofile the excretion of fiunitrazepam following 1, 3 and 4 mg oral doses.

References 1. Anglin, D., Spears D. L, Range Hutson, H. Acad. Emerg. Med. 1997; 4- 323. 2. E1Sohly, M. A., Feng, S., Salamone. S. J,, Wu, R. Anal. Tox. 1997; 21: 335.

National scientific medical meeting 1997 abstracts

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