Showing papers in "Irish Journal of Medical Science in 2014"

Thyroid dysfunction in children with Down syndrome: a literature review.

Abstract: This article is an evidence-based review of thyroid disease in children with Down syndrome, including a comparison between various professional guidelines for the management of thyroid disease in children with Down syndrome. Aspects of thyroid disease which are discussed include: congenital hypothyroidism; autoimmune thyroid disease; subclinical hypothyroidism; and hyperthyroidism. The national professional guidelines of Ireland, the United Kingdom, the United States of America, Australia and Canada are reviewed and compared. A literature search was conducted using Medline and PubMed. Search terms included ‘Down syndrome’ and ‘thyroid disease’, ‘hypothyroidism’, ‘hyperthyroidism’, ‘subclinical hypothyroidism’. Eighty-nine articles were retrieved and reviewed for inclusion. The guidelines on the medical management of children with Down syndrome of five expert groups have also been retrieved and reviewed for this discussion. These various guidelines offer largely similar advice regarding frequency of thyroid function tests, with only Ireland and the UK testing less frequently than annually. Only the United Kingdom and Irish Down Syndrome Medical Interest Group guidelines suggest testing for thyroid antibodies at every thyroid screen. None of the guidelines offer suggestions on the optimal course of action to pursue after the discovery of subclinical hypothyroidism. In conclusion, more evidence is required regarding the optimal course of treatment for subclinical hypothyroidism. Such evidence may be best obtained by conducting a prospective randomized control trial.

Completeness of case ascertainment at the Irish National Cancer Registry.

Abstract: Cancer registries play a major role in cancer control, including quantifying the burden of cancer in the population, informing health service planning, and evaluating service provision. Registries must achieve a high level of completeness of case ascertainment. Completeness of case ascertainment for the National Cancer Registry (NCR) in Ireland was estimated. For all invasive cancers, and the four most common sites, we used two quantitative methods which use information from death certificates to obtain estimates of completeness of registration—the Lincoln–Petersen (LP) estimator (which provides a lower bound estimate) and the flow method (which estimates completeness at a fixed time-point, in this case 5 years). Data were extracted at the end of 2010. Independent case ascertainment was used to assess completeness of breast cancer registration in the 50–64 age group and of rectal cancer in surgical patients diagnosed in 2007. Completeness of case ascertainment was >99 % for the breast screening age-group and for surgical rectal cancer cases. A lower bound on completeness of case ascertainment for all invasive cancers excluding non-melanoma skin cancers is 94.3 % using the LP estimator. The estimate from the flow method is 97 % after 5 years, [95 % confidence interval (96.2 %, 97.7 %)]. Five-year levels of completeness for the four commonest cancers using the flow method were: colorectal, 97.4 %; lung, 98.7 %; prostate, 95.8 % and breast, 98.0 %. The estimated levels of completeness for the NCR are satisfactory. Further work is required to compare the methods used.

Getting a handle on the general practice workforce in Ireland

Abstract: General practice makes a critical contribution to healthcare in Ireland. However, there is a weak understanding of the general practice workforce in Ireland. The aim of this study is to estimate the number of general practitioners (GPs) and practice nurses in Ireland. A variety of data sources was used to corroborate counts of general practitioners and practice nurses. Capture–recapture methods were used to estimate the hidden population of GPs not identified by the databases included. There are 2,954 general practitioners in Ireland, equivalent to 64.4 per 100,000 population. There are 1,700 practice nurses nationally, equivalent to 37.1 per 100,000 persons. There is substantial regional variation in the number of general practitioners and practice nurses per 100,000. To some extent, deficits in one discipline may be counterbalanced by a surplus in the other. In the absence of a centralised register, it is not possible to track the number of GPs or practice nurses working in Ireland at present. This is despite the fact that there are twice as many general practice visits per annum compared to hospital visits.

Elevated prevalence of abnormal glucose metabolism in patients with primary aldosteronism: a meta-analysis.

Abstract: To conduct a meta-analysis of studies assessing abnormal glucose metabolism (AGM) prevalence among patients with primary aldosteronism (PA), calculating a combined pooled prevalence and summarizing metabolic parameters associated the pooled prevalence for comparative group. Four electronic databases (PubMed, EMBASE, Cochrane CENTRAL, and ISI-Web of Science) were systematically retrieved with no language and time restriction. Studies about elevated level of glucose metabolism in primary aldosteronism were included. Data were available in 16 studies. The pooled analysis revealed that the prevalence of elevated glucose in PA was 22.41 % (95 % CI 16.77–28.05 %), the retrospectively calculated prevalence was 31.20 % (95 % CI 15.81–46.60 %) for impaired fasting glucose, 26.19 % (95 % CI 15.17–37.21 %) for impaired glucose tolerance, 15.22 % (95 % CI 9.93–20.51 %) for diabetes mellitus. Prevalence of AGM in PA was higher than that in essential hypertension (OR = 1.55, 95 % CI 1.01–2.36, p = 0.04). From comparative groups, patients with primary aldosteronism had a lower level of insulin sensitivity indicators in comparison with normal group (p < 0.01). On the other hand, insulin resistance which presented by HOMA index was stronger in PA group than in normal control group (WMD = 0.41, 95 % CI 0.17, 0.65; p = 0.001), whereas it was weaker than that in EH group (WMD = −0.37, 95 % CI −0.62, −0.13; p = 0.003). There is a significant prevalence of elevated level of glucose metabolism in patients with PA. Awareness and treatment of this pre-diabetic or diabetic state are necessary.

The microbiology of bacterial peritonitis due to appendicitis in children

Abstract: Aim The aim of this study was to investigate the microbiology of secondary bacterial peritonitis due to appendicitis and the appropriateness of current antimicrobial practice in one institution.

Effects of sildenafil treatment on patients with Peyronie’s disease and erectile dysfunction

Abstract: It has been shown on experimental rat models that type 5-phosphodiesterase isoenzyme (PDE5) inhibitors have anti-fibrotic effects for Peyronie’s disease (PD); however, this issue has not been addressed clinically. The aim of this study was to document the effects of PDE5 inhibitors used for erectile dysfunction (ED) seen in PD patients on the main course of the PD clinically. A total of 39 PD patients with ED were divided into two groups. Patients in Group 1 (n = 18) served as controls and received 400 IU vitamin E per day. Those in Group 2 (n = 21) received 50 mg sildenafil per day for 12 weeks. Penile plaque volume was assessed by palpation and by duplex ultrasound. Erectile capacity, penile deformity and plaque characteristics were assessed by the International Index of Erectile Function questionnaire form (IIEF-5) and penile duplex ultrasound. Statistically significant improvement in all parameters was observed within both groups except for IIEF score in Group 1 when compared with the initial values. Significant reduction in plaques and pain were observed in 7 (33.3 %) and 14 (66.6 %) patients in Group 2 and 6 (33.3 %) and 9 patients (42.8 %) in Group 1, respectively. At the end of the therapy, improvement in IIEF score and reduction in pain were statistically significant in Group 2 compared with Group 1 (p = 0.028 and p = 0.045, respectively). We conclude that continuous administration of oral PDE5 inhibitors may be a candidate for medical treatment of PD; however, more controlled studies are needed.

Factors affecting warfarin dose requirements and quality of anticoagulation in adult Egyptian patients: role of gene polymorphism

Abstract: Warfarin is the mainstay of anticoagulation therapy worldwide. CYP2C9 and VKORC1 are two major genetic factors associated with inter-individual and inter-ethnic variability in the warfarin dose. This study aims to assess the impact of VKORC1–1639G>A polymorphism and the most common CYP2C9 variant alleles (*2 and *3) on warfarin response in Egyptian patients. Genetic analysis of VKORC1–1639G>A and CYP2C9*2, CYP2C9*3 was performed using real-time PCR system. Patients maintained on a constant dose targeting an international normalized ratio range of 2–3.5 for at least three consecutive times were considered as good candidates. A stepwise linear regression analysis was used to determine the independent effects of genetic and non-genetic factors on daily warfarin dose requirements. Patients carrying VKORC1 and CYP2C9 variant genotypes needed a 44.8 % lower mean daily warfarin dose as compared to wild types. Patients with G allele for VKORC1–1639G>A had a significantly higher number of thromboembolic complications per month during therapy. On the first 30 days of therapy, presence of a variant allele either in VKORC1 or in CYP2C9 was associated with increased time required to achieve stable dosing. Multiple regression analysis showed that, VKORC1–1639G>A, age, CYP2C9*3, and smoking status explained 43.4 % of the overall variability in the warfarin dose. VKORC1–1639G>A and CYP2C9 polymorphisms contribute to the difference in warfarin dose requirements and quality of anticoagulation amongst Egyptian patients. Study results support using personalized warfarin treatment in Egyptian patients.

Chemotherapy induced peripheral neuropathy: the modified total neuropathy score in clinical practice

Abstract: Chemotherapy-induced peripheral neuropathy (CIPN) is a common, potentially reversible side effect of some chemotherapeutic agents. CIPN is associated with decreased balance, function and quality of life (QoL). This association has to date been under-investigated. To profile patients presenting with CIPN using the modified Total Neuropathy Score (mTNS) in this cross-sectional study and to examine the relationship between CIPN (measured by mTNS) and indices of balance, quality of life (QoL) and function. Patients receiving neurotoxic chemotherapy regimens were identified using hospital databases. Those who did not have a pre-existing neuropathy were invited to complete mTNS, Berg Balance Scale (BBS), timed up and go (TUG), and FACT-G QoL questionnaire. mTNS scores were profiled and also correlated with BBS, TUG and FACT-G using Spearmans correlation coefficient. A total of 29 patients undergoing neurotoxic chemotherapy regimens were tested. The patients mTNS scores ranged between 1 and 12 (median = 5), indicating that all patients had clinical evidence of neuropathy on mTNS. No significant correlations were found between mTNS and BERG (r = −0.29), TUG (r = 0.14), or FACT-G (r = 0.05). This study found a high prevalence of CIPN in patients treated with neurotoxic chemotherapy regimens. The mTNS provided a clinically applicable, sensitive screening tool for CIPN which could prove useful in clinical practice. mTNS did not correlate with BBS, TUG or FACT-G in this sample, possibly due to relatively mild levels of CIPN and consequent subtle impairments which were not adequately captured by gross functional assessments.

A treatment for large defects of the tibia caused by infected nonunion: Ilizarov method with bone segment extension.

Abstract: To investigate the efficacy of the Ilizarov technique with bone segment extension in tibial infected nonunion. From September 2003 to June 2011, we treated 30 patients (21 males, 9 females; age 19–49 years, mean 34.1 years) for tibial infected nonunion with bone defects. Eleven cases were compound fractures internally fixed with steel plates, nine were compound fractures internally fixed with IM Nails, eight were compound fractures externally fixed with external fixation devices, and two were closed fractures internally fixed with steel plates. All 30 patients underwent debridement followed by the Ilizarov technique using bone segment extension. After follow-up of 12 months–6 years (mean 29 months), stable union of fracture was achieved in all 30 patients. The time from bone fracture to union was 6–24 months, mean 8.8 months; external fixation was in place for 8–14 months, mean 10 months. External fixation index was 41 days/cm. Complications were three cases of pin site infection, one skin allergy, two fractures malunion, one early mineralization and one wire breakage. There were no cases of deep infection, nonunion or stiffness of the knee joint. According to the Paley fracture healing score criteria, 30 cases had excellent outcomes and two were good. The Ilizarov technique with bone segment extension is effective in treating tibial infected nonunion with large bone defects.

Characteristics of patients admitted to the intensive care unit following self-poisoning and their impact on resource utilisation.

Abstract: Self-poisoning accounts for up to 10 % of hospital admissions, some of whom require admission to ICU. Few studies have looked at the epidemiology of these patients in an Irish setting. To quantify the proportion of ICU admissions attributable to self-poisoning, to examine the characteristics and outcome of these patients, and to assess their ICU resource utilisation. Retrospective review of ICU admissions from 2006 to 2010. Data were collected on patient age, sex, admission diagnosis, substances involved, APACHE II score, length of stay, organ support, and outcome. There were 80 admissions to ICU following self-poisoning accounting for 3.8 % of ICU admissions and 13 % of all hospital admissions for self-poisoning. M:F ratio was 0.9:1. Mean age 35 (range 16–75), APACHE II score 14 (2–36). Commonest substances involved were benzodiazepines, opioids, tricycle antidepressants. Median ICU stay was 2 days (IQR 0.96–4.5). 84 % of patients were ventilated, 27.5 % required inotropic support, 14 % renal replacement therapy. When opioids were involved requirement for inotropes and CRRT were higher. ICU mortality was 6.3 %. These patients consumed 280 bed days. Self-poisoning accounted for 3.8 % of ICU admissions. Patients tend to require a short period of ventilation, with a minority requiring additional organ support. The cost of ICU care is calculated based on previously published methodology to be €7,717 per patient. Extrapolated nationally the annual cost for ICU care for self-poisoning is estimated to be in the order of €5 m.

DOCSS: doctors on-call smartphone study

Abstract: Smartphones have revolutionised our demands for constant access to information. The usage of smartphones in the clinical setting is becoming widespread. The aim of our study was to assess smartphone ownership and usage across a cohort of interns. A voluntary novel questionnaire was distributed to interns in two university hospitals. Details regarding smartphone ownership and usage were assessed. Likert scales were utilised for analysis. Sixty-one (74.4 %) interns responded to the survey. Sixty (98.4 %) owned a smartphone with iPhone® being the most popular (76.7 %). Fifty-five (91.6 %) interns have downloaded medical applications (‘apps’), while 29 (52.3 %) reported paying for them. Regarding smartphone use on-call, 30 (50 %) interns agreed it aids diagnoses, 26 (43 %) agree it helped in interpreting laboratory values, 31 (51.7 %) agreed it helped in dosing of medication and 33 (55 %) agreed it was of assistance in medical emergency protocols. Forty-two (70 %), 42 (70 %) and 46 (76.7 %) interns agreed or strongly agreed smartphones have a positive influence on them in terms of levels of stress, confidence and level of knowledge, respectively. Smartphone usage is widespread among our intern cohort. The introduction of hospital applications with local guidelines would be welcomed; however, this may require informed patient consent regarding their use.

Dexamethasone for preventing postoperative sore throat: a meta-analysis of randomized controlled trials

Abstract: Background Postoperative sore throat (POST) is a common complication following tracheal intubation. The effectiveness of prophylactic dexamethasone on POST needs further elucidation.

Positive changes in the medical educational environment following introduction of a new systems-based curriculum: DREEM or reality? Curricular change and the Environment.

Abstract: Evaluation of a new systems-based curriculum in an undergraduate Irish Medical School was carried out with the validated Dundee Ready Educational Environment (DREEM) inventory. Comparison was made with the results from a previous DREEM study in the old curriculum. DREEM was administered to 225 medical students enrolled in the new curriculum. Data analysis was carried out using SPSS 17.0 and the Student unpaired t test. Increased mean scores supported greater satisfaction with the educational environment in the new curriculum. Students perceived better opportunities to develop interpersonal skills, ask questions and learn about empathy. Areas of concern included timetabling, support for stressed students and provision of feedback. Clinical students perceived their overall environment more positively. Pre-clinical students were more confident about passing exams and felt better prepared for clinical practice. Male students were more positive about the environment and found the teaching more stimulating. Female students perceived greater development of their problem-solving skills. Non-Irish students no longer perceived the atmosphere and their social self-perceptions more negative than Irish students, as was the case in the old curriculum. DREEM is a valuable tool in evaluating the educational environment and monitoring the impact of curricular change.

Pre-pregnancy care and pregnancy outcomes in type 1 diabetes mellitus: a comparison of continuous subcutaneous insulin infusion and multiple daily injection therapy.

Abstract: Background Pre-pregnancy care improves pregnancy outcomes in type 1 diabetes mellitus (T1DM). Continuous subcutaneous insulin infusion (CSII) therapy and multiple daily injection (MDI) therapy can both be used to achieve glycaemic targets, but few data are available to compare their efficacy in pre-pregnancy care.

Prescribing of antidiabetic therapies in Ireland: 10-year trends 2003-2012.

Abstract: Background Over the last decade there have been significant changes in the prescribing of antidiabetic therapies. It is of interest to know about these trends and variations in the Irish population so that future prescribing patterns can be estimated.

Timeliness of care and prognosis in patients with lung cancer.

Abstract: Timeliness of care is an important dimension of health care quality. The determining factors of less timely care and their influence on the survival of patients with lung cancer (LC) remain uncertain. To analyse the delays in the diagnosis and treatment of LC in our health area, the factors associated with the timeliness of care and their possible relationship with the survival of these patients. A retrospective study was conducted on all patients with a cytohistologically confirmed diagnosis of LC between 1 June 2005 and 31 May 2008. The time delays for consultation (specialist delay), diagnosis (diagnosis delay), and treatment (treatment delay), were analysed, as well as the factors associated with these delays and the influence of the timeliness of care on survival. A total of 307 cases were included (87 % males). The mean specialist delay was 53.6 days (median 35 days), diagnosis delay 31.5 days (median 18 days), treatment delay 23.5 days (median 14 days). The greater age of the patient and a more advanced stage were associated with a shorter specialist delay. Male sex, a more advanced stage, and poor general status were associated with a shorter treatment delay. The survival is longer in patients with a longer treatment delay. The delay in the diagnosis in our population seems to be excessively long. The greater the age, a more advanced tumour stage, male sex, and poor general health status are associated with shorter delays. A longer treatment delay is associated with a longer survival.

Superselective renal artery embolization in the treatment of renal hemorrhage

Abstract: Background Renal hemorrhage is a potentially life-threatening event that may follow trauma, operation, biopsy, and sudden spontaneous rupture of renal tumors or aneurysms. Superselective renal artery embolization (SRAE) is a well-established method for such cases.

Early diagnosis of tuberculous meningitis by an indirect ELISA protocol based on the detection of the antigen ESAT-6 in cerebrospinal fluid

Abstract: Background Early diagnosis of tuberculous meningitis (TBM) is still a challenge; the present study aimed to establish a method of detecting the antigen early secreted antigenic target 6 (ESAT-6) in cerebrospinal fluid (CSF) by an indirect enzyme-linked immunosorbance assay (ELISA) protocol and to study the value of detecting ESAT-6 in CSF in the early diagnosis of TBM.

Parent-child relationships in gender identity disorder.

Abstract: To describe the relationship between parents with gender identity disorder (GID) and their child(ren) as described by the parent and to understand how being a parent affects transitioning from one gender to the other. Fourteen parents with GID underwent a semi-structured interview and completed the Index of Parental Attitudes (IPA). An IPA score of greater than 30 indicates parent–child relationship difficulties (range 0–100). The authors also conducted the SCID-I to establish other Axis I disorders. We assessed 12 male to female and two female to male parents with GID residing in Ireland. In total, 14 GID parents had 28 children. Three children had no relationship with their GID parent. The other 25 children, as reported by the parent, had good relationships with their children. In addition, these 25 children average score IPA score was 6.4 (range 0–25). Twelve GID parents (86 %) believed that being a parent had no effect on their desired level of transitioning, while two were influenced not to transition. Eleven GID parents (79 %) reported that being a parent had increased the time taken to commence transitioning, two have stopped transitioning altogether, while one cited no effect on time. Parents with GID report positive relationships or no relationship with their children and the IPA revealed no clinical problems. Being a parent can prolong transitioning time in people with GID and can affect overall achieved level of transitioning.

Increased leptin levels in patients with rheumatoid arthritis: a meta-analysis

Abstract: Published data regarding the association of leptin levels with rheumatoid arthritis (RA) are contradictory. To derive a more precise estimation of this relationship, a meta-analysis was performed. Published literature from PubMed, Embase and Cochrane Library was obtained. Pooled standard mean difference (SMD) with 95 % confidence interval (CI) was calculated using fixed-effects or random-effect model analysis. Heterogeneity among studies was evaluated using the Cochran Q and I 2 statistics. The study quality was assessed by the Newcastle–Ottawa scale. A total of 20 studies including 998 RA patients and 692 controls were finally included in the meta-analysis. Compared to healthy controls, RA patients had significantly higher leptin levels (SMD 1.19, 95 % CI 0.59–1.79). Subgroup analyses showed that region, race, age, body mass index (BMI), disease duration and disease activity were positively associated with plasma leptin levels in RA patients. Sensitivity analysis showed no significant change when any one study was excluded. Publication bias was also undetected. The present meta-analysis suggested that leptin levels were higher in RA patients than those in healthy controls, which may be subject to different region, race, age, BMI, disease duration and disease activity.

Postgraduate training in Ireland: expectations and experience

Abstract: Postgraduate medical training in Ireland has been compared unfavourably with training abroad and blamed for an “exodus” of graduates of Irish medical schools. Exploration of features of a good training environment and development of tools to measure it have been the focus of much published research. There have been no Irish studies examining training environment using such validated tools. The aim of this study was to use a validated tool, to examine the expectations and experience of training, amongst those training under the Royal College of Physicians of Ireland (RCPI). The Dutch Residency Education Climate Test (D-RECT) is a 50 item tool to measure postgraduate learning environments. D-RECT was sent to all new entrants to RCPI training programmes in July 2012 (n = 527) and completed in regard to expectations of training (response rate 80.6 %). In March 2013, D-RECT was sent to all RCPI trainees (n = 1,246) to complete in relation to the post held on 1 March (response rate 32.6 %). Data were analysed in SPSS version 18. Experience fell short of expectations for basic specialist training, however, scores for experience rose with greater seniority to match expectations. Positive aspects were teamwork, consultant willingness to discuss patients and respectful treatment of trainees. Areas of weakness were provision of feedback and time to learn new skills. Measurement of learning environment at a national level using a quantitative tool provides useful information for quality assurance and improvement of training.

The effects of Valsalva maneuver on venipuncture pain in children: comparison to EMLA(®) (lidocaine-prilocaine cream).

Abstract: Venipuncture is one of the most painful events for children in hospitals. Valsalva maneuver (VM) decreases the incidence and severity of pain on venipuncture pain in adults. This study was designed to evaluate VM as compared with Eutectic Mixture of Local Anesthetic (EMLA®) cream for venipuncture pain in children. In this study, we evaluated the effect of VM on venipuncture pain in children. 60 patients scheduled for elective surgery were randomly divided into three groups. In Group V, children were punctured during VM. In Group E, EMLA® 5 % cream and in Group C (control group) vaseline was applied on the non-dominant hand 60 min before the venipuncture. Patients made a pain assessment using visual analog score (VAS). Mean arterial pressure (MAP), heart rate (HR), and SpO2 measurements were obtained during the venous cannulation. Respectively, the VAS was 2.15 ± 1.95 for Group V and 1.00 ± 0.79 for Group E and 2.55 ± 2.74 for Group C. A significant reduction in the severity of pain was observed in Group E. The difference being statistically significant (p 0.05). On the basis of data from this study, the VM is a simple and a practical method to reduce venipuncture pain in children but not as effectively as EMLA®.

Problem alcohol use among problem drug users: development and content of clinical guidelines for general practice

Abstract: Problem alcohol use is common and associated with considerable adverse health and social outcomes among patients who attend GPs in Ireland and other European countries for opioid substitution treatment. This paper aims to describe the development and content of clinical guidelines for the management of problem alcohol use among current or former opioid users attending general practice for methadone treatment. Methods: The guidelines were developed in several stages: i) identification of key stakeholders; ii) development of evidence-based draft guidelines, and iii)determination of a modified ‘Delphi-facilitated’ consensus among the group members. These guidelines were informed by a review of scientific evidence and a qualitative study, results of which will be presented also at this conference. Results: The guidelines incorporate advice for GPs on all aspects of care of this problem, including i) definition of problem alcohol use among problem drug users, ii) screening / identification of problem alcohol use, iii) interventions for treatment and management of problem alcohol use, iv) referral to secondary services and v) role of GPs in the management of persistent problem alcohol use and on-going care. Conclusions: General practice has an important role to play in the care of problem alcohol use among problem drug users, especially patients who attend for methadone treatment. Further research on strategies to inform the implementation of this study is a priority.

Orthopaedic triage at a physiotherapist-led 'Musculoskeletal Assessment Clinic': a seven-month service evaluation of outcomes.

Abstract: Background A number of clinical specialist physiotherapist (CSP)-led musculoskeletal triage clinics have been established in the Republic of Ireland as a means of managing patients referred for an outpatient orthopaedic consultation.

Ulysses: the effectiveness of a multidisciplinary cognitive behavioural pain management programme-an 8-year review.

Abstract: To characterise a cohort of patients with chronic pain registered to the Ulysses cognitive behavioural pain management programme (CBT-PMP) and to evaluate the effectiveness of the CBT-PMP 6 months post-discharge. A review of patients referred to the Ulysses CBT-PMP from 2002 to 2010 was undertaken. The profile of patients was established. Domains measured included pain, physical and psychological function. Relationships between these factors were explored. Clinically significant changes in outcome measures were established at the 6-month follow-up. In total 553 patients registered to the CBT-PMP, pre–post data were available for 91 % of patients and 52 % at 6 months. The majority of patients were female and aged between 40 and 50 years. Most patients had significant psychological morbidity (76 % depression, 84.5 % anxiety), moderate reports of pain [numerical rating scale, mean (SD) 6.0 (2.2)], and low levels of functional activity. At 6 months follow-up, statistically significant positive findings for physical and psychological outcome measures are supplemented by results showing their clinical significance. With regard to psychological function, a clinically significant change (depending on outcome measure) was shown between 1 in 2 and 1 in 10 patients. Improvements in physical function were lower with rates of 1 in 4 to 1 in 14 reporting significant gains. The effectiveness of the Ulysses CBT-PMP is established with measures of clinically significant change for physical and psychological outcomes contributing to the evidence for this novel approach of analysis. Future research determining benchmarks for CBT-PMP outcomes will assist clinicians in monitoring and enhancing patient’s progress in clinical practice.

Explaining the increase in breastfeeding at hospital discharge in Ireland, 2004–2010

Abstract: Despite a steady increase in the rate of breastfeeding in Ireland over the period 2004–2010 (from 46.8 % in 2004 to 55.7 % in 2010), Irish rates of breastfeeding are still low by international standards. Over this period, the characteristics of mothers and babies changed, with mothers increasingly older, having fewer children and increasingly born outside the Republic of Ireland. The purpose of this paper is to understand the extent to which changing maternal and birth characteristics explained the increase in the breastfeeding rate in Ireland over the period 2004–2010. We apply non-linear decomposition techniques to micro-data from the 2004–2010 Irish National Perinatal Reporting System to examine this issue. The technique allows us to quantify the extent to which the increase in the breastfeeding rate over the period 2004–2010 is due to changing maternal and birth characteristics. We find that between 55 and 74 % of the increase over the period can be explained by changing characteristics, with the increasing share of mothers from Eastern Europe, and increasing maternal age the most important contributors. These findings suggest that the existing policy initiatives have been relatively ineffective in increasing breastfeeding rates in Ireland, i.e. most of the observed increase occurred simply because the characteristics of mothers were changing in ways that made them increasingly likely to breastfeed.

Medical, cognitive and academic outcomes of very low birth weight infants at age 10–14 years in Ireland

Abstract: Low birth weight (LBW) is a leading cause of infant mortality and morbidity, and a specific risk for the development of neuro-developmental and academic problems. To examine the medical, cognitive and academic outcomes of VLBW (<1,500 g) children, born in one maternity hospital in Dublin between 1995 and 1997. The study employed a prospective/cohort design, with semi-structured, and standardised measures, along with the completion of a study-specific questionnaire. Ratings were obtained from parents and teachers. Of the 127 surviving VLBW cohort, 64 (50 %) consented to assessment at a mean age of 11.6 years (SD 1.0) along with a matched-weight and gender control sample of 51. VLBW children had an increased risk of chronic medical problems and neuro-sensory deficits, but without any increased use in services. Similarly, they had lower IQ (mean 89.7 compared to NBW 101.3, p < 0.001) and more were identified by teachers to have special education needs (33 % VLBW vs. 7 % NBW, p < 0.005). With regard to academic attainments, birth weight had a significant [t(98) = −4.54, p < 0.001] and robust effect (η2 = 0.17) on mathematical attainment scores. Those with lower SES fared least well off. Although significant advances have been made in reducing infant mortality, there is a recognised increased risk of subsequent disability especially with decreasing gestational age, and when coupled with low SES. Having facilitated the survival of vulnerable infants, services must be available for the necessary on-going medical and educational support and treatment that they require throughout adolescent years.

Breast clinic referrals: can mastalgia be managed in primary care?

Abstract: Centralisation of breast cancer services in Ireland has resulted in a significant increase in the number of patients attending symptomatic breast units (SBU). A considerable proportion of patients referred to SBU present with non-suspicious symptoms and fall into a “low-risk” category for breast cancer. It has been proposed that consideration be given to a primary care-delivered service for these patients. To evaluate SBU attendances and correlate with diagnosis to identify a cohort of patients who may be suitable for management in the primary care setting. Data were collected from a prospectively maintained database on patients attending SBU at two tertiary referral centres (Beaumont Hospital and University College Hospital Galway) from January 2011 to 2012. Reasons for attendance, outcome of triple-assessment and incidence of malignancy were analysed. 14,325 patients underwent triple assessment at the SBU in this time period. 5,841 patients were referred with mastalgia, of whom 3,331 (57 %) reported mastalgia as the only symptom. The incidence of breast cancer in patients presenting with mastalgia alone was 1.2 %. All patients diagnosed with breast cancer in this cohort were over 35 years of age. The incidence of breast cancer in patients referred to SBU with mastalgia as an isolated symptom is extremely low. Patients under 35 years of age, with mastalgia as an isolated symptom do not require breast imaging and have a sufficiently low risk of breast cancer that they may be suitable for management in the primary care setting.

Readability and content of patient information leaflets for endoscopic procedures.

Abstract: Informed consent requires good communication. Patient information leaflets (PILs) may be helpful, although some PILs are too hard to read for the average patient. We sought to examine the readability of PILs provided for patients prior to endoscopic procedures in 24 gastrointestinal and 16 respiratory departments of 24 Irish public hospitals. Readability, measured using the Flesch Reading Ease and the Flesch–Kincaid Grade Level scores, and content of all PILs were examined. We received 61 PILs from 17 gastrointestinal and 7 respiratory departments, a response rate of 60 % (24/40). Overall, 38 (62 %) PILs met a minimum standard of a Reading Ease score of 60 or more. Only two (3 %) PILs met the optimal reading standard of being comprehensible to an average 10- to 11-year-old, while 35 (57 %) PILs would be comprehensible to an average 13- to 14-year-old. There were striking differences between PILs (and particular departments) in the amount of information given regarding potential complications—in particular, serious complications. With the exception of PILs for endoscopic retrograde cholangiopancreatography, less than half of PILs mentioned death as a possible rare outcome. This study raises significant concerns about the readability and content of current Irish PILs, and it is unlikely that these issues are restricted to leaflets given prior to endoscopy. A standardised approach to developing PILs for common elective procedures, with minimum standards for readability and a uniform approach, based on current Irish legal requirements, to risk disclosure, might be helpful.

Diagnostic values of carcinoembryonic antigen in predicting peritoneal recurrence after curative resection of gastric cancer: a meta-analysis

Abstract: Aim A meta-analysis was performed to assess the diagnostic values of carcinoembryonic antigen (CEA) in predicting the peritoneal recurrence after curative resection of gastric cancer.