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Introduction: Lean methodologies have been used successfully in both industry and healthcare to reduce waste. The operating room (OR) and central supplies department (CSD) are areas associated with high hospital costs. The aim of this study was to employ Lean methodologies to support the rationalisation of surgical trays in paediatric inguinoscrotal surgery in order to reduce instrument wastage, processing times and overall costs in a European setting., Methods: This was a prospective, pilot observation and implementation study using Lean methodology including DMAIC (Define, Measure, Analyse, Improve and Control) cycles. Relevant tray set-up included trays for boys ≥12 months age undergoing open elective inguinoscrotal surgery. A comparative analysis of two phases, pre and post-standardization was then carried out with respect to operating times, instrument set-up times, tray weights, and costs. Instruments that were used <40% of the time were eliminated from the surgical tray., Results: Rationalization of the inguinoscrotal tray led to a 34.7% reduction in tray size, with a concomitant time-reduction of >2 min per case. The average overall instrument utilisation rate increased from 56% to 80% across users. Cost savings were projected at €5380.40 per annum based on current changes. There were no differences in operative time, or adverse outcomes., Discussion: At the hospital level, the reduction in variation, and rationalisation of this single surgical tray could lead to both operational (Tray assembly process; Operating rooms; Ergonomic functionality) as well as economic (Sterilisation; Instrument repair; Purchases) financial and ergonomic improvements for the healthcare system. The reduction in time taken to count and sterilise instruments can lead to a potential manpower saving involving a redistribution of activities to other areas which may require them., Conclusion: Surgical tray rationalisation is emerging Lean concept with overlap across a number of specialities, and represents a technique by which to manage costs, and improve supply chain efficiency without any adverse effect in patient healthcare outcomes., (Copyright © 2023 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background: Xanthogranulomatous pyelonephritis (XGP) is an uncommon chronic destructive granulomatous inflammation of the kidney. It was first described in 1916, and is thought to affect 6/1000 cases of pyelonephritis. Its manifestations are varied, and with a limited number of cases in the literature, the optimal diagnosis and management of XGP in the paediatric cohort is still unknown., Material and Methods: The medical records of children who were diagnosed and treated for XGP at the current unit during the period 1963-2016, inclusive, were retrospectively reviewed. Information pertaining to each patient was recorded, including: demographic data, past medical history, clinical and biochemical characteristics, diagnostic procedures, treatment methods, histopathologic diagnosis of the removed specimen, and outcome., Results: A total of 66 children with a median age of 4.84 years (range 1.1-14.81), with an M:F ratio 1.35:1 underwent nephrectomy for XGP and had a median follow-up of 7.19 years (range 0.11-17.45). The most common presentations were systemic illness (62.1%), pain (60.6%), urinary tract infections (54.5%) and an abdominal mass (39.4%); pyrexia was present in 53%. Biochemical abnormalities included anaemia (86.3%), thrombocytosis (80.3%) and hypomagnesemia (65.1%). There was an 83.3% concordance between intraoperative cultures and positive mid-stream urines. Index kidneys were significantly larger than the contralateral side (mean 1.32 cm; P = 0.002). Staging of XGP demonstrated extension beyond the kidney in 79% of kidneys. Computed tomography (CT) was performed in 11 cases (Summary figure). Dimercaptosuccinic acid (DMSA) scan showed 0-10% function in 90.47% of cases. Surgical procedures included nephrectomy (n = 63) and partial nephrectomy (n = 3). Perioperative complications included colonic resections (n = 5) and abscess formation in 18%., Conclusions: This is the largest series to date of XGP in a paediatric cohort. XGP should be included in the differential diagnosis of all children presenting with perirenal or psoas abscesses, renal masses and/or non-functioning kidneys with/or without associated urolithiasis. Clinical awareness and a high index of suspicion is required to achieve the correct pre-operative diagnosis and appropriate management., (Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background: The prevalence of urinary tract infections (UTIs) caused by extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae is increasing and the therapeutic options are limited, especially in primary care. Recent indications have suggested pivmecillinam to be a suitable option. This pilot study aimed to assess the viability of pivmecillinam as a therapeutic option in a Dublin cohort of mixed community and healthcare origin., Methods: A prospective measurement of mean and fractional inhibitory concentrations of antibiotic use in 95 patients diagnosed with UTI caused by ESBL-producing Enterobacteriaceae was carried out. 36 % patients were from general practice, 40 % were admitted to hospital within south Dublin, and 25 % samples arose from nursing homes. EUCAST breakpoints were used to determine if an isolate was sensitive or resistant to antibiotic agents., Results: Sixty-nine percent of patients (N = 66) with urinary ESBL isolates were female. The mean age of females was 66 years compared with a mean age of 74 years for males. Thirty-six percent of isolates originated from primary care, hospital inpatients (26 %), and nursing homes (24 %). The vast majority of ESBL isolates were E. coli (80 %). The E tests for mecillinam and co-amoxiclav had concentration ranges from 0.16 mg/L up to 256 mg/L. The mean inhibitory concentration (MIC) of mecillinam ranged from 0.25 to 256 mg/L, while co-amoxiclav MICs ranged from 6 to 256 mg/L. The percentage of isolates resistant to mecillinam and co-amoxiclav was found to be 5.26 and 94.74 % respectively., Conclusions: This is the first study exploring the use of pivmecillinam in an Irish cohort and has demonstrated that its use in conjunction with or without co-amoxiclav is an appropriate and useful treatment for urinary tract infections caused by ESBL-producing organisms.

Introduction: Hypospadias, the most common congenital malformation of the penis, is characterized by an abnormal ventral opening of the urethral meatus, abnormal ventral curvature of the penis, and an abnormal distribution of the foreskin around the glans, with a ventrally-deficient hooded foreskin, and has been described in modern peer-reviewed literature since Noble's description in 1853. A dramatic increase in the literature on hypospadiology has focused on two main topics: The aetiology of the condition including molecular mechanisms and environmental influences, as well as surgical techniques to repair the defect, however there have been a number of facets of research stemming from this poorly understood condition in a developing subspecialty (Figure). The majority of these publications focus on the evolution of surgical technique and management. Urethral reconstruction should offer the ability to stand to urinate and combine a satisfactory cosmetic result. The tubularized incised plate repair, popularized by Snodgrass et al., and the Mathieu repair, have been the mainstay for distal hypospadias, however, there have still been a large number of well-described techniques, with no consensus as to the ideal method of repair, some of which is attributed to non-uniform standards of reporting outcomes. There is also no standard objective means to qualitatively assess the importance of each of these contributions., Objective: The objective of this study was to determine the top 150 peer-reviewed articles in the field of hypospadiology by way of citation analysis as a means to determine the importance/relevance of each contribution throughout 8 decades of research., Study Design: A cited reference search was carried out for indexed citations within Web of Science™ Core Collection. The top 150 indexed cited articles containing the topic "hypospadias" in specific subject categories were compiled using a component of Science Citation Index command. References were then evaluated, and analysed across a number of indices, and over time., Results: The mean number of citations was 76 for each article. The top 150 articles were published across 21 countries, with the majority originating from the USA. The lead research institution was the University of Texas (Southwestern) Medical Center. In total, the top 3 centers represented 33 publications within the top 150 citations. The most commonly utilized journal was the Journal of Urology. The most cited author was W.T. Snodgrass. 39% papers in the top 150 cited articles were published prior to 1990. Three out of the five papers cited in the 1940s dealt with operative technique to repair hypospadias. The period 2000-2010 in contrast, demonstrated a significant inverse correlation between molecular biology citations, and those for operative techniques, with the incidence of the latter dropping to 6% of all cited papers., Discussion: This is the first study of its kind to analyse the most influential articles in hypospadiology, and their characteristics assessed for authorship, content and impact factor. Furthermore it allows data analysis by topic and between time points. This not only de-clutters the wealth of accumulated data on this subject, but also provides an important adjunct to education and training. As with this study, other citation analytical studies in urology found a significant preponderance in cited studies originating from the USA. The prevalence of the US in cited papers doesn't reflect any inherent bias, just a greater number of publications., Conclusion: Although there are inherent potential elements of bias in citation analysis, this study demonstrates that citation analysis in a complicated topic can provide a high-throughput, uncomplicated method of quickly deciphering important contributions of authors and institutions to the field of hypospadias research., (Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Introduction: The 2005 international society of urological pathology consensus statement on Gleason grading in prostate cancer revised Gleason scoring in clinical practice. The potential for grade migration with this refinement poses difficulties in interpreting historical series. We report the characteristics of a recent cohort of consecutive Gleason score 9 or 10 prostate cancers in our institution. The purpose of this study was to define the clinicopathologic variables and staging information for this high-risk population, and to identify whether traditional prostate staging techniques are adequate for this subcohort of men., Materials and Methods: A computational review of our pathology database was performed. Between May 2010 and September 2012, 1,295 consecutive biopsies were undertaken, 168 of which were high-grade tumours (12.97 %). This group were divided into two cohorts of which 84 (12.05 %) had a highest reported Gleason score of 9 (N = 79) or 10 (N = 5) and 84 were reported as Gleason 8. All biopsies were double-reported by pathologists with a special interest in uropathology., Results: Men diagnosed with a Gleason pattern 5 tumour were statistically far more likely to have advanced disease on direct rectal examination of the prostate compared with Gleason sum 8 tumours (p < 0.001) and a positive first-degree family history of prostate cancer (p < 0.001). Overall, Gleason sum 9/10 prostate cancers were also found to be statistically more aggressive than Gleason sum 8 tumours on TRUS core biopsy analysis with significantly higher levels of perineural invasion (p < 0.0001) and extracapsular extension (p = 0.001) as well as a higher levels of tumour found within the core biopsy sample. Those men diagnosed with Gleason pattern 5 prostate cancer also had radiological indicators of increased tumour aggressiveness compared with Gleason sum 8 cancer with respect to bone (p = 0.0002) and visceral (p = 0.044) metastases at presentation., Conclusions: This series of Gleason score 9/10 prostate cancers serves to highlight the large disease burden, adverse pathologic features, and locally advanced nature of this aggressive subtype, which has previously been under-described in the literature, and differs from historical series in having a large high-grade cohort demonstrating high rates of metastatic disease. A history of prostate cancer amongst first-degree relatives was particularly prevalent in this population raising the issue of screening in a high-risk population. The high incidence of visceral metastatic disease at presentation supports upfront staging with CT thorax, abdomen, and pelvis in patients with Gleason 9 or 10 prostate cancers.

Background: Recent evidence has suggested that the introduction of rapid access prostate cancer programs has led to a more streamlined pathway for patients, and was designed to ultimately reduce referral delays., Aims: To identify the initial impact of the introduction of the rapid access prostate clinic on Gleason grading within the prostate cancer cohort, as well as the impact of distance from a tertiary referral center on subsequent Gleason grading., Methods: A prospective database was maintained from those men attended the rapid access prostate clinic in St. Vincent's University Hospital. Data relating to demographics, biopsy results, retrospective PSA readings, and subsequent treatment pathways were all recorded and analyzed. Statistical significance was taken at p<0.05., Results: Prospective data from the rapid access prostate clinic illustrated similar results in patient demographics, Gleason grade and choice of treatment outcomes to other published institutions, however, for the first time demonstrate emerging evidence of the effect of the rapid access prostate clinic leading to a downward shift in Gleason grade over a 2-year period, as well as data showing an inverse correlation between leading Gleason grade and distance from our tertiary referral center., Conclusion: These results suggest that the introduction of the rapid access prostate clinic has initially begun to demonstrate an initial downgrading in Gleason scoring patterns. Our data also reflects a poorer Gleason score in those patients living further away from the rapid access prostate clinic. This may be in part attributed to a surge in referrals of those patients previously managed outside a tertiary institution, and suggests that patients should undergo prompt referral following suspicion for prostate cancer.

Objective: To investigate the changing pattern of antimicrobial resistance in Escherichia coli urinary tract infection over an eleven year period, and to determine whether E. coli antibiotic resistance rates vary depending on whether the UTI represents a nosocomial, community acquired or urology patient specific infection., Patient and Methods: A retrospective analysis of the 42,033 E. coli urine isolates from the 11-year period 1999-2009 in a single Dublin teaching hospital was performed. WHONET(TM) software was used to analyse the changing pattern of sensitivity and resistance of E. coli to commonly used antibiotics over the study period. The origins of the urine samples were stratified into three groups: inpatients with nosocomial UTIs; urine originating from the emergency department and general practice (community UTIs); and UTIs in urology patients., Results: Urinary tract infections in the urology patient population demonstrate higher antibiotic resistance rates than nosocomial or community UTIs. There were significant trends of increasing resistance over the 11-year period for ampicillin, trimethoprim, gentamicin and ciprofloxacin, and significant differences in co-amoxyclav, gentamicin, nitrofurantion and ciprofloxacin resistance rates depending on the sample origin. Ampicillin and trimethoprim were the least active agents against E. coli, with total 11-year resistance rates of 58.3 and 33.8%, respectively. The overall gentamicin resistance rate was 3.4% and is climbing at a rate of 0.7% per year (P < 0.001). Within the urology patient population the resistance rate was 6.4%. Ciprofloxacin resistance approaches 20% in the nosocomial UTI population and approaches 30% in the urology population; however, it remains a reasonable empirical antibiotic choice in this community, with an 11-year resistance rate of 10.6%., Conclusions: E. coli remains the commonest infecting uropathogen in the community and hospital setting with its incidence climbing from 50 to 60% of UTIs over the 11-year period. Neither penicillins nor trimethoprim represent suitable empirical antimicrobials for UTI and ciprofloxacin resistance in this Dublin-based study renders it unsuitable empirical therapy for nosocomial UTIs and UTIs in the urology population. The dramatic 11-year rate increase in gentamicin resistance is of paramount concern., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

The aim of this study was to provide baseline data on chronic disease management (CDM) provision in Irish general practice (GP). The survey instrument was previously used in a study of primary care physicians in 11 countries, thus allowing international comparisons. The response rate was 72% (380/527).The majority of GPs (240/380; 63%) reported significant changes are needed in our health care system to make CDM work better. Small numbers of routine clinical audits are being performed (95/380; 25%). Irish GPs use evidence based guidelines for treatment of diabetes (267/380; 71%), asthma / COPD (279/380; 74%) and hypertension (297/380; 79%), to the same extent as international counterparts. Barriers to delivering chronic care include increased workload (379/380; 99%), lack of appropriate funding (286/380; 76%), with GPs interested in targeted payments (244/380; 68%). This study provides baseline data to assess future changes in CDM.

Background: Gun-related crime offences have increased in the Republic of Ireland steadily over the past number of years. Regional trauma units are witnessing unprecedented numbers of injuries in the Republic of Ireland with limited prior experience., Aims: Eight-year retrospective study analysing demographic data, management and outcome of firearm-related injuries., Results: Patients who experience gunshot injuries in this region are statistically likely to be young, male and unemployed with a single shotgun injury to an extremity. Post-operative survival rates of 100% for those who undergo an exploratory laparotomy., Conclusion: Ireland has comparable survival outcomes to other international centres with similar patient demographics due to timely and appropriate operative intervention. These results serve to provide a template for further patient management.

Background: The Structure of Irish General Practice over 23 years was the third in a series of national studies that examined the development of general practice in 1982, 1992, and 2005., Aims: This study analysed specific data from the 2005 survey to determine the types of services offered by GPs, and to examine the changes in access to diagnostic/treatment services from 1982 to 2005., Methods: A questionnaire was sent to a stratified random sample of Irish GPs seeking information on their practice., Results: 476 (87%) valid questionnaires were returned. The range of services offered by GPs had increased. Access to diagnostic/treatment services was limited, and varied considerably depending on the type of practice. Access to chest X-rays and skeletal X-rays had decreased., Conclusions: Access to existing services must be increased, and significant resources must be put into the development of dedicated primary care services.

Objective: General practice co-operatives have led to significant improvements in quality of life for general practitioners. Little is known about general practitioners' own experiences with the working arrangements and governance of co-operatives. This study investigates GP satisfaction, the working environment, governance and future developments in co-operatives., Methods: A questionnaire was sent to GPs in two co-operatives in the Republic of Ireland, covering mixed urban and rural areas., Results: Of 221 GPs in the co-operatives, 82% responded and confirmed the co-operatives' positive effects on their lives. However, 57% still received requests for out-of-hours care while off duty, most commonly from patients who preferred to see their own doctor. Half felt overburdened by out-of-hours work, especially those over 40 y of age. Twenty-five per cent were dissatisfied with the GP complaints mechanism. The majority (63%) would prefer a GP/health board partnership for the organization of out of hours, while 23% wanted sole responsibility. GPs indicated a strong need for better ancillary services such as nursing, mental health, dentistry, pharmacy and social work. Access to records is an important issue in terminal care and mental illness., Conclusion: While GP co-operatives are a success story for general practice, they will work better for general practitioners and their patients if nursing, mental health, dentistry, pharmacy and social services are improved. Support and training is needed in mental health, palliative and emergency care to increase competence and reduce stress. GPs are willing to work with health authorities in further co-operative development. More attention needs to be paid to the complaints and suggestions of GPs in the running and governance of their co-operatives.

Background: A national cervical screening programme is being established in Ireland and there is little information on the level of resources required., Aims: To obtain information on attitudes of Irish general practitioners (GPs) and on the resources needed by them in relation to participation in the programme., Methods: An anonymous postal questionnaire was sent to a random sample of 600 GPs, approximately 25% of the total population of GPs in Ireland., Results: A response rate of 87.5% was obtained. The majority (88%) would participate in a national programme. Those who would not were more likely to be in single-handed practice, aged over 44 years, have no ancillary staff, no computer and be in rural practice. GPs were in favour of a special fee for smear taking, a training programme and management guidelines on the test report. They did not want bonus payments for achieving targets or the report to be sent to the client as well as the doctor., Conclusion: GPs will support a national cervical screening programme but a number of organisational issues must be discussed with them to ensure a successful programme.

Dublin has an estimated 13,460 opiate drug users. The role of general practice in providing care for this group has increased over the last four years. A Central Methadone Treatment List (CMTL) registers all clients currently on treatment. To obtain a social, demographic and drug using profile of opiate users attending general practitioners (GPs) for methadone maintenance. A cross sectional survey of opiate users attending general practice for methadone maintenance in the Dublin area in early 1999. Data was collected on 571 clients (62% of total number attending general practice), of whom 97% had used heroin in the past and 12% had never injected. Although clients had been receiving methadone maintenance in general practice for a mean of 14 months, 16% were still using heroin, of whom 31% were still injecting. The mean age of first drug use was 15.5 years and of first injecting was 19.4 years. Younger clients are starting both to use drugs and inject drugs at an earlier age. Record keeping was good, with most items of information present in over 70% of the charts surveyed. A total of 17% of clients recorded on the CMTL could not be traced to the GP recorded as providing care. Despite treatment with methadone maintenance, there is a high level of continued risk activity in this group. Furthermore, a trend towards earlier initiation to drug use is apparent. The CMTL registration process requires further exploration.

Background: The evaluation of a structured protocol for the discharge of stabilised patients on methadone maintenance to general practice provided an opportunity to evaluate the impact on the attitudes of general practitioners (GPs) and practice staff., Aim: To assess attitudes, expectations and experience among GPs and practice staff before the introduction of structured methadone maintenance and six months after its introduction., Methods: A postal questionnaire was sent to 31 GPs and 23 receptionists in 23 Dublin general practices before the patient's first visit and six months later at the end of the study period. Outcome measures were staff attitudes, incidence of disruption, perceived difficulties in providing care and in prescribing methadone, and stress levels., Results: There was a generally positive attitude to provision of methadone in general practice for stabilised patients, although it was not anticipated to be problem free. Following six months involvement attitudes were similar; stress levels were unchanged, but fewer GPs anticipated problems in delivering the service. All continued to participate in the scheme., Conclusion: GPs and receptionists in this sample had mixed views about methadone maintenance which were unchanged by six months experience of the service. The study illustrates important issues in the recruitment and support of general practice in meeting this need.

The objectives of this study were to examine aspects of organization of a proposed national screening programme based in general practice. The target population of women aged 25-59 years and their general practitioners (GPs), in a defined inner city area, was identified from a population register of persons eligible for free medical services; a computerized system was developed for invitations and record linkage of cytology results. Smears were examined in one laboratory and follow up of women with abnormal smears was undertaken by one gynaecologist. A random sample of non-responders was surveyed by questionnaire. Response following two invitations was only 20%. Practices with male doctors only had significantly lower response rates (P < 0.001) than those with a female doctor/nurse. A survey of non-responders showed that over 20% of addresses were incorrect and 16% of those interviewed were ineligible for smear tests. A preference for a female to undertake smears was expressed by 67%, and 77% believed that the purpose of the cervical smear was to detect cancer. An accurate population register, health promotion, support for GP practices, provision of alternative venues for smear tests, development of computer systems, accurate data entry and fail-safe follow up are aspects of a cervical screening service which must be addressed prior to setting up a national service.

Information on the social class distribution of illness is scarce in Ireland. The aim of this study was to document the social class distribution of 12 common chronic conditions in middle-aged persons in Dublin. Data were collected on 3,111 individuals attending three large general practices over the course of a calendar year, and 1,024 individuals living in the same areas. Ten out of the 12 conditions studied were significantly more common in those from social classes five and six, than those from social classes one and two. Persons from social classes three and four, classes five and six, had an overall excess morbidity rate of 21% and 70% respectively. The distribution of chronic illness in middle-aged residents of Dublin is social class related.

In order to study their attitudes to and experience of general practitioner care, 150 attenders at the only HIV specialist clinic in the Republic of Ireland were asked to complete an anonymous, self administered questionnaire. (81%) of respondents reported having a regular GP and 94% of those indicated that the GP was aware of their HIV diagnosis. The majority (64%) of patients with a regular GP reported seeing their doctor on more than 5 occasions during the previous year. Most patients were satisfied with the support which they received from their GPs. Even so, the majority of patients (72%) would go directly to the hospital clinic for any problem which they perceive to be HIV related.

This study measured the prevalence of chronic medical conditions in 4,549 middle aged persons attending three large general practices in Dublin over the course of a calender year. The prevalence of the following conditions were measured: coronary heart disease, hypertension, stroke, diabetes, asthma, chronic bronchitis, rheumatic disorders, dyspepsia, depression, anxiety disorders, psychoses, and cancer. In order to obtain a valid denominator for the study a second community based study was carried out in the same areas to determine what proportion of persons visit their general practitioner over the course of a year. Overall 40.5% of males and 44% of females suffered from a least one of the twelve conditions, with rheumatic disorders having the highest prevalence (14.5%) and psychotic disorders the lowest (0.75%).

A group general practice in Dublin's inner city has had extensive experience of intravenous drug users since the late 1970s. Since 1985 a total of 54 human immunodeficiency virus (HIV) seropositive patients have attended the practice, of whom 48 are intravenous drug users, four are the children of drug users and two have been infected through sexual contacts. Three patients have developed the acquired immune deficiency syndrome and at least eight have symptomatic HIV disease. Sixty per cent of Ireland's seropositive population have been infected through intravenous drug abuse but nationally only 16% of all intravenous drug users tested are seropositive; in the study practice, however, at least 35% (48/137) of known intravenous drug users are seropositive.