Merlin Park University Hospital

OBJECTIVE: Methotrexate has shown efficacy for the treatment of several diseases, especially rheumatoid arthritis (RA). Methotrexate has also been implicated as a causative agent in interstitial lung disease. Patients with RA may develop pulmonary manifestations of their disease and are at increased risk of respiratory infection. The aim of this study was to evaluate the relative risk (RR) of pulmonary disease among patients with RA treated with methotrexate. METHODS: We searched the PubMed and Cochrane databases (publication dates January 1, 1990 to February 1, 2013) for double-blind, randomized, controlled trials of methotrexate versus placebo or active comparator agents in adults with RA. Studies with <100 subjects or with a duration of <24 weeks were excluded. Two investigators independently searched both databases, and all of the investigators reviewed the selected studies. We compared differences in the RR using the Mantel-Haenszel random-effects method. RESULTS: A total of 22 studies with 8,584 participants met the inclusion criteria. Heterogeneity across studies was not significant (I(2) = 3%), allowing combination of the trial results. Methotrexate was associated with an increased risk of all adverse respiratory events (RR 1.10, 95% confidence interval [95% CI] 1.02-1.19) and respiratory infection (RR 1.11, 95% CI 1.02-1.21). Patients treated with methotrexate were not at increased risk of death due to lung disease (RR 1.53, 95% CI 0.46-5.01) or noninfectious respiratory events (RR 1.02, 95% CI 0.65-1.60). A subgroup analysis of studies in which pneumonitis was described revealed an increased risk associated with methotrexate (RR 7.81, 95% CI 1.76-34.72). CONCLUSION: Our study demonstrated a small but significant increase in the risk of lung disease in patients with RA treated with methotrexate compared with other disease-modifying antirheumatic drugs and biologic agents.

BACKGROUND: Despite a recent ideological shift towards the recognition of sexual autonomy for people with an intellectual disability (ID), there are continuing social and cultural barriers to sexual expression. Part I of the current two-part study assessed the sexual knowledge, experiences and aspirations of service users through focus groups and also examined their perceptions of impediments to achieving sexual autonomy. METHOD: Thirty-two participants (20 male, 12 female) attending an ID service participated in focus groups delineated by gender and age group (13-17 years; 18-30 years; 31+ years). RESULTS: Analysis of the focus groups showed that service users, especially those over the age of 18 years, had an understanding of their sexual rights but also identified a number of social and cultural barriers that they felt prevent them from achieving sexual autonomy. Those under the age of 18 years had only rudimentary knowledge of sexuality issues, for example pregnancy and sexual anatomy, but aspired to relationships and marriage similar to those over the age of 18 years. Family and staff attitudes appeared to be very influential in the views of respondents. All service users had received some form of sex education, although the benefits of such education appeared most enduring for those over 18 years. CONCLUSION: Service users had an understanding of their sexual rights and the social and environmental barriers that prevent them from fulfilling their rights. The provision of sex education training and promotion of positive attitudes towards appropriate sexual expression is critical to the realization of sexual autonomy for people with an ID.

OBJECTIVE: To investigate whether the Irish smoking ban has had an impact on secondhand smoke (SHS) exposures for hospitality workers. DESIGN, SETTING, AND PARTICIPANTS: Before and after the smoking ban a cohort of workers (n = 35) from a sample of city hotels (n = 15) were tested for saliva cotinine concentrations and completed questionnaires. Additionally, a random sample (n = 20) of city centre bars stratified by size (range 400-5000 square feet), were tested for air nicotine concentrations using passive samplers before and after the ban. MAIN OUTCOME MEASURES: Salivary cotinine concentrations (ng/ml), duration of self reported exposures to secondhand smoke, air nicotine (microg/cubic metre). RESULTS: Cotinine concentrations reduced by 69%, from 1.6 ng/ml to 0.5 ng/ml median (SD 1.29; p < 0.005). Overall 74% of subjects experienced decreases (range 16-99%), with 60% showing a halving of exposure levels at follow up. Self reported exposure to SHS at work showed a significant reduction from a median 30 hours a week to zero (p < 0.001). There was an 83% reduction in air nicotine concentrations from median 35.5 microg/m3 to 5.95 microg/m3 (p < 0.001). At baseline, three bars (16%) were below the 6.8 microg/m3 air nicotine significant risk level for lung cancer alone; at follow up this increased to 10 (53%). CONCLUSIONS: Passive smoking and associated risks were significantly reduced but not totally eliminated. Exposure to SHS is still possible for those working where smoking is still allowed and those working where smoke may migrate from outdoor areas. Further research is required to assess the true extent and magnitude of these exposures.

Methotrexate is the first line drug treatment for a number of rheumatic and non-rheumatic diseases. It is effective in controlling disease activity and preventing disease-related damage, and significantly cheaper than many alternatives. Use in rheumatoid arthritis infers a significant morbidity and mortality benefit. Methotrexate is generally well tolerated but can cause symptomatic adverse events. Multiple serious adverse events have been attributed to methotrexate, based largely on older reports using high or daily doses, and subsequent case reports and circumstantial evidence. The risk with modern dosing regimens: Lower doses, weekly schedules, and concomitant folic acid is less clear. Clarification and dissemination of the actual risk is crucial so appropriate judgements can be made for patients who may benefit from this treatment. Methotrexate has been associated with a range of liver related adverse events ranging from asymptomatic transaminase elevations to fibrosis and fatal hepatic necrosis. Concern over potential liver toxicity has resulted in treatment avoidance, cessation, or recommendations for investigations which may be costly, invasive and unwarranted. Modern laboratory monitoring of liver blood tests may also influence the risk of more serious complications. The majority of present day studies report an approximate doubling of the relative risk of elevated transaminases in methotrexate treated patients but no increased risk of symptomatic or severe liver related adverse events. In this article we will review the evidence around methotrexate and liver related adverse events.

BACKGROUND: Recent ideological shifts in service provision promote appropriate sexual expression for people with an intellectual disability (ID), although there is little evidence that such advances in ideology are matched by current service provision. Part II of the current two-part study assessed the attitudes of staff and family carers to the sexuality of people with an ID. METHOD: A questionnaire survey which included case scenarios was carried out with family (n = 155) and staff carers (n = 153) of people with an ID in the west of Ireland. RESULTS: In general, staff carers were more inclined than family carers to openly discuss issues of sexuality with service users, and to suggest environmental, rather than service-user characteristics, as impediments to such discussions. Attitudinal differences emerged with significant differences between staff and family carers and between younger and older carers. Staff carers were more likely to support service-user engagement in intimate and non-intimate relationships whereas the majority of family carers (80%) showed a preference for low levels of intimacy in service-user relationships. CONCLUSION: When compared with the attitudes of family carers towards the sexuality of people with ID, the attitudes of staff carers more closely match those promoted by ideological developments. However, differences in attitudes between carer groups may lead to inconsistent approaches to the management of sexuality. As a consequence, we conclude that there is continued need to provide staff and family carers with opportunities for dialogue and an ongoing need for training in the area of sexuality.

BACKGROUND: Although modifying diets, by thickening liquids and modifying the texture of foods, to reduce the risk of aspiration has become central to the current management of dysphagia, the effectiveness of this intervention has been questioned. This narrative review examines, and discusses possible reasons for, the apparent discrepancy between the widespread use of modified diets in current clinical practice and the limited evidence base regarding the benefits and risks of this approach. DISCUSSION: There is no good evidence to date that thickening liquids reduces pneumonia in dysphagia and this intervention may be associated with reduced fluid intake. Texture-modified foods may contribute to undernutrition in those with dysphagia. Modified diets worsen the quality of life of those with dysphagia, and non-compliance is common. There is substantial variability in terminology and standards for modified diets, in the recommendations of individual therapists, and in the consistency of diets prepared by healthcare staff for consumption. Although use of modified diets might appear to have a rational pathophysiological basis in dysphagia, the relationship between aspiration and pneumonia is not clear-cut. Clinical experience may be a more important determinant of everyday practice than research evidence and patient preferences. There are situations in the management of dysphagia where common sense and the necessity of intervention will clearly outweigh any lack of evidence or when application of evidence-based principles can enable good decision making despite the absence of robust evidence. Nevertheless, there is a significant discrepancy between the paucity of the evidence base supporting use of modified diets and the beliefs and practices of practitioners. CONCLUSION: The disconnect between the limited evidence base and the widespread use of modified diets suggests the need for more careful consideration as to when modified diets might be recommended to patients. Patients (or their representatives) have a choice whether or not to accept a modified diet and must receive adequate information, about the potential risks and impact on quality of life as well as the possible benefits, to make that choice. There is an urgent need for better quality evidence regarding this intervention.

UNLABELLED: Intrathecal (IT) morphine provides excellent postoperative analgesia but may result in many side effects, including postoperative nausea and vomiting, pruritus, and respiratory depression, particularly at larger doses. Older patients may be at particular risk. The optimal dose of spinal morphine in older patients undergoing hip arthroplasty is not known. We designed this prospective, randomized, controlled, double-blinded study to evaluate the analgesic efficacy and side effect profile of 50-200 microg of IT morphine in older patients undergoing elective hip arthroplasty. Sixty patients older than 65 years undergoing elective hip arthroplasty were enrolled. Patients were randomized to receive spinal anesthesia with 15 mg of bupivacaine and IT morphine in four groups: 1). 0 microg, 2). 50 microg, 3). 100 microg, and 4). 200 microg. IT morphine 100 and 200 microg produced effective pain relief and decreased the postoperative requirement for morphine compared with control. IT morphine 50 microg did not provide effective pain relief. Both 100 and 200 microg of IT morphine provided comparable levels of postoperative analgesia. There were no between-group differences in postoperative nausea and vomiting, sedation, respiratory depression, or urinary retention. Pruritus was significantly more frequent with 200 microg of IT morphine. In conclusion, 100 microg of IT morphine provided the best balance between analgesic efficacy and side effect profile in older patients undergoing hip arthroplasty. IMPLICATIONS: The dosage of intrathecal morphine that provides the best balance between analgesic efficacy and side effect profile in the older patient undergoing hip arthroplasty is not known. This prospective, randomized, controlled, double-blinded clinical trial demonstrates that a dose of 100 microg of intrathecal morphine provides the best balance between efficacy and side effects, compared with doses of 0, 50, and 200 microg of morphine, in this patient population.

Nocturnal leg cramps are common in older people. Such cramps are associated with many common diseases and medications. Physiological methods may be useful for preventing cramps in some people, but there have been no controlled trials of these approaches. Quinine is moderately effective in preventing nocturnal leg cramps. However, there are concerns about the risk/benefit ratio with this drug. In patients with severe symptoms, a trial of 4-6 weeks' treatment with quinine is probably still justified, but the efficacy of treatment should be monitored, for example using a sleep and cramp diary.

The optimum cementing technique for the tibial component in cemented primary total knee replacement (TKR) remains controversial. The technique of cementing, the volume of cement and the penetration are largely dependent on the operator, and hence large variations can occur. Clinical, experimental and computational studies have been performed, with conflicting results. Early implant migration is an indication of loosening. Aseptic loosening is the most common cause of failure in primary TKR and is the product of several factors. Sufficient penetration of cement has been shown to increase implant stability. This review discusses the relevant literature regarding all aspects of the cementing of the tibial component at primary TKR.

BACKGROUND: To provide the optimum level of healthcare, it is important that the supply of well-trained doctors meets the demand. However, despite many initiatives, Ireland continues to have a shortfall of physicians, which has been projected to persist. Our study aimed to investigate the migration intentions of Irish medical students and identify the factors that influence their decisions in order to design appropriate interventions to sustain the supply of trained doctors in order to maintain a viable medical system. METHODS: An online cross-sectional survey was undertaken of all Irish medical students studying in the Republic of Ireland. The survey included nominal, ordinal, and scale items to determine migration intentions, factors influencing their decisions, and understanding of the Irish healthcare system. RESULTS: A total of 2 273 medical students responded (37% response rate), of whom 1 519 were classified as Irish medical students (having completed secondary school in Ireland). Of these, 88% indicated they were either definitely migrating or contemplating migrating following graduation or completion of the pre-registration intern year. Forty percent expressed an intention of returning to Ireland within 5 years. The factors most influencing their decision to leave were career opportunities (85%), working conditions (83%), and lifestyle (80%). CONCLUSION: The migration intentions expressed in this study predict an immediate and severe threat to the sustainability of the Irish healthcare service. Urgent interventions such as providing information about career options and specialty training pathways are required. These must begin in the undergraduate phase and continue in postgraduate training and are needed to retain medical school graduates.

INTRODUCTION: Contrast-induced acute kidney injury, also referred to as contrast-induced nephropathy (CIN), is a potentially serious renal complication associated with the use of iodinated contrast media (CM) in patients at risk. With the dramatic growth in contrast-enhanced imaging services worldwide, including procedures involving exposure to iodinated CM, efforts to reduce the occurrence of CIN have received considerable attention in recent years. To date, these efforts have met with little success since the 12% prevalence of CIN today remains unchanged from 2 decades ago. METHODS: We conducted a systematic literature review of the most recent evidence available from published reports of contemporary (2000-2008) prospective, randomized, controlled trials that have investigated CIN either by comparing CM or by comparing preventive strategies. The objective was to critically review the findings in light of several aspects of study design and then to establish a set of parameters for consideration in the planning of future CIN trials so as to optimize the strength of evidence obtained. RESULTS: Whether future CIN trials are investigating comparative CM nephrotoxicity or dealing with prophylactic strategies for risk reduction, the complexities that must be addressed include a standardized definition of CIN, appropriate timing of SCr measurements with timing standardized for all subjects in a given study population, awareness of study population risk profile, hydration protocols, and pharmacological prophylactic strategies. CONCLUSIONS: Large, well-designed trials (ideally with hard clinical outcome measures) that consider all the complexities involved in CIN and its prevention are needed before the clinical community has the evidence-based direction required for optimized patient care.

Osteoarthritis (OA) has historically been classified as 'primary' where no discernible cause was evident and 'secondary' where a triggering factor was apparent. Irrespective of the triggering events, late-stage OA is usually characterized by articular cartilage attrition and consequently the anatomical basis for disease has been viewed in terms of cartilage. However, the widespread application of magnetic resonance imaging in early OA has confirmed several different anatomical abnormalities within diseased joints. A key observation has been that several types of primary or idiopathic OA show ligament-related pathology at the time of clinical presentation, so these categories of disease are no longer idiopathic - at least from the anatomical perspective. There is also ample evidence for OA initiation in other structures including menisci and bones in addition to articular cartilage. Therefore, a new classification for OA is proposed, which is based on the anatomical sites of earliest discernible joint structural involvement. The major proposed subgroups within this classification are ligament-, cartilage-, bone-, meniscal- and synovial-related, in addition to disease that is mixed pattern or multifocal in origin. We show how such a structural classification for OA provides a useful reference framework for staging the magnitude of disease. For late-stage or end-stage/whole organ disease, the final common pathway of these different scenarios, joint replacement strategies are likely to remain the only viable option. However, for younger subjects in particular, near the time of clinical disease onset, this scheme has implications for therapy targeted to specific anatomical locations. Thus, in the same way that tumours can be classified and staged according to their tissue of origin and extent of involvement, OA can likewise be anatomically classified and staged. This has implications for therapeutic strategies including regenerative medicine therapy development.

Genomic disorders affecting the genes encoding factor H (fH) and the 5 factor H related proteins have been described in association with atypical hemolytic uremic syndrome. These include deletions of CFHR3, CFHR1, and CFHR4 in association with fH autoantibodies and the formation of a hybrid CFH/CFHR1 gene. These occur through nonallelic homologous recombination secondary to the presence of large segmental duplications (macrohomology) in this region. Using multiplex ligation-dependent probe amplification to screen for such genomic disorders, we have identified a large atypical hemolytic uremic syndrome family where a deletion has occurred through microhomology-mediated end joining rather than nonallelic homologous recombination. In the 3 affected persons of this family, we have shown that the deletion results in formation of a CFH/CFHR3 gene. We have shown that the protein product of this is a 24 SCR protein that is secreted with normal fluid-phase activity but marked loss of complement regulation at cell surfaces despite increased heparin binding. In this study, we have therefore shown that microhomology in this area of chromosome 1 predisposes to disease associated genomic disorders and that the complement regulatory function of fH at the cell surface is critically dependent on the structural integrity of the whole molecule.

OBJECTIVE: To evaluate the relative risk (RR) of pulmonary disease among patients with rheumatoid arthritis (RA) treated with leflunomide (LEF). METHODS: We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials to April 15, 2014. We included double-blind randomized controlled trials (RCT) of LEF versus placebo or active comparator agents in adults with RA. Studies with fewer than 50 subjects or shorter than 12 weeks were excluded. Two investigators independently searched both databases. All authors reviewed selected studies. We compared RR differences using the Mantel-Haenszel random-effects method to assess total respiratory adverse events, infectious respiratory adverse events, noninfectious respiratory adverse events, interstitial lung disease, and death. RESULTS: Our literature search returned 5673 results. A total of 8 studies, 4 with placebo comparators, met our inclusion criteria. There were 708 respiratory adverse events documented in 4579 participants. Six cases of pneumonitis occurred, all in the comparator group. Four pulmonary deaths were reported, none in the LEF group. LEF was not associated with an increased risk of total adverse respiratory events (RR 0.99, 95% CI 0.56-1.78) or infectious respiratory adverse events (RR 1.02, 95% CI 0.58-1.82). LEF was associated with a decreased risk of noninfectious respiratory adverse events (RR 0.64, 95% CI 0.41-0.97). CONCLUSION: Our study found no evidence of increased respiratory adverse events in RCT of LEF treatment.

BACKGROUND: Surgical navigation allows continuous intraoperative monitoring of ACL graft anisometry and 3-dimensional obliquity. However, normative anisometry and obliquity measurements for different single-bundle anterior cruciate ligament graft positions are not well described. HYPOTHESIS: ACL Grafts placed in anteromedial and posterolateral bundle positions will have distinct anisometric profiles and 3-dimensional obliquities. A graft placed centrally in anterior cruciate ligament insertion sites will have different obliquity and anisometry than a conventional (single-bundle) graft extending from the tibia's posterolateral aspect to the femur's anteromedial aspect. STUDY DESIGN: Controlled laboratory study. METHODS: Five cadaveric knees were tested. A surgical navigation system was used to create 4 virtual graft positions in the anterior cruciate ligament footprint: (1) anteromedial, (2) posterolateral, (3) central, and (4) posterolateral tibia to anteromedial femur (conventional). Obliquity at various flexion angles and anisometry of each virtual graft's central fiber were determined. RESULTS: Anteromedial and posterolateral fibers are relatively parallel up to 30 degrees of flexion. At higher degrees of flexion, the anteromedial position is more oblique in the sagittal plane, while the posterolateral position is more oblique in the axial plane. The conventional single-bundle position is significantly more vertical than the central position in multiple planes throughout the range of motion. The anteromedial fiber is most isometric, while the posterolateral fiber is the least isometric at all flexion angles. There is no significant difference in the anisometry between the central or conventional positions at any flexion angle. The posterolateral, central, and conventional fibers were longest at full extension and slackened with progressive flexion. CONCLUSION: Anteromedial and posterolateral graft positions can be distinguished by sagittal and axial plane obliquity at flexion angles >30 degrees and by anisometry measurements. Conventional positioning produces a relatively vertical graft placement compared with the central position but has similar anisometry characteristics. Our data suggest that posterolateral, central, and conventional grafts should be fixed at or near full extension to avoid excessive tightening during motion. CLINICAL RELEVANCE: This study provides anisometry and 3-dimensional obliquity data for various graft positions using surgical navigation. The failure of single-bundle anterior cruciate ligament reconstruction to restore intact knee kinematics may be partly due to the relative vertical placement of conventional grafts compared with the central anterior cruciate ligament footprint position.

BACKGROUND: Conventional tunnel positions for single-bundle (SB) transtibial anterior cruciate ligament (ACL) reconstruction are located in the posterolateral (PL) tibial footprint and the anteromedial (AM) femoral footprint, resulting in an anatomic mismatch graft that is more vertical than native fibers. This vertical mismatch position may significantly influence the ability of an ACL graft to stabilize the knee. HYPOTHESIS: Anatomic ACL fibers undergo a greater change in length during anterior translation and internal rotation than a conventional SB reconstruction from the PL tibial footprint to the AM femoral footprint. STUDY DESIGN: Controlled laboratory study. METHODS: The Praxim ACL Surgetics navigation system was used to acquire kinematic data during a flexion/extension cycle and to register all points within the ACL footprint from 5 fresh-frozen cadaveric knees. Virtual fibers were placed in the center of the AM and PL bundles as well as central and conventional SB positions. After transection of the ACL, the absolute length change and apparent strain of the fibers were computed for each knee during the Lachman and anterior drawer tests and internal rotation at 0 degrees and 30 degrees of flexion. RESULTS: Each of the anatomic fibers (AM, PL, and central) had more elongation and apparent strain than the conventional SB fiber during the Lachman maneuver. During the anterior drawer test, the AM and central (but not the PL) fibers lengthened significantly more and the AM had more apparent strain than the conventional SB fiber. During internal rotation at 0 degrees and 30 degrees of flexion, anatomic fibers elongated significantly more than the conventional fiber. Except for the AM fiber with the knee at full extension, apparent strain was greater in all anatomic fibers than in the conventional SB fiber during internal rotation maneuvers. CONCLUSION: In ACL-deficient cadaveric knees, anatomic fibers undergo greater elongation and apparent strain in response to anterior translation and internal rotation maneuvers than a conventional SB graft. Because of their optimal orientation, anatomic fibers may resist pathologic anterior translation and internal rotation more than the conventional SB position. CLINICAL RELEVANCE: Conventional placement of a single-bundle graft results in suboptimal changes in fiber length and strain, suggesting that alternatives such as anatomic placement of an SB graft or double-bundle reconstruction may result in greater control of translation and rotation.

We have analysed the management and clinical outcome of a series of consecutive patients who had a total hip replacement and developed post-operative surgical site infection (SSI) with methicillin-resistant Staphylococcus aureus. The incidence of this infection was 1% over a period of five years. We studied SSI in 15 patients (16 infections) with a mean age of 72.7 years (53 to 81). In all, 12 of the infections occurred early and half of the infections involved the prosthesis, resulting in an increase of 11-fold in the cumulative hospital stay. Methicillin-resistant Staph. aureus was successfully eradicated in all the patients after a mean follow-up of 53.6 months (25 to 88). Superficial incisional infections resolved after antibiotic therapy alone while deep infections required multiple operative debridements. Attempted retention of the implant in early organ space infections was successful in only one of five patients. Only three patients with implant-level infections obtained a pain-free, functional prosthesis while a further three required excision arthroplasty. We have formulated a protocol of treatment which may serve as a guide in the management of these infections.

BACKGROUND: Testing of orientation to time is an important part of mental status examination. The validity of errors in different aspects of temporal orientation was examined in older hospital patients as a guide to the presence of dementia or delirium and as a measure of the severity of dementia, as defined by the Global Deterioration Scale. METHODS: Inpatients and outpatients attending an acute hospital underwent independent assessments by two doctors on the same day to determine orientation to time and cognitive status. Optimum cut-offs for error scores on the different aspects of temporal orientation were calculated to maximise the sum of sensitivity and specificity for detection of dementia or delirium. RESULTS: Of the 262 patients assessed, 62 (23.7%) had dementia or delirium. The best cut-offs for detection of these disorders were: any error in identifying the year, month, day of the month or day of the week; and an error of more than 1 h in identifying the time of day. Failure to identify the year correctly was the most valuable single sign of dementia or delirium (sensitivity 86% and specificity 94%); failure to identify either year or month correctly was 95% sensitive and 86.5% specific for the detection of cognitive impairment. Severity of temporal disorientation, measured using a number of approaches, was strongly associated with severity of dementia. CONCLUSION: Disorientation to time is a useful guide to the presence and severity of dementia or delirium in older hospital patients. Failure to identify the year or month correctly is a sufficiently sensitive and specific indicator of dementia or delirium to warrant more detailed cognitive assessment in this population.

STUDY OBJECTIVE: To determine what relation, if any, exists between mortality patterns, indicators of deprivation, general lifestyle and social attitudes, as exemplified by general election voting pattern, in the Republic of Ireland. A relation has been demonstrated previously between voting and mortality patterns in the United Kingdom. DESIGN: Cross sectional ecological study using three data sources. Standardised mortality ratios (SMR) were based on mortality rates at county level and 1996 census data from the Central Statistics Office, 1997 general election first preference voting data in all 41 constituencies were aggregated to county level. Selected reported measures of health status, lifestyle and social circumstances are from the first ever National survey on lifestyles, attitudes and nutrition (SLAN). This study comprised adults over 18 years sampled by post using the electoral register from 273 representative district electoral divisions. Univariate inter-relations were examined at individual level for the dataset as a whole, adjusting for age and at aggregated level for 26 county borough areas, which included the two largest cities and for 22 county areas, which afforded correlation with voting pattern, using the method of Pearson's correlation coefficient. PARTICIPANTS: 1,806,932 votes were cast nationally at the 1997 general election, representing a voter turnout of 65.92 %. There was an overall response rate of 62% to SLAN comprising 6539 adults (47% male). The demographic pattern of survey respondents was consistent with that of the general population over 18 years. MAIN RESULTS: At individual level there was a large number of highly significant inter-relations between indicators of deprivation, various measures of self rated health status and lifestyle factors. Aggregated at 26 county level percentage unemployed (r=0.408, p=0.038), and level of education (r=0.475, p=0.014) related significantly to SMR and inversely to both fruit and vegetable consumption (r= -0.672, p=0.001) and excess alcohol consumption among men (r= -595, p=0.003). Those rating their health as fair or poor were more likely to report a poor quality of life (r=0.487, p=0.022), to have none or primary school education only (r=0.428, p=0.047), or to have a means tested medical services card (r=0.428, p=0.047). There was no significant relation between SMR and voting pattern for the two main political parties (67.28% first preferences) but a significant relation with left wing voting (r=0.446, p=0.037). Fianna Fail voting pattern was inversely related to level of dissatisfaction with health (r= -0.59, p<0.05). There was a positive significant relation between left wing voting and dissatisfaction with health (r=0.51, p<0.02) and rate of smoking (r=0.47, p=0.03). Smoking pattern also related positively to rates of voter abstention (r=0.526, p=0.12). CONCLUSIONS: These data are consistent with those in other countries in showing a relation between deprivation indicators and lifestyle, but differ in that no relation with SMR and the votes cast for the main parties was seen in a country with a mainly centre right voting pattern. The relation between left wing voting pattern and some indicators of deprivation and lifestyle suggest that party political voting patterns and affiliations could be a useful indicator of vertical social capital. However, its variability as a measure across countries suggests that the inter-relation between sociocultural and economic factors and the consequent influence on health status is not straightforward.

Dislocation after total hip arthroplasty is part of spectrum ranging from neck impingement to subluxation before frank dislocation occurs. Objectives: To assess various parameters as potential risk factors for postoperative hip dislocation. Setting: Department of Orthopaedics in Merlin Park Regional Hospital, Galway Period: 5 years Study Design: Observational Material and Methods: In our study we reviewed 1096 patients who underwent primary total hip arthroplasty in a consecutive period of five years. We assessed various parameters as potential risk factors for dislocation. Results: During this period 16 (1.45 %) patients dislocated their hips. According to our study the Important factors that led to these dislocations were Retroverted cup (5 cases), trochanteric malunion/ avulsion (5 cases), Epilepsy (1 cases), Confusion/ Dementia (2 cases) Parkinsonism (2 cases). Abduction angle was found to be greater than 50 degrees in 8 cases. Conclusion: Familiarity with the risk factors assists in prevention and dictates aspects requiring further assessment, when dislocation occurs. Protection of the hip by bracing should be considered following revision surgery but is of questionable use in primary cases.