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 Irish Medical Journal Press Releases

October 2018 ■ Volume 111 ■ Number 6 - Official Journal of the Irish Medical Organisation

Lack of exercise rehabilitation available for patients with cancer

October 2018 ■ Volume 111 ■ Number 6 - Official Journal of the Irish Medical Organisation

A study published in the October edition of the Irish Medical Journal has identified that physiotherapy led exercise rehabilitation services available to patients with cancer in Ireland are extremely limited and exercise rehabilitation is not an element of standard care for patients with cancer in Ireland. The results of the study highlight the lack of structured group exercise rehabilitation for post-operative care and the lack of prehabilitation services available despite evidence suggesting that prehabilitation has a role in reducing post-operative complications.

Exercise is reported to be safe and beneficial both during and after cancer treatment. Exercise rehabilitation, throughout the cancer care continuum and into survivorship may ameliorate many of side effects including decreased muscles mass, reduced bone strength and lymphedema. Exercise programmes have been shown to improve quality of life, physical functioning, aerobic exercise and fatigue levels and may also reduce rates of disease recurrence and mortality.

The study aimed to identify the physiotherapy exercise rehabilitation services available to patients with cancer in Ireland and to identify barriers to the provision of services. In total nine cancer centres and fifteen public hospitals as described by the HSE NCCP were identified for the study. Seven private hospitals were identified through online searching and nine inpatient hospices were identified through the Irish Hospice Society website.

Cancer Centres

  • Of the eight cancer services centres, seven had a designated oncology physiotherapist, ranging from a 0.5 whole time equivalent (WTE) basic grade to 3.0 WTE senior physiotherapists.
  • None of the cancer centres providing surgery reported a formal exercise prehabilitation service, however four reported completing routine pre-operative assessments for patients with certain cancers, namely breast, prostate or pancreatic.
  • All seven cancer centres providing surgery offered standard post-operative care to their patients and six of those offered oncology specific exercise rehabilitation for patients with specific cancers in addition to standard care.
  • Five centres offered this service to post-operative breast cancer patients focusing primarily on lymphodema management or shoulder exercises.
  • One centre provided oncology specific exercise rehabilitation for patients’ post-surgery for gynaecological cancer and one centre provide such services for post-surgical prostate cancer patients.
  • Physiotherapy services for patients during chemotherapy and radiotherapy were routinely available in five centres.
  • No centre had exercise classes available for patients with cancer.

Public Hospitals

  • There were no designated oncology physiotherapists within the public hospitals interviewed.
  • One physiotherapy department provided pre-operative assessments for patients with esophageal cancer.
  • In surgical centres standard post-operative respiratory and mobility care was offered as part of the physiotherapy respiratory service however no formal exercise rehabilitation specific to cancer diagnosis was provided.
  • Physiotherapy service was available during chemotherapy/radiotherapy treatment in four of the seven public hospitals and none of those interviewed had exercise classes available to their patients with cancer.

Private Hospitals

  • A designated oncology physiotherapist was available in three hospitals of the five private hospitals interviewed.
  • Routine preoperative assessments and prehabilitation programmes were available in one hospital and standard post-operative care was available in all hospitals.
  • Four hospitals provided exercise rehabilitation for their patients with breast cancer. Post-operative exercise rehabilitation was routinely available to all patients with cancer in one hospital. Physiotherapy services were available to patients undergoing chemotherapy and radiotherapy in all hospitals and group exercise programmes were offered by one private hospital.

Inpatient Hospices

  • Each physiotherapy manager in the six hospices interviewed had a palliative care senior physiotherapist within the service.
  • Physiotherapy was provided on a blanket referral basis in four hospices.
  • Home visits were carried out by two of the hospices.
  • Rehabilitation programmes were available within the hospice service with three offering classes including tai-chi, mobility classes and education regarding transfers. These programmes were not exclusively for oncology patients, however managers were confident that the majority of their caseload included patients with cancer.

The authors identified four main themes from the data gathered during the study; service provision, sub-optimal inter-professional communication, barriers to service development and follow up of patients post discharge from acute services. Service provision was not uniform across the sector. Many patients undergoing chemotherapy and radiotherapy were not referred to physiotherapy and physiotherapy was often used to treat patients after adverse events such as falls rather than acting preventatively. Gaps in the service included a lack of nationwide lymphoedema care and pre-operative prehabilitation programmes. Several managers reported not having the capacity to offer services to patients receiving chemotherapy on an outpatient basis. Concerns about inter-professional communication were identified whereby physiotherapy was not always viewed as a core member of the oncology team. Barriers to developing and delivering exercise rehabilitation included low staffing levels and the limited resources such as gym space. The absence of an established physiotherapy pathway for patients throughout their cancer care was also mentioned.

Limited availability of services was evident across the entire cancer trajectory and can be most clearly seen by the lack of prehabilitation services available despite evidence suggesting that prehabilitation has a role in reducing post-operative complication. Although many of the cancer centres and private hospitals had designated oncology physiotherapists, several reported that they did not have the capacity to see patients receiving chemotherapy on an outpatient basis despite the proven role of exercise during active cancer treatment.

In palliative care it was seen that patients are often referred when they have severely limited mobility or have suffered an adverse event such as a fall despite the fact that exercise interventions may prevent such adverse events and have proven to be safe, feasible and beneficial in patients with advanced stage cancer.

In addition to staff shortages, limited gym space inhibited the ability to run exercise rehabilitation programmes. Poor inter-professional collaboration and a lack of support from multidisciplinary team members was also described. Education of other multidisciplinary team members including oncologists and oncology nurses on the role of physiotherapy and the benefits of exercise therapy may be a vital step in ensuring that all appropriate patients are referred to physiotherapy and that patients receive clear, consistent messages about exercise.

In the absence of physiotherapy led exercise rehabilitation for patients with cancer, the void may be filled by private rehabilitation services or non-physiotherapy led services. Consideration should be given to the fact that while private rehabilitation may be feasible for some patients, there is a need for rehabilitation for all patients with cancer including those during treatment.

Despite the evidence for exercise rehabilitation, it is not an element of standard care in Ireland. The identification of the lack of exercise rehabilitation available for patients with cancer may be a useful step in guiding the development of these services with the aim that exercise rehabilitation should be recognised as standard care for all patients with cancer in Ireland.

The researchers note a number of limitations to this study. Some centres may have been excluded as participants were identified through online searches as there is no central database available for physiotherapy services for patients with cancer. In addition to this the availability of such services within the private and community care setting was not captured, thus highlighting an area for future research. Despite these limitations they conclude that “this study provides a foundation for future work exploring the availability of exercise rehabilitation for patients with cancer.”



All references, author names and graphs and tables are contained in the full article in the October edition of the Irish Medical Journal.

September edition of the Irish Medical Journal

September edition of the Irish Medical Journal


National Survey Of The Aetiological Assessment Service Of Permanent Childhood Hearing Loss In Ireland

Balfe et al report that in 2016, the screening programme identified 106 infants with permanent childhood hearing loss (PCHL).  This is an incidence of 1.66 per 1000 babies screened.  Only 24.2% of the paediatricians were able to assess for cCMV infection within the 6 weeks window necessary for starting treatment.  Although MRI IAM has a high diagnostic yield, the investigation was only ordered for 57% of the children.


The Physical Examination on Admission to the Acute Psychiatric Unit -complete Audit cycle

Elzain et al state that newly admitted psychiatric patients should have a complete physical examination within 24 hours.  In the first audit the findings were 64% complete, 32% partial and 4% no examination.  Following the introduction of a bundle of measures, a second audit was undertaken.  The findings were 80% complete, 18% partial and 2% no examination.


The Experience of the Management of Eating Disorders in a Pop-up Eating Disorder Unit

McHugh et al state that anorexia nervosa affects 0.5% of the population, 90% being female.  It has the highest mortality of any psychiatric illness.  The authors describe the experience of managing 20 patients with a team consisting of a psychiatrist, physician, dietician, and a nurse.  They employed the MARSIPAN guideline (management of really sick inpatients with anorexia nervosa).  Among the sabotaging behaviour witnessed was opening windows in order to shiver, vigorous page turning and tooth brushing, heavy hair accessories and faecal/urine loading on weigh days, use of computer key pads, and animated conversations.


Cannabis Oil in an Irish Children’s Critical Care Unit

Fennessy et al report a 5 year child receiving cannabis oil for refractory epilepsy.  It was obtained by her parents from the US.  When she was admitted to hospital for a tonsillectomy, the treated team were unaware that she was on this treatment.  An administration regime was agreed in order that the cannabis oil could be continued while she was in the hospital.


Ovarian Cancer Screening Editorial



If you have any queries please contact the IMO Communications Unit and we will try to assist as necessary.



July/August 2018 ■ Volume 111 ■ Number 7 - Official Journal of the Irish Medical Organisation

Emergency Department Overcrowding And The Full Capacity Protocol Cross Over Study:

July/August 2018 ■ Volume 111 ■ Number 7 - Official Journal of the Irish Medical Organisation

Emergency Department Overcrowding And The Full Capacity Protocol Cross Over Study:

The inability of patients requiring emergency admission to be moved to ward beds in a timely manner is thought to be one of the key contributing factors to ED overcrowding. Delays in accessing wards results in patients admitted through the ED being boarded on trolleys and chairs in the ED for extended periods of time often including overnight stays. New research published in the July/August edition of the Irish Medical Journal aims to establish patient preferences when waiting for a ward bed in an Irish Hospital. Patients preferred to be an extra patient on the ward rather than in the Emergency Department. From a clinical care perspective and taking patients’ preferences into account patients requiring emergency admission should be placed in extra beds on wards rather than kept in overcrowded Emergency Departments.

In the study patients’ attitudes towards boarding in the ED as opposed to being in extra beds on the wards were assessed. Eighty three patients (83.83%) preferred being an additional patient on the ward, 12.12% had no preference and 4 (4.04%) preferred being boarded in the ED.

Moving patients from the ED into extra beds on the wards creates space, facilitating safer care delivery. The vast majority of patients who have experienced both prefer being boarded in the ward rather than in the ED.

The Full Capacity Protocol (FCP) is activated to move patients to temporary extra beds placed in the inpatient wards. The FCP is the final step in the escalation protocol and is employed when other actions have failed to alleviate pressure on the ED. Patients who are ambulant, who do not have infectious diseases, are not confused, not requiring intensive or coronary care management, not requiring suctioning and not requiring more than four litres per minute of oxygen are deemed suitable and appropriate to be placed on extra ward beds.

For the study, a structured questionnaire was developed to compare patient satisfaction with boarding in the ED versus boarding in extra beds on the wards. All patients in the hospital who had been moved to an extra bed on a ward as a result of the FCP and were still in the hospital when the survey was conducted were offered the opportunity to take part in the study if they were capable of consenting.

The data for patients who preferred the temporary ward bed was compared to the patients who preferred boarding in the ED or those who felt there was no difference between the two areas. For each theme assessed the results were simplified to reflect a preference for the ward, preference for the ED, or having no preference between the two areas. Comparisons were made between groups of patients based on age (less than 50 years of age versus 50 years and above), gender and their duration of stay in the ED and their preferences.

A total of 99 patients were enrolled in the study.  The average age of patients in the study was 46 ranging from 18 to 82 years. 40.% were male and 60% were female patients. Eighty three (83.8%) patients preferred being an extra patient on a ward to being boarded in the ED, (12.1%) had no preference and 4.04% preferred being boarded in the ED.

Patients were asked to compare the extra bed to being boarded as an extra patient in the ED under a number of qualitative headings. In general, the data in each section showed a propensity towards favouring the extra bed on the ward.

Categories where the extra ward beds were strongly favoured included ability to sleep/rest, comfort and peace and quiet. Areas that slightly favoured ward bed over no difference included safety and privacy. Categories showing preference for ED or no difference included availability of medical treatment, confidentiality and dignity/ respect.

The only result approaching significance in the study  was that older patients showed a marked preference for ward beds over the ED in ability to sleep at 95%. The younger cohort, though not as strongly favouring the extra ward bed, still had a high preference at 78%.  Most of the other results show a strong similarity in patient preference relating to hospital treatment.

The primary concern expressed by patients in the study about the extra beds was the absence of conveniences not afforded to the extra beds such as curtains for privacy, storage lockers for personal belongings and access to power sockets to charge electronic devices. When asked about the ED patients said they were "not expecting a lot", and that "it was mayhem, packed on them", "I could see it was packed when I got there", and "no sooner than they have a trolley washed another patient arrives in". With regard to boarding in the ED patients reported "I just accepted I had to stay on a chair all night" and "the hardest thing about it was the chair”. One patient felt "very lucky to get a cubicle". Patients said that the "staff were great and efficient but under constant pressure", "They're doing the best they can". The prevailing sentiment was that patients "didn't want to be down there".

When asked about the extra bed on the ward patients replied "It's grand after being down there", "10 times better than downstairs", "A bed's a bed… just want to get better and get out of here", "it's grand, better than the chair". Some went as far as describing it as "like winning the lotto” or that they were "one of the lucky ones [and] got a bed in a few hours".

Other studies have noted that having an overcrowded ED has been associated with increased rates of ambulance diversion. With the introduction of an FCP the frequency of ambulance diversions can be significantly reduced.

The authors conclude that the use of the FCP to combat ED overcrowding acknowledges that crowding is evidence of system failure and requires reform measures from all parts of the health care system.


All references, author names and graphs and tables are contained in the full article in the July/August edition of the Irish Medical Journal.

For further information, contact: Communications Unit, Irish Medical Organisation, 10 Fitzwilliam Place, Dublin 2.  


June 2018 ■ Volume 111 ■ Number 6 - Official Journal of the Irish Medical Organisation

The Doctor Can See You Now: A Key Stakeholder Study Into The Acceptability Of Ambulance Based Telemedicine.

June 2018 ■ Volume 111 ■ Number 6 - Official Journal of the Irish Medical Organisation

In a world where people can use smart phone technology to video link themselves to others in place of traditional phone calls it seems logical that a video link from the scene of an emergency to the ED could be useful. A study published in the June edition of the Irish Medical Journal examines how key stakeholders involved in emergency care: patients, ambulance personnel, doctors and nurses, would feel about a duplex (two way) audio and simplex (one way) video link from the scene of the emergency to the ED, if these groups would want and accept telemedicine in pre-hospital emergency care and if they felt it could be potentially beneficial.

The results from the study showed that 98.5% of patients, 89% of doctors, 76% of nurses and 91% of ambulance personnel saw the potential of an audio-visual link from the pre-hospital environment to the ED and the results indicate that they thought it would be most useful in dealing with situations where early diagnosis and intervention were key to patient recovery.

The study was performed in the ED of an 800 bed academic teaching hospital based in Dublin, where a questionnaire-based study in the pre-hospital environment involving patients, paramedics, doctors and nurses in the ED asked if they would want and accept telemedicine in pre-hospital emergency care. Separate questionnaires were developed for patients and staff.

ED Staff Demographics

The more experienced staff members tended to describe themselves as less comfortable with the use of technology. The attitudes regarding the use and implementation of telemedicine in the pre-hospital environment were very positive.

When asked what potential benefits there would be from the use of video communication technology, 41.4% of ED staff answered that it would make the ED more efficient with regards to the diagnosis of time-dependent illnesses, improve time management in the ED, increase hospital preparedness for incoming patients and increase timeliness of triage.

When asked about any concerns or apprehensions about the video-link technology, both doctors and nurses were most concerned about:

a) Patient confidentiality 64.5%

b) Technological limitations 45.2%

c) Staff liability 16.1%

Doctors and nurses expressed concerns that because the patient video data is to be transferred over a wireless network to a screen in the Emergency Department, there could be the potential for a breach in patient confidentiality.

With regards to technological limitations, staff members were concerned that there may be difficulty operating the technology in certain situations such as adverse weather conditions, low light levels and in remote areas without network coverage. Concerns were also expressed regarding the quality of the video and the limitation of the view. The third overall concern was one of liability. Doctors had concerns about the apportioning of blame in the event of an incorrect diagnosis made over a telemedicine link.

If technical issues can be addressed and managed adequately, the authors remark that telemedicine has been found to be efficient and reliable in various emergency situations, such as in the remote assessment of stroke severity in fast-moving ambulances using a system dedicated to pre-hospital telemedicine and 4G technology.

Ambulance Personnel Demographics

Three ambulance services were included in the study. The majority of ambulance personnel respondents i.e. 91% saw a positive role for video communication technology in pre-hospital care and 67% would be willing to adopt it in their own practice. Suggested uses included medical input, ECG review, stroke assessment and major trauma. Possible advantages identified were on scene advice, drug dosage, to alert the hospital team and reduce inappropriate attendances. Disadvantages identified included lack of reliability, causing delay, equipment durability and weight of equipment.

Patient Demographics

82.1% of patients survey for the study had used the ambulance service in the past between 0 to 5 times, 14.3% had used the service 6 to 10 times and 3.6% had used it more than 20 times.

When asked to rate their comfort with new technologies such as computers, tablets and smartphones on an adjectival scale rating from “extremely comfortable” to “not at all comfortable” 35.7% said they were extremely comfortable, 23.2% were very comfortable with technology, 19.6% were moderately comfortable and 14.3% patients described themselves as not at all comfortable with these technologies.

98.5% patients said they would like the ambulance service to use video link telemedicine technology to contact a doctor in the ED so they could be assessed before arriving at hospital.

In relation to the use of this technology in possible stroke cases examples of the responses given were: “It could make the difference as to whether I live or die, so I’m definitely in favour.’’ “Potentially a life saving service.’’ and “Time saves lives.’’

In relation to the use of this technology in a major trauma case, responses given included: “It could be important to determine which hospital they need to go to” and “if they are aware of the type of treatment required before arriving at hospital, it will reduce wait time”.

In cases of possible MI and the use of this technology, responses given included; “Time is critical here so could be lifesaving” and “Certainly does no harm and could save a life”.

Gilligan et al cite that early intervention in medical emergencies improves clinical outcomes. Telemedicine in MI has shown a positive impact and in stroke management telemedicine is now recommended by the American Heart Association to reduce treatment delays, yet the adoption of these emerging technologies has been slow. End user engagement in the adoption of new technologies in healthcare does not depend solely on clinical validation and regulatory considerations.

For those using the ambulance service the first point of contact with healthcare is the ambulance personnel. Currently if a paramedic requires further medical input they obtain it via a telephone link to a doctor. This current practice does not facilitate the ED doctor in visualizing the patient and ascertaining other potentially vital information directly from the patient.

Telemedicine in the pre-hospital setting could bring a hospital based specialist opinion to the patient sooner. It also has the potential to open up faster and more efficient communication channels between the patient, ambulance personnel and the ED staff, through the immediate transmission of medical data, informatics and images from the ambulance setting to the ED.

The authors of the study conclude that the challenge now is to address the hardware, software and network requirements of providing a reliable, safe, real time audio-visual link from wherever the patient is to the Emergency Department because the majority of key stakeholders being ambulance personnel, patients, doctors and nurses feel a pre-hospital audio-visual link to the ED would help to improve outcomes and potentially save lives.


May 2018 ■ Volume 111 ■ Number 5 - Official Journal of the Irish Medical Organisation

How would Mary Poppins fare in labour? Practically perfect? Unlikely.

May 2018 ■ Volume 111 ■ Number 5 - Official Journal of the Irish Medical Organisation

With increasing influence of social media, there is the potential for women to feel pressure to have the “perfect” birth. New research in the May edition of the Irish Medical Journal provides useful statistics for providing realistic expectations for first time mothers. The study has calculated that the percentage of “practically perfect” births in nulliparous women in the National Maternity Hospital over a 2 year period (2014/2015) was 0.8%. The authors defined  a “practically perfect” birth  as a spontaneous labour without intervention, an intact perineum and a positive neonatal outcome. The study poses the questions whether the unrealistic expectations of labour in first time mothers can present challenges to physicians and midwives.

To extract the perfect births, deliveries <37 weeks, induction/pre labour Caesarean Section (CS), Artificial Rupture of Membranes (ARM), oxytocin, fetal blood sample, emergency CS/instrumental deliveries, perineal damage and suboptimal Apgar scores were all excluded. The focus of the study was on the 8292 nulliparous labours.

The following exclusion criteria were applied in the following order:

  1. Delivery <37 weeks
  2. Induced/Pre labour Caesarean section
  3. Artificial rupture of Membranes
  4. Oxytocin
  5. Fetal Blood Sample
  6. Emergency Caesarean section/Forceps Delivery/Ventouse Delivery
  7. Perineal Outcome: first degree tear +/- sutures, Second degree tear +/- sutures, 3rd degree tear, episitomy +/- sphincter damage, labial tears
  8. Neonatal Outcome: Apgars of <9 at 1 or 5 minutes

Among 18698 there were 8292 nulliparous women of whom 7616 delivered after 37 weeks. Of these, 4171 went into spontaneous labour, while 2753 were induced. 692 had a caesarean section as a primary procedure. 2111 women were noted to have an artificial rupture of membranes in labour and 857 received oxytocin. After excluding these, there were 1203 remaining. 172 women had a fetal blood sample taken, leaving 1031.

Of the 1031 women who had a spontaneous labour without any of the interventions mentioned above, 57 had an emergency caesarean section, 86 had a ventouse delivery, 33 had a forceps delivery, 2 were spontaneous breech deliveries and 5 were born before arrival to hospital. That excluded a total of 183 leaving 848 practically perfect births.

All tears and episiotomies were excluded which left 68 with an intact perineum. Out of these 68, 2 were extracted based on suboptimal Apgar scores. This left 66 “perfect” deliveries or 0.8% of all nulliparous mothers who had a practically perfect birth. Out of the 66 “perfect” deliveries 15 were noted to have opted for community midwife care. When those who went with community midwife care and the standard obstetric care group were separated, the rate of “practically perfect” births was 3% in the midwife group compared to 0.7% in the obstetric group.

This study was carried out in a maternity unit that practises active management of labour, which utilizes early amniotomy and oxytocin and has been proven to reduce the duration of labour along with the rate of caesarean section without affecting womens satisfaction with their labour and delivery. 

The author’s demonstrate that while there is a poor chance of a “practically perfect birth”, neonatal outcomes remain positive: with only 2 excluded based on Apgar scores. Of note, these Apgar scores were 8 at 1 minute & 9 at 5 minutes. With such a low result it is important to examine the areas of the exclusion criteria that had the greatest effect. Two of the most significant exclusion criteria were Artificial Rupture of Membranes (ARM) and perineal outcome.

If the 51% of the cohort that had an ARM in spontaneous labour were included, the proportion of practically perfect births increases to 1.4%. It can also be said that only accepting intact perineums into the practically perfect group was too stringent. When the authors took the objective measure of whether mothers required sutures or not and included labial tears, first degree tears without sutures and second degree tears without sutures, the number of practically perfect births doubles (1.6%). 

If the same applications are made to the midwifery led cohort, the percentage rises from 3% to 6%. The authors note that this is potentially an area for future research. However, it is important to note that midwifery led services are reserved for the lowest risk mothers. While there was a significant difference between the rate of practically perfect births in the midwifery led cohort compared to the obstetric cohort, statistical comparison would not be practical due to the small number in the midwifery group.

The study included those who received epidurals during their labour. Neither antenatal nor postnatal complications were included; this is a potential limitation to the study. This study objectively defined a practically perfect birth resulting in stringent exclusion criteria. No input from the mothers themselves was accounted which is both a limitation and an area for future research.

The authors conclude the study by asking whether imparting this information to first time mothers evoke fear of labour or provide realistic expectations.


April 2018 ■ Volume 111 ■ Number 4 - Official Journal of the Irish Medical Organisation

Further Reductions in Road-Related Deaths and Injuries in Irish Children

April 2018 ■ Volume 111 ■ Number 4 - Official Journal of the Irish Medical Organisation

A study published in the April edition of the Irish Medical Journal reveals that road related deaths and injuries in children dropped by over 70% over the three time periods spanning from 1996 to 2013. The study reviewed the rates of road related fatalities and injuries in a paediatric population over three 5 year time periods. The authors of the study assessed the differences, if any, in the injury and fatality rates and assessed the likely causes associated with these results.

All road and traffic collisions requiring police assistance occurring on public roads in Ireland in three separate time periods spanning five years (1996-2000, 2004-2008 and 2009-2013) were included in the study. Accident details are recorded by the attending police officer on the CT [68] form. This form collects information on severity of the accident, road user category, contributing factors such as road factors, vehicle factors, environmental factors and also what safety precautions were in place at the time of the accident (such as seatbelt use, bicycle helmet use and pedestrian data ). The information was then entered into an SPSS database and accident trends were analysed and reviewed by the Research Section of the Road Safety Authority.

Injuries were sub-classified as fatalities, serious [those admitted to hospital, fractures, severe head injuries, severe internal injuries or shock requiring treatment] and minor. From this database information pertaining to those children and adolescents aged fifteen years and younger was analysed. Results from the initial cohort in 1996 – 2000 were then compared with both 2004-2008 and 2009-2013.

There was a decrease in the total number of children injured or killed on our roads from 5928 to 3903. Minor injuries fell by from 5063 to 3659, serious injuries fell from 712 to 201 and fatal injuries by from 163 to 43 (a 72% drop).

Car passenger fatalities

Car passenger fatalities fell from 69 (1996-2000) to 44 (2004-2008) and 17 (2009-2013). The majority of these children were travelling in the rear seat however 7 of 17 car passenger fatalities were front seat passengers and 25 of 92 serious injuries were front seat passengers.

Pedestrian Injuries

There was a slight rise in pedestrian injuries from the 2004-2008 cohort (1232) to the 2009-2013 cohort (1258) but pedestrian deaths fell from 61 (1996-2000) to 32 (2004-2008) with a further drop to 20 (2009-2013). Pedestrian injuries accounted for 32% of the total injury toll.

Cyclist Injuries

Cyclist fatalities fell from 25 (1996-2000) to 6 (2004-2008) but remained at 6 (2009-2013) reflecting a disappointing halt in progress. In contrast to previous years none of the fatalities in this category were under the age of 10. There was no information available on the use of helmets in any of the fatalities.

Road traffic collisions (RTCs) are a major cause of childhood death (1-14yrs) annually throughout the EU, and the primary cause of death among adolescents (15-19yrs) globally, despite being largely preventable. With prioritisation given to road traffic injuries on the global health agenda in recent years child fatality rates from RTCs have declined in many countries.

In line with EU wide initiatives, a number of national road safety strategies have been implemented in recent years in an effort to address the death toll on Irish roads. However, there has been no separate target for reducing child fatalities and the impact of these interventions on fatality rates in the paediatric population has not been evaluated. Young people have been highlighted as an important risk group in Ireland with rates higher than the EU average.

The authors conclude that road traffic injuries in children are predictable and therefore preventable and to reduce the injury toll further requires a coordinated and collaborative effort across many sectors. A national road safety campaign, greater police enforcement and a cultural change has seen road – related deaths and injuries in children drop very significantly and this campaign should continue. The success of the past 17 years should act as a spur to further reduce this toll in our vulnerable road users.


March 2018 ■ Volume 111 ■ Number 3 - Official Journal of the Irish Medical Organisation

Factors that Influence Uptake of Vaccination in Pregnancy

March 2018 ■ Volume 111 ■ Number 3 - Official Journal of the Irish Medical Organisation

A study published in the March edition of the Irish Medical Journal looks at identifying factors influencing pregnant patient’s knowledge, beliefs and perceptions on the influenza and pertussis vaccination. The study found that even though fewer participants were aware of the pertussis vaccine it had a relatively higher uptake than flu vaccine. The study demonstrates a lot of uncertainty amongst patients surrounding vaccine safety as well as a lack of knowledge about the risks posed to themselves and their babies from influenza and pertussis.

Influenza and Pertussis are vaccine preventable diseases carrying significant morbidity and mortality in pregnant women and infants. Vaccinations against influenza and pertussis are safe, recommended in pregnancy in Ireland and are administered in primary care.

Influenza increases the risk of cardiorespiratory complications for pregnant women and heightens risks of premature labour, low birth weight and intrauterine death. It is estimated that immunisation could prevent 1-2 hospitalisations per 1,000 pregnant women. Infants under 6 months have the highest rate of death from influenza.

In Ireland, since August 2012, the National Immunisation Advisory Committee (NIAC) has recommended that pregnant women should be offered Tdap (low dose diphtheria and acellular pertussis) in each pregnancy. Influenza vaccination is recommended at any gestation during the flu season.

There is very little evidence on vaccination hesitancy in pregnancy in Ireland. The authors concentrated the research on practices in the South East, with the aim of understanding the influences and barriers surrounding vaccination uptake amongst pregnant patients.


All study participants were pregnant women, of mean age 31 years (range 18-42 years), 88 patients completed surveys.

  • 95% of respondents were aware of flu vaccine and 75% were aware of pertussis vaccine 75%
  • However uptake levels at 67% was higher for the pertussis vaccination than for flu vaccine 40%
  • 66% recognise that contracting flu during pregnancy could be serious for themselves. A larger number 80% felt the illness could seriously impact the health of new-borns.
  • 55% believe flu vaccine is safe for them in pregnancy but 40% were unsure if it posed danger to their unborn baby.
  • 65% thought contracting whooping cough while pregnant could be serious for themselves with 78% feeling that pertussis is dangerous for new-borns.
  • 50% were unsure if pertussis vaccine could harm them or their baby.
  • The overwhelming majority at 91% found their GP to be a reliable source of information on vaccination in pregnancy, closely followed by their Obstetrician or hospital clinic at 81%.

Vaccination of pregnant patients offers a single intervention that will protect two individuals: direct immunity is conferred on the susceptible antenatal patient and maternally driven antibodies offer vital neonatal protection via placental transfer.

The authors recommend that positive health messages emphasizing immunisation benefits for their infants would encourage antenatal patients to vaccinate. Post education uptake has been demonstrated to increase in the literature.

The key message of the study and literature review is the following: health care provider recommendation is the most powerful tool to improve vaccination uptake. The research clearly identifies GPs as the most trusted source of information to pregnant women, largely correlating with literature that doctors and health care providers as dependable and trustworthy in this context. Therefore, it is crucial that GPs deliver accurate information to this high-risk group.

The authors conclude that if targeted education on immunisation during pregnancy has such a positive impact on maternal vaccination coverage, then an onus is on health care providers to facilitate this. The authors suggest further research into opinions of all Irish antenatal care providers would be valuable in light of studies showing vastly increased uptake amongst patients whose health care provider advocated for vaccination. The study recommends that hospital based Obstetrics teams prioritise internal educational sessions on the importance of vaccination in pregnancy carried out in Primary care. Written information leaflets should be routinely provided to patients in antenatal packs. Local CME groups represent an excellent platform for dissemination of accurate information to GPs.


February 2018 ■ Volume 111 ■ Number 2 - Official Journal of the Irish Medical Organisation

The Prevalence of Severe Sepsis or Septic Shock in an Irish Emergency Department

February 2018 ■ Volume 111 ■ Number 2 - Official Journal of the Irish Medical Organisation

Irish Medical Journal - Press Release       

February 2018 ■ Volume 111 ■ Number 2 - Official Journal of the Irish Medical Organisation

The Prevalence of Severe Sepsis or Septic Shock in an Irish Emergency Department

A new study in the Irish Medical Journal has found that ED prevalence of severe sepsis or septic shock was 11.7 patients per 1000 ED attendances. This translates to approximately one in every 100 patients attending the ED meeting the criteria for severe sepsis or septic shock.

In Ireland, up to 60% of all hospital deaths have a sepsis or infection diagnosis. Severe sepsis and septic shock remain a major cause of emergency department (ED) attendances and intensive care unit (ICU) admissions and are associated with significant morbidity, mortality and healthcare costs. Despite the central role the emergency department (ED) plays in the early identification of patients presenting to hospital with sepsis, the prevalence of severe sepsis and septic shock in the Irish ED setting has not been described.

The primary aim of this study was to measure the prevalence of severe sepsis or septic shock in an Irish adult ED setting. The secondary aim was to determine the demographic and clinical characteristics of ED patients who met the criteria for severe sepsis or septic shock.

This study was performed in the ED of Beaumont Hospital, Dublin. The clinical records of patients presenting to the ED over a four-week period were retrospectively reviewed to determine if they met the current Health Service Executive (HSE) criteria for severe sepsis or septic shock. Overall, 3585 adult patients attended the ED during the study period, with 42 patients meeting the criteria for severe sepsis or septic shock. The cross-sectional study involved screening the clinical records of consecutive patients presenting to the ED over a one-month study period (July-August 2015) for sepsis using the Health Service Executive (HSE) Sepsis Screening Form. The definitions of severe sepsis and septic shock employed in this study were those used in the HSE Sepsis Screening Form.

Data on patient age, gender, temperature, heart rate, systolic blood pressure (SBP), mean arterial pressure (MAP), respiratory rate, need for oxygen to achieve a saturation > 90%, Glasgow Coma Scale (GCS) score, blood glucose, white cell count, presence or absence of diabetes, blood lactate, urine output, serum creatinine, serum bilirubin, prothrombin time (PTR), activated partial thromboplastin time (aPTT) and platelet count were obtained from the clinical records. Where one or more of the systemic inflammatory response syndrome (SIRS) criteria used to diagnose sepsis had not been recorded for an individual, the diagnostic criteria were applied to all available data.

Patients who met the criteria for severe sepsis or septic shock

Overall, 42 of 3585 ED patients met the criteria for severe sepsis or septic shock. This represents 11.7 patients with severe sepsis or septic shock per 1000 ED attendances or 1.17% (95% CI 0.81 – 1.54 %) of ED patients. Table 1 shows the number of SIRS criteria met by ED patients who met the criteria for severe sepsis or septic shock.

Table 1. The number of SIRS criteria met by ED patients who met the criteria for severe sepsis or septic shock

Number of SIRS criteria met

Number of ED patients who met criteria for severe sepsis or sepsis shock (%)


23 (54.8%)


13 (31.0%)


5 (11.9%)


1 (2.4%)


0 (0%)

There was a significant difference in the age distributions of ED patients with severe sepsis or septic shock and those without; patients who met the criteria for severe sepsis or septic shock were on average older than those who did not (Table 2). There was no significant difference in the gender distributions of ED patients with and without severe sepsis or septic shock

There was a statistically significant difference between the underlying age distributions of the male and female patients who met the criteria for severe sepsis or septic shock. Among patients who met the criteria for severe sepsis or septic shock, males (median age 75 years) were significantly older than females (median age 68 years).

Table 2. Age and gender distribution of ED patients with and without severe sepsis or septic shock

Patients without severe sepsis or septic shock

(n = 3543)

Patients with severe sepsis or septic shock

(n = 42)



Male (%)

1753 (49.5%)

17 (40.5%)

p = 0.25

Female (%)

1790 (50.5%)

25 (59.5%)

Age (years) median (IQR)

46 (31 – 66)

72 (60.5 – 80)

p < 0.001

Suspected Source of Sepsis

The most common suspected source of sepsis in patients who met the criteria for severe sepsis or septic shock was the respiratory system The genitourinary system was the second most common source of sepsis (Table 3). There were as many patients with an unknown source of sepsis as those with a suspected respiratory source.

Table 3. Suspected sources of sepsis in ED patients who met the criteria for severe sepsis or septic shock, including the subset of patients transferred to ICU.

Suspected source of sepsis

Number of ED patients who met criteria for severe sepsis or septic shock (%)

Number of ED patients with severe sepsis or septic shock who were admitted to the ICU


11 (26.2)



11 (26.2)



10 (23.8)



5 (11.9)


Central nervous system

3 (7.1)


Skin and skin structures

2 (4.8)


Patients transferred to the intensive care unit (ICU)

Five patients with severe sepsis or septic shock were transferred to the ICU for further management. These patients had a median age of 61. The suspected sources of sepsis in these patients are outlined in Table 3.

The authors of the study state that prevalence data are critical in determining healthcare resource allocation. Due to the fact that the majority of patients with severe sepsis are admitted to ICUs from the ED, measuring the ED prevalence of severe sepsis and septic shock is important in determining healthcare resource allocation, such as critical care utilisation and ICU admissions.

The study found that there was a significant difference in the age distribution of ED patients with severe sepsis or septic shock and those without severe sepsis or septic shock. Patients who met the criteria for severe sepsis or septic shock were significantly older than those without severe sepsis or septic shock. This is consistent with previous studies reporting sepsis as a disease of the elderly.  


January 2018 - Volume 111 - Number 1 Official Journal of the Irish Medical Organisation

Management of Bone Fragility in Primary Care in Ireland

January 2018 - Volume 111 - Number 1 Official Journal of the Irish Medical Organisation

A study in the January issue of the Irish Medical Journal of the current practice in the detection and management of bone fragility in Primary Care has shown that fracture risk assessment did not seem to take place in many patients prior to commencement of bone strengthening treatments in the form of bisphosphonates and or calcium / vitamin D supplementation.

According to the research carried out in this study the implications are that bone fragility management warrants urgent review.

Osteoporosis is characterised by low bone mass and structural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture, particularly fractures that result from mechanical forces that would not ordinarily result in fracture, known as fragility fractures. Osteopaenia is a less severe form of osteoporosis but is also associated with an increased risk of fracture. The burden of osteoporosis in Ireland is substantial and increasing. The prevalence of osteoporosis rises markedly with age and it is estimated that approximately 50% of women and 20% of men aged over 50 years’ experience an osteoporosis-related facture at some point in their lifetime. With an increasingly elderly population this has become an extremely important health issue.

The aim of this study was to determine if the prevention and management of bone fragility fractures in an Irish general practice setting adhere to best practice guidelines and to the authors knowledge this is the first study carried out of this topic

This study evaluated the prevention of bone fragility fractures in a representative sample of four Irish general practices. The clinical records of 243 patients potentially at risk of bone fragility were studied. 114 (47%) had a dual energy x-ray absorptiometry (DEXA) scan.

Osteoporosis was established in 42 (17%) and osteopaenia in 28 (11%). 152 (63%) were currently being prescribed bisphosphonates. 34 (22%) of those on bisphosphonates did not have a baseline DEXA scan performed prior to commencing treatment and further analysis did not show a clear rationale for initiation of the treatment in this group of patients. 46 (30%) patients on bisphosphonates had been prescribed them for over 5 years without any apparent review to see if they were still indicated. There was no record of any of the practices having carried out a fracture risk score assessment prior to commencing bone fragility treatment.

However, there is considerable controversy over the optimal duration of anti-resorptive therapy, particularly since the reporting of side-effects, including atypical subtrochanteric fractures during long-term bisphosphonate therapy.

The Fracture Risk Assessment Tool “FRAX” was developed in 2008 to provide a prediction tool for assessing an individual’s risk of fracture in order to provide general clinical guidance for treatment decisions11. It has been adapted to the Irish population using estimates about life expectancy and fracture incidence in Ireland. It is readily calculated at the time of DEXA scan.

Prior to prescribing anti-resorbtive medication for patients, the National Institute for Health and Clinical Excellence (NICE) published recommendations on the process of risk assessment of fragility fractures which should be undertaken. These have been updated more recently, but their fundamental recommendations regarding initial assessment and prescription of anti-resorbtive medications remain unchanged.

Four practices affiliated with the University of Limerick Graduate Entry Medical School with a senior medical student on general practice placement in 2012/13 participated in this study. The practices were based in two of Ireland’s four healthcare regions (South, West) and are broadly representative of general practices nationally by size, patient eligibility for free medical care and urban/rural location.

Records were then checked for the presence of a fragility fracture risk assessment prior to or during bisphosphonate prescription. The clinical records of a subsample that were prescribed bisphosphonates were studied for documented indications for initial prescription and duration of treatment. The proportion of patients who had a Dual Energy X-ray Absorptiometry (DEXA) scan was also studied. DEXA scan results, if present, were analysed in all patients. Osteopaenia was diagnosed when bone mineral density (BMD), as measured by DEXA scanning, was less than one standard deviation (SD) of young adult female reference mean but greater than minus 2.5 SD. Osteoporosis was diagnosed when the DEXA result was less than minus 2.5 SD.

Study Results

A total of 243 patient records were studied: 136 from the rural practices and 107 from the urban practices.

DEXA Scan analysis

  • 42% of the females aged over 65 years studied had had a DEXA scan
  • 53% of those who were currently being prescribed bisphosphonates had had a DEXA scan

The rate of and results of DEXA scanning were analysed in 183 patients in 3 of the practices studied (75% of the total study population).

  • A total of 114 DEXA scans were taken in this group (47% of the total study population) in the course of the study period.
  • In this subgroup of 183 patients, osteoporosis was established in 42 patients (17% of the total study population 23% of the population in which the test result was analysed, and 22% of those who were currently being prescribed bisphosphonates).
  • Osteopaenia was established in a further 28 patients, (11% of the total study population, 15% of the population in which the test result was analysed and 6% of those who were currently being prescribed bisphosphonates).
  • 18 DEXA scan results were normal.

Bisphosphonate group

  • 63% of total study population (152 patients) were currently being prescribed bisphosphonates. This figure was made up of all of the 107 patients currently on bisphosphonates plus 45 from the group of females aged over 65 years.
  • 33% of the 136 females aged over 65 years (45 patients) were being prescribed bisphosphonates. This number was greater than all the patients with DEXA diagnosed osteoporosis and osteopaenia combined in this category.
  • 22% of the 136 females aged over 65 years (30 patients) were being prescribed calcium and vitamin D supplements. This parameter was not studied in the study group who were prescribed bisphosphonates.

In one practice where 47 patients were on bisphosphonates and where the DEXA results were analysed, osteoporosis was established in 51% (24 patients), and osteopaenia in a further 15% (7 patients). Thus 34% of patients on bisphosphonates had a normal DEXA scan. Further analysis of these patients’ files showed that these patients had other risk factors for bone fragility: being prescribed on high dose steroids, had rheumatoid disease or x ray changes suggesting reduced bone density. However in another practice studied, 57% (34 patients) of those on bisphosphonates had not had any baseline DEXA scan performed prior to commencing treatment and further analysis did not show a clear rationale for initiation of the treatment.

Of those being prescribed bisphosphonates, 30% (46 patients) had been prescribed the drugs for over 5 years without any apparent review to see if they were still required. There was no record of any of the practices having carried out a fracture risk score assessment prior to commencing bisphosphonate therapy.

This study has shown that fracture risk assessment using tools such as FRAX or QFracture did not seem to take place in many patients prior to commencement of bone strengthening treatments in the form of bisphosphonates and or calcium / vitamin D supplementation.

It is possible that such risk assessment may have been done in the practices and no specific record made of the exercise. Many patients prescribed bisphosphonates did not have bone density assessed beforehand. Also 30% of those being prescribed bisphosphonates were taking them for over 5 years without any indication that a review had taken place to consider stopping them or switching to another treatment. This study showed that of the 92 patients being prescribed bisphosphonates where the indication was studied, only 46% (42 patients) had DEXA confirmed osteoporosis. Many of these patients may well have been taking the bisphosphonates with little benefit and potential risk of harm. Neither was there any indication of the use of non-drug measures, which are also recommended for the building up of bone mass and prevention of fractures.

GPs should also ensure that their patients have an adequate intake of calcium and vitamin D, avoiding excessive intake, in line with international guidelines. It has also been suggested that calcium intake should be estimated at the time of DEXA scanning to guide supplementation needs. There appears to be a significant amount of confusion currently in the screening for and treatment of bone fragility in Irish general practice with a view to preventing fractures. The authors acknowledge that GPs are busy clinicians who deal with a variety of problems, one of the most challenging being multi-morbidity. It is unrealistic to expect GPs to think of and complete all parameters in all conditions in an un-resourced and unstructured work environment.

Success has been previously documented in diabetes care when a standardised and resourced approach was introduced. This could be used as a paradigm for the management of other chronic illnesses such as bone fragility in a community setting. The authors conclude that future research should involve a larger sample size of GPs, investigating the use of validated fracture risk assessment tools and the factors involved in the decision to commence bone strengthening medication.


November/December 2017 ■ Volume 110 ■ Number 10 - Official Journal of the Irish Medical Organisation

The Avocado Hand – A case report

November/December 2017 ■ Volume 110 ■ Number 10 - Official Journal of the Irish Medical Organisation

The authors of a case report in the November/December edition of the Irish Medical Journal detail a case of a 32-year-old woman who sustained a significant hand injury while preparing an avocado. The authors hope to add to the educational awareness in the recent media by publishing this classic case.

Avocado hand relates to the accidental self-inflicted knife injury while using a knife to cut/peel the fruit. With this rise in popularity of the avocado fruit, there has also been an apparent increase in avocado related hand injuries. Classically, the patients hold the avocado in their non-dominant hand while using a knife to cut/peel the fruit with their dominant hand. The mechanism of injury is usually a stabbing injury to the non-dominant hand as the knife slips past the stone, through the soft avocado fruit. These stabbing injuries have the potential to cause significant neurovascular, tendinous and/or bony injuries.

A recent article published in The Times has coined the term “avocado hand” to describe this injury. In the article, Mr Simon Eccles, secretary of the British Association of Plastic and Reconstructive Surgery, has called for safety labels to be put on avocados to warn the public of the potential dangers of mishandling them. This has also been published by other media outlets.

The “avocado hand” appears to be resulting in increased emergency and hand surgery department presentations. These patients often present with neurovascular, tendinous or bony injuries affecting their non-dominant hand. This seemingly innocuous slip of the vegetable knife can cause significant injuries, often requiring exploration under regional or general anaesthetic.

The patient in this case required exploration and repair of a digital nerve under regional anaesthesia and has since made a full recovery. “Avocado hand” is a mechanism of injury becoming increasingly more common and the authors of this case conclude that public education is paramount in trying to prevent further injuries from occurring.


A 32-year-old right-hand dominant female presented to the Emergency Department (ED) with a self-inflicted stabbing injury to her left ring finger. The injury was sustained while she was preparing an avocado. On arrival to the ED, the knife was still impaled through patient’s finger as well as the avocado (figure 1).

On examination, there was decreased sensation over the radial aspect of her ring finger. The finger was well perfused with no deficit of the flexor and extensor mechanisms. The knife was removed in the ED after administering digital nerve regional anaesthesia and the wound was washed out. Tetanus and antibiotics were administered. The patient was transferred to theatre and underwent exploration of the wound under axillary block and brachial tourniquet. The radial digital nerve which had been transected was identified and repaired under x3.5 loupe magnification using a 9-0 nylon suture. 

The patient was discharged the same day. Post-operative recovery was unremarkable with return of full range of motion and an advancing Tinel’s sign noted at last review.


*Tables and figures are all contained in the full study in the November/December edition of the Irish Medical Journal.

All references, author names and graphs are contained in the full article in the November/December edition of the Irish Medical Journal

For further information, contact: Communications Unit, Irish Medical Organisation, 10 Fitzwilliam Place, Dublin 2.   

Decrease in the uptake of seasonal influenza vaccine in persons aged 65 years and older in Ireland since the 2009 influenza A (H1N1) pdm09 pandemic

October 2017 ■ Volume 110 ■ Number 9 - Official Journal of the Irish Medical Organisation

This is the first study looking at the Irish influenza vaccine data for the elderly by time, comparing the uptake before and after the 2009 influenza pandemic and providing a measurable outcome for this difference. The study’s results found that in Ireland, the levels of seasonal influenza vaccine uptake in persons aged 65 years and older are lower after the 2009 influenza pandemic compared to before.

In Ireland, there is year-on-year variation in the seasonal influenza vaccine uptake for people aged 65 years and older. We obtained aggregate vaccine uptake data (2004/05-2014/15) by area and age group and applied the 2011 relative deprivation score and GP-density by area. Using Poisson regression model, we estimated the associations between those variables and uptake before and after the 2009 pandemic.

After adjusting for age, deprivation status and GP-density, overall persons aged ≥65 years were less likely to receive the vaccine after the pandemic compared to before. Uptake increased with age; both those in the 70-74 and ≥75 year age groups were more likely to receive the vaccine compared to those aged 65-69 years

The data for seasonal influenza vaccine uptake was obtained from PCRS. Influenza vaccine uptake was calculated by dividing the number of paid claims by the number of medical/GP visit cardholders. The number of paid claims is reported by month from September to August for each influenza season. The number of medical and GP visit cardholders is reported to HPSC every month and the number in the study’s formula represents the median number of card holders for the period September to December, which is the period of time when the majority of influenza vaccinations were administered.

Two variables were created the period before (2004/05-2008/09) and after (2010/11-2014/15) the 2009 pandemic. The 2009/10 pandemic season was excluded from the analysis because the 2009 pandemic vaccine uptake data was collected separately and were not captured by the seasonal influenza vaccine surveillance data. For that reason, despite the high uptake of the pandemic vaccine that year, there was an artificial low uptake for seasonal vaccine that would influence the results of our analysis.

Influenza vaccine uptake in Ireland before the 2009 pandemic (2004/05-2008/09) fluctuated at higher levels compared to the period after the 2009 pandemic (2010/11-2014/15).

The highest uptake (70.1%) was observed during the 2008/09 season, while the lowest (56.9%) was during the seasons 2011/12 and 2012/13. Data from the 2009 pandemic are excluded.

The median uptake for those aged 65 years and older was 62% before and 59% after the pandemic period. After adjusting for age, deprivation status and GP density, those aged 65 years and older were less likely to receive the seasonal influenza vaccine after the 2009 pandemic compared to before.

Those aged 75 years and older had the highest uptake across all seasons, followed by those aged 70-74 years. The lowest uptake was in the 65-69 year age group and was much lower compared to the other two age groups across all seasons.

There was no significant association between uptake and deprivation score by area. HSE areas with the highest/lowest uptake remained consistent across all seasons. Finally, no association was found between GP density by area and influenza vaccine uptake

Looking at the uptake by area, the study found that those with the highest/lowest uptake remained consistent across all seasons. The consistently higher uptake in some areas could be due to the sustained health promotion work done locally promoting influenza vaccination.

This is also the first study that investigated the association of influenza vaccine uptake with age, deprivation status and GP density by area and provided a measurable outcome for these associations. Another strength of this study is the good quality of data provided by PCRS. Unlike other countries, in Ireland, GPs and pharmacies need to report to PCRS the number of vaccines administered in order to receive payment and, thus, the data are very complete and accurate.

The authors recommend a greater focus on qualitative work is required to investigate public and healthcare professionals’ perceptions on the risks of influenza and the vaccine as well as vaccine effectiveness in order to improve uptake. Qualitative studies should also be undertaken to further explore whether the uptake has been influenced by changes in public funding and policy including funding for public medical services.

The study notes that the introduction of pharmacies administering the vaccine in 2011 and changes concerning the payment of GPs for vaccine administration in 2013 could possibly influence the GPs’ attitude towards promotion of the vaccine to patients. They also note that it would be important to further investigate the reason for the differences in uptake between age groups. The fact that GPs might be more likely to recommend the vaccine to older age groups or the different response of people to communications related to the vaccine could  explain this difference and  could help us address ways to improve this gap. Also, free administration of the influenza vaccine for all those aged 65-69 years may improve the uptake in this age group.

This study shows that seasonal influenza vaccine uptake for persons aged 65 and older increased with age but decreased overall since the 2009 pandemic. No significant association between uptake and deprivation status or GP density by area was identified but disaggregate data are needed to further explore these associations. More qualitative work related to people’s risk-benefit beliefs around influenza and influenza vaccination should be prioritised in order to find ways to improve uptake and reach the recommended EU target of 75%.


Growing old in the Emergency Department – the need to plan for the current and future healthcare needs of elderly patients within and beyond acute hospitals.

September 2017 ■ Volume 110 ■ Number 8 - Official Journal of the Irish Medical Organisation

Irish Medical Journal - Press Release       

September 2017 ■ Volume 110 ■ Number 8 - Official Journal of the Irish Medical Organisation

Growing old in the Emergency Department – the need to plan for the current and future healthcare needs of elderly patients within and beyond acute hospitals.

The age and seasonal profile of Emergency Department (ED) attendances over a 10-year period are examined in a study in this month’s Irish Medical Journal with results highlighting that the ED is busy all year round (but for different seasonal reasons) and point to an overdue need to plan for the current and future healthcare of older patients within and beyond acute hospitals.

A widespread public perception is that Emergency Departments are busiest in the winter months. Frail and elderly members of the population can be more susceptible to winter ailments and suffer more adverse effects which may require emergency care. Media headlines such as “551 people on hospital trolleys as flu outbreak worsens” and “Rise in flu pushes A&E trolley crisis back to the brink” tend to fuel and validate the perceived impact of seasonal ailments on ED crowding.

Healthcare professionals working in EDs however say that they are busy all year round with little or no reprieve during the summer months. Misconceptions about underlying trends and behaviours can lead to poor decision making at all levels, from local management to governmental, and consequently result in inefficient use of budgets and resources. Consequently, well-intentioned changes may not deliver expected results, for instance it has been shown that adding extra beds in the ED can actually make problems worse depending on circumstances. To help better inform decision making, the age and seasonal profile of ED attendances over a 10-year period were examined.

Older patients can present specific challenges for ED care, including: a higher prevalence of cognitive disorders, multiple co-morbidities and atypical symptoms and they are more likely to be admitted with disproportionate time boarding in the ED. Given that the OECD predicts that the percentage of over 65 year olds in Ireland will go to 26% by 2050, the care requirements of elderly patients will need to feature heavily in health care planning processes, along with and as part of the need to streamline hospital processes (e.g. managing discharges and increasing day cases) and integrate effective community care initiatives as noted in other reports.

The Emergency Department at Beaumont Hospital receives over 50,000 patient attendances per annum and is consistently amongst the most overcrowded in the country. One of the many contributing factors to the ED workload is that the population of the catchment area is significantly older than the national average. Data from the 2011 census shows that in the Dublin North Central region, 18% of the population is over 65 years of age as compared to a national average of 12%.

The number of ED attendances per annum has grown from 48,000 in 2005 to over 51,000 in 2014 (a 7% increase in demand). In addition, the acuity of care required has changed even more significantly in that time. The establishment of other care services in the community to deal with relatively minor ailments (e.g. VHI Swiftcare and D-Doc) has dealt with many patients that would otherwise have attended the ED. This can be seen in the respective reduction of 66% and 55% in non-urgent (category 5) and routine (category 4) triage category arrivals at Beaumont ED from 2005 to 2014 where the same Manchester triage system has been in place over the time period.

This means that the overall growth in demand is driven predominantly by the more serious urgent (triage category 3) and very urgent (triage category 2) categories that have grown by 40% and 58% respectively. Accordingly the number of ED patients requiring admission has grown from 9,000 in 2005 to over 12,000 in 2014.

In the ten year period covered, the mean age of the ED patients has shown a statistically significant increase from 43.8 years to 48.2 years, with the percentage in over 65 years age group increasing from 20.8% to 27%. Conversely, there is a drop in the number of 20 to 30-year-olds attending which may be attributed to emigration and to the community care options noted above. This is significant as older patients have a greater likelihood of admission to the hospital.

Contrasting effects of age were witnessed when component waiting times within PET (Patient Experience Time) were analysed. Age had a negative effect on waiting times for time to first medical, meaning older patients wait on average less time to see an Emergency Department doctor than younger patients. Significantly longer waiting times from bed request to hospital admission were identified for older patients.

It is apparent from the data that age has a significant impact on PET with a 0.5% increase per year which equates to approximately a half an hour PET increase for every 10-year increase in patient age. The variable “admitted to hospital” has the largest impact on PET. An increase of one patient in the system increases the time waiting by one percent.

With regard to total patient experience time, there are significant differences between different triage categories with patients in the very urgent (triage category 2) facing the longest waits followed by other categories respectively.

Gender was found to have a relatively small impact on time to discharge, with males waiting more time on average. However, while statistically significant, this difference is too small to be regarded as practically significant.

An examination of the monthly data for the years 2012 to 2014 indicated a number of seasonal variations. The number of patients presenting to the ED was highest in the summer months. However, the number requiring admission remains relatively constant throughout the year. Waiting times for beds are significantly higher over the winter, but in contrast waiting times to first medical are significantly higher in summer. The former may be due to the older cohort of patients in winter. Patients in December, January and February were found to be an average of 1.5 years older than the average for the rest of the year.

The authors note that while the care given by the external services introduced over the last ten years is welcome and prevents many younger patients with minor ailments from entering the ED, it has done little to improve the overcrowding crisis as this crisis is overwhelmingly driven by admitted patients being boarded in the ED whilst waiting for hospital ward beds.

Amongst those waiting for beds, the elderly have been shown to wait longer. Older patients do have higher admission rates and although the mean age of patients does increase in winter, the demand for beds from the ED is relatively constant throughout the year.

The results of this study raises questions as to why age has such a significant effect on patient experience time in the ED and suggests that the overcrowding crisis that manifests in the ED is dependent on the planning of activities (particularly the care of older patients) in other areas of the hospital and wider health care system. It is also indicative of the fact that elderly patients with complex care needs are harder to find ward beds for because specialty wards are concerned about the bed base being used for patients with an increased likelihood of complex discharge planning needs.

Patients with protracted hospital stays in turn mean that wards are not in a position to provide those beds for planned care requirements. In short, hospital wards cherry pick the younger patient who is likely to have a shorter hospital stay with the result that the elderly wait longer in the Emergency Department. In real terms this means that not only is the Emergency Department crowded but it is crowded with elderly patients with complex care needs and significant morbidity which creates a huge additional workload for the emergency medical nursing staff and in turn means they are not available for the newly arriving patients experiencing an emergency.

The research presented in this study provides evidence that the “overcrowding crisis” and other challenges associated with the provision of emergency care need to be carefully distinguished and tackled accordingly. For instance, the ED needs to be resourced to deal with increased demand as evidenced by more elderly and sicker patients attending while the hospital needs to prevent “Exit Block” so as to allow patients timely access to a ward bed and in turn alternate care settings need to be available for those patients who have completed their acute hospital stay but who are unable to be discharged to their own homes. With similar trends seen in 2008 and a confirmed ageing national population in Ireland, this research emphasises an overdue need to plan for the current and future healthcare needs of elderly patients within and beyond acute hospitals.


All references, author names and graphs are contained in the full article in the September edition of the Irish Medical Journal

For further information, contact: Communications Unit, Irish Medical Organisation, 10 Fitzwilliam Place, Dublin 2.  

One third of pregnant women in Ireland are still not offered routine fetal anomaly ultrasound - Maternity Ultrasound in the Republic of Ireland 2016; A Review

July/August 2017 ■ Volume 110 ■ Number 7 - Official Journal of the Irish Medical Organisation

A study published in the July/August edition of the Irish Medical Journal determining the scale of the provision of maternity ultrasound services in the Republic of Ireland has found that one third of pregnant women in Ireland are still not offered routine fetal anomaly ultrasound. This study highlights the current variations that exist in relation to maternity ultrasound services in Ireland, and in particular with regard to the provision of fetal anomaly ultrasound.

Obstetric ultrasound is a recognised and necessary component of good antenatal care. Internationally, the widely accepted minimal schedule for antenatal ultrasound comprises of two examinations; a dating ultrasound in the late first trimester, followed by a fetal anomaly scan, usually performed between 20-22 weeks’ gestation. Since 2000 the Royal College of Obstetricians and Gynaecologists (RCOG) has recommended that all pregnant women should be offered these two ultrasounds for the accurate dating of a pregnancy as well as the diagnosis of fetal anomaly.  This two stage ultrasound approach was endorsed by the UK National Institute for Health and Clinical Excellence (NICE) in 2008.  In January 2016, the Department of Health published the National Maternity Strategy which also recommended that all women have “equal access to standardised ultrasound services, to accurately date the pregnancy (and) to assess the fetus for ultrasound diagnosable anomalies as part of a planned Prenatal Fetal Diagnostic Service”.

Previous research reported by Lalor et al in 2007 and Walsh et al in 2013 (published in the Irish Medical Journal) revealed a large variation in the number and type of ultrasounds provided by the maternity units around Ireland. Recent high-profile media reports, highlighting a lack of diagnosis of lethal fetal anomalies over the last number of years, suggest that availability to fetal anomaly ultrasound remains inconsistent.

A telephone survey of all Irish obstetric units was undertaken in February 2017 by the authors. Respondents were asked to provide verbal answers to standard questions relating to the provision of maternity ultrasound services in their unit for the year 2016. The domains focused on were; first trimester ultrasound, fetal anomaly ultrasound and early pregnancy assessment (EPA) ultrasound. In all cases a senior clinician, either a consultant obstetrician or a lead sonographer was contacted in order to ensure that respondents had a thorough knowledge of the services provided in their unit.

In total 100% of Irish maternity units were successfully contacted and completed the survey. Approximate annual delivery rates for 2016 were provided from each respondent for their respective units and ranged from 1062 to 9186 births with the total number of combined births 65,500. All 19 units have a dedicated Early Pregnancy Assessment Ultrasound service available. A dedicated maternity ultrasound department is present in 16/19 (84%) of the units.

Fetal anomaly ultrasound is offered universally to all women in 7/19 (37%) units, selectively to some women in 7/19 (37%) units and not offered at all in the remaining 5/19 (26%) units. In units offering selective anomaly scanning the variation in percentage of women receiving a scan ranges from 10-42%.  Overall 41,700 (64%) women receive a fetal anomaly ultrasound nationally.

First trimester pregnancy scanning is offered universally to all women in 10/19 units (53%), offered but does not meet international criteria for first trimester ultrasound in 5/19 units (26%) and is not offered in the remaining 4/19 (21%) units. In the units providing some level of first trimester ultrasound, it is performed in the Ultrasound Department in 12/15 (80%) units while in 3/15 (20%) units it is performed in the antenatal clinic. Therefore the survey identified that routine first trimester ultrasound performed in a dedicated ultrasound department by a suitably qualified sonographer is offered to only 47% of women nationally.

Respondents were asked if there had been any staff expansion in the ultrasound department since the publication of the National Maternity Strategy in 2016. In 2/19 (11%) units some staff expansion has occurred in the last year. However, in 2/19 (11%) units the ultrasound staffing levels have declined over the same time period.

In 2013 Walsh identified 7/20 (35%) maternity units routinely offered fetal anomaly ultrasound to all women, with a further 9/20 (45%) offering selective fetal anomaly ultrasound. While the number of units offering routine fetal anomaly ultrasonography in 2016 has not changed, the number now offering selective fetal anomaly ultrasound has declined from nine to seven. The authors conclude that it is disappointing that their study findings reflect those of the previous two national ultrasound surveys (2007, 2012) and confirm that there has been no expansion in Irish maternity ultrasound services in the last decade.

Finally, the authors state that while they welcome the publication of the National Maternity Strategy and other Irish national clinical guidelines recently published that advocate for different types of antenatal ultrasound in specific settings, they strongly recommend the development and implementation of an Irish guideline on obstetric ultrasound.  The authors propose that a national guideline should set out the standard components of the anomaly ultrasound scan, and the optimum gestation for provision, as well as specify the training of sonographers and set requirements for ultrasound machines and image storage. An algorithm describing appropriate referral pathways to fetal medicine expertise in the event of an abnormal finding needs to also be described. International guidelines already exist in this area which can be consulted to expedite development of Irish guidelines.

“If we are serious about equity of care and access to specialist services for all Irish women, regardless of geographical location or financial means, there must now be substantial investment by healthcare policymakers. Without recognition of the deficit that currently exists in both the numbers of suitably qualified sonographers as well as in the provision of facilities and equipment, we will be unable to meet one of the fundamental aims of the 2016 National Maternity Strategy – equal access to standardised ultrasound services to every pregnant woman in Ireland.”


June 2017 ■ Volume 110 ■ Number 6 - Official Journal of the Irish Medical Organisation

Older Motorcyclists in Ireland

June 2017 ■ Volume 110 ■ Number 6 - Official Journal of the Irish Medical Organisation

Older motorcyclists are less likely to be fatally injured in single vehicle collisions and are generally safer than younger riders but the proportion of older motorcyclist injury is rising. A study by O’Neill et al in the June edition of the Irish Medical Journal explores the trend of ageing riders and factors in older motorcyclist collisions and injuries and why older motorcyclists are under-recognised as vulnerable road users.

In 2005, 17 motorcyclists ≥55 were injured compared to 31 in 2012. Motorcyclists aged between 30 and 49 years and ≥50 have longer lengths of stay compared to riders <30. In 2014, motorcyclist fatalities in Ireland were 28.45 times greater than those of private car drivers and passengers per mile travelled. Growth in motorcycle popularity is slowing in recent years and the number of motorcycles being registered for the first time is reducing. In 2015, only 2830 motorcycles were registered for the first time compared to 7420 in 2007. Older car drivers have an excellent safety record: older motorcyclists, however, appear to be a particularly vulnerable group and have attracted less recognition. Several studies internationally have documented a rise in fatalities and injuries in older motorcyclists.

Fatalities and Injuries

While fatalities involving younger riders appear to be progressively declining, the number of older motorcyclist fatalities is relatively constant. From 2005 to 2007, there were 28 fatalities in riders ≤24, compared to 6 aged ≥55. From 2012 to 2014, there were 16 fatalities in riders ≤24 compared to 6 aged ≥55. The vast majority of motorcyclist fatalities, both young and old, are men. Between 2007 and 2015, 12 female motorcyclists (3 of whom were ≥55) died in motorcycle accidents compared to 181 men9.

Nonfatal injuries are similarly less common in older age groups in Ireland. However, the number of nonfatal injuries is increasing disproportionately in older motorcyclists. In 2005, 17 motorcyclists over the age of 55 were injured compared to 31 in 2012.

This is similar to trends in other developed countries. In the EU, between 2004 and 2013, motorcyclists fatalities fell in all age groups except the ≥50 age group11. In a study of 1.4 million motorcyclists attending US emergency departments, the percentage of injuries in motorcyclists aged ≥65 increased from 2.96% in 2001 to 7.1% in 20086.

Injury Severity

Many studies in other countries have found older motorcyclists have higher mortalities and suffer more severe injuries. They have higher injury severity scores, longer lengths of stay in hospital, longer lengths of stay in ICU, more complications and increased complexity of fractures. 992 motorcyclists were hospitalised in Ireland between 2012 and 2014. Motorcyclists aged between 30 and 49 years and ≥50 had a longer length of stay compared to riders <30, but there was no significant difference between the ≥50 group and the 30 – 49 group. In 2014, the mean length of stay was 8.29 days for the ≥50 group, 7.5 days for the 30 – 49 group and just 3.75 days for the <30 group.

Injury Pattern

In Ireland, the most common location of injury is the knee and lower leg followed by injuries to the head and neck, shoulder and upper extremity, abdomen and lower arm. Injuries to the abdomen/lower back, hip and thigh and head or neck are associated with the longest length of stay in Ireland. Other studies have shown that head, thoracic and abdominal injuries are associated with the greatest severity and mortality. Older motorcyclists are significantly more likely than younger riders to sustain thoracic and head injuries. Riders ≥40 are nearly twice as likely to die from head injuries and abdominal injuries. Injuries at all sites are more severe in older adults.

Types of crash

In Ireland, older motorcyclists are more likely to be fatally injured in a collision with another vehicle, rather than a stationary object, compared to younger motorcyclists. Between 2007 and 2015, 4 motorcyclists aged ≥55 died in single vehicle collisions compared to 9 ≤24 and 16 aged 25 to 34. Single vehicle collisions are more likely to be the result of rider error16, suggesting that older motorcyclists are generally safer riders.

Larger motorcycles

In Ireland, as in most other developed countries larger motorcycles have become more popular. The percentage of motorcycles with an engine capacity of 750cc or greater increased from 39.6% in 2007 to 46.7% in 2015. Approximately two thirds of motorcycles registered in the last 8 years have been greater than 501cc. Other studies have shown that older adults are more likely to purchase motorcycles with large engines than young adults. Older motorcyclists generally have greater purchasing power and can afford the more expensive powerful motorcycles. In addition, many older motorcyclists ride their vehicles for leisure purposes rather than commuting and choose more powerful motorcycles for this purpose. Motorcycles with larger capacity engines are likely associated with higher crash rates and more injuries.

National licensing data does not indicate the number of motorcycle licence holders who are actively riding and therefore it is difficult to quantify the number of older motorcyclists on Irish roads. The authors state that much of the increase in older motorcyclist injuries is likely due to the increased proportion of older motorcyclists on the road as is the case in other countries. The authors suggest that it would be useful if this data were available to put the increased proportion of older motorcyclist injuries into the context of the increasing age of motorcyclists in general.

Older motorcyclists are more likely to ride for recreational purposes. Thus, they are more likely to crash on higher speed roadways and in rural areas, which may also partially explain the greater severity of their injuries. Recreational riding is associated with double the crash risk of commuting or general transport. In Ireland, the majority of fatal motorcyclist collisions occur at the weekend during summer months.

O’Neill et al remark that it has been suggested that older motorcyclists and older car drivers are more likely to crash due to changes associated with aging including poorer vision, balance and reaction times. There is no evidence to this and indeed, both older motorcyclists and older car drivers have been consistently found to be less likely to crash compared to their younger counterparts.

Many interventions have been demonstrated to be effective in preventing injuries and fatalities in both younger and older motorcyclists: road infrastructure and conditions, wearing helmets, motorcycle and rider conspicuity, enforcing speeding and alcohol laws and electronic aids such as ABS.  Stricter licensing laws have been implemented but these may decrease crashes by reducing the number of motorcyclists on the road rather than making motorcyclists safer riders. The process of obtaining a licence to ride a motorcycle in Ireland is now much more convoluted and expensive which likely discourages potential younger riders from motorcycling and has contributed to the proportional increase in older compared to younger Irish motorcyclists.

The authors of this study determine that motorcyclists are more vulnerable road users than car occupants. Both the vulnerability of older motorcyclists and the importance of motorcycling as a leisure pursuit and means of transport should be acknowledged. Irish road safety strategies and trauma services need to develop preventive and treatment strategies to protect the growing cohort of older motorcyclists to ensure they can travel on our roads safely.


May 2017 - Volume 110 - Number 5 - Official Journal of the Irish Medical Organisation

Vaccine Preventable Admissions

May 2017 - Volume 110 - Number 5 - Official Journal of the Irish Medical Organisation

Vaccine Preventable Admissions

In Ireland, children are offered vaccinations as part of the State-funded scheduled immunisation programme and include diphtheria, pertussis, tetanus, pneumococcus, hepatitis B, meningococcus C, haemophilus B, polio, measles, rubella and mumps. A study in the May edition of the Irish Medical Journal by Crowe et al reveals that bacterial and viral infections continue to result in significant morbidity and mortality in a small number of Irish children. Children who do not receive immunisation remain vulnerable to life-threatening infection from a number of different bacterial and viral pathogens. There are several additional vaccines available through general practitioners (GP), with parents paying for the vaccine and its administration.

Each year, the 23-bed university-affiliated Paediatric Intensive Care Unit in Our Lady’s Children’s Hospital, Crumlin, admits 900-1100 patients. A paper published in the May edition of the Irish Medical Journal describes the ongoing pattern of admission and outcomes due to vaccine preventable conditions over a four year period (2011-2015). The authors note that this pattern is subject to change in the future, as vaccines are added to the funded schedule.

The results of the data collected revealed that there were 39 admissions, (3.7% of total PICU admissions), with 34 children surviving to discharge. There were no admissions with hepatitis B, diphtheria, measles, mumps, rubella, polio and meningococcal C infections. Streptococcus pneumoniae infection accounted for 9 admissions, meningococcus B infection precipitated 17 admissions, varicella 8 admissions, haemophilus influenza 4 admissions, and there was one admission due to pertussis infection. Death occurred in four children infected with pneumococcus, and one infant with pertussis. There were no deaths in the varicella or meningococcal patients. Serious morbidity occurred in 19 of 39 admissions, and varied from skin loss requiring grafting, limb and digit loss, seizures, acute kidney injury and haemorrhagic cerebral infarction.

The authors of the study note that there are many reasons why children do not receive their scheduled immunisation, including illness.  Children are screened for fever, rash and malaise before vaccination and this may result in planned vaccination being deferred. Parents may choose not to have their child immunised following the routine schedule because of concerns over the effects of vaccine medications . There were no cases of vaccine failure resulting in serious illness. Eight younger infants who presented with severe pneumococcal infection less than 6 weeks of age had not commenced their schedule of vaccines.

One infant was admitted to PICU with pertussis infection, at corrected age of 2 weeks. The infection occurred 4 weeks before the anticipated age for administration, and this child did not survive. Neonates rely on herd immunity to protect them against infection. The level of immunity decreases when overall rates of immunisation fall within a community, which is why the Health Protection Surveillance Centre (HPSC) has strongly recommended that pregnant women receive pertussis immunisation in the third trimester.

Children with varicella infection, presented with secondary bacterial infection. Organisms isolated included invasive Group A Streptococcus and Staphylococcus aureus and these super-infections led to systemic sepsis, cellulitis and empyema. Varicella infection may be avoided with an organism-specific vaccine, which is not funded by the Irish Health Service . Parents may ask their GP to administer this two dose vaccine at an average cost of 300 euro.

Meningococcal B sepsis was the largest diagnostic group, with 10 patients experiencing serious morbidity. There were no deaths in this group, reflecting improvements in early recognition and critical care management. The vaccine for meningococcal B infection is commercially available since 2014, at a cost of approximately 300 euro. Routine administration as part of the primary schedule is planned. Families who cannot afford to pay would not be offered these vaccines routinely.

The authors conclude by stating that critical care admission is costly in terms of physical, psychological and family support required, and in socio-economic terms. Although overall numbers are small, each case represents a child and family who have had a traumatic and avoidable experience, some with serious long-term consequences. 


April 2017 - Volume 110 - Number 4 - Official Journal of the Irish Medical Organisation

Caring for Obese Children - A change in Paradigm.

April 2017 - Volume 110 - Number 4 - Official Journal of the Irish Medical Organisation

Childhood Obesity is a problem of epidemic proportions and represents the largest public health concern of this generation. In the paediatric population 7% of Irish children aged nine are obese and 19% are overweight. The causes are complex and treatment results are variable with much research ongoing. In a study published in the April edition of the IMJ Doyle et al analysed the initial assessment forms of a group of patients attending the W82GO! Healthy Lifestyle service at The Children’s University Hospital, Temple Street to look at the population and their specific needs. The analysis revealed a high proportion of emotional and behavioural problems along with bullying..

Well documented complications of obesity include: low physical fitness, hypertension, early signs of cardiovascular disease and metabolic syndrome, mental health and well-being is adversely affected. Furthermore, children with obesity are frequently subjected to teasing, bullying, discrimination and other forms of social marginalisation which are associated with lower self-esteem, depression, adverse social functioning as well as lower academic achievement14.

The objective of this study was to describe the children at the commencement of obesity treatment in relation to emotional health, behavioural difficulties, learning difficulties and bullying. The study reviewed the initial assessment of 111 children who attended the service. The study’s aim was to describe some of the characteristics of the group referred to the clinic.

5% of the children were under 5
95% were over 5.
The average age at initial consultation was 10.57 years.

The majority of referrals (49.5%) came from consultants based in Temple Street, GP referral accounted for 36% of referrals and the remaining 14.5% were from other hospitals, public health agencies and allied health professionals in the community.

At initial screening 33% disclosed emotional difficulties and 46% of whom were linked to mental health services prior to commencing the programme. Of the emotional difficulties which the children described low mood, deliberate self-harm and low self- esteem are examples. The 54% who described emotional difficulties were all seen by the psychologist on the team and in some instances were referred on to local Child and Adolescent Mental Health Services for ongoing treatment.

Behavioural difficulties featured in this cohort also with 26% of those assessed reporting difficulties. Often the parents disclose this information on behalf of the child. 52% of those with behavioural difficulties were already attending mental health services in the form of counselling or Child and Adolescent Mental Health Services. The incidence of learning difficulties as reported by the parents was 30% and 15% reported developmental delay at some point requiring some intervention. The degree of delay varied but speech delay and Autistic Spectrum disorder made up a large proportion of the difficulties. Comparison with the general population is difficult as there is a paucity of data on this. In part, this is related to the wide range of severity of learning difficulty. The National Council for Special Education study on the prevalence of Special Needs Education estimated prevalence rates of 23% in 2011. This is different to other national estimates of learning difficulty, therefore comparison with our group is not possible.

Bullying represents a very big issue within the group. 63% of the children reported being teased about their weight in the past with 12% missing days from school as a result of bullying. Almost half of those teased were teased by their peers although a small percentage (2%) was teased by strangers. The social stigma attached to obesity clearly plays a big role and indeed this is a barrier to treating obesity. The effects of bullying are low self-esteem, absenteeism and low mood. The result can be social isolation and difficulties mixing with peers during sports and other activities. Our group showed a high incidence of absenteeism as a direct result of bullying.

Failure to adopt a healthier lifestyle and reduce body mass index results in increased health problems, psychological problems and increased projected healthcare expenditure. This retrospective review highlights the difficulties faced in treating these children as they have psychological difficulties which can affect their progress thus making them a more demanding cohort of patients. Emotional health represents a significant issue within the cohort of patients attending for an initial assessment with less than half of those affected attending mental health services. Worryingly, these figures are in contrast to the data collected by The Growing Up In (GUI) Ireland in 2011, which shows that the majority of children analysed were developing without emotional problems. That particular study represented a cross sectional cohort of 9 year old children. The research showed that 15-20% of the children surveyed were in difficulty. This figure is based on mother and teacher reports.

This study highlights the high incidence of emotional difficulties in this cohort when compared to the general population. It also highlights a demand on resources when treating these children. The incidence of behavioural problems within the group surveyed is significant. The treatment offered is a group outpatient family based healthy lifestyle programme which is unsuitable for some of these children who have problems in a group setting. Moreover, 48% of the families attending the service are dealing with these behavioural issues without professional help. The psychologist on the team assesses all children and provides support until other services are put in place.

This study highlights the complexity of caring for children with obesity as a result of their emotional, behavioural and learning difficulties. Left untreated, the health consequences of obesity are severe, therefore a multi- disciplinary team approach is needed. This must include a psychologist and all members of the team must be mindful of the complex issues these children have. Moreover, given the increasing prevalence of childhood obesity, all professionals working with children must consider the psychological difficulties these children have and their potential effect on treatment.

While this study highlights the complexity of this group, it looks at only parent reporting as part of an initial assessment. Further analysis of psychological health, by analysis of teacher and more in-depth parental questioning is required. The authors conclude that further research is needed to analyse the effect treatment has on the psychological well-being of these children.


All references, author names and graphs are contained in the full article in the January edition of the Irish Medical Journal

For further information contact: Communications Unit, Irish Medical Organisation, 10 Fitzwilliam Place, Dublin 2.   

March 2017 - Volume 110 - Number 3 - Official Journal of the Irish Medical Organisation

Out of sight, out of mind?A national survey of paediatricians in Ireland regarding Fetal Alcohol Spectrum Disorders

March 2017 - Volume 110 - Number 3 - Official Journal of the Irish Medical Organisation

A study published in the March edition of the Irish Medical Journal suggests that prenatal alcohol exposure may not be routinely considered in the evaluation of children with developmental delay by paediatric doctors in Ireland. Fetal Alcohol Spectrum Disorders (FASDs) are characterised by variable mental, physical, neurological and behavioural deficits, and are recognised internationally as a major contributor to intellectual impairment and disability and one of the major causes of preventable developmental delay. FASDs make a significant contribution to hidden disability as many affected patients have long delays before a diagnosis is made or are never diagnosed at all. There is no register of children with FASDs in Ireland.

The aim of this study was to evaluate self-reported knowledge and practice of doctors working in paediatrics in Ireland with regards to FASDs and alcohol consumption during pregnancy. A survey was circulated to all paediatric doctors in Ireland either enrolled in specialist training or registered as trainers for specialist training programmes.

The umbrella of FASD includes Fetal Alcohol Syndrome (FAS), Partial Fetal Alcohol Syndrome (pFAS), Neurobehavioural Disorder associated with Prenatal Alcohol Exposure (ND-PAE) and Alcohol-related Birth Defects (ARBD), although the terminology has changed frequently. Fetal Alcohol Syndrome comprises only 10-15% of all cases, and over 75% of children with FASDs have no dysmorphic features to suggest an underlying aetiology to a clinician. Diagnosing these conditions is challenging, and recent research suggests only half of American Academy of Paediatrics members are confident in their ability to make the diagnosis.

A key current concern is that children with FASDs other than Fetal Alcohol Syndrome may go undiagnosed due to the absence of dysmorphic features, a lack of accurate information regarding prenatal alcohol exposure, and the frequent incidence of coexisting neurodevelopmental or psychiatric conditions in children with FASDs; many cases of FASDs present with chronic mental health or neurodevelopmental problems.

No quantity of alcohol has been proven to be safe to consume during pregnancy; neither is any period of pregnancy immune to the effects of alcohol on the fetus. Any alcohol consumption by expectant mothers at any point during pregnancy, including the third trimester, could be associated with adverse outcomes for the fetus, particularly given the frequency of binge drinking in Ireland. Alcohol also increases the risk of miscarriage and premature delivery. Adverse outcomes have been reported in Irish and international studies across low, moderate, and high levels of periconceptual alcohol exposure.

Historically, the lack of a precise dose-response relationship has led to inconsistent advice from healthcare providers and professional bodies with regards to the safety of alcohol in pregnancy. Complete abstinence is now recommended in national guidelines for the USA, UK, Canada, New Zealand and Australia.

Recent Irish studies have found that 75-81% of expectant mothers in Ireland reported consuming alcohol in the periconceptual period. One of these, a retrospective study covering 1987-2005, found that the majority of expectant mothers reduced their alcohol intake during pregnancy, and 27.6% abstained completely.  Nonetheless, it concluded that “the risk of alcohol related foetal (sic) harm in Ireland is high” and that systemic change would be required to support paediatricians and other doctors in the assessment and diagnosis of children exposed to alcohol in utero.

Doctors involved in the care of babies and children have a unique opportunity to identify children with problems related to alcohol exposure in utero. Research suggests that with early diagnosis and intervention, the impact of FASDs on a given child can be reduced; children with FASDs have a unique profile of needs and respond differently to treatments than children with other neurodevelopmental problems. The lack of data regarding the prevalence of FASDs in Ireland in comparison to published prevalence rates in other countries, in the context of reported rates of alcohol consumption, suggests that these conditions may be underdiagnosed.

The authors of the study circulated an online survey by email in June 2015 to all paediatric doctors in Ireland who were either enrolled in specialist training programmes (Senior House Officers or Specialist Registrars) or registered as trainers (Consultant Paediatricians). 179 responses were received which gave a 58% response rate.

More than half of those surveyed reported that they do not routinely discuss maternal alcohol consumption in the context of developmental delay in children. Additional selected results include the following:

  • 17.3% believe mild alcohol intake in the third trimester is safe.
  • almost one third were unaware of the existence of FASDs
  • over one third of respondents stated they believed that most children with FASDs have dysmorphic features.

The study’s results as a whole suggest that paediatric doctors in Ireland may not routinely consider alcohol as a potential aetiological factor in the evaluation of children with developmental delay. 75% of children with FASDs have no dysmorphic features or growth restriction, and the authors3 hypothesize that in the absence of such features children with FASDs may go undiagnosed; this has been reported in other countries. The lack of specific training reported by respondents in this area may be contributory.

Only 24% of respondents reported having encountered a patient with FASDs other than Fetal Alcohol Syndrome. If international data indicating prevalence rates of over 1% of the total child population are to be believed, it is likely that most respondents have encountered children with undiagnosed FASDs.

The prevalence of alcohol use during pregnancy in Ireland, despite a lack of evidence for any safe limit for alcohol consumption in pregnancy, is a significant public health concern and a target for intervention. FASDs are 100% preventable if mothers abstain from alcohol consumption while pregnant, and previous research suggests health professionals do not always offer consistent advice in this regard.

There are many additional considerations beyonf knowledge and awareness of FASDs. Alcohol may not be discussed routinely if another aetiology is readily apparent. Fetal Alcohol Spectrum Disorders are technically challenging to diagnose and share some features with other disorders, including some which can exist as co-morbidities alongside FASDs (e.g. autism, ADHD). Opinions from a number of specialists may be sought before a diagnosis is reached, and genetic investigations may be indicated. This is before one considers understandable concerns about causing unnecessary guilt or anger in mothers which may arise from questions about alcohol consumption. Furthermore, standardised assessment and treatment pathways are not currently in operation for children with FASDs in Ireland.

It is worth acknowledging, as affirmed by the The International Charter for Prevention of Fetal Alcohol Spectrum Disorder5, that mothers should not be exposed to this kind of guilt or blame; alcohol consumption occurs within a larger cultural and social context and addressing these is more complex than simply improving awareness of FASDs amongst health professionals. However, professionals have an opportunity and a responsibility to offer expectant mothers accurate advice about the risks of alcohol consumption during pregnancy and to remain vigilant for its consequences.

International data regarding the prevalence of FASDs and Irish data regarding alcohol consumption suggest that Fetal Alcohol Spectrum Disorders are a significant hidden public health issue in Ireland. The authors assess that will only begin to be addressed when the disease burden is measured; defining the current practices of doctors in the evaluation of developmental delay in the context of alcohol consumption is a key step. In conclusion, the authors suggest conversations about alcohol are often not included in the routine evaluation of developmental delay in children in Ireland. The fact that a majority of those surveyed indicated that further training would be welcomed is a source for optimism but a more far-reaching multiagency approach will be required to begin to address the burden of FASDs and to change the culture regarding alcohol consumption in Ireland.


All references, author names and graphs are contained in the full article in the January edition of the Irish Medical Journal

For further information contact: Communications Unit, Irish Medical Organisation, 10 Fitzwilliam Place, Dublin 2.  

February 2017 - Volume 110 - Number 2 - Official Journal of the Irish Medical Organisation

Parental Decisions regarding pre-hospital therapy and costing of the Emergency Department Visit

February 2017 - Volume 110 - Number 2 - Official Journal of the Irish Medical Organisation

A study in the February edition of the Irish Medical Journal explores the reasons for paediatric patient’s attendance at an ED, the treatment initiated at home and parental perception of the economic cost of attendance.  This study was undertaken to explore parental knowledge and decision-making regarding prehospital therapy and the economics of the ED visit. Results from the study suggest that attendances are often prompted by parental worry rather than clinical deterioration and that prior ED usage is common among those presenting for assessment.

Paediatric patients represent a large percentage of Emergency Department (ED) visits and there is often a perception that the acuity of these presentations is low. 

Many parents had attempted community therapy with 128/200 patients (64%) having been see previously by a healthcare professional and medical therapy at home having been employed by 114/200 (57%) parents before attendance.  Parental knowledge of the safety of over-the-counter medications was variable and the economic cost of an ED visit was poorly understood by participants.

The study was conducted in the ED at Mayo University Hospital and utilised a cross-sectional survey which evaluated a) patient demographics b) illness symptoms c) healthcare utilisation, d) treatment strategies inclusive of medications, and e) knowledge of medications used. The study was restricted to children and adolescents under 16 years presenting to the paediatric ED over a 2-month period (May-June2013), not requiring immediate resuscitation.


Two hundred and seventy-five parents were invited to participate of whom 200 (73%) completed surveys.  128/200 (64%) had a letter of referral from a healthcare professional (GP/medical officer/public health nurse).  59/200 (29.5%) stated that they had never used the ED service before. 

One hundred and eighty-eight parents provided information on ED usage in the previous year with results as follows:

0 attendances 96/188 (51.1%)
1 attendance 41/188 (21.8%)
2 attendances 22/188 (11.7%)
3 attendances 16/188 (8.5%)
Greater than 4 attendances 13/188 (6.9%).

Respiratory, gastrointestinal and pyrexia-related symptoms were the commonest reasons prompting ED attendance.  114/200 parents had administered some form of medical therapy before consultation reflecting previously established norms in parental care of children in times of illness. Medications given were usually appropriate to symptoms present and all medications employed were licensed for paediatric use.  83% (95/114) reported that they would use the medication again despite only 57% (65/114) reporting value for money with the product used.

Parental beliefs on safety of medications in children were assessed by asking directly about their willingness to use 4 commonly prescribed medications and whether they felt these medications were safe in children. Parents were also asked how they would decide on dosing for each of the 4 medications. Response rates for this question varied greatly between the 4 medications (range of response rates 27%-61%). Of those who responded on average 11.2% stated that they would use the instructions on the label.

The majority of those surveyed had consulted a general practitioner (GP) prior to arrival, and while it has been suggested that >80% of GP referrals are discharged home from the paediatric ED, published data shows that the majority of paediatric patients are managed appropriately in primary care without hospital referral. 

The qualitative data in this study suggests that many attendances were prompted by parental decisions rather than referrals by healthcare professionals based on objective clinical deterioration, and existing research suggests that while parents recognise illness in their children they may have difficulty grading severity.  Data from general practice suggests that the majority of minor childhood illnesses are managed by parents at home, and medical consultation is only undertaken if they perceive home therapy to be ineffective or symptoms have not improved. Despite this, the data from this survey shows that prior ED usage among parents was very common, with less than 30% having never used the ED before and almost half of patients having attended at least once in the past year, a figure similar to that recorded in previous studies.

ED attendance in Ireland is free with either a state-provided medical card or a referral letter from a medical practitioner and fewer than ¾ parents were aware of this.  Knowledge of the actual fee incurred when neither of these is available was variable and this combined data reflects poor parental awareness of the economics of an ED visit.   Data on the perceived value from the ED visit showed that the experience was generally considered to be good value with the average Likert score being 4/5 for those incurring direct expense.

Parental desire for control over worrisome symptoms drives much of their management strategy prior to hospital attendance and their management of minor illness is not ideal.  The authors recommend that strategies in the ED should focus more on managing parental expectations than on managing the illness itself and utilise the visit to both educate and empower the parent.

January 2017 - Volume 110 - Number 1 - Official Journal of the Irish Medical Organisation

Trends in the Fractures and Fatalities of Farmyard Injuries in Ireland: A 10 year analysis

January 2017 - Volume 110 - Number 1 - Official Journal of the Irish Medical Organisation

The farming and agricultural sector remains one of Ireland’s primary industries. Fatality rates remain higher than the European average. The aim of this study published in the January edition of the Irish Medical Journal was to critically analyse the national data for hospital admissions with fractures resulting from farmyard injuries over the last 10 years in the Republic of Ireland, and to explore the associated fracture and fatalities trends.

It is estimated that over 600 fatalities related to the agriculture and forestry sector occur each year in the EU, with an average farm fatality of 12 per 100,000. Published official reports show that current Irish farm fatality rates remain high, with 30 recorded in 2014. In Ireland, fatalities rates associated with injury in the agricultural and farming sector remain up to eight times higher than any other Irish industry.

Previous local and regional studies have documented farmyard injury presentations to emergency departments in rural Ireland. Livestock and machinery were the main sources of injury on Irish farms, with the months June, July and August recording the largest number of presentations to the Accident and Emergency Departments.

Awareness of this problem has been low among the farming community despite recent media attention. The EU framework directive on Occupational Health and Safety (89/391/EEC) was implemented in Ireland via the Safety, Health and Welfare at Work Act (1989), and a national publicity campaign has been attempting to tackle the overall incidence of injury by educating agricultural employees through a Farm Safety Code of Practice. By 2009, 40% of farmers had completed the programme8.

Although there have been published analyses of the causes of farming injuries, information on the nature and severity of the injuries is sparse. Orthopaedic trauma has been identified in around 47% of an historical Canadian study with a higher incidence in fatalities9. In addition to the association with other life-threatening injuries, fractures often result in prolonged disability, with an impact on the long-term ability to work5,7.

Data was collected and analysed from the ‘Hospital In-Patient Enquiry’ registry (HIPE)10, which is the principal source of national data on discharges from acute hospitals in Ireland. All 54 acute public Hospitals in Ireland are included, with data taken from medical charts or records and coded by trained clinical coders before entering into HIPE system. All HIPE data between 2005-2014, which included a principal diagnosis of ‘fracture, poisoning or certain other consequences of external causes on farms’ was collated. The definition included farm buildings, land under cultivation or ranches and excluded the farm house or home premises of the farm. The term “fracture” specifically relates to fractures necessitating hospital admission.

This collation was supplemented with agricultural statistics and farm fatality data from two other official government sources, in Ireland and in Europe: the Agriculture and Food Development Authority (Teagasc) survey on National Farms in Ireland11 and the Irish Health and Safety Authority Annual Reports to the European Parliament on Farming Hazards4. Fatality figures for farm injuries in Ireland were accessed directly from the Health and Safety Authority in Ireland website for annual statistics.

From 2005-2014 there were 2064 farm-related fractures admitted as inpatients to Irish Hospitals, representing 0.89% of all-cause national fractures. The number of annual farming fractures has shown an overall decline from 235 in 2005 to 197 in 2014.  Both sets of data demonstrated an isolated spike in fracture incidence in 2010.  Fractures of the wrist and hand had the highest incidence. 

During the period of greatest economic activity (2006-2009), fractures decreased in most categories, including lower leg, arm, wrist & hand and thorax. Categories including lumbar spine and pelvis, femur, skull, facial bones and neck did not decrease overall during this time. Since 2010, economic activity has been static without any significant trends in overall fracture incidence or within categories. The lower leg and ankle accounted for 21.2% of total fractures. When combined, the lower limb (femur, lower leg, foot and ankle) sustained the greatest percentage of fractures 39.8%. The combined upper limb (shoulder, upper arm, forearm, wrist and hand) was the second most commonly injured 32.6% and the axial skeleton (skull, facial, neck, ribs, sternum, spine and pelvis) made up 27.6% of those injured.

Farm fatality data demonstrated 192 farm fatalities recorded in Ireland over this period. Sub analysis of this demonstrates that farm vehicles/machinery and livestock accidents accounted for 72% of these. The lowest recorded total all-cause number of fatalities was in 2009 with 9 deaths, and the highest peak occurred in 2014, with 30 deaths. There was a declining trend in fatality numbers through 2005-2009, with a mean of 15.6 deaths, with an increase from 2010 to 2014 with a mean of 22.8 per year. 30 deaths occurred in 2014, the highest in fatality in twenty years and in that year represented 55% of all Irish work-related deaths.

The overall number of people working in the agriculture sector declined from 109,600 in 2005, to 85,000 in 2010. The official calculated farm fatality rate increased from 15 per 100,000 workers in 1996, to 22 per 100,000 by 2009. The age profiling of farm fatalities shows elderly farm labour workers  >65 years old frequently make up 40-50% of annual fatalities, with children aged up to 17 years old varying from 10-20% each year.

The authors declare that this study provides an invaluable insight into the patterns of national farmyard fracture rates and associated farmyard fatality rates in Ireland. They identified an overall decreasing trend in the overall number of farmyard-related fractures from 2005-2014, representing a 21% decline over the examined period. National all-cause fracture numbers also declined over the same period by 14.9%. However, the total number employed in the agriculture sector reached a high in 2008, and by 2010 had fallen by 25%, only eventually recovering by 2013. Thus, the relative risk of sustaining a fracture whilst working on a farm has not declined.

The lower limb remained the most commonly injured site with 39.8% of injuries during the study period, followed by the upper limb 32.6% and the axial skeleton 27.6%. Often a severe fracture such as those profiled in previous farm injury papers results in a prolonged recovery and absence from work. The economic consequences may be significant. In Ireland 90% of all farm injuries are suffered by farm family members, compounding the social and economic impact. The period of most economic growth in Ireland coincided with a decrease in most fracture categories except those indicating the most severe injuries, including skull, femur and pelvis.

Ireland was affected by the economic recession since 2008-2009, particularly in rural farming communities. There was an emergence of a ‘part-time’ farmer, with supplementary employment during the week and a farm managed ‘on the side’. This activity to supplement income may have exposed workers to the recognized hazards on a farm, but without the daily familiarity of full time farming routine and accompanying safe practice.

Statistics collected from the Teagasc National Farm Survey supported these findings, showing an overall decline in total injury numbers, albeit with a spike in 2010.  Teagasc findings showed the farm operator to be the most commonly injured farmyard worker (73.3%) and the farmyard being the most common location of injury (71.5%).

The most concerning finding of this study was the increase in fatal injuries on the farm and agricultural setting. Total fatalities have increased from 2010-2014, and 2014 has been the worst year on record, with 30 deaths. A higher proportion of injuries therefore is resulting in fatal outcomes. Age is now a major contributory factor in farmyard accidents, both fatal and non-fatal. With the average age of a farmyard worker in Ireland standing at 57 years old and increasing, a significant injury is more likely to result in a fatal outcome than the equivalent injury in a young worker. Teagasc data recorded that in 2011, more than 50% of farm fatalities occurred in those over 65, and up to 70% in those over 55.

The authors of the study assert that awareness campaigns to address this issue should therefore consider targeting farmers over 55 years old, particularly those with extensive machinery, and those with livestock. Campaigns need to engage with the spouse and family, given the alarming fatality rates involving the family and those under 17 years of age.

Voluntary safety courses reported attendance rates as low as 22% in 2011, showing the penetration and engagement of education campaigns remaining a challenge. For medical teams, the data analyses should increase the awareness of the complexity, fatality rates and injury severity patterns of farmyard injuries, to direct local emergency departments, and to prioritize trauma management protocols. Multimedia, exhibitions and education at annual farming calendar events may promote such awareness.


All references, author names and graphs are contained in the full article in the January edition of the Irish Medical Journal

November/December 2016 - Volume 109 - Number 10 - Official Journal of the Irish Medical Organisation

Diagnosing Lynch Syndrome

November/December 2016 - Volume 109 - Number 10 - Official Journal of the Irish Medical Organisation

Irish Medical Journal - Press Release       

November/December 2016 ■ Volume 109 ■ Number 8 - Official Journal of the Irish Medical Organisation

Diagnosing Lynch Syndrome

A new study in the Irish Medical Journal looks at Lynch Syndrome and its underdiagnosis in Ireland.  Gleeson et al acknowledge that identification of genetic predisposition to Lynch syndrome associated malignancies in a healthy population offers a powerful cancer prevention opportunity. Gleeson et al state that “It is important that Ireland replicates international efforts to transition healthcare to a more preventive service over the next decade.”

Lynch Syndrome, also known as Hereditary Non-Polyposis Colorectal Cancer (HNPCC), is a hereditary condition that increases an individual’s risk of developing a constellation of cancers. These most commonly arise in the colon, but also involve other solid organs such as the endometrium and ovaries in women, the stomach, brain and the skin. In this study the authors assert that Ireland’s small population offers an opportunity to identify all those with Lynch Syndrome (LS) in the country, which would represent a powerful preventive opportunity to meaningfully impact on the incidence of cancer in Ireland.

There are 2486 incident cases of colorectal cancer (CRC) in Ireland per year, and more than one million per year worldwide. LS accounts for approximately 2-4% of these, meaning there are up to 100 preventable cases in Ireland every year caused by LS. The average age of diagnosis of colorectal cancer in LS cases is 45 years (vs. 69 years in the general population). Early-onset malignancies have a particularly significant societal impact and LS-associated malignancies in younger individuals are oftentimes preventable. Efforts to improve the diagnosis of LS in Ireland requires improved physician and patient awareness of this condition and its diagnostic pathway, and a coordinated multidisciplinary national effort.

The commonest cancer seen in LS is colon cancer. LS patients have a ≥70% lifetime risk of colon cancer, although this varies by genotype.

The revised Amsterdam criteria (Amsterdam II) and Bethesda criteria, determine in whom molecular testing for LS should be considered. The Amsterdam II criteria require at least three relatives with a LS-associated cancer. One should be a first-degree relative to the other two, at least two successive generations should be affected and at least one should be diagnosed before age 50. The Bethesda criteria requires diagnosis of a colorectal cancer in a patient who is less than 50 years of age or the presence of multiple primary (synchronous or metachronous) colorectal or other LS-associated tumours, regardless of age. Colorectal cancer with the MSI-H histology diagnosed in a patient who is less than 60 years of age is an alternative criterion, however including the cut-off age remains controversial.

There is a systematic approach to diagnosing LS. Once a personal and family history of cancer meets the Amsterdam II and/or Bethesda criteria, the tumour should be tested for a deficiency of the MMR proteins by immunohistochemistry (IHC), or alternatively for MSI by PCR. 

Genetic sequencing techniques are then used to confirm the germline mutation in the DNA MMR gene identified by IHC testing. Such genetic testing in Ireland is coordinated through cancer genetics clinics in Our Lady’s Children’s Hospital Crumlin, St. James’s Hospital and the Mater Misericordiae University Hospital.

These early onset malignancies have a significant impact in society. Screening all colorectal cancers with IHC testing, and/or MSI testing, is being introduced nationally.  Once initiated, whether due to clinical suspicion of LS or universal IHC testing, the diagnostic pathway must be pursued to completion. The author’s stress that Ireland must develop a national infrastructure for the management of this and other molecular testing. “Apart from the clinical benefit this cancer prevention example offers, there would also be considerable cost saving for the cancer care budget. The molecular testing described is relatively inexpensive, especially compared with the costs of managing cancer. This must be considered in planning for the future of Irish cancer care.”

Physician and patient awareness regarding the heritability of colorectal cancer is improving but remains behind that of hereditary breast cancer. Identification of genetic predisposition to Lynch syndrome associated malignancies in a healthy population offers a powerful cancer prevention opportunity. Accurate Lynch Syndrome diagnosis would provide a useful pilot for Ireland to transition healthcare to a more preventive service over the next decade.  The authors conclude that a nationally funded structure with specific protocols will be needed to ensure appropriate molecular testing and downstream clinical care.


All references and author names are contained in the full article in the November/December  edition of the Irish Medical Journal 

October 2016 - Volume 109 - Number 9 - Official Journal of the Irish Medical Organisation

The epidemiology of emergency in-patient hospitalisations among those with ‘no fixed abode’

October 2016 - Volume 109 - Number 9 - Official Journal of the Irish Medical Organisation

The epidemiology of emergency in-patient hospitalisations among those with ‘no fixed abode’ (homeless) 2005-2014: what lessons can be learnt.

The health of homeless people is a fundamental issue that needs addressing. A new study published by O’Farrell et al in the Irish Medical Journal provides a valuable insight into patterns of emergency admission among those with no fixed abode and raises a number of fundamental concerns in terms of meeting the health needs of homeless people.

Estimates show that homelessness is increasing in Ireland.  All available evidence indicates that there has been a significant increase in the level of homelessness since 2010.  Since April 2014, the Department of Environment has published data on the number of people accommodated in local authority managed emergency accommodation. Between 2014 and 2015, the number of adults experiencing homelessness has risen by almost 60% (2,477 in April 2014 rising to 3,930 in February 2016). 

The reasons for homelessness are complex.  Many people find themselves homeless as a result of unemployment, lack of affordable housing, income poverty, drug or alcohol abuse, domestic violence, mental health problems, and limited social supports. Many homeless people experience difficulties maintaining good health due to poor access to primary care and have worse health outcomes when compared to the general population.

International studies have found that individuals who are homeless are more likely to be hospitalized particularly for ambulatory care sensitive conditions (ACSCs).  ACSCs are a core set of 19 conditions for which it is possible to prevent acute exacerbations and reduce the need for hospital admission through active management in primary care setting, vaccinations, or lifestyle interventions. 

The aim of this study was to analyse emergency in-patient hospitalisations in Ireland for persons with ‘no fixed abode’ over a ten year study period (2005-2014 inclusive); to identify those with ambulatory care sensitive conditions (ACSCs) and to identify factors that may be associated with ACSCs  with a view to reducing the need for emergency in-patient care.

All in-patient emergency admissions to acute hospitals in Ireland between 2005-2014 for which area of residence was recorded as ‘no fixed abode’ were anonymised and analysed.

Results from the study

  • The study found that there  were 2,051 in-patient emergency admissions of people classified with ‘no fixed abode’ during the study period, an increase of 406% since 2005 (78 in 2005 vs. 395 in 2014).
  • Over the 10 year study period, one in ten (280; 13.7%) were admitted for ambulatory care sensitive conditions (ACSCs) including convulsions/epilepsy (N=92/280; 32.9%), cellulitis (62/280; 22.1%) and COPD (29/280; 10.4%).   However, the proportion of ACSCs reduced from 20.5% in 2005 to 15.6% in 2014.
  • The mean age was 40.6 yrs and the majority were male (83%) with a ratio of approximately five males to one female for each year. 
  •  Over half of the patients (57%) had a mental/ behavioural diagnosis and of these 34.3% had an alcohol misuse diagnosis and 21.0% had a substance misuse diagnosis recorded. 
  • The majority of the admissions were to Dublin hospitals (84.1%).
  • The average length of stay was high at 6.5 days with no significant difference over the ten year study period.
  •  A total of 95 (4.6%) required intensive care and the average length of stay in intensive care was  4.6 days.
  • 29 (1.4%) died in hospital over the study period  and the mean age of those who died was 48.2 years.
  • Older patients (≥50 yrs) were one and half times more likely to be admitted with an ACSC  when compared to younger patients (< 50 yrs).

This study provides a valuable insight into patterns of emergency admission among those with no fixed abode and raises a number of fundamental issues in terms of meeting the health needs of homeless people.

The increase in admissions for persons of no fixed abode show two significant ‘spikes’ – in the period 2005/2006 (114%) and again in 2013/14 (102%). While this recent increase does not correlate with any increase in recorded rough sleeping, it does reflect a period in which the number of people accommodated in TEA ‘one-night-only’ beds increased substantially.

The authors note that the increase in emergency in-patient admissions among this cohort of homeless (i.e. the roofless who are sleeping rough or in one-night-only shelters) is likely to be contributing to the overcrowding difficulties experienced by emergency departments.  In addition, with an average length of stay of 6.5 days they are also placing demands on acute beds.

Compared to emergency admissions generally, the average age of the homeless patient is younger than the general hospital population.

Although health issues may have contributed to homelessness (e.g. alcohol and drug misuse), these findings suggest that being homeless itself has a significant impact on health. Indeed the average age of this cohort that died in hospital was 48.2 years, which is significantly lower than the current average life expectancy.    

With over half experiencing mental health disorders of which up to a third experience alcohol and substance misuse, it is clear that pathways to care need to be established as such health issues will have a significant impact on the cycle of homelessness if not addressed.

The reduction in the proportion of admissions due to ACSCs  over the ten year study period is to be welcomed and suggests that access to primary care services for those of “no fixed abode” may be increasing.  Nonetheless, there is still a need for easier access to primary care services which may be difficult due to the transient nature of homelessness.

Homeless services have long identified the discharge of vulnerable people from hospitals as one of the key areas where prevention strategies should be focused but there has been less strategic focus on the overall interaction between hospital admission, primary health services and homelessness. Focus Ireland is currently in the second year of a Dublin Regional Homeless Executive funded pilot to prevent homelessness arising from hospital discharge. Currently referral to this service is through medical social workers. It would be important that this initiative reviews all those classified as ‘no fixed abode’  in hospitals so as to ensure homeless people are not ‘slipping through the net’ on discharge.

The authors assert that best solution to this problem involves ending the homelessness of the individuals involved. There is growing international evidence that providing housing and intensive support using the Housing First model has high success rates and has significant positive impact on patterns of accessing health services for people who are chronically homeless. The Dublin Housing First project (run jointly by Focus Ireland and the Peter McVerry Trust) has provided long-term homes for 50 people with long histories of rough sleeping. But this approach will not be able to assist everyone in the foreseeable future and there is clearly scope for substantial improvements in the interaction between  those who are homeless and health services.

Overall the study suggests that the growing number of admissions of people who are homeless to acute hospitals represents both a serious problem and a real opportunity.

The problems reside both in the poor health of the homeless population; the transient nature of homelessness which leads to poor access to primary care services  and the substantial cost to the health service in dealing with these problems in an acute hospital setting.

The opportunities arise in the potential to reconfigure the relationship between homeless services and health services so that the transition between the two systems cease to be places where vulnerable people can become lost and instead  become intersections where pathways to appropriate supports can be identified and made available.


All references and author names are contained in the full article in the October edition of the Irish Medical Journal

September 2016 - Volume 109 - Number 7 - Official Journal of the Irish Medical Organisation

In the September Edition of the IMJ

Editor-in-Chief Dr John Murphy examines the sensitive topic of errors in medical practice resulting in death of patients

Medical Error as a Cause of Death Revisited

Hourihane et al discuss rhinoconjunctivitis in elite amateur sport in Ireland

The Prevalence of Grass Pollen-Related Allergic Rhinoconjunctivitis in Elite Amateur Irish Athletes

Frere and Tepper look at the possibility of using Ketamine as a possible treatment for Treatment-Resistant Depression

Ketamine: Future Treatment For Unresponsive Depression?

July/August 2016 - Volume 109 - Number 7 - Official Journal of the Irish Medical Organisation

Accrual to Cancer Clinical Trials

July/August 2016 - Volume 109 - Number 7 - Official Journal of the Irish Medical Organisation

Irish Medical Journal - Press Release       

July/August 2016 ■ Volume 109 ■ Number 6 - Official Journal of the Irish Medical Organisation

The current state of Cancer Care Trials in Ireland

Accrual to cancer clinical trials (CCT) is imperative to safeguard continued improvement in cancer outcomes.  A study in the latest edition of the Irish Medical Journal examines the current rate of accrual to CCTs in Ireland and the factors influencing recruitment. This study was performed in a North Dublin cancer centre in association with Cancer Trials Ireland. The study’s secondary objective identifies the progress that has been made in Ireland in relation to CCT accrual relative to decade ago; accrual has doubled and the number of trials opened has tripled.    

A total of 3-5% of all cancer patients annually enroll in clinical trials worldwide. This statistic has not improved since the 1980s. Clinical Trials Ireland (previously known as the All Ireland Co-operative Clinical Research Group (ICORG)) coordinates cancer clinical trials in Ireland.  It has established the infrastructure necessary to attract international research groups to open studies in Ireland. As a result Cancer Trials Ireland has forged a strong network with international collaborative research organisations.  This ensures that cancer patients in Ireland have access to treatments not otherwise available outside of the clinical trial arena.  Understanding the patterns of recruitment to CCTs is an essential step towards improving accrual.  In 2005, Morris et al, explored factors influencing enrolment to CCTs in a North Dublin cancer centre. The overall accrual rate to CCTs was 2.4%.  At that time, the main factors influencing recruitment to CCTs in Ireland were the absence of trial protocols for specific cancer types and stage of disease

Over the last decade, the rate of accrual to CCTs has in fact doubled and the number of trials open to recruitment has tripled.  Ongoing governmental and philanthropic support is necessary to continue this trend to further expand CCT patient options with a target accrual rate of 10%.

During a four-month period, all patients requiring the introduction of or a change in systemic therapy that attended a North Dublin cancer centre were assessed for potential eligibility for a CCT. The study population included new and established patients that had experienced disease progression or relapse.  Patients with all cancer types and stages of disease were included.  Patients were identified from a prospectively maintained dataset of all patients commencing a new systemic treatment between 1st November 2014 and 28th February 2015. Systemic treatment included intravenous or oral anti-cancer treatments.  Patients requiring the introduction of or a change in anti-hormonal therapy for breast cancer were not included in this study.  A retrospective chart review was conducted to determine the number of patients eligible for and the overall rate of accrual to a CCT.  Each week, the outpatient clinic lists were screened in advance to identify potentially eligible patients for CCTs.  The final decisions regarding patient treatment plans were made at consultant level.  In the case where there was no CCT option available for a patient, the reason for this was recorded. The overall rate of accrual to a CCT and the reasons for failure to recruit were also identified.  

Results from the study

A total of 140 oncology patients were considered for initiation of or a change in systemic therapy during the period of assessment. Nineteen CCTs were open for recruitment (clinical studies =74%, translational studies = 26%).  Five trials closed and no trials opened during the study period.  The CCTs were available for 10 different cancer types and included a variety of stages of disease and lines of treatment. The median age was 60.5 years.  The majority of patients were aged between 36 and 65 years (60%).  A third were aged greater than 65 years (36.4%) and 5 patients were aged less than 35 years old. The majority of the population was female (66%) and Caucasian (100%). Breast and colorectal cancer were the most common cancer types represented within the population accounting for 37% and 25% of the cancer diagnoses respectively. The group was evenly split as regards cancer stage (early stage, (48%), advanced disease, (52%)). This division was reflected in the lines of treatment under consideration: adjuvant, (29.3%), neo-adjuvant, (17.1%) and palliative treatment including: 1st line, (21.4%), 2nd line, (11.4%) or 3rd line/higher, (20.7%). Less than a third (29%) of the population had a CCT option available to them.  The treating physician considered the CCT option in the majority of cases (63.4%). The option of CCT participation was discussed with the patient in just over half (54%) of these cases.  The reasons for failure to discuss the trial option included physician’s discretion; patient ineligibility; and patient previously declined enrolment in the CCT. A total of 8 patients agreed to participate in a CCT.

There was no CCT option available for the majority of the population (71%). The absence of a trial for a specific cancer type, stage of disease and line of treatment were the most common reasons underlying the limited CCT options available to this population. The accrual rate to a CCT for this period of study was 5%, which is in line with international figures.  This study highlighted multiple factors to explain the failure to recruit to CCTs

The authors assert that poor accrual to CCTs is one of the rate limiting factors for continued progress in cancer care. In order to safeguard continued advancement, regular evaluation of factors influencing accrual to CCTs is necessary. This study identifies a 5% accrual rate to CCTs, which is comparable to internationally reported figures.  However, this accrual rate is low and the authors declare that we must strive for better.  Regular auditing is encouraged to ascertain if targets are being reached.  Possible interventions to promote recruitment to CCTs include: gap analyses, physician champions and appropriate diversification of the clinical trial portfolio. 

This study identifies the lack of a CCT option as the main reason for failure to recruit to CCTs.  Absence of a trial protocol available for a specific cancer type, stage of disease and line of treatment were the three most common reasons why patients did not have the option to participate in a CCT. This problem is not unique to Ireland.  The availability of CCTs is dependent on the total number of trials offered by a CTU. The obvious solution to the recruitment issue would be to open more studies.  However, the running of a CTU is costly and there are many practical barriers that influence patterns of recruitment to CCTs. The cost per trial participant in many studies is often much higher than the per-case study reimbursement offered. The shortfall incurred by CTUs creates difficulty for them to run cost-neutral or cost efficient research programs.  This financial strain limits the ability of sites to open new studies. Maintaining compliance with regulations that oversee the conduct of clinical trials, adhering to codes of good clinical practice and providing the intense patient monitoring and follow-up required by clinical trial protocols are labour intensive. Funding for CTUs is often dependent on the number of study participants enrolled in the previous year.  However, increasing the accrual rate to CCTs increases the workload, which can strain a workforce of already limited resources..  

Of the 29% of patients with a clinical trial option available to them the clinical trial was considered and discussed with the majority of patients. In order to overcome oversight by a clinical research team not to consider a clinical trial for a patient regular unit meetings with the research team and designating “physician champions” for specific trials that help to educate and raise awareness of the clinical trials available at the site among all team members are recommended.  A total of 6 patients declined the option to take part in a CCT.  It is important to establish the reasons why patients decline participation.  This information might offer insight into how we can improve accrual to CCTs in the future.

The first study to examine patterns of patient participation in CCTs in Ireland was published almost a decade ago. Comparison of these two studies draws upon two main conclusions.  Firstly, both studies identified similar reasons to explain failure to accrue to CCTs.  Secondly, progress has been made in the area of CCTs and accrual to CCTs in Ireland over the past decade.  The rate of accrual to CCTs has doubled and the number of trials open to recruitment has tripled.  The CCT portfolio has expanded to include translational studies and encompass a broad range of cancer types. 

All references and author names are contained in the full article in the July/August 2016 edition of the IMJ –

Title: Accrual to Cancer Clinical Trials

For further information contact: Communications Unit, Irish Medical Organisation, 10 Fitzwilliam Place, Dublin 2.  


It must be acknowledged that none of the progress we have witnessed would have been possible without funding from the Health Research Board of Ireland, the Irish Cancer Society and other charitable donations.  However, it must also be recognized that funding designated for CTUs in Ireland has been significantly reduced since the downturn in the Irish economy in 2009.  Clinical Trials Ireland and the respective clinical trial units should be commended for their perseverance to advance cancer care in Ireland despite dwindling resources.  This attitude instils confidence that in ten years’ time the CCT accrual target of 10% will be achieved.

June 2016 - Volume 109 - Number 6 - Official Journal of the Irish Medical Organisation

Cycling injuries presenting to an Irish emergency department

June 2016 - Volume 109 - Number 6 - Official Journal of the Irish Medical Organisation

Irish Medical Journal - Press Release       

June 2016 ■ Volume 109 ■ Number 6 - Official Journal of the Irish Medical Organisation

Cycling injuries presenting to an Irish emergency department

Cycling is now a very popular means of transport and exercise activity in Ireland and using hospital based data, it is possible that EDs may provide a vector for guiding injury prevention strategies in the future. There is little published data on cycling injuries in Ireland, a study published in the latest edition of the Irish Medical Journal gives a retrospective review of cycling-related injuries presenting to the ED of St. Vincent’s University Hospital (SVUH) from 1st of January to 31st of December 2014.

The Central Statistics Office (CSO) reported in the 2011 census that there was a 9.6% increase in the number of people cycling to work when compared to 2006. As the number of cyclists increases, this may lead to more cycling injuries presenting to hospital. The Road Safety Authority (RSA) reported that 639 cyclists were injured on Irish roads in 2012. This represented a 56% increase in the number of injuries when compared to 2011.

The RSA data is collected from reports regarding any collision on a public road involving a cyclist that was reported to the police. The RSA conclude from the 2012 report that 83% of cycling injuries in Ireland involved a collision with a motor vehicle.  There is little published research on the prevalence of cycling injuries presenting to Irish emergency departments (EDs) and the RSA does not include hospital data in their collation of cycling statistics.

The aim of this study was to determine the cycling related injuries presenting to the ED of a tertiary urban university hospital.

Data gathered included: demographics including age and gender, injury details including date and time of injury, mechanism of injury, helmet use, ED investigation and management, ED and hospital length of stay (LOS), disposition details, morbidities and mortalities. Hospital records of admitted patients were also reviewed.

Five hundred and thirty four patients fulfilled the criteria for the purpose of the study accounting for just over 1.0% of all attendances.

The main statistics from the data collected were as follows:

  • Just over 71% of the patients were male. The mean age was 36.6 years.
  • Twenty-two patients (4.1%) were aged between 14 and 18 years
  • 21 patients (3.9%) were over the age of 65 years. 
  • 14.8% of patients presented following a collision with a motor vehicle. Forty-two (7.9%) had a collision with a pedestrian while 17 patients (3.2%) had a collision with a fellow cyclist.
  • Forty patients required admission to hospital following their injury with 6 of these patients spending time in the intensive care unit.
  • The highest number of presentations was in September (72, 13.5%). One hundred and forty-seven patients (27.5%) presented on a weekend. The most frequent day of attendance was Monday.
  • The time of attendance to ED varied with patients most commonly presenting between 12am and 6pm.

The statistics on the injuries sustained were as follows

  • One hundred and sixty-two patients (30.3%) sustained a fracture.
  • One hundred and nineteen (75.3%) of these fractures involved the upper limb
  • There were 6 shoulder dislocations and 1 elbow dislocation.
  • Twelve patients (7.4%) suffered an acromioclavicular joint subluxation. There was one Achilles tendon rupture and one anterior cruciate ligament rupture.
  • Two hundred and seventy-six patients (51.7%) were diagnosed with a “soft tissue injury” which did not require any follow up arrangements.
  • Eighty-three patients were documented as having a head injury. Four of these patients (0.75%) were found to have an intracranial haemorrhage. Two patients (0.37%) had skull fractures and 7 patients (1.3%) had facial bone fractures.  A diagnosis of concussion was made in 70 patients (13.1%).
  • There were two mortalities (0.37%) during the study period.

Further statistics on the management in ED, Duration in ED and Disposition are contained in the published article

If all the hospital data in Ireland were to be analysed the authors conclude that the total of cycling injuries presenting to Irish hospitals would be much higher than current RSA data trends suggest. This study found that 14.8% of injuries involved at least one motor vehicle. When compared with the RSA’s findings (83%), this indicates that there may be a large number of cycling collisions occurring that are not being reported and therefore are not included in the RSA collision statistics.

The authors noted “It is clear that the true number of cycling injuries on Irish roads is being under-reported and that cycling safety requires a scrutinizing review. Using hospital data may inform future policy regarding the implementation of higher safety standards on Irish roads for cyclists. This would correlate with the findings in this study and suggests that there needs to be an alternative mechanism for reporting cycling injuries in Ireland.”

The authors conclude by saying “Cycling is now a very popular means of transport and exercise activity in Ireland and using hospital based data, it is possible that EDs may provide a vector for guiding injury preventing strategies in the future.”


All references and author names are contained in the full article in the June 2016 edition of the Irish Medical Journal

May 2016 - Volume 109 - Number 5 - Official Journal of the Irish Medical Organisation

Perceptions of Challenges in General Practice in Ireland

May 2016 - Volume 109 - Number 5 - Official Journal of the Irish Medical Organisation

In Ireland, there is a critical shortage in the supply of general practitioners that is projected to worsen. Ireland already has one of the lowest ratios of general practitioners per capita in Europe, in addition, 13.2% of Irish general practitioners are currently over the age of 65 and a third of the GP workforce are international medical graduates, which is one of the highest in the OECD. This study in the May edition of the Irish Medical Journal aimed to describe the challenges that medical students and general practitioners perceive in the field of general practice. Addressing these concerns is crucial to attract and retain future general practitioners.

In Ireland, it has been projected that the supply of GPs will be 5.7% less than required by 2021. The National Doctors Training and Planning Unit estimate that by 2025, the predicted shortage of general practitioners will range from 493 to 1,380. 

In times of economic crisis, medical student career intentions shift towards specialties with increased job security, with less emphasis on remuneration. As a result, the authors hypothesized that student perception of increased challenges in general practice may influence their decision to pursue a career in general practice. The authors aimed to identify the challenges that medical students and GPs perceived in the field of general practice in Ireland.

A cross-sectional online survey of 96 medical students and 35 general who attended the Vasco da Gama Movement (VdGM) Forum in February 2015. (VdGM is the WONCA Europe Network for new and future general practitioners.)

The most commonly perceived challenges included remuneration, stress, access to imaging, respect from fellow medical professionals, treating the ageing population, and complexity of patients. These challenges were also generally rated as of high priority. There was large congruence between students and practitioners as to the challenges and what priority they represented.

Of the 96 medical students, 20 (20.8%) were junior medical students, 35 (36.5%) were intermediate medical students and 41 (42.7%) were senior medical students. Mean age of participants was 24.9 years and 93 (71.0%) were female. Of the 35 general practitioners, 31 (88.6%) were currently practicing in Ireland and 4 (11.4%) were practicing in the UK.

The most frequently identified challenges were access to imaging, where only 13.0% respondents agreed or strongly agreed that GPs have sufficient access to imaging. In addition, 91.6% respondents agreed or strongly agreed that the ageing patient population is a challenge and 72.5% indicated that patients are becoming more complex.

Communication with specialists was a major challenge, with only 19.8% of respondents believing that there was an adequate level of communication. Of medical students 45.8% believed that they received adequate exposure to the field of general practice, compared to 25.7% of GPs.

Participants were asked to prioritise the importance of each challenge to them on scale from one to ten, with one being the most important and 10 being the least important. Participants provided the highest priority scores to lack of time in clinic, increased workload and financial constraints. In the GP cohort, the concept of the complex patients was highly prioritised.

When asked about their career of choice at the time, 17.7% of medical students indicated general practice, 53 (55.2%) indicated it was not general practice and 26 (27.1%) were unsure. Interest rose with stage of medical training with 15.0% of junior medical students indicated an interest in general practice career, compared to 8.6% of intermediate medical students and 26.8% of senior medical students.

In the era of an aging patient population and increased demand for general practitioners, the study aimed to assess perceptions of challenges facing the field of general practice as well as medical student interest in a career in general practice. The study results identified that in 18% of medical students, general practice was their current career of choice. The most common challenges that were identified included access to imaging/investigations, the aging population and increasing complexity of patients.

The authors observe that communication between hospital physicians and general practitioners is a challenge not unique to Ireland that needs to be addressed. Previous work in this area has highlighted several possible solutions including developing relationships and opening lines of communication between hospital physicians and general practitioners.

The results of this study identify several challenges perceived by medical students and general practitioners in the field of general practice in Ireland. Addressing these concerns is crucial in order to attract and retain the next generation of general practitioners. Future studies should aim to take a qualitative approach and aim to elicit the origin of these challenges and suggestions from GPs on how they can be overcome.

Note to editors:

The present study has several limitations which were noted by the authors. The low response rate (12.4%) poses the significant risk of non-responder bias. In addition, students with an interest in general practice may have been more inclined to participate in the study, leading to the risk of sampling bias. However, the results of the survey provide some preliminary data that may be used to direct future research in this field.

Acknowledgements: The authors would like to thank all the participants who took part in the study and VdGM forum organisers who facilitated the dissemination of the survey.

Click here for the full study

Profile of Frequent Attenders to a Dublin Inner City Emergency Department

April 2016 - Volume 109 - Number 4

In the April edition of the Irish Medical Journal a retrospective review of the demographics, co-morbidities and substance misuse of the 20 most frequent presenters to the Mater Misericordiae University Hospital emergency department during 2014 is published. The review was carried out in an attempt to better understand the epidemiology of their presentations.

Overcrowding in emergency departments (ED) and appropriate utilisation of the emergency department facilities are topics of much interest in the Irish healthcare system. Within the literature on ED usage, there is only a small focus on frequent attenders. It is known however, that a small number of patients are responsible for a disproportionate amount of ED visits with up to 4% of patients accounting for 18% of total ED visits in one particular study. This small but distinctive group of patients repeatedly seeking ED care often have psychosocial, substance misuse and/or chronic illness issues which play a factor in their repeat attendances. Early identification of these patients and targeting them for effective community based-care treatment strategies could improve their quality of life, decrease their cost of care and ultimately lead to more effective utilisation of our already overburdened emergency departments. The patient population at the Mater Misericordiae University Hospital contains a number of frequent attenders. The authors sought to review the demographics, co-morbidities and substance misuse of the most frequent presenters in an attempt to determine the epidemiology of their very frequent presentations.

This review found that eighty-five percent of patients were male and 15% female. The average age was 40.6 years with a median 38.5 years. All were unemployed and general medical scheme (GMS) card holders. Seven (35%) had no fixed abode. Thirteen patients (65%) lived within an[AM2]  average of 4.5 kilometres from the ED. Five of this thirteen had recently been homeless and were living in temporary hostel accommodation. Nineteen of the twenty most frequent presenters were single or separated from partners (95%).

Eighty-five percent admitted to smoking (17/20), they had a significantly higher average attendance rate than non-smokers (84 v 36). Psychiatric conditions predominated with 65% having a previous mental health issue (13/20). One patient (5%) had Bipolar affective disorder, 1(5%) had obsessive compulsive disorder and 1 (5%) had schizophrenia. Two (10%) had personality disorders, four (20%) had depression and 4 (20%) had co-existent depression and schizophrenia. The average number of attendances for those without a mental illness was 43.4 compared to 94.8 in those that did.

The presence of a mental illness was associated with a significantly higher attendance rate. Only 30% (6/20) denied misuse of alcohol with the majority being alcohol dependent (60%, 12/20) or admitting to alcohol abuse (10%, 2/20). The average number of attendances for those misusing alcohol was 87 compared to 54 in those who did not. Misuse of alcohol was associated with significantly higher attendance rates.

Half of the patients had no drug related issues, with 15% having an opiate (heroin) addiction (3/20), 30% had a benzodiazepine addiction and 5% had a polydrug addiction. Of those who misused drugs, their average attendance rate for 2014 was twice that of who did not misuse drugs (103 vs 51). Misuse of drugs was associated with significantly higher rates of attendance.

In keeping with previous studies on re-attenders this study found that there were significantly more men in the top twenty re-attenders to the hospital. In Dublin itself, there have been mixed reports with some studies concurring that males predominate, whereas others have shown no significant difference in the gender of frequent presenters. Similarly, in comparison to other studies with regard to age, both an increased frequency of attendance with increasing age and weighting towards young adults have been demonstrated.

It has been shown within Ireland that those who are unemployed or hold a GMS card are significantly more likely to be frequent attendees. This was also highlighted by the results of this review which showed all the twenty most frequent presenters to our institution were unemployed and holding GMS cards. It is impossible to tell from these or other results the cause or effect relationship of unemployment and frequent ED attendance and whether unemployment and more free time causes patients to represent more frequently or the act of representing has led to the impossibility of maintaining continuous employment. The authors recommend that this area should have further study as it could be a target area for government organisations combating re-attendance.

There was a negative correlation, though not statistically significant, between distance of a patients residence from the ED and number of attendances in the 12 month period. This is in keeping with previous work in this area which found that there was a significant relationship between proximity of a patients dwelling to the ED and number of attendances in a given year. Five out of the nine most frequent attendees had no fixed abode and so could not be included in the calculation. It is possible that if they had, it may have extenuated the results and become significant as many of these patients were staying in emergency accommodation local to the hospital or sleeping rough on the streets nearby.

Looking at the 12 homeless (including temporary hostel accommodation) and comparing them to those living at home we can see that homeless patients attended an average of 95 times in one year whereas non-homeless attended an average of 49 times. Thus, homelessness was significantly associated with an increase in frequency of attendances in this study in keeping with international data.

Anecdotally, the authors comment that further study would be needed to see if placement in a hostel or permanent accommodation reduces re-attendance to emergency departments. Case series on these patients might help build a case for increased investment in accommodation and other social interventions in an effort to reduce ED attendances and the increased waiting times that accompany it.

Eighty percent (16/20) of the most frequent attendees misused either drugs or alcohol. Of the remaining four each had a chronic disease which accounted for the majority of their presentations including asthma, chronic obstructive pulmonary disease, paranoid schizophrenia and end-stage renal disease. Despite these conditions, those with drug or alcohol misuse problems collectively had a significantly higher average attendance rate than those without (85 vs 42). This highlights the fact that in the catchment area, drug and alcohol misuse impacts our emergency department to a greater extent than chronic disease.

Looking at the twenty most frequent presenters the authors found alcohol and drug misuse reported in 70% and 50% respectively. This highlights the great burden of alcohol and drugs on Irish society and in this department in particular from frequent attenders and the authors notes that resources must be put in place to assist in rehabilitation and relieve pressure on emergency services.

Previous articles have shown anecdotal evidence that many regular attenders have combinations of mental health, substance misuse and social care issues. This is again clearly highlighted in this article where 50% (10/20) had drug related issues. This sentiment is mirrored for those with mental health issues. The presence of a mental illness was associated with a significantly higher attendance rate. It is proposed that insufficient community-based mental health services may contribute to the reasons why people represent to the ED.  Again, the authors state that it highlights the need for the political will to affect change to alleviate this burden on acute care.

The authors note that the results of this study are only for a very small sub-group of re attenders. Thus, their results are difficult to generalise for all re-attenders. The data was collected from only one inner city centre in Ireland so its results cannot be accepted as representative for other institutions inside or outside of Ireland. It does however; give an understanding of the high level of substance misuse, mental health issues and social poverty that very frequent attenders suffer.

In conclusion, this study the presence of a mental illness, homelessness, alcohol or drug misuse were associated with significantly higher attendance rates. Early identification of these patients and targeting them for effective case-based community-led treatment strategies could improve their quality of life, decrease their cost of care and ultimately lead to more effective utilisation of our already overburdened emergency departments. Significant investment is required to improve services both inside and outside the hospital to relive the pressure felt from re-attenders in the emergency department. Additionally, more studies must be carried out on a local, national and international level to identify and manage causes of very frequent attendance.

All references and author names are contained in the full article in the April edition of the Irish Medical Journal

February 2016 - Volume 109 - Number 2

The Role of Medical Personnel in Sports Concussion

February 2016 - Volume 109 - Number 2

The Irish Medical Journal February edition editorial focuses on the role of medical personnel in sports concussion. Author Professor Nicholson examines how sports-related concussion has become a ‘hot topic’ in the media and medical press and discusses its initial recognition, management and long-term outcomes.  Prof Nicolson emphasises the need to encourage greater participation but aim to avoid serious injury including concussion.

With the likelihood in rugby of one injury per team severe enough for a player to leave the pitch and with at least one attendance for a suspected concussion per match, there is clear evidence that those on the sideline should be trained to recognise potentially serious injuries

Over the past 20 years, sports concussion has become one of the most researched topics in sports medicine.  There is great variability in clinical presentation and recovery.  Concussion is a clinical syndrome caused by either direct or indirect biomechanical forces to the brain and manifests as a rapid onset of neurological dysfunction which typically resolves spontaneously. Prof Nicholson notes that the Irish Rugby Football Union have produced an excellent guide to concussion in rugby union via the Safe Rugby Programme and have backed it up with seminars for coaches, players and medical back up staff.

Concussion remains a clinical diagnosis and the most obvious marker for injury is a loss of consciousness only occurs in a small percentage of concussion presentations. Both coaches and referees have key roles as many games proceed without medical personnel present. In essence if concussion is suspected by the referee, the team doctor, the coaching team or supervising parent, then the player should be removed from the pitch and should not return if at youth level. The author states that the ‘Recognise and Remove’ mantra is the only one to follow.

For concussion, no single sideline tool assures complete diagnostic accuracy although tools such as the updated SCAT 3 are available. The visible clues of suspected concussion include lying motionless on the ground, being unsteady or falling over, a vacant or dazed look, confusion or very rarely a loss of consciousness.  Recovery needs to be monitored very carefully  and recent research has focussed on biomarkers of neurological injury and the potential use of functional MRI or PET scanning but these are still research tools.  Conventional imaging (CT or MRI) is rarely indicated except if deterioration of clinical status, focal neurological deficits or prolonged loss of consciousness. Neuropsychological testing is very helpful but cannot on its own determine the timing of a return to play. Players should have cognitive rest post-concussion whereby they limit activities that require focus, concentration and attention such as reading, studying, texting, videogame play and computer use.

A stepwise approach to return to play has a number of guiding principles including initial rest and recovery to pre-injury baseline, a graduated increase in physical activity (light exercise, advanced exercise, non-contact activity and full contact). In Ireland, 16 to 19 year olds are advised not to return to play until at least 22 days post-concussion compared to 13 days as recommended by the International Rugby Board.  The rate of stepwise progression is contentious and dependent on the individual player but may extend well beyond 3 weeks in some players. There is no doubt that many schools players stated that they would want to play in an important match even if still recovering from concussion. The author states that peer acceptance and coach support are vital to avoid a too speedy return to play. Players are sadly willing to take risks, even if armed with knowledge of concussion, are reluctant to report concussion and are sometimes motivated to play despite concussion.

Prevention of concussion has focussed on protective equipment (such as mouthguards), cervical muscle strengthening, teaching young players how to tackle properly and rule changes that govern the sport. In effect protective headgear helps reduce head lacerations and mouthguards prevent dental injury but neither prevent concussion.  Neck strengthening exercises do potentially lower concussion risk especially in youth and female players. The tackle area is where most rugby injuries now occur and application of the laws forbidding high tackles or clearing out at rucks need to be enforced.

Medical Indemnity is an issue that has now been clarified in that the IRFU has put medical professional liability in place for medics (defined as physicians, consultants, general practitioners and physiotherapists) working within their scope of practice at club or schools games but you are required to register details with the IRFU medical department and all serious injuries and concussions must be reported to the provincial branch on a designated form.

Best international advice, backed by anecdotal experience, is if any concerns re concussion the player should be immediately removed from play and should not return if at youth or school level. Spinal injuries have reduced dramatically since the scrum has been depowered in school and youth rugby but occasionally occur in high impact tackles. Strength and conditioning training, higher impact collisions and high intensity games create a very exciting spectacle but do place added burdens and responsibilities on medical personnel on the sideline. The author comments that weight as opposed to age restrictions, tackle and ruck law changes may be required to make schools and youth rugby safer. Similar principles apply to other contact sports. Prof Nichols concludes that “we need to encourage greater participation but aim to avoid serious injury including concussion”.

All references and author names are contained in the full article in the February 2016 edition of the IMJ –

Title: The Role of Medical Personnel in Sports Concussion

For further information contact: Communications Unit, Irish Medical Organisation, 10 Fitzwilliam Place, Dublin 2.  

Chlamydia screening during Cervical Screening in General Practice

January 2016 - Volume 9 - Number 1

Research has indicated that the incidence of Chlamydia trachomatis (CT) & Neisseria gonorrhoeae (NG) are rising in Ireland. Both are often undiagnosed and may cause infertility amongst other complications. Screening for these is not routinely offered during cervical cancer screening. Between 2000 and 2014 the annual notifications of CT in Ireland have increased from 1343 to 6707 and GC notifications have risen from 290 to 1336.  In 2014 women accounted for 3623 (54%) reported cases of CT and 223 (17%) cases of NG. CT is asymptomatic in 85% of women and 40% of men. CT and NG cause infertility as well as other health complications.

This study aims to ascertain if it is feasible for GPs and acceptable to patients to combine screening for CT/NG with cervical screening, and to measure the diagnostic yield of STI screening, thereby ascertaining if it is worthwhile exploiting the potential health gain at a useful and established point of care relating to sexual health. Screening was offered to women aged 25-40 years attending four participating general practices as part of Cervical Check. 

Ethical Approval was obtained from Trinity College Dublin HSE GP Training Scheme Ethics Committee. The study was carried out in 4 Teaching Practices (3 urban, 1 suburban) (July 2014 - January 2015). Initially the authors retrospectively assessed the number of women who underwent opportunistic CT/NG testing in the participating practices at the time of cervical screening in the previous 3 months. The target population for STI screening included all patients aged 25-40 years attending as part of the national cervical screening programme (Cervical Check) over a 6 month period. Uptake and opt out rates were recorded.

Women attending for cervical screening were made aware of the study using an information sheet and waiting room notice. This enabled informed consent by advising on the purpose of the study and invitation to decline or participate. Written consent for the study was obtained along with consent for cervical screening. An endocervical swab was performed at time of smear, and forwarded to the National Viral Reference Laboratory. The order in which the swab and cervical smear were taken wasn't specified. Patients who tested positive for CT or NG were offered a follow up appointment at the practice free of charge. In those who tested positive for CT, a prescription for 1g of azithromycin was given and contact tracing for partners was provided. Regular partners of those who tested positive were offered treatment regardless of their own test results. Patients testing positive for NG were to be referred to the Department of Genitourinary Medicine and Infectious Diseases (GUIDE) Clinic at St James’s Hospital Dublin for intramuscular (IM) ceftriaxone treatment and culture. All patients testing positive for CT or NG were recommended to have additional screening performed (syphilis/human immunodeficiency virus (HIV)/ and Hepatitis B), at either the practice or the GUIDE clinic and to have full contact tracing.

Two hundred and fifty five patients were included in the study. Of these, 236 (93%) consented to screening for CT/NG. Three patients were excluded based on age. All other participants were between 25 and 40 years (median age = 33 years). Five samples were not processed. Six patients (2.4%) tested positive for CT; there were no positive results for NG. The retrospective review indicated that out of 138 smears performed, in the three months prior to the study period, CT/NG testing was performed in 10 (7%) of cases.

Results from the pre-test demonstrated 36% had been tested for CT or NG previously. When asked, 30 (13%) of respondents indicated they would have requested it themselves. Furthermore, 42 (18%) of respondents believed that STI testing was part of the routine smear test.

A retrospective review of the three months preceding the study period, indicated that out of 138 smears, CT/NG testing was performed in 10 (7%) of cases. 236 (93%) patients consented to screening for CT/NG. The detection rate for Chlamydia was 6 (2.4%), with no positive results for NG. Feedback from patients was positive. Interestingly the authors note that 42 (18%) of participants who completed the questionnaire believed STI screening was already part of the routine smear. 

The initial retrospective review of CT/NG screening at the time of smear testing demonstrates opportunistic screening is not routine practice and confirms a low rate (7%) of patient requested testing.  The high participation rate (93%) and largely positive results of the feedback questionnaire clearly indicate CT/NG screening is both feasible and acceptable to patients and providers alike. From 2007-2009 The Royal College of Surgeons in Ireland carried out a cost efficacy study examining opportunistic screening for CT in Ireland, ultimately concluding that it was ineffective. While a high level of uptake and a good level of patient acceptability was noted, less than 10% of eligible candidates were actually offered screening. GPs cited lack of payment, time pressure (screening at that time involved more time consuming, less efficient urinalysis PCR testing) and difficulty of raising the issue of STIs as obstacles to screening. This study highlights an excellent opportunity to increase the uptake for screening at the time of smear test, when the previously described obstacles are not present, and results here supersede this previous study. While there is no national CT screening programme in Ireland, the UK National Chlamydia Screening Programme actively screens those aged under 25 years, the population generally considered to be at highest risk of infection. Figures from the UK show a prevalence rate for CT of 3.1% among sexually active 16-24 year olds.  American data has shown increasing prevalence of STIs in patients aged 24-40 years from 2008 – 2012 suggesting a shift in the perceived at risk population groups.  The diagnostic rate of CT (2.4%) in this study of 25-40 year olds supports the notion that screening in an older age group may also be of benefit.

In 2011, Ogbechie and colleagues found 71.7% of younger women mistakenly believed cervical cancer screening also screened for CT. While numbers in our study were lower, almost one in five (18%) participants believed STI screening was carried out during smear taking. The need for greater patient education is clearly evident regarding this aspect of cervical screening, and separately, the need for STI testing, and what it involves. In our study approximately half of those who gave a reason for not participating believed they were not at risk, as in a long term relationship or not sexually active and the remaining respondents had been recently tested.  A study by Bowden and colleagues in 2008 demonstrated routinely offering Chlamydia screening at the time of smear approximately doubles the rate of Chlamydia testing in general practice. The rise in STI testing rates from a baseline of 7% up to 93% during the study period shows an even more marked effect and affirms the high level of patient and provider acceptability. There were no positive results for NG infection despite the number of diagnoses having increased considerably in the past decade. This may in part be attributable to the fact that this increase has affected males more than females with a ratio of 4 to 1.1

The authors note a number of limitations to the study which included the exclusion of women under 25, those over 40, and men (except as part of contact tracing). The lower age limit reflects the lower age limit of the CervicalCheck programme. The upper age limit reflects the concern that older women attending for cervical screening who consider themselves to be at low risk of STI may be upset at being offered screening. The study did not include a cost benefit analysis, and while feedback from service providers in practices was anecdotally strongly positive, cost benefit was not systematically measured.

While the authors state that it was beyond the scope of this feasibility study to carry out a full cost analysis of implementation of a national screening programme, the HPSC carried out a pilot study of opportunistic screening for genital Chlamydia trachomatis infection in Ireland between 2007 and 2009 which included a cost analysis. Based on their list of costs, in combination with the findings of our study, we estimate that Chlamidia screening alone per year would cost €5,256,489.  No comparable cost analysis was available to estimate the cost of screening for NG.

Offering STI screening is a sensitive subject that can be difficult for GPs and potentially offensive to patients. The acceptability and feasibility of testing during cervical screening to both patient and doctor in this study strongly suggests it is an appropriate setting. By normalising STI testing, patients are less likely to feel they are specifically being targeted, and stigma associated with STI screening is likely to be reduced.

This study demonstrates an efficient additional screening opportunity in a group of patients at risk of an often clinically silent but important condition, for which an effective treatment is readily available. The study builds on the trust, acceptability and confidentiality of the general practice setting, and practically reflects an important and well recognised growing public health risk among sexually active adults. It includes individuals who may not otherwise have considered screening, creating an opportunity to systematically provide important information to the population at risk. The authors conclude that they believe the results from this study strongly support the need to conduct a regional or population based study on screening for Chlamidia trachomatis as part of cervical screening.

All references and author names are contained in the full article in this month’s IMJ, p.326

Title: Screening for Chlamydia is acceptable and feasible during Cervical Screening in General Practice

For further information contact: Communications Unit, Irish Medical Organisation, 10 Fitzwilliam Place, Dublin 2. 

Mental Health Policy in Ireland: A Decade after A Vision for Change, Where Are We Now?

November – December 2015 Volume 108 Number 10

In 2006, the Irish government published A Vision for Change: Report of the Expert Group on Mental Health Policy, a comprehensive mental health policy document which sought to consolidate and deepen moves towards community-based mental health care in Ireland. Did it work? Long before A Vision for Change was published, there was already a well-established commitment to community mental health care, dating from The Psychiatric Services: Planning for the Future (1984) and even the 1967 Commission of Enquiry on Mental Illness which recommended “radical and widespread changes” moving away from “barrack-like structures characterised by large wards, gloomy corridors and stone stairways” and towards the provision of community care. As a result, well before A Vision for Change appeared in 2006, there was a strong emphasis on community care, at least in certain parts of the country, as reflected in the reduction of the number of “mentally ill” persons in institutions from 18,188 in 1966 to 4,522 in 2000

Since 2006, however, the rate of implementation of A Vision for Change has been commonly criticised as being too slow. In 2008, one study of 32 mental health services reported that just 16% of services had received the resources promised in order to implement the new policy; 32% had not been promised such resources and nor was there tangible evidence of the requisite enhancement of clinical teams; and there was significant concern about low levels of recruitment to multidisciplinary teams. In September 2009, a report by Indecon International Consultants, submitted to Amnesty International, made some similar points, highlighting that while definite progress had been made, significant deficits remained in relation to the number of community mental health teams and their composition. The report also pointed to an over-reliance on traditional acute and long-stay inpatient facilities, and presented a series of recommendations for future development of services, including setting new, realistic implementation targets. The rate of implementation was also a key concern of the Independent Monitoring Group (IMC) established as part of A Vision for Change in March 2006. In June 2012, the IMC, in its sixth annual report, concluded that implementation of the policy was still “slow and inconsistent”. The IMC pointed in particular to the “continued absence of a National Mental Health Service Directorate with authority and control of resources. Such a body has the potential to give strong corporate leadership and act as a catalyst for change”.

On a more positive note, there was “evidence of many local and regional initiatives being developed in line with A Vision for Change. These are principally ‘bottom-up’ developments led by local leadership”. Nonetheless, there was still much to be done. Many of the same themes recurred in a further, independent study of implementation published in 2014, which identified a significant body of opinion that saw implementation as slow, haphazard and uneven. This study identified a need for authoritative, accountable leadership as a key factor for implementation and, in 2013, the HSE duly appointed a National Director for Mental Health.

The HSE Mental Health Division now has responsibility for all HSE mental health services. In addition, the National Clinical Programme for Mental Health was set up in 2010, in collaboration with the College of Psychiatrists of Ireland, to standardise high quality evidence-based practice across mental health services in relation to (a) management of patients presenting to emergency departments following self-harm; (b) early intervention for people developing first episode psychosis; and (c) eating disorders.

While change of this magnitude is invariably complex, significant progress has been reported in several areas with, for example, 23 of the 35 posts identified to address self-harm in Emergency Departments in place by March 2015, and the remainder in the recruitment process. Notwithstanding these positive developments, challenges remain in relation to A Vision for Change. In 2014, the Chairman of the Mental Health Commission pointed to some of the key issues: “The implementation of policy to date is still reliant on innovative and imaginative clinical and administrative leadership at regional and local levels. There is considerable commitment to the policy.

Despite these actions the policy is being implemented unevenly and inconsistently across the country and there is a requirement for innovative actions to be supported and reinforced by strong corporate governance at national level”. While acknowledging recent progress in relation to governance, budgetary assurances, physical infrastructure and certain other areas, the Commission was still “concerned regarding a number of specific areas of service provision which impinge on human rights and where, in 2013, standards fell below what is acceptable”. These areas included individualised care plans (implemented appropriately in an estimated 60% of approved centres), unacceptable use of seclusion and restraint, continued admission of children to adult facilities (22.3% of all child admissions in 2013), the absence of reformed, enacted mental capacity legislation, and various issues relating to staffing. Clearly, the decade since A Vision for Change was published has seen substantial progress. Equally clearly, however, the next decade needs to see further progress if the Vision is to be finally, fully realised.

All references and author names are contained in the full article in November-December IMJ p.293

Title: Mental Health Policy in Ireland: A Decade after A Vision for Change, Where Are We Now?

Young, Male and Feeling Suicidal in Ireland: Is Help or Harm Just One Click Away?

November – December 2015 Volume 108 Number 10

Suicide is a major international public health problem and Ireland has the 4th highest youth suicide (15-24) in the EU. The ‘My World’ survey (2012) indicates that the internet is one of the most preferred sources of mental health information for young people where it can provide support and empathy for those experiencing a mental health crisis. However, reports suggest that it can act as an incitement towards suicide.

This study in the November-December edition of the Irish Medical Journal designed a survey of internet websites to determine the types of materials a suicidal person might find through a ‘front page’ internet search. Using the terms previously reported the authors simulated a person in suicidal distress, going online. The terms in previous international research were keyed in, ‘feeling depressed’, ‘feeling sad’, ‘suicide’ into Search history was cleared and ‘Google ads’ disabled, in order to decrease bias and content variability. The authors also examined the websites of a number of key Professional Medical Organisations to see what help they offered (Royal College of Physicians of Ireland, Irish College of General Practitioners, College of Psychiatrists of Ireland). Websites were coded by two raters together with consensus discussions with the two senior researchers who were independent of the research process and therefore ‘blind’ to the results.

Voluntary suicide help websites accounted for 7/12 front page hits. The front page included National Suicide Research Foundation (NSRF), National Office for Suicide Prevention (NOSP), an anonymous and unregulated blog and a newspaper article regarding assisted suicide. Statutory agencies (NSRF, NOSP) referred help-seekers to the voluntary sector (6 of 8 links on NSRF and 4 of 8 links on NOSP). Most sites were difficult to navigate and required multiple ‘clicks’ to access helpful content.

Most referred to GP, and to Emergency Departments during out-of-hour’s. ‘Face to face’ support was minimal; most sites had limited opening hours, considerable geographical spread and were not cost-free. The Samaritans was the most common recommended onward site. On-line support was not tailored for specific groups. Sections on donations and volunteering were prominent and vied with or overshadowed help materials. Links to painless methods to complete suicide as well as other harmful and explicit content were prominent. Irish Professional Medical Organisations did not appear on the front page. When explored, the College of General Practitioners recommended “contacting a GP in your area” as well as journal articles and conferences on suicide prevention.

For suicidal people, the internet front page information is variable in content and includes signposting for harm/suicide. Statutory and voluntary agencies refer to community help-sites with limited hours and often at some distance from the help-seeker. Overall, ehelp responses in other countries appear more coordinated, advanced and tailored to specific groups (, and include Skype, hearing impaired and different language options. The authors state that front page signposting towards suicide that was analysed during the study was of serious concern.

In 2005 the Australian Government banned ‘inciting, promoting or teaching people how to commit suicide on the internet’, as it may influence suicide risk in young people. Like Recupero et al (2008) the authors found that professionally relevant medical bodies were not well represented among the results of this study and did not guide people towards care. The authors observed that recent technology initiatives by groups such as Reachout, the Samaritans and sporting bodies are welcome but are not receiving prominence on the ‘front page’. The authors suggest that professional, voluntary and statutory agencies should work together to generate an enhanced and coordinated, frequently updated and evaluated ‘front page’ epresence, targeted for specific groups. This could start by focusing on 18 to 24 year old males who are at highest risk, are high internet information-seekers and where simulated patient experience could play a valuable role.

All references and author names are contained in the full article in the November December IMJ

Title: Young, Male and Feeling Suicidal in Ireland: Is Help or Harm Just One Click Away?

For further information contact: Communications Unit, Irish Medical Organisation, 10 Fitzwilliam Place, Dublin 2.   

October 2015 - Volume 108 - Number 9

Paediatric Obesity Clinic - Pilot study report

October 2015 - Volume 108 - Number 9

In Ireland, 25% of Irish youths are overweight or obese, are at significantly increased risk of overweight or obesity in adulthood and of having obesity-related health consequences throughout their adult lives. The prevention and treatment of paediatric obesity has been identified as a key public health initiative. Regular monitoring of diet and physical activity behaviours is essential to ensure compliance with recommendations from healthcare providers.  However, resources available to manage paediatric obesity are limited. The objective of this report published in the November edition of the Irish Medical Journal is to detail the establishment of a Paediatric Obesity Clinic (POC) at the University Hospital Limerick (UHL), which aims to provide a multidisciplinary medical service for obese paediatric patients, within resource limitations.

Obesity management is conservatively estimated to cost between 0.09 - 0.61% of total gross domestic income in Western and Northern Europe. The aetiology of obesity is multifactorial, including excessive caloric intake, insufficient physical activity and excessive sedentary behaviour. Children with overweight and obesity are at increased risk of obesity-related comorbidities, including type 2 diabetes mellitus, obstructive sleep apnea, dyslipidaemia and psychological consequences. Obesity tracks into adulthood: obese children are likely to become obese adults.

At the Paediatric Obesity Clinic, referrals for paediatric patients with high levels of excess adiposity were accepted from consultant paediatricians in UHLs catchment area. The POC comprised a full day clinic visit (of which 2 were scheduled) and a follow-up full day clinic (of which 1 was scheduled for all patients to attend). Invitations to the POC were sent to the parents/guardians of referred paediatric patients. On arrival for the first day of clinic, attendees and their parents completed the Obesity measures of anthropometrics and blood work and provided feedback on progress made since the initial POC.

Of the initial 15 referrals to the pilot POC, 12 paediatric patients (mean age=8.1; Range=3.6-13.6 yrs) and their parents attended the POC. All attendees were accompanied by their mother, with only one attendee accompanied by both their mother and their father. At the time of measurement, three attendees had 3 cardiometabolic risk factors at levels exceeding the expected values. All attendees at the POC had a waist-to-height ratio of greater than 0.5. Of the 12 attendees that were invited to return to the follow-up clinic day, only 1 patient returned.

Parent/Guardian reported information

The Obesity Clinic Assessment Questionnaire assessed parent/ guardian-reported health behaviours for the attendees of the POC. A range of poor dietary behaviours were observed in the majority of attendees, including high levels of sugary drinks consumed daily, a lack of structured meals in the home, low levels of vegetable intake and high levels of snacking. Furthermore, only 2 attendees consumed vegetables regularly, with remaining attendees consuming little or no vegetables daily. Although 66% of patients participated in school-based physical education, 58% exceeded the daily recommended amount of TV viewing (>2 hours/day), while 83% did not participate in any form of organized physical activity.

Parental Feedback

At the end of the POC days, parents and patients were asked to provide feedback to the multidisciplinary team. Many positives were identified, including: the broad range of accessible healthcare providers throughout the clinic; the individual consultations with healthcare providers (e.g. paediatricians and dietitians); the opportunity to meet and discuss issues with parents in similar situations; and the quantity and quality of information provided to help modify dietary and physical activity behaviours. Negative issues identified included: the lack of prior information provided in relation to clinic structure; the lack of available food and water for attendees; the absence of a point of contact within the clinic for queries; and the amount of available space for attendees and their families.

The authors state that “There is an important medical and public health need to address paediatric obesity, both in hospitals and in the community. POCs have the potential to be an effective and efficient resource to facilitate and achieve weight reduction in overweight/obese individuals.” The provision of clinic days, similar to those described here, presents a potential template for the efficient and effective delivery of professional healthcare support and assistance to overweight/obese paediatric patients and their families. Similar clinics, or interim clinics, in primary care would greatly complement the POC model described in this report. Alternatively, interim nurse-led hospital-based clinics to provide ongoing support to weight loss would complement this model.

Although attendance rates at the initial POC days were high, the attendances at POC follow-up days were disappointingly low. The absence of on-going funding for administration, dietetic and physiotherapy support throughout the year resulted in the delay of provision of a follow-up clinic, resulting in a prolonged period (approximately 6 months) between the initial POC and follow-up. Furthermore, due to the lack of administration support, only limited notification for parents/guardians of POC attendees was possible. Disappointingly, only 1 patient returned for follow up. Existing research suggests that parents of obese children require regular contact (weekly/monthly) with services for support and motivation, particularly when encountering difficulties in implementing interventions to modify dietary behaviour. The provision of funding to support administrative, dietetic, medical, nursing and physiotherapy services to future POC services would provide increased communication and support to parents/ guardians of attendees and their families, increased opportunities for consultations with attendees, increased capacity for the POC and opportunity to follow up, providing the opportunity to evaluate the effectiveness of the POC.

Some issues were identified by healthcare providers delivering the service. The broad age range of attendees made delivery of workshops and relevant information difficult. The streamlining of age cohorts for future clinics should be considered, enabling the more efficient delivery of key information to specific age groups.

Further defined criteria for eligibility is required for attendees, including where attendees are referred from (i.e. consultants only or GP’s and consultants), where attendees are referred to post-clinic (back to consultants/GP’s), the ages of attendees (i.e. potentially limiting children between the ages of 5 - 15), the BMI centile of attendees (i.e. only children > 95 percentile), the requirement of provision of blood samples (some parents reluctant to give consent for further phlebotomy) and the requirement for attendance at multiple clinics (i.e. initial POC day, potential for second POC day and final follow-up/evaluation POC day).

The authors conclude that the pilot POC at University Hospital Limerick has identified the need for clinics that aim to modify the health behaviours of patients with paediatric obesity. For such clinics to be successful, additional administrative and financial support is required to ensure the “buy in” from attendees and their families, to ensure the continued attendance at future clinic dates and to ensure the provision of an efficient and effective service.

All references and author names are contained in the full article in this month’s IMJ, p.2

Title: The Establishment of a Pilot Paediatric Obesity Clinic at the University Hospital, Limerick

For further information contact: Communications Unit, Irish Medical Organisation, 10 Fitzwilliam Place, Dublin 2.  

September 2015 - Volume 108 - Number 8

Twitter in Medicine – A valuable online teaching resource?

September 2015 - Volume 108 - Number 8

Surgical Grand Rounds (SGR) have traditionally been a keystone of clinical medical teaching. Despite the educational potential of SGR, often the material presented is not routinely stored. Presentations are often transiently available and not accessible for medical students at key times of revision for examinations.

Previous studies have demonstrated the efficacy of novel web based technology such as Facebook, YouTube and Twitter as educational tools. In this study the authors O’Kelly et al sought to describe the usage of Twitter to allow a readily accessible, searchable online repository of SGR presentations for final year medical students.

The Twitter profile @surggrandrounds was created was created for the purpose of this study and presenters at SGR were asked to email presentations in Microsoft PowerPoint format to a central Royal College of Surgeons in Ireland email address. Presentations were edited to remove any images or text which might compromise the anonymity of the cases being presented. The PowerPoint files were then saved in portable document format (PDF). The website is one maintained by the authors for the purposes of postgraduate surgical education.

A link to each presentation with a short description was posted as a ‘tweet’ on the @surggrandrounds Twitter profile. The creation of @surggrandrounds Twitter profile was announced at the commencement of the academic year for the final year medical students attending the Royal College of Surgeons in Ireland. After an initial three month period a Likert scale questionnaire given to students on clinical rotation assessing the usage and perceived usefulness of the Twitter based online repository.

Within a two week period following its launch the @surggrandrounds profile had more than 120 medical students following the Twitter feed. Over the three month period a total of 43 Tweets were sent, and 28 SGR presentations were made available. Overall 93 final year students were invited to complete the Likert-based questionnaire, there were 84 respondents giving a response rate of 90%. A total of 31 respondents (36.9%) used the @surggrandrounds Twitter feed to access SGR presentations over the three month period. Of these 25 (80.6%) felt that the online provision of SGR through twitter was “useful”. The majority felt that the online content was easily accessible, with 8(25.8%) undecided, and 1(3.2%) stating the content was not easily accessible. All of the respondents who had used the @surgrandrounds Twitter feed to access SGR presentations felt that it should continue as part of surgical clinical teaching in the Royal College of Surgeons in Ireland.

Recent studies have shown that online media tools can be integrated into daily educational practices and augment learning and collaboration. In this study the authors sought to use a social media strategy to improve the uptake and accessibility of SGR presentations. With such ease of access these high quality presentations were available to students at exam time and as a reference in clinical settings. An increased uptake was noted in particular in students who regularly use social media including Twitter. However the authors note that despite the relatively high levels of social media (92.9%) use, and in particular Twitter (57.1%) usage, only 36.9% of students regularly accessed the @surggrandrounds Twitter feed. The authors suggest that this might represent a desire of students to keep their social media identities personal rather than integrate them into their professional lives.

The authors note that the model presented in study could be easily replicated for ease of access to SGR presentations. This opens the possibility of expanding the @surgrandrounds Twitter feed to other hospitals associated with RCSI. The authors conclude “The novel use of social media is a useful educational tool, allowing ease of access to an invaluable repository of SGR presentations at times of revision. The majority of students using the Twitter SGR feed found it easily accessible, useful and felt it should be continued as part of hospital-based surgical education.”

All references and author names are contained in the full article in this month’s IMJ, p.249

Title: Using Social Media to Increase Accessibility to Online Teaching Resources

For further information contact: Communications Unit, Irish Medical Organisation, 10 Fitzwilliam Place, Dublin 2.   

GP study shows cost as a major factor of AED availability in General Practice

July/August - Volume 108 - Number 7

In Ireland GPs are well placed to deliver early care in many communities; however the question of whether GPs are likely to have an AED available has to date been unanswered. This study in the July/August edition of the Irish Medical Journal explores the availability of advisory external defibrillators (AEDs) amongst GPs not already involved in the Merit project. The University College Dublin MERIT Project is a prospective observational study of cardiac arrest with resuscitation attempts by GPs in Ireland.

There are approximately 2,000 sudden cardiac deaths in Ireland annually. In up to 80% of cases, sudden cardiac death is related to coronary artery disease with the commonest mechanism of death being due to ventricular fibrillation (VF). VF is a sudden onset of chaotic disturbance of the heart’s electrical rhythm, which stops the output of blood from the heart. An AED (Advisory External Defibrillator) is a small, portable piece of equipment that can deliver an electric shock in order to convert VF to a sustainable or usual rhythm (defibrillation). Survival rates following cardiac arrest are directly related to time to defibrillation. Each minute of delay between cardiac arrest and defibrillation reduces the probability of survival to discharge by 10–12%.

A valid sample paper survey response rate of 115/195 (59%) was achieved.
- Of the 35 GPs who reported not having an AED, 49% of GPs detailed cost as a reason.
- 67% of GPs reported having one or more AED(s) available for use at their practice.
- 53% of GPs who had not responded to the paper survey but were contactable by telephone had an AED available.

When AED availability was examined by practice setting a higher proportion of rural and mixed settings had AEDs available than in urban and city areas. The authors noted that this is an important finding in the context of Merit data, which illustrated that more cases of cardiac arrest with GP involvement occurred in rural and mixed settings than urban ones. Cost was reported as the most common reason for not having an AED.

Of the 74 GPs who had an AED available;
- 51 (69%) had AEDs that were only available at the practice premises,
- 14 (19%) had AEDs also available on house calls and 9 (12%) had AEDs available at the practice, on house calls and whilst the doctor was off duty.
46% of GPs who confirmed AED availability via the postal survey reported that they had used an AED to treat cardiac arrest in the preceding 10-year period. On average those GPs who had used an AED to treat cardiac arrest did so 2.2 times over that period. One GP reported using an AED on 10 occasions.

GPs reported using an AED to treat cardiac arrest on 75 occasions in total with survival to hospital discharge reported on 26 occasions representing a reported survival to hospital discharge rate of 35% in cases where an AED was used.

The basic issues of GP involvement in cardiac arrest management continue to draw mixed responses; Toon recently questioned the value of Basic Life Support training for GPs , the 2010 RACGP ‘Practice Standards 4th Ed’ do not require an AED as essential emergency equipment and in Britain, the Care Quality Commission recommends but does not require general practices to have defibrillators.
In Ireland the HSE Primary Care Reimbursement Scheme and Irish College of General Practitioners provide no guidance on defibrillator availability. Despite the above observations this study has demonstrated that a significant proportion of Irish GPs have already equipped themselves with an AED.

If Merit practices are considered to represent one third of an estimated 1,500 Irish general practices then this study would suggest that overall at least two thirds of Irish general practices have an AED available at the present time. This observation would compare favourably with published studies of AED availability in other European countries. The authors suggest that promoting strategies to insure rural GPs continue to be equipped with an AED might form part of a strategy to provide evidence based interventions to patients who suffer cardiac arrest in more remote locations with longer statutory EMS response times.

Data from the Merit Project suggests that a high percentage of cases of cardiac arrest (47%) occur in the patient’s own home. Although GPs perform house calls as part of their day to day work, the data collected in this study demonstrated that AED availability was primarily at the surgery location (69%) and fewer GPs had AEDs available on house calls (19%) and when off duty (12%).
There may be potential to improve cardiac arrest outcomes by increasing GP AED availability outside of the surgery. Data from this study suggests that almost half of the GPs who did not have an AED available listed cost as a factor. In a time of significant funding pressures cost is an issue that warrants consideration. The issue of AED cost is not new and has been previously described as a limiting factor in the international literature.

Although cardiac arrest is not a frequent clinical occurrence in Irish general practice it is likely that over time many GPs will encounter it. The authors conclude that although a high percentage of Irish GPs are already equipped with an AED, additional capacity could be developed by focusing on a number of specific issues such as cost supports and prioritisation of remote and rural areas.

All references and author names are contained in the full article in this month’s IMJ, p.212

Title: Advisory External Defibrillator Availability in General Practice

For further information contact: Communications Unit, Irish Medical Organisation, 10 Fitzwilliam Place, Dublin 2.

Notes to the Editor
The cohort of GPs already known to possess an AED (via participation in the Merit Project) was excluded.

Silver Surfers –Trends of Internet Usage and the Potential Health Benefits

June 2015 - Volume 108 - Number 6

A study in this this month’s Irish Medical Journal highlights the potential of Internet-based interventions to improve healthcare in the elderly. The study looks at the trends in Internet use in the elderly over the last 12 years in Europe and, in particular, Ireland. The study demonstrates how Internet use amongst over-65s both in Ireland and the EU is increasing; nearly trebling over the ten year period. Online interventions have many benefits for older people as they may overcome impaired mobility, social isolation and limited access to transport.

The analysis focused especially on 1606 Irish individuals. Internet use among the elderly has increased broadly in line with the rest of Europe but we still lag far behind some European countries. Older people in the Netherlands, Denmark, Sweden and Norway are more than twice as likely to have access to the Internet when compared to Irish people.

The Internet provides medical information and interventions with promising benefits. This cross-sectional study explored the trends in Internet use among the elderly in Ireland from 2002 to 2010 and considers possible implications for health benefit. Data were analysed on 1606 Irish individuals.
Internet use in Ireland is increasing at similar rates to the rest of Europe; the percentage of over- 65s using the Internet in Ireland nearly trebled from 2002 to 2010, from 26(8.3%) to 92(24.1%). Subgroups of this population displayed significantly higher rates of Internet usage; namely those with a better education, living with a partner, males and urban dwellers. Of those with good subjective general health, 230 (21%) had internet access, versus 36 (7.1%) with poor health.

Recently, the Internet has been used for healthcare interventions. Many studies have looked at online peer-based support groups and, while these studies have had mixed results; the authors acknowledge that it is an area with great potential that warrants further study.

These interventions are effective in the self-management of chronic illnesses. It is best demonstrated in diabetes and chronic pain but there is emerging evidence for online interventions in cardiovascular disease including smoking cessation. The interventions aid in the practical aspects of a disease (e.g. reminders to take medication, advice on how to control risk factors) and help with the emotional aspects of illness via chat rooms and forums. In addition to directed interventions there is preliminary evidence that Internet and e-mail use, in and of themselves, may improve cognitive functioning in the elderly.

Web-based interventions have shown promising results in mental health, specifically depression, anxiety and substance misuse. Internet Cognitive Behavioural Therapy (ICBT) has comparable efficacy to face-to-face treatment. Web-based interventions are a useful adjunct to clinician-delivered treatment, as well as an initial treatment for those reluctant to seek help20.

The benefit of Internet therapies is that information can be delivered in a way that is appealing to patients, such as using audio-visual cues, interesting graphics and, perhaps most importantly, 24-hour access. Another key advantage is cost-effectiveness, as they require minimal expenditure after development; a particularly appealing idea in the current economic climate.
In the elderly population, the Internet has the potential to improve mental health. The increased rates of chronic illness, bereavement and social isolation expose older people to many risk factors for mental illness. Use of the Internet in the elderly can prevent loneliness and online interventions are a viable option for those who have trouble seeking face-to-face healthcare (e.g. those with poor mobility or limited access to transport). Moreover, substance misuse and depression are common in the elderly and these disorders have been shown to be successfully treated via the Internet

A cross sectional study was used to address the research question. Data from the European Social Survey (ESS) was analysed. Individuals who reported having “no Internet access at home or in work” and individuals who reported never using the Internet were classified as non-Internet users. Individuals who reported using it less than once a month or more were classified as Internet users. The primary exposure was the year the data were collected in.

This study primarily focused on those over 65 living in Ireland but, where it was relevant, comparisons were made to other countries in Europe. All data were weighted according to the ESS guidelines.

Overall, comparing 2002 to 2010, there was a 290% rise in Internet use. The authors found that on average there was a 41% rise every two years in the proportion using the Internet. After controlling for age, gender, subjective health, whether a person lives with a partner or not, educational history and area of residence there was a 63.0% increase in Internet access every two years. This is compared to TV watching in the over-65s which only saw a 3.1% rise (64.1% to 66.1%) and both radio listening and newspaper reading which have actually decreased since 2002.

• Gender

Irish females were less likely to have access to the Internet compared to their male counterparts. While Irish females are less likely to have access to the Internet, their Internet access is growing at nearly twice the rate of their male counterparts. Males on average see a 28.7% rise, while females have seen a 61.2% rise during each two year period.

• Age
While those aged over 74 are much less likely to have access to the Internet, analysis saw that this group is seeing a more rapid increase. In the 65-74 year olds there was a 38.4% increase in those with Internet access in each two year period, however, there was a much larger increase in those over 74 of 66.4%.

• Education

Those with a history of leaving education earlier are less likely to have access to the Internet but this population has a faster rate of increase in online access (62.2 compared to 46.0% every two years)

• Geographical Location

The increase in access of the Internet has occurred at a similar rate in urban and rural settings. Subjective Wellbeing and Subjective Health Internet access has increased at similar rates between those with good and poor subjective health. Analysis was done on the Irish population to see if there were higher rates of subjective wellbeing in those with Internet usage compared to those without and, whilst there was a small increase in subjective wellbeing in those with access to the Internet, no statistically significant difference was found.

In comparison with reading the newspaper, listening to the radio and watching TV, this study shows that Internet access is the most rapidly growing medium for conveying information in those over 65. Internet access is becoming an important factor in healthcare and has a similar level of importance as literacy. As such, it is a key component of any social history and physicians should routinely enquire about it.

The authors recommend that “web-based interventions targeting the elderly should become more available. These could be particularly useful in populations with limited access to transport and mobility.” The authors support the establishment of Internet courses for elderly people and further study into the potential of Internet access and online based interventions in older people. Existing online interventions should be tailored to older people and new services should be developed. Such interventions could include appointment reminders, medication reminders, medical education and ICBT.

All references and author names are contained in the full article in this month’s IMJ, p.171
Title: The Silver Surfer: Trends of Internet Usage in the Over 65 and the Potential Health Benefits
For further information contact: Communications Unit, Irish Medical Organisation, 10 Fitzwilliam Place, Dublin 2.
Notes to Editor
The ESS is an academically driven biennial cross-sectional survey that has conducted surveys between 2002 and 2012. ESS data are available on an open-access basis at ( Data were collected by an hour long face-to-face interview24. In this study the primary outcome was Internet usage, recorded as a binary variable.

Irish study assesses treatment outcomes for adolescents abusing alcohol and cannabis

May 2015 - Volume 108 - Number 5

Alcohol and cannabis are the primary substances contributing to referrals of adolescents to substance use treatment services. According to recent studies half of Irish 16 year-olds report have used alcohol in the past month and 18% report lifetime cannabis use. Cannabis has become the dominant drug leading to referrals into adolescent addiction treatment services in the past decade. Their outcome has not been examined in Ireland. The aim of this study in the May edition of the Irish Medical Journal by Smyth et al was to assess the three-month outcomes for patients presenting with high risk alcohol and high risk cannabis use following attendance at a specialist outpatient treatment service for adolescents. The study followed up 35 high risk users of alcohol and 55 high risk users of cannabis.

Motivation among adolescent treatment attenders tends to be poorer than among adults. In large clinical trials examining treatment of adolescent cannabis use, interventions tend to yield reductions in days of drug use of 25-38%. Heterogeneity in treatment interventions and in measured outcomes makes it difficult to provide succinct comment on outcome of adolescent alcohol use disorders. Some interventions show no change, while others report up to 50% abstinence at three months.

As abstinence is rarely sustained in adolescents, harm reduction approaches have been proposed. It has been argued that evaluations of addiction treatments should measure the proportion of patients who achieve reductions in substance use which are of clinical and statistical importance, but fall short of abstinence.

The study setting was a specialist outpatient treatment service for adolescents experiencing substance use problems. The treatment provided included individual counselling and family therapy. While abstinence is encouraged, it is not a compulsory goal. Involvement of parents in assessment and treatment is encouraged but not mandatory. While treatment is tailored to the individual’s needs, a basic treatment episode involves about six sessions over two months, with family input into two or three of these.

Psychiatric treatment is offered where comorbidity is identified. The primary outcome measure in the study was the number of days consuming alcohol and/or cannabis in the previous month.

The study used the ASSIST questionnaire which provides estimates of substance-related risk. The SOCRATES assesses an individual’s motivation to change their substance use, examining alcohol and drugs separately.
‘Regression to the mean’ complicates assessment of behaviour change in simple pre/post study designs. Therefore, the proportion of patients who achieve a ‘reliable change’ in their baseline substance use was also examined.
• There were 143 consecutive eligible patients, of whom 35 did not enter the study (16 patients refused, 14 cases unable to obtain consent from a parent and 5 cases unclear).
• Past month criminal activity was reported by 51%, with drug selling (30%) and shoplifting (22%) being most common.
• 49 (45%) patients were identified as having ‘high risk’ use of more than one substance.

Motivation was low or very low among the majority of high risk users of each individual substance apart from high risk opioid users. Among those reporting both high risk use of alcohol and high risk drug use, motivation scores were significantly higher regarding the drug problem compared to the alcohol problem.

• The median number of appointments attended by patients was seven (Inter-Quartile range [IQR], 5-12).
• The median number of appointments attended by parents was three, and in 34% of cases parents did not attend any clinical appointments.
The authors of the study conducted follow-up interviews with 87 (81%) participants. Among those identified as high risk drinkers, alcohol was their most problematic substance in just 52% of cases. Among these high risk drinkers, follow-up information was available in 35 (83%) cases.

Although the high risk drinkers achieved a significant reduction in median number of days drinking, only four (11%) were abstinent at follow up. A further five (14%) achieved a reliable reduction in days of drinking. One person had reliably deteriorated while 25 (71%) were unchanged.
The median days of alcohol use reduced from 12 at baseline to 7. The mean days dropped by 27%, from 11 days per month to 8 days. There was also a significant reduction in the number of standard drinks per month, reducing from a median of 120 to 60.
Among high risk cannabis users, follow-up information was available on 55 (71%) people. The median days of use reduced from 25 to 15 and this was statistically significant. The mean days dropped by 32%, from 22 days per month to 15 days. Six people (11%) were abstinent at follow-up and a further 20 (36%) had reliably improved. There were four (7%) patients who reliably deteriorated, while 25 (45%) were unchanged.

The outcome of the cannabis users was not significantly associated with gender, referral source, baseline criminal activity, baseline motivation, family involvement in treatment or dose of treatment.
Assessing the results of the study, Smyth et al have noted that motivation was very poor when compared to adult treatment-attending groups and motivation regarding alcohol problems was particularly poor. Where drug and alcohol problems co-occurred, patients were more motivated to address the drug problem. This highlights the complexity of motivation in real world clinical settings, where patients can be quite motivated to make some changes while being unmotivated to address other issues.
The authors say “Unfortunately, given the interconnections between alcohol and drug use, a disinterest in addressing problem drinking may impede progress in tackling drug use. Although high risk drinkers reduced their days of drinking and total monthly alcohol consumption, the magnitude of improvement was quite modest.“

Pharmacological agents to treat alcohol use disorders were not prescribed to this patient group, but some have argued that there is a growing role for these in adolescents. Only one in nine high risk drinkers achieved abstinence. This illustrates again the elusive nature of this goal in adolescents with significant substance use disorders. The authors note that the alcohol outcomes in this study are probably poorer than those reported in international, mainly American, studies. The cultural context of youth drinking is very different in Ireland, as there is a lower legal drinking age, a decline in actual age of drinking onset, increased adult drinking, and unhealthy drinking is the norm. This ‘wet’ society may impact negatively on the ability of Irish adolescents to recognise their own unhealthy drinking and to change it when they do.
Although only one in nine of the high risk cannabis users were abstinent at follow-up, a further one third achieved substantial reductions in their cannabis use. Across the group of high risk cannabis users, the mean days used per month fell by 32% and seems acceptable, falling within the range of other international studies.

The authors note the limitations of the study including the fact that the treatment intervention was not manualised. For ethical and practical reasons there was no control group in this study. Consequently, it was not possible to determine whether this treatment was better than no treatment. However, the use of the reliable change methodology compensates for this deficiency to some extent, by identifying the magnitude of change that is likely to be independent of ‘regression to the mean’.

Although changes in substance use were reliant upon self-report, there is a high concordance between self-reported drug use and toxicology in young people. As the vast majority of the participants fell into the poor motivation category, this reduced the power to detect possible significant associations between motivation measures and outcome. The time gap to follow-up of three months may have been too short for some patients to make substantial changes to their substance use.

The authors conclude that as motivation tends to be quite low, especially for alcohol use disorders, services should assess it at the outset of treatment and target poor motivation where it does exist. Although the average reductions in substance use were modest, and broadly in line with international studies, the proportion of patients who achieved abstinence was low. It is important that patients, parents, referrers and funders of adolescent drug and alcohol services have realistic expectations of treatment.

All references and author names are contained in the full article in May 2015 IMJ, p.137

Title: Treatment Outcome for Adolescents Abusing Alcohol and Cannabis: How Many ‘Reliably Improve’?

April 2015 - Volume 108 - Number 4

GP Experiences on assessing fitness to drive

April 2015 - Volume 108 - Number 4

Assessing fitness to drive is part of the role of general practitioners. GPs act as medical examiners for driver licensing purposes and informed advisers to their patients in relation to safer driving. In a study published in this month’s Irish Medical Journal GPs experiences on assessing fitness to drive is analysed.
Cognitive impairment may impair an individual’s ability to drive safely. With an increasingly elderly population assessing fitness to drive in patients with cognitive impairment is something GPs are faced with regularly. Progressive cognitive decline is one of the main reasons to advise older drivers to stop driving. However younger people may have cognitive impairment from a variety of aetiologies. Mild cognitive impairment is a state between normal cognition and dementia where there is evidence of cognitive decline but the activities of daily living are preserved. The cognitive domains which may be impaired in dementia are memory, language, abstract thinking and judgement, praxis, visuospatial skills, personality and social conduct.

However regardless of age, cognitive impairment has consistently been shown to increase the risk of crashing. In Ireland, it is a legal requirement for those aged over 70 years to undergo a medical assessment to be certified as fit to drive. Certification may be granted for one or three years. This may change as the National Programme Office for Traffic Medicine has recommended a shift in focus away from age-defined medical screening. A study published in Denmark in 2012 demonstrated that cognitive screening of older patients and subsequent revoking of fit to drive status resulted in a significant increase in the mortality of older road users. This suggests that loss of their driving licence resulted in the use of significantly less safe modes of transportation.

The authors Doherty et al mention that driving is a key element of social inclusion and independence at all ages, requiring the integration of numerous cognitive, visual and motor functions. An elderly person who can no longer drive is less likely to receive the services they need and more likely to enter a nursing home. Driving cessation can cause depression, social isolation and strain on the doctor-patient relationship.

Relatives may express their concerns to the GP about an individual’s fitness to drive. Unfortunately patients with dementia will eventually lose the ability to drive. It is important to decide with the patient when driving cessation should occur, what assessments are needed and what alternative transport is available. Guidelines such as those from the Road Safety Authority (RSA) provide limited advice on driving and cognitive impairment.

Performance based road testing is the closest to a gold standard in the area of driving assessment. Problems associated with on road testing including the cost and a lack of standardisation. Restricted licensing (e.g. avoiding motorways or only driving by day), is practiced in parts of Australia and in the state of Utah for people with impaired driving ability. There is no provision in Irish law for restricted licencing.

Findings of the survey among two hundred GPs in counties Mayo, Galway and Roscommon fournt
• 96.8% of GPs agreed that assessing fitness to drive is an important issue, with 84% of respondents assessing fitness to drive on a weekly or daily basis.
• 68.8% (n=86) use guidelines; with 75.5% (n=65) of those citing the Road Safety Authority (RSA) as the primary guideline in use. However only 31.2% (n=39) of GPs agreed that the RSA provide adequate guidance.
• When assessing fitness to drive 66.4% formally assess cognitive function in patients where there are any concerns. The most commonly used assessment tool was the Mini-Mental State Examination (83.2%).
• 78.4% of respondents have referred patients for further assessment. The commonest places of referral were geriatrics (74.4 %), psychiatry of later life (32.6 %), external driving assessors (30.6 %) and Occupational Therapy (8%).
• Nearly all GPs (97.6%) would refuse to certify someone fit to drive if they had concerns about cognitive impairment.
• More than one in five GPs (21.6%) had patients leave their practice over revoking a driving licence.
• 41.6% of GPs stated that they would certify someone fit to drive with verbal restrictions on driving. However, rural GPs opted for this approach significantly more often than urban GPs
• GPs agreed that patient isolation (69.6%) and lack of alternative transport (54.4%) were factors which influenced their decision. Rural GPs were significantly more likely to be influenced by a lack of public transport than urban GPs (68.18% vs 39.13%).
• 76.8% had concerns over their legal liability.
• 60% of respondents felt that a GP should be the primary assessor of fitness to drive.
• Almost half (47.2%) stated that it may interfere with the doctor-patient relationship.
• 59.2% of respondents indicated they would like further education on assessing cognitive function.

The majority of GPs in this study agreed that assessing medical fitness to drive is an important issue that they dealt with on a daily basis. GPs are confident in their ability to assess fitness to drive and would not certify someone if they had concerns about cognitive impairment. However there is a paucity of guidance both in Ireland and internationally for General Practitioners with regard to driving assessment in cognitive impairment. The authors note that the newly published guidelines from the Road Safety Authority, ‘Sláinte agus Tiomáint’, were unavailable at the time of this study.
In other countries, New Zealand for example, Occupational Therapists have a well-developed and established role in assessing fitness to drive and are frequently consulted with difficult cases. This contrasts with the findings of this study, which shows that OTs are not being frequently referred to. OTs can assess visuoperceptual skills and judgement, cognitive domains which, from a practical perspective, are not amenable to comprehensive assessment in a GP surgery. There may be an opportunity in Ireland to expand the role of the community OT to encompass driving assessment.

The results of the survey found that rural GPs were more likely to take patient isolation and lack of public transport into account when making driving assessments. “Many rural patients need their car to access basic services like the shops, post office and GP surgery. Taking away their licence may result in loss of the ability to live independently, and may have negative social, psychological and medical effects. Restricted Licencing is attractive as it allows the patient to maintain this vital link with society while protecting other road users” the authors observed.

The study highlights the fact that a significant number of GPs- 76.8% -have concerns about their own legal liability. Similar concerns are highlighted in the literature. GPs also feel that assessing fitness to drive can have a negative effect on the doctor-patient relationship, with a fifth of GPs surveyed stating they have had patients leave their practice because of driving issues. GPs in this study also cited pressure from patients and patient’s families as a factor which has influenced driving assessments. Driving is a hugely emotive issue and a GP has to balance his/her role as an advocate for the patient’s independence with their own responsibilities towards road safety.

Finally the authors state that there are several measures which would assist with the task of assessing patients with cognitive impairment for driving fitness. These include the issuing of clear driving assessment guidelines to GPs, the availability of a legal back up for restricted licencing and government funded driving assessors to help GPs deal with difficult cases. This would enable patients to maintain maximum independence, keep the roads as safe as possible and improve the doctor-patient relationship.

All references and author names are contained in the full article in April 2015 IMJ  p.112

March 2015 - Volume 108 - Number 3

Open-Access Ultrasound Referrals from General Practice

March 2015 - Volume 108 - Number 3

A study published in the March edition of the Irish Medical Journal presents evidence to support the provision of a nationwide direct access referral system for general practitioners. Direct access referral for radiological investigations from General Practice (GP) provides an indispensable diagnostic tool and avoids the inherently long waiting time that referral through a hospital based specialty would entail.

A 2011 HIQA report recommended that the HSE should carry out a review of the benefits of a direct access referral system. According to the authors no such review has been carried out to date. There is significant data supporting the benefits of direct access referral for ultrasound, though little in the recent literature and none in Ireland. This study aimed to review all direct GP referrals for ultrasound investigations to a tertiary referral teaching hospital and to assess the waiting times and diagnostic outcomes.

Ultrasound is a non-invasive, radiation free investigation with a wide variety of clinical applications. Direct access for General Practitioners (GPs) to hospital based radiology services, in the form of plain film radiography, is well established. Direct access to ultrasound however is not universally available in Ireland. The traditional patient care pathway in Ireland involves referral to a hospital specialist who may then request imaging if deemed appropriate.

Direct access to ultrasound for general practitioners allows the referring physician to make an informed decision with regard to the need for specialist referral. The authors believe that the findings from the study help support the case for national direct access to diagnostic ultrasound for general practitioners.
Patients who had an ultrasound requested by a GP were included in the study; patients were excluded if the referral was from a Hospital Consultant. The radiology reports from the studies were reviewed by a Specialist Registrar in radiology. Patients were divided into two possible groups: those with positive findings and those with normal studies. A positive finding was classed as any finding which could explain the patient’s symptoms or a significant incidental finding. The number of patients who had a recommendation for subsequent specialty referral or who underwent follow up imaging investigations was also noted.

The results of the study found:
• Over the 7 month period, there were a total of 7,624 ultrasound investigations carried out in our department.
• Of these, 1,090 referrals (14.3%) originated from general practice.
• A total of 327 different referring physicians were identified. The majority of these (304) referred less than 10 patients each.
• 21 GPs made between 10-20 referrals and 2 physicians sent in excess of 20 referrals in the 7 month period.
• The average age of patients was 43.7 years (range 16-91 years).
• The median turnaround time was 56 days from the time of referral to the time of scan.
• Of the 1,090 studies, there were positive findings in 332 (30.5%) patients.
• 71 patients (6.5%) had further imaging investigations either to further characterise a lesion seen on ultrasound or to ensure resolution or stability of a detected lesion.
• 35 patients (3.2%) had a recommendation for subsequent referral to a hospital based specialist based on the result of their ultrasound.

Within the category of positive findings, there were 9 patients who required urgent specialist referral including; 2 large abdominal aortic aneurysms both of which underwent endovascular repair within 2 days; 2 patients with newly diagnosed metastatic disease to the liver; 1 suspicious thyroid mass later confirmed as papillary thyroid cancer; 1 patient with extensive lymphadenopathy later confirmed as Hodgkin’s lymphoma; 1 patient with hydronephrosis secondary to an obstructing calculus; 1 patient with a neck abscess requiring surgical drainage. Further review of the indications for these studies demonstrates that urinary tract infection was the most common reason for referral, accounting for 47 of 131 cases (44 of which were normal) while flank pain accounted for 32 cases (28 of which were normal).

Direct access ultrasound for general practitioners has been consistently shown to yield a similar rate of positive diagnostic outcomes to referrals generated from the hospital outpatient department which demonstrates that general practitioners make good use of the resource when it is made available to them. There are well established referral guidelines available to GPs, such as the Royal College of Radiologists “iRefer”, to guide GPs in the appropriateness of referral and to ensure the correct radiological investigation is performed to “obtain maximum information with the minimum of radiation, inform clinical management, reassure the patient and add confidence to the clinician’s diagnosis.
In the case of a normal result, the GP is able to provide reassurance to the patient and avoid unnecessary specialist referral.” In the absence of a direct referral system, GPs have no choice but to refer patients that require imaging to hospital based specialists. The authors point out that from the results of this study it up to 1,046 patients were able to benefit from a diagnostic study and avoid an unnecessary outpatient visit. By removing the need to go through a hospital specialty a considerable saving can be made in terms of waiting time.

This study provides further evidence to support the provision of a nationwide direct access referral system for general practitioners. At a time where outpatient departments are stretched to capacity and there is a politico-economic movement towards re-emphasising the role of primary care physicians as the gatekeepers to the hospital system, we believe that providing an adequately resourced direct access ultrasound service is of benefit to hospitals, general practitioners and patients alike

All references and author names are contained in the full article in March 2015 IMJ, p.83
Title: Open-Access Ultrasound Referrals from General Practice

February 2015 - Volume 108 - Number 2

Children’s Television and Nutrition

February 2015 - Volume 108 - Number 2

In the editorial of this month’s Irish Medical Journal, a study which investigated the frequency and type of food and beverage in children’s television programming within the Irish context is analysed.

Food advertising aimed at children is dominated by high calorie, low nutritional quality foods. Advertisements provide a convenient opportunity for children to eat; evidence suggests that people snack more while watching television. Thus, foods that should be eaten in moderation comprise a large proportion of children’s food advertisements. Encouragingly, however, the number of food advertisements children are viewing appears to be decreasing.

The authors of this study investigated the frequency and type of food and beverage in children’s television programming, and described the context, motivating factors and outcomes of food and beverage placements on public broadcast channels within Ireland (RTE) and the UK (BBC). The authors describe these as “public-good” channels, which aim to inform, educate and empower audiences. In the study, unhealthy foods such as sweet snacks and candy accounted for 47.5% of all food-specific placements and sugar-sweetened beverages accounted for 25% of all beverage placements.

The results of the study were consistent with previous research, social or celebratory motivations for food and beverage depictions within children specific programming were most common. Motivations and outcomes for cues were similar across UK and Irish television programming. Thus, eating (particularly, eating fatty and sugary foods and sugar-sweetened beverages) is portrayed to children in an attractive and appealing light.

The authors further analysed the portrayal, motivating factors and outcomes of food and beverage placements within different genres of children television including cartoon, animated, movies, quiz, and tween programming (unpublished data).

Overall, more than 50% of depicted food cues across genres were for unhealthy foods. Fruit and vegetable related cues were evenly distributed across most genres (about 10%). A high proportion of fast food and convenience foods was seen within tween programming and a high proportion of sweet snacks and sweets/candy-related cues were seen in animated, cartoon and children genre programmes. A very small proportion of unhealthy food types were depicted within quiz programming. These results highlight the high proportion of unhealthy foods depicted, independent of program genre.

To date, most research on children’s television advertisements has focused on advertisements during broadcasts within the United States, thus to address this issue the authors of the study recently examined advertisements within Irish television during children specific programming. The results of this showed that 31% of advertisements related to food or beverage products, with 66.3% of food advertisements for foods that should be eaten in moderation. The most frequently recorded food advertisement was for fast food products (27.3%), followed by sweets/candy (21.6%) and dairy products (17.0%). Significantly there were no advertisements broadcast for healthier foods such as fruit or vegetables.

Television has the power to either aid in or oppose the fight against the current obesity epidemic in children. In 2012, new regulations issued by the Broadcasting Authority of Ireland, prohibited the endorsement of foods with high fat, sugar and salt content by celebrities, sports stars, programme characters, characters and personalities from cinema releases, and prohibited health or nutrition claims, or inclusion of promotional offers. The authors of the study not that “these regulations do not address the positive and frequent portrayal of unhealthy food products during children specific television broadcasting. We suggest that parents, policy makers and physicians should be aware of the frequent portrayals of unhealthy food and beverages in children’s television.”

In conclusion the authors say the potential impact of unhealthy food and behaviour portrayals on children requires further research. Future, children’s television programmes makers should address these concerns by including frequent and positively associated connotations with healthy foods and behaviours. The future of children’s programming should include the active inclusion of more frequent and positively associated connotations with healthy foods and behaviours. In addition to attempting to restrict the amount of time spent watching television programming it is also important to change the messages being portrayed regarding food and eating habits on the programs being viewed.

All references and author names are contained in the full article in February 2015 IMJ, p.37
Title: Children’s Television and Nutrition

January 2015 - Volume 108 - Number 1

Pedestrian Deaths in Children – Potential for Prevention

January 2015 - Volume 108 - Number 1

A study reviewing pedestrian deaths in children published in the January edition of the Irish Medical Journal reveals that the highest proportion of deaths (53%) occurred in the 1-4 year age group. The authors of the study Hamilton et al reviewed the National Paediatric Mortality Database (NPMR) for the six year period 1st January 2006 to 31st December 2011. The National Paediatric Mortality Register (NPMR) is based in Temple Street and collects data on all paediatric deaths in the Republic of Ireland aged from 29 days to 16 years.

Injury from road traffic incidents is a leading cause of child deaths worldwide. In Ireland, progress has been made in decreasing child road- related deaths and injuries in recent years; the number of paediatric pedestrian fatalities reduced by 50% between the timescales 1996-2000 and 2004-2010.

In the period 2006-2008 pedestrian death rates increased (from 0.8 to 1.31 per 100,000 population aged 0-14yrs) however from 2009-2011 rates have continued to decline (1.06 to 0.41 per 100,000 population aged 0-14yrs).
The authors identified 45 child pedestrian fatalities in the period examined. Traffic related deaths accounted for 58% (n=26) vs. 42% (n=19) non-traffic related. Analysis of the deaths showed there was a male preponderance (62%, n=28), weekend trend (49%, n=22) with an evening (35%, n=16) and summer peak (44%, n=20). The highest proportion of deaths occurred in the 1-4year age group (53%, n=24), with 28% (n=13) due to low speed vehicle rollovers, mainly occurring in residential driveways (61%, n=8).

Sixty eight per cent of non-traffic related deaths were due to low speed vehicle rollovers. The mean age for the rollover deaths was 21.7months. In all cases of rollovers the cause of death was due to head injuries sustained in the incident. In 81% of cases the incident took place outside the child’s residence. In 54% of cases the driver of the vehicle was a family member and the vehicle was performing a reverse manoeuvre.

The authors of the study assert that child pedestrian fatalities are highly preventable through the modification of risk factors including behavioural, social and environmental. Preventative action needs to be addressed, particularly in relation to non-traffic related deaths i.e. low speed vehicle rollovers.

Young children lack the cognitive skills, attention and perception skills to interact safely with road vehicles. Children may fail to appreciate the danger associated with fast moving traffic and be unable to integrate speed and distance of vehicles. Play activity places children in unsafe locations such as driveways, and children are highly influenced by the behaviour of peers and heavily rely on adult supervision. Reversal alarms and rear-view cameras are a new tool with the potential to make driveway reversing safer. No large-scale data are available in this area although early studies are encouraging.
The authors assert that “In preventing pedestrian injuries and deaths, one important measure is school road-safety programmes. Although such interventions may improve children’s knowledge, this does not necessarily translate into better road crossing behaviours. Furthermore, education programmes may be unreliable as they can be overly dependent on the individual teacher delivering them. Thus the development of better education programmes that effectively alter crossing behaviour remains essential. Simple knowledge, such as appropriate crossing location, has a big impact on injury severity and is amenable to classroom learning.”

“Safety training for children using virtual models represents an exciting new prospect in tackling this problem and avoids exposing children to physical traffic hazards. One well established risk factor for paediatric pedestrian injury is the built environment in which the injury occurs.” state the authors. A meta-analysis of previous studies established a direct link between the built environment and risk of pedestrian injury.

A number of environmental features (e.g. multiple family dwellings, lack of playgrounds, the presence of major roadways, increased traffic levels and roadside parking) are significant risk factors. In a resource-poor setting, built environment features such as lack of road markings are of relevance. The environmental features that best improve pedestrian safety are the provision of playground/recreation features and traffic calming. These relatively simple interventions have a significant and lasting impact on improving child pedestrian safety at a local level.

The authors note that the increased use of mobile phones could also have a negative impact on children’s road crossing abilities as early research suggests they distract children to a significant degree and may increase their risk of collision.
In conclusion, the study found potential for prevention in relation to pedestrian deaths in Irish children, particularly the need to reduce driveway deaths. Preventative measures should include education of parents and caregivers, separation of driveways from play areas (particularly on farms), adequate supervision of children and installation of object vicinity sensors in vehicles.

All references and author names are contained in the full article in January 2015 IMJ, p.8
Title: Pedestrian Deaths in Children – Potential for Prevention

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