Irish Medical Journal ■ November-December 2014 ■ Volume 107 ■ Number 10
Official Journal of the Irish Medical Organisation

A study published in the latest edition of the Irish Medical Journal highlights the significant difficulties associated with sexual orientation concerns in adolescents in Ireland where a major indicator of the level of their difficulties was the high prevalence of attempted suicide. The study shows that adolescents with concerns regarding their sexual orientation experience significantly higher levels of victimisation and psychosocial difficulties. The wide ranging study examined victimisation, substance misuse, relationships, sexual activity, mental health difficulties and suicidal behaviour among adolescents with sexual orientation concerns in comparison to those without such concerns.

1112 Irish students (mean age 14yrs) in 17 mixed-gender secondary schools completed a self-report questionnaire with standardised scales and measures of psychosocial difficulties. 58 students (5%) reported having concerns regarding their sexual orientation. Compared with their peers, they had higher levels of mental health difficulties and a markedly-increased prevalence of attempted suicide (29% vs. 2%), physical assault (40% vs. 8%), sexual assault (16% vs. 1%) and substance misuse. Almost all those (90%) with sexual orientation concerns reported having had sex compared to just 4% of their peers. These results highlight the significant difficulties associated with sexual orientation concerns in adolescents in Ireland. Early and targeted interventions are essential to address their needs.
Identity issues are common in adolescence, including confusion over sexual orientation and sexuality increased rates of psychosocial difficulties, such as depression, anxiety and substance misuse have been reported amongst lesbian, gay or bisexual (LGB) young people, who more commonly report a history of having experienced child sexual abuse. Given that each of these factors are recognised risk factors for suicidal behaviour, it is not surprising that young people in a sexual minority group have been shown to be at higher risk of suicidal ideation and attempted suicide.

Saving and Empowering Young Lives in Europe (SEYLE) is a school-based health promotion and suicide prevention programme. It was implemented in 11 European countries and funded by the EU 7TH Framework Programme. In Ireland, 17 randomly-selected, main-stream, mixed-gender secondary schools in Cork and Kerry participated. The parent(s)/guardian(s) of 1722 adolescents mostly in second year were asked to consent to their child participating in the project. A total of 1112 adolescents participated, representing a response rate of 65%. Students were aged 13-16 years and most were 14 years of age.

Participants completed a self-report questionnaire in the classroom setting. It included a range of internationally recognised scales: the Beck Depression Inventory; the Zung Self-Rated Anxiety Scale; the Paykel Suicide Scale; the Deliberate Self-Harm Inventory; the WHO Well-being Scale and the Strengths and Difficulties Questionnaire (emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, pro-social behaviour).
Students were also asked about victimisation, sexual assault, physical assault, alcohol, drugs and tobacco use, relationships and sexual activity. In Ireland, the students were also asked “have you had worries about your sexual orientation i.e. that you might be lesbian, gay or bisexual?” Those who answered positively to this question were compared with those who answered negatively in relation to a range of factors using Chi-square tests for categorical factors and one-way analysis of variance for continuous factors.
More than half of the 1112 students were male (600 (55.7%) male; 496 (45.3%) female), the vast majority were either 13 or 14 years of age (409 (37.5%) 13 years; 598 (54.8%) 14 years; 55 (5.0%) 15 years; 29 (2.7%) 16 years; Mean = 13.7 years) and over 80% lived with their mother and father (914; 83.4%). Of the 1079 who answered the question, 58 (5.4%, 95% confidence interval = 4.1-6.9%) indicated that they had concerns regarding their sexual orientation. This group consisted of 35 (60.3%) boys and 23 (39.7%) girls with a mean age of 14.1 years.

The young people who reported having concerns regarding their sexual orientation reported significantly increased levels of victimisation, especially regarding physical and sexual assault (Table 1). They were five times more likely to have been physically assaulted (40% vs. 8%) and one in six of them (16%) had been sexually assaulted compared with 1% of the adolescents with no sexual orientation concerns. Stronger associations were found regarding substance misuse. One fifth of the adolescents with sexual orientation concerns drank alcohol frequently compared to 1% of the other young people. Only 36% had never been drunk compared with 91% of their peers. Three quarters of this group indicated that they were smokers compared with less than one fifth of their classmates. They were also much more likely to have used hash or marijuana (41% vs. 2%).

The students with sexual orientation concerns did not differ significantly from their classmates in terms of getting along with people their own age or feeling that they are liked and wanted in doing with their spare time compared with 15% of their peers. The group with sexuality concerns had higher levels of depressive symptoms, anxiety symptoms, emotional and behavioural problems, suicidal behaviour and lower levels of wellbeing. The association was most evident with attempted suicide - 29% of these students having tried to take their own life compared to just 2% of the students without sexual orientation concerns.

The authors note that the findings could be interpreted as suggesting that students with high levels of victimisation and psychosocial difficulties are more likely to have concerns about their sexuality. These difficulties may induce uncertainty regarding sexual identity. For instance, abuse and dysfunctional backgrounds are known to adversely affect identity formation, of which sexual identity is one facet. Alternatively, it is possible that these difficulties arise as a result of being a young person with concerns regarding sexual orientation. This may be particularly true in Ireland, given its strong identification with Catholicism, which views homosexual acts as sinful. Moreover, male homosexuality was only decriminalised in Ireland in 1993.

The degree to which LGBT people have been alienated in all aspects of Irish life and culture has been well-documented. Stigmatisation and internalised homophobia have been identified as other factors contributing to negative health outcomes amongst lesbian and gay adolescents. Therefore, it is likely that some of the adverse experiences identified in this study are associated with being an LGB youth in Ireland. These include the high levels of victimisation, sexual and physical assault, substance abuse and risky sexual behaviour found in the current sample, all of which corroborate previous findings from other countries. This may be compounded by the low levels of parental attention reported by this group. Positive parental attention is associated with better psychological well-being and reduced substance abuse amongst adolescents.

Despite the high levels of victimisation and bullying reported by this group, they did not differ from their classmates in terms of getting along well with others, feeling like they belonged to a group and the extent to which others liked having them in the group. This suggests that the high levels of peer relationship problems reported by these young people are due to interactions with peers outside their circle of friends.

This study supports the view that some young people become concerned about their sexual orientation at a young age. Previous research has indicated that most sexual-minority young people disclose their sexual identity towards the end of their secondary school years. This happens even later among Irish LGBT people. These years of concealed sexual orientation or gender identity coincided with psychological vulnerability and distress. The authors state that “the current findings support the need for an environment that facilitates adolescents’ free expression of their sexual orientation concerns.”

The authors Cotter et al state that future studies should include multiple dimensions of sexual orientation in single as well as mixed gender schools, across different time periods, with a focus on protective factors. Future studies could also examine whether the identified sexual experiences occur with same or opposite gender partners and also look at rates of attendance at mental health services e.g. Child and Adolescent Mental Health Services, as an indication of the severity of the identified difficulties. Reach Out, the Irish National Strategy for Action on Suicide Prevention identifies LGBT people as a marginalised group and, as such, highlights the need to develop specific supports for them.
At a preventative level, school and community-based health awareness programmes should include topics on sexuality and sexual orientation. The aim should be to inform young people with worries about these issues and reduce the level of stigmatisation and victimisation. These interventions should also be sensitive to the cultural contexts of LGBT young people. Key elements that should be addressed include the development of healthy sexual identities and helping young people to disclose their sexual identity to peers and adults. It is possible that adolescents with sexual orientation concerns are in need of alternative means of interacting with the health services and different treatment methods. Awareness of the mental health issues of these young people should become a standard part of training for professionals working in these areas.

All references and author names are contained in the full article in this month’s IMJ, page 310
Title: Victimisation and Psychosocial Difficulties Associated with Sexual Orientation Concerns: A School-Based Study of Adolescents

November-December 2014 Irish Medical Journal

Notes to Editor
The authors state that in light of the findings in this study, it is important to mention the study’s limitations. Although, participants were randomly selected without reference to sexual orientation, which is a strength of the study, the group with sexual orientation concerns was small. This precluded the use of more complex statistics to explore heterogeneity in the sample. This study collected self-report data, in a classroom setting. Therefore, as previously shown, reporting may have been inaccurate for some sensitive questions. The phrasing of the key question (have you had worries about your sexual orientation i.e. that you might be lesbian, gay or bisexual?), could be seen as problematic. This could be viewed as self-exploration rather than a measure of sexual identity. LGB young people who were not worried about their sexual orientation may not have answered this question positively. 

Irish Medical Journal ■ October 2014 ■ Volume 107 ■ Number 9
Official Journal of the Irish Medical Organisation

Sex Trafficking in Ireland from a Health Care Perspective

Sex trafficking within Ireland is a hidden phenomenon. Estimation of the prevalence is problematic due to the criminal nature of sex trafficking and its overlap with the related activities of prostitution and illegal immigration, and due to the extreme fear which makes disclosure by a victim unlikely
The authors of a newly published study ‘Sex Trafficking in Ireland from a Health Care Perspective’ in the October edition of the Irish Medical Journal assert that there is a real need for an awareness raising and training programme amongst health care professionals dealing with sex trafficking in Ireland.
The under-detection of victims of sex-trafficking is a real issue in Ireland and an awareness raising and comprehensive training exercise should be implemented for health care professionals. The referral guideline presented here could be distributed widely to health care professionals within Ireland to enable them to respond and refer appropriately.

While the authors acknowledge that there is no single set of symptoms or signs that differentiates sex-trafficked victims from other sex workers, an awareness of common physical and psychological health problems associated with sex trafficking by health care professionals may increase victim detection rates. The paper presented in the IMJ, summarises indicators, approach mechanisms, screening questions and a referral guideline relevant to the Irish health care system.
Sex trafficking victims usually have poor access to healthcare and thus may only present when their medical situation becomes severe or life threatening. Although sex trafficked victims are less likely to use health and social services than non-trafficked sex workers, the data from other countries indicate that victims may present to various healthcare settings: within the asylum process, outreach services for prostitution or migrant groups and sexual assault units.

One study found that 28% of victims had access to a healthcare provider while still in captivity; however the fact that they had been trafficked went undetected. This illustrates the potential opportunity for intervention by health care professionals if they are equipped with the knowledge of the indicators, appropriate approach mechanisms and screening questions associated with sex trafficking. The authors state that “If health care professionals are aware of these barriers, they can ensure that these victims are informed of all the relevant referral pathways and support services in place in Ireland which enable them to make an informed decision.”

A National Referral Mechanism (NRM) and four dedicated state units have been setup in Ireland since the Criminal Law (Human Trafficking) Act 2008 was enacted. A sixty day recovery and reflection period for suspected victims of trafficking and six months Temporary Residence Permission (renewable) exist conditional on participation with authorities.

Sexual exploitation is the most common form of human trafficking with 70% of cases reported to authorities. Women constitute the majority of victims. The most prevalent countries of origin were Eastern Europe, Nigeria, other parts of Africa, South America and Asia.
The results of the research conducted by the authors identified that health care professionals are not aware of the occurrence of sex trafficking nor have they been trained to identify victims. No Irish guidelines or referral pathways existed to assist health care professionals. Many declined interviews citing lack of knowledge and awareness. Currently existing awareness and training strategies are not tailored to the health care system.

The authors of the paper created a list of indicators and victim approach advice that is tailored to Irish health service providers. Based on an IOM publication, two tables were adapted taking into consideration the Irish support services available. No single set of symptoms or signs differentiates sex-trafficked victims from other sex workers. However, by being aware of the common physical and psychological health problems associated with sex trafficking health care professionals can increase victim detection rates. Screening questions are used to establish whether the definition of trafficking is satisfied12, and all questions should be tailored to the victim’s health.

The lack of awareness and training for victim identification and referrals may exacerbate the under-detection of sex-trafficked victims within the Irish health care system. There are many barriers that prevent victims from reporting the crime to health care professionals: threats to the victims’ family, fear or coercion from traffickers, distrust of authority due to past experiences with corrupt systems within their country of origin and also lack of information on their rights and support services available. The time constraints in clinical consultations may not allow sufficient time to develop trust, an essential component of disclosure. Health care professionals tend to focus on the presenting complaint, possibly missing other indicators and deliver healthcare without tailoring their service to the needs of this vulnerable group5.

The authors state that “educating healthcare providers to identify, assess, and intervene appropriately on behalf of sex-trafficked victims is critical to provision of a comprehensive anti-human trafficking response, and has not been done in this country to date.” Victims’ needs vary and the complexity of each situation is acknowledged in this. Health care professionals should be aware that safety is the primary consideration when dealing with victims of human trafficking. Recognising a victim is only the first step and training is necessary on the different referral avenues available, without compromising both safety and ethical principles.

While intervention can be beneficial, making the wrong referral decisions can result in unintended consequences, often causing further damage to victims. Entrance to the NRM is conditional on the patient severing all ties with the trafficker and assisting with investigation. An Garda Síochána have been appointed the first point of contact in the NRM as they are specialized to investigate the validity and in risk assessment. The complexity of situations varies and some victims make the informed decisions not to disclose. Assigning An Garda Síochána as the first point of contact to the NRM may, however, prevent victims from coming forward. The Care Plan constructed by HSE Anti-Human Trafficking Unit (AHTU) consists of 8 categories to fully support the victims towards recovery. If in doubt, health care professionals can refer directly to HSE AHTU who will then activate the referral cascade and contact An Garda Síochána. Having leaflets and information readily available in different languages with contact information can enable health care professionals to deliver contact information discretely to patients.

The authors conclude that “the under-detection of victims of sex-trafficking is a real issue in Ireland and an awareness raising and comprehensive training exercise should be implemented for health care professionals. The referral guideline presented here could be distributed widely to health care professionals within Ireland to enable them to respond and refer appropriately.”

All references and author names are contained in the full article in this month’s IMJ, page 270
Title: Sex Trafficking in Ireland from a Health Care Perspective

Irish Medical Journal ■ September 2014 ■ Volume 107 ■ Number 8
Official Journal of the Irish Medical Organisation

A case report in the latest edition of the Irish Medical Journal examines the first reported clinical pregnancy following PGD carried out in Ireland.
Awareness of CF carrier status in Ireland is increasing following the introduction of neonatal screening

in 2011. PGD is the most acceptable reproductive strategy for many at risk Irish couples but until now the treatment necessitated travelling abroad. Introduction
Cystic Fibrosis (CF) is an autosomal recessive condition caused by mutations of the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Ireland has the highest incidence of CF in the world and 1 in 19 of the population is a carrier. The birth of an index case has always identified couples at risk (where both parents are carriers) but awareness of CF risk is now rising due to the introduction of neonatal CF screening in July 2011 (identifying both disease and carrier status). Couples at risk must make difficult reproductive choices.

Pre-implantation genetic diagnosis (PGD) is an established alternative to prenatal testing for couples at risk of transmitting genetic disorders such as cystic fibrosis (CF). PGD screens pre-implantation embryos, allowing the safe transfer of those identified as unaffected. Until now it has been necessary to travel abroad for the treatment. In 2012, the Irish Medicines Board licenced two Irish fertility clinics to carry out embryo biopsy for PGD.

A couple was referred to Cork Fertility Centre (CFC) for assessment with regard to PGD. Both partners underwent routine fertility assessment. Blood samples from both partners were sent to Reprogenetics (Oxford, U.K.) for preliminary genetic analysis. Polymerase chain reaction (PCR) was used to amplify a fragment of DNA containing the CFTR gene. The presence or absence of the mutation was then determined using mini-sequencing. Additionally, polymorphisms (highly variable pieces of DNA situated in close proximity to the CFTR gene), were amplified and analysed. The risk of a misdiagnosis from this technique is negligible. However current technology allows for an error rate of 1 to 2%.

The female partner underwent a routine IVF cycle. Thirty eggs were collected and inseminated by intracytoplasmic sperm injection (ICSI) using the cryopreserved sperms. Fifteen embryos were biopsied on day 3 following egg collection; a single blastomere was removed from each and sent to Reprogenetics for genetic analysis while the embryos remained in culture. Five days following egg collection the genetic analysis results identified 5 unaffected embryos. A fresh embryo transfer was not carried out because of concerns about the possibility of ovarian hyperstimulation syndrome and the embryos were cryopreserved using a closed vitrification system. A frozen embryo transfer cycle was carried out 8 weeks after the fresh cycle, with a single embryo transferred. Ultrasonography confirmed a viable singleton intrauterine pregnancy.

The author’s state that this case, the first reported clinical pregnancy following PGD carried out in Ireland is an important milestone. Its outcome depended on the reliability of several technical advances- ICSI/TESE, blastocyst culture, embryo biopsy and embryo vitrification. Although cryopreservation, in this case, had not been intended at the outset it will be a necessary part of all PGD cases in the future as biopsy moves from day 3 to day 5 (the day 5 embryo is more robust and several cells can be removed, increasing the certainty of genetic diagnosis). The challenge involved here was greater because only 50% of embryos were likely to be unaffected by CF (compared to 75% when both partners are carriers for the condition).The authors conclude that “Increasing awareness of genetic risk is inevitable and where Irish couples are burdened with difficult reproductive choices, the option of PGD in Ireland is a welcome development.”

All references and author names are contained in the full article in this month’s IMJ, p.239
Title: Clinical Pregnancy Following Pre-Implantation Genetic Diagnosis for Cystic Fibrosis
For further information contact:
Communications Unit, Irish Medical Organisation, 10 Fitzwilliam Place, Dublin 2. Tel. 01 676 7273

September 2014 IMJ

Irish Medical Journal ■ September 2014 ■ Volume 107 ■ Number 8
Official Journal of the Irish Medical Organisation

There has been an increase in gun-related crime in Ireland over the last decade and this places a burden on hospital services not previously encountered. A study in the latest edition of the Irish Medical Journal reviews the sharp increase in the numbers of admissions from gunshot injuries in a West Dublin hospital in Ireland in the past decade. The aim of this study was to examine the demographics of gunshot injuries and the impact on the radiology department.

Personal firearms are licensed in Ireland and can only be owned under strict conditions. This has been suggested as a reason for the low rates of firearm injuries traditionally seen in Ireland. Redmond HP et al published a review of ten years of gunshot injuries in 1985 and found 21 injuries, 20 of which were with low velocity weapons, and four of whom died.

Recent increased use of handguns in Ireland heralded a marked increase in mortality, to 8 of 17 (47%) in a paper published in 2008, whereas mortality from low velocity (shotgun) injuries was 1/31(3%).
All patients presenting or brought by ambulance to Connolly Hospital Emergency Department (ED) between 2001 and 2010 were eligible for inclusion in this study.
• 65 patients with gunshot injuries were seen in the emergency department between 2001 and 2010, of whom charts were available in 59.
• The patients were aged between 15 and 52 (mean age 27.4), and only one was female.
• 29 gave their profession as unemployed, and 10 were from the travelling community in Ireland.
• As previously demonstrated, mortality for high velocity wounds was much higher (10/23, 43%) than for low velocity shotgun injuries (2/34, 6%).
It was also shown that bullet wounds tended to be focused around the torso, head and neck, and shotgun wounds tended to be concentrated around the peripheries. Eight patients died in the ED. Of the 51 patients that survived beyond the ED, 43 had radiography, and 15 had CT scans in the emergency setting, and a further 10 had follow up CT scans. Five patients were transferred for emergent management in interventional radiology. Four patients underwent emergency ultrasound scans.

The authors of this review describe the results as “showing a dramatic increase in gun crime in Dublin over the previous four decades”. The age profile had decreased (mean age 27 years, decreased from 31), and the mortality had increased, with a marked increase in high-velocity firearms, i.e. handguns, rifles and semi-automatic weapons which has been widely attributed to increased gangland activity and the illegal drug trade.

The experience gained in large urban centres can be useful in dealing with gunshot injury, as it relatively rare in Irish residency training. Despite the fact that some patients had succumbed to their injuries prior to medical assistance, many are still referred to the radiology department. During the period of the study, 15 cases underwent post-mortem radiological scanning. These cases are usually for forensic and legal purposes e.g. for dental age estimation, or bullet retrieval.

The authors conclude that despite the evident increase in gunshot injuries, the numbers in Ireland are still low by comparison with other developed countries, and the burden on radiology departments remains relatively low. Should the increasing trend continue, further resources and expertise may be required.

All references and author names are contained in the full article in this month’s IMJ, page 242
Title: Imaging of Gunshot Injuries in a West Dublin Teaching Hospital – A Ten Year Review
 

September 2014 IMJ

Irish Medical Journal ■ July-August 2014 ■ Volume 107 ■ Number 7
Official Journal of the Irish Medical

Childhood asthma and black smoke in Galway City - A twenty year study

Data presented in a study published in the July/August edition of the Irish Medical Journal proposes that air pollution is an important factor in the epidemiology of acute childhood asthma. The study by Loftus et al examined the relationship of air pollution and climatic variables to asthma admission rates of children in Galway city over a 21 year period.

Paediatric epidemiological studies have shown that exposure to pollution has a detrimental effect on lung function in children, which is reversed when they move to a cleaner area. Over the past 20 years in Galway, asthma admission rates increased steadily to a peak in 1995 and thereafter diminished dramatically.

Data collated for the study was obtained by recording paediatric asthma admissions from 1985-2005 and admission rates per thousand calculated for pre-school (1-4 years), school aged (5-14 years) and all children (1-14 years) on a monthly and annual basis. The data was compared to average monthly and annual climatic variables (rainfall, humidity, sunshine, wind speed and temperature) and black smoke levels for the city.

Asthma admissions were retrieved from the paediatric unit register and Hospital Inpatient Enquiry System. Given the difficulty of differentiating virus-associated wheeze from asthma in infants, children under one year of age were excluded from the study. Raw numbers of asthma admissions for children with a Galway city address were converted to a rate per 1000 by using census data from 1986, 1996, 2002 and 2006 to define the population.
When all data was collected:
• There was evidence of a positive association between asthma admissions and black smoke levels for the 1-4 year olds and a positive trend for 5-14 year olds separately.
• There appears to be a stronger association between black smoke and admissions rates in ages 1-4, thus explaining the intermediate significance of the combined 1-14 years analysis.
• There was evidence of a positive association between asthma admissions and particulate concentrations for all subjects (1-14 years).

The data presented in the study shows a strong association between black smoke levels and admission to hospital with childhood asthma. The association between smoke and acute admissions is more evident when plotted annually. Though the hypothesis is biologically plausible, these changes could be coincidental.

The authors determine that the reason for the rise and fall in black smoke from the mid-nineties is probably a combination of changes in domestic and vehicular fuel use. Coal sales changed little from 1985 to 1995, suggesting that the rise in black smoke came from other sources. The predominant coal supplier in the area noted a trend to the use of smokeless coal in Galway in the mid-1990s. More stringent emission standards for bituminous coal were implemented in 1995, so coal supplied in Galway after that year had both lower sulphur content and lower smoke emissions. Sale of bituminous coal was banned in 2000 and this was associated with a further small reduction in smoke levels. Therefore some of the fall in smoke levels from 1995 is due to “cleaner” coal. The rise in smoke levels up to 1995 coincided with a growth in registered vehicle numbers in the county (from 44,000 to 108,000) and the proportion of diesel powered vehicles (from 18% to 35%) , indicating that vehicular traffic was a factor in elevating smoke levels.

In conclusion, the authors present an association between a measure of childhood asthma morbidity and black smoke in Galway city. The authors hypothesise that regulatory changes in the nature of coal and diesel, and more stringent vehicular emission rules have improved air quality and contributed to the reduced incidence of hospital admissions.

All references and author names are contained in the full article in this month’s IMJ, page 198
Title: Acute Childhood Asthma in Galway City from 1985-2005: Relationship to Air Pollution and Climate
 

July-August Irish Medical Journal

Irish Medical Journal ■ June 2014 ■ Volume 107 ■ Number 6
Official Journal of the Irish Medical Organisation

Informed consent for epidural analgesia in labour: A survey of Irish practice

A study in the latest edition of the Irish Medical Journal assess practice in obstetric units in Ireland with regard to obtaining informed consent prior to epidural insertion, and whether the risks discussed with women are being documented. The results of the survey show that there is major variation across Ireland both in which risks are discussed with women in labour and what risks are quoted.

The role of the anaesthetist has been expanding over the last few decades and anaesthetists have become increasingly involved in procedures separate from other specialties, an example of which is providing epidural analgesia for labour, which may be the only medical intervention in the occurrence of natural delivery. Traditionally the complications and risks of anaesthesia were discussed as part of the surgical procedure. This has been always a matter of debate as anaesthesia has its own risks which are distinct from surgery, e.g. nerve injury from the epidural needle. Currently, there is no national standard regarding epidural consent in Ireland

The aim of the study was to evaluate whether verbal or written consent is obtained, which risks are routinely discussed with patients and what risk is quoted. Each lead anaesthetist was also asked if they use an information leaflet and if they felt that there should be a standardised National Epidural Information Leaflet, detailing the benefits and risks of epidural analgesia, for use in all hospitals in Ireland.

Some units reported that patients were informed of risks, but an exact risk was not specified. Other units reported exact risks with the quoted incidence varying greatly from unit to unit. The most frequently quoted risks were headache (93.8% of the respondents), partially/not working epidural (93.8%), drop in blood pressure (87.5%) and temporary backache/local tenderness (75%). The more serious risks were not discussed as frequently: permanent nerve damage (50%), paralysis (50%), epidural abscess/haematoma (37.5%), meningitis (18.7%).
In ten units (62.5%), written consent was obtained. In all other units, verbal consent was obtained prior to epidural insertion. Consent was documented in all units on either a specific consent form for epidural (75%) or in the patients’ notes (25%).

The authors noted that there was a particularly low reported discussion of the serious risks of epidural analgesia. The lead anaesthetist’s practice was taken to be representative of the standard practice in their unit. “While this may not be the case, there is still an unacceptably large variation in practice reported. The “reasonable patient standard” asks what a reasonable patient would consider reasonable and material to the decision to consent to a procedure offered. It is incumbent on the physician to ascertain what is reasonable and material for the patient.” state the authors.

The recent guidelines from the AAGBI agreed with this standard and recommended that the decision to omit mentioning a risk should be rational and stand up to logical analysis. It has been shown that women in labour would prefer to be informed of all risks associated with epidural analgesia and that non-disclosure of the risks is unacceptable to them. We cannot morally refrain from discussing the more serious risks of epidural insertion with patients. It is difficult to quantify the incidence of these risks as they occur rarely.

When obtaining consent from a woman with poor English, the majority of respondents (93.7%) reported that they either got a family member or friend to translate or used an official translator. Only one respondent reported that they would insert the epidural without consent if a translator was not available. No one reported that they would abandon the procedure.
Eleven units (68.7%) reported that they have a local Epidural Information Leaflet, which is shown to all women prior to epidural insertion. In four of these units, it is routinely documented that the information has been read and discussed with the patient prior to epidural insertion.

The vast majority (87.5%) of respondents supported introduction of a national standardised information leaflet, detailing all the benefits and risks of epidural analgesia, to be shown to all women before consenting to epidural insertion and that this should be available for use in all obstetric hospitals in Ireland.

The Obstetric Anaesthetists Association (OAA) has an Epidural Information Card with quoted risks derived from the literature, views from experts in the field and members of the OAA’s Information for Mothers Subcommittee. The authors state that the figures from the OAA Epidural Information Card should be quoted to patients pre-epidural insertion.

There is evidence that women in labour retain more information when provided with both verbal and written information, than verbal information alone. We do not have a national Epidural Information Leaflet detailing the benefits and risks of epidural analgesia.

“Our survey shows that there is overwhelming support for the use of a national standardised information card, such as the OAA’s Epidural Information Card. Documentation in the notes that such a card had been read by the patient would also serve as medicolegal evidence for informed consent “ states author Dr Hegarty.

The Antenatal Clinic would be the best environment in which to give women information about epidural analgesia. Women would prefer to be informed about epidural insertion prior to the onset of labour, therefore the Antenatal Clinic would be an ideal location for distribution of such a card.

All references and author names are contained in the full article in this month’s IMJ, p183
Title: Informed consent for epidural analgesia in labour: A survey of Irish practice
 

Irish Medical Journal ■ June 2014 ■ Volume 107 ■ Number 6
Official Journal of the Irish Medical Organisation

Debt Crisis Ahead for Irish Medical Students

A recent study from UCC has highlighted an alarming debt crisis among medical students in Ireland. The study published in the June edition of the Irish Medical Journal reveals:

“61% of Graduate Entry Medical Students took out specialised term loans from private institutions to cover tuition and living, and will graduate with debts averaging €80,000”.

“26% of Direct Entry Medical Student respondants with student debt expected debts averaging over €17,000”

“Fees for Graduate Entry Medicine Students are in excess of €14,000 per year and these students are not entitled to apply for the Student Grant.”

“Graduates are voting with their feet with many opting to leave Ireland in search of better working conditions abroad. A number of factors are at play but past research has established that debt is an important predictor of medical workforce migration.”

“Medicine, particularly at the Graduate Entry level is almost exclusively represented by students from higher income families.”

“Solutions to medical school debt must be part of medical workforce planning.”

Background on Medical Education in Ireland

Medical Education in Ireland comprises Direct Entry Medicine (DEM) i.e. school leavers and Graduate Entry Medicine (GEM) courses. GEM programmes offer graduates of any discipline the opportunity to study an accelerated four-year medical programme in contrast to the traditional 5 year undergraduate courses. A small number of places are also reserved for mature and disadvantaged students. Fees for EU GEM students are between €14,580 and €14,915 on a tuition only basis, for each of the four years of the programme. These figures exclude the cost of living which is estimated to be €7,902 for students living away from home, bringing the total direct cost for this graduate student cohort to €22,482 per annum at a minimum. GEM students cannot qualify for the student grant or any other state financial aid and must fund their entire tuition and cost of living privately through personal loans and family support, where available. In contrast, DEM students who are eligible for the free fees initiative pay a registration fee of €2,500 per annum and are eligible to apply for state financial supports.

All references and author names are contained in the full article in this month’s IMJ, p 185Title: Debt Crisis Ahead for Irish Medical Students

Irish Medical Journal ■ May 2014 ■ Volume 107 ■ Number 5
Official Journal of the Irish Medical Organisation

Managing Type 1 Diabetes during the Junior Certificate Examination

Little is known of the experience of adolescents with type 1 diabetes in Ireland during the Junior Certificate examination. In a study published in the May edition of the Irish Medical Journal, authors Scully et al describe the adherence to recommended diabetes care during the Junior Certificate and the uptake of available accomodations by adolescents with type 1 diabetes. Through this study the authors aimed to gain a better understanding of the compliance of children with type 1 diabetes during the Junior Certificate Examination, and to ascertain their perceived effect of type 1 diabetes on examination performance.

In order to facilitate individuals with type 1 diabetes reaching their potential in academic performance, accommodations during examinations are available. All students with chronic conditions, including Type 1 diabetes, which may affect performance, may apply to the State Examinations Commission for “reasonable accommodations” to be made. The purpose of these is to lessen the impact of the condition on their performance, while ensuring that the child is not given an unfair advantage over other candidates. Specifically, a child with type 1 diabetes in Ireland can apply for multiple short “rest breaks” during each examination. The total of these rest periods cannot exceed 20 minutes. This time may be used to perform diabetes related tasks, if necessary. These rest breaks must be applied for in advance, so patients should be informed of these accommodations early in the academic year.

The mean patient age at the time of Junior Cert was 15.4 (SD 1.6) years and the patients had diabetes for a mean duration of 5.2 (SD 3.5) years. Three (7%) reported experiencing hypoglycaemia during an examination, and 2 patients (13.3%) did not bring a fast acting glucose remedy to treat hypoglycaemia with them to the examination centre. Mean HbA1c did not change significantly prior to and after the Junior Certificate (8.5% vs 8.6%). Uptake of the available rest breaks for students with type 1 diabetes was low, with only 27% availing of this accommodation. Almost half of the patients felt that diabetes affected their examination performance. When asked to explain why they felt this happened, the answers included 1) worry that hypoglycaemia was affecting concentration, 2) general concern that blood sugar levels were unstable, and 3) diabetes added to the stress of the examinations.
Optimal diabetes control during academic examinations is important to avoid adverse effects on performance. Rest breaks are available for students with type 1 diabetes to complete each examination, but just over a quarter of patients in this study availed of this support. These breaks are intended to facilitate diabetes self-care including glucose checks during the examination. On the day of examination, the student should also be prepared for possible stress-related increase in insulin requirement.

Almost half of the patients did not bring a glucometer into the examination centre. Only 53% checked their capillary glucose levels during the examinations and 13% did not have a hypo remedy with them. Adolescents, their parents and schools need to ensure that this equipment is available during examinations.

The authors note that in the event of hypoglycaemia during an examination, it is possible that the allowance of extra time may be insufficient to overcome the cognitive effects of the episode of low blood glucose. Glycaemic control in the study participants was suboptimal, with a mean HbA1c over one percentage point above the recommended 7.5%. Possible reasons for this include low priority of diabetes control during the examination year and stress associated with the Junior Certificate, as well as other well recognised issues affecting diabetes control in adolescence.
Almost half of patients in the study felt that their diabetes affected their examination performance. The authors recommend discussing upcoming academic examinations at the beginning of the academic year where the importance of optimising control to maximise performance is emphasised. “Parents should be informed of the special accommodations available to their children at the exam and should also be encouraged to discuss this with their child’s school prior to the examination. A plan should be in place for the day of the exam, where a checklist is provided for the adolescent outlining the equipment that should be brought into the examination centre” state the authors.

The authors would also recommend that the Department of Education issue all schools with clear guidelines for accommodating children with diabetes. In addition, invigilators in examination centres where children with diabetes are sitting examinations should have a basic understanding of the common diabetes related self-care procedures that may be required during the examination. The authors would hope that the addition of these interventions may reduce the proportion of patients who feel that type 1 diabetes has a negative impact on examination performance.

All references and author names are contained in the full article in this month’s IMJ, p 155
Title: Difficulties Associated with Diabetes Management During the Junior Certificate Examination

Irish Medical Journal - May

Irish Medical Journal ■ April 2014 ■ Volume 107 ■ Number 4
Official Journal of the Irish Medical Organisation

Children with type 1 diabetes require specialised care, provided by a team with appropriate expertise. The first study to describe in detail the diabetes services for children with type 1 diabetes in the Republic of Ireland is published in the April edition of the Irish Medical Journal.

Type 1 diabetes is a chronic condition affecting 5-40 per 100,000 of the paediatric population. The incidence is higher in the United Kingdom, Ireland and Scandinavia than in most of Central and Southern Europe and is rising, particularly in children aged under 5 years.
Nineteen centres were identified in the study as managing children with type 1 diabetes. The criterion for inclusion as a centre was the attendance of children with type 1 diabetes to the outpatient department for routine diabetes care.

The total number of patients attending these centres was 2518. Eight centres initiate insulin pump therapy. Insulin pump usage ranged from 0 to 42% of patients attending each centre. Self-reported clinic mean haemoglobin A1c ranged from 8.2 to 9.4% (66.1 to 79.2 mmol/mol). Variation existed in guideline availability, frequency of clinic appointments, age of transition and insulin types used.
Only one centre had appropriate diabetes nurse specialist to patient ratio to meet the recommended 70-100 patients per diabetes nurse, but this centre did not have a dedicated paediatric diabetes nurse specialist. Insulin pump initiation was available in 8 (47%) of the 17 centres. Those centres that did not initiate pump therapy arranged shared care or transfer of care to another centre for this. The number of patients using insulin pumps varied between centres, ranging from 0 to 42%.

The authors note that the results of the study demonstrated a wide variation in the structure and process of care between centres. Specifically, these variations are noted in patient numbers, team resources, initiation of insulin pump therapy, clinical guidelines availability, age of transition and HbA1c outcomes.

Diabetic ketoacidosis is present in approximately one quarter of children at diagnosis, which can rarely be associated with life threatening cerebral oedema and appropriate guidelines for management should be followed. All centres that responded to this survey have guidelines for this.
Following initial management, structured education should be provided to empower patients and their families in diabetes care and most centres also have guidelines for this. However, only one fifth of Irish centres have guidelines in place for the management of children who fail to attend clinic regularly or have persistently poor glycaemic control, and for adolescents being transitioned to adult care.

The data presented in the study highlight significant deficiencies across multidisciplinary teams in Ireland. It has previously been identified that many consultants delivering paediatric diabetes care in the Republic of Ireland as part of their general paediatric workload may not have specific training and on-going Continuing Medical Education in paediatric diabetes. Many services have insufficient diabetes nurses and dieticians and poor access to psychosocial services.

High quality care delivery requires trained, adequately staffed multidisciplinary teams. The authors note that “it may be infeasible to provide this multidisciplinary care in smaller centres without sufficient patient numbers to justify the resource. “

The authors conclude that in the context of limited resources “regionalising diabetes care for children with type 1 diabetes should be considered.” Large patient numbers are necessary to justify full time employment of a large multidisciplinary team. This would allow for the maintenance of skills, attendance at best practice meetings and improvement in patient care. It would also facilitate skilled out-of-hours coverage as well as emergency cover of sick leave or unexpected absences.

While this may improve patient outcomes, it will be associated with an increased requirement for patients to travel to appointments and careful geographic consideration of location of centres is required to mitigate the burden for families. The authors stress that “Current wide variation in service provision and glycaemic outcomes must be addressed to improve care of children with type 1 diabetes in the Republic of Ireland.”

All references and author names are contained in the full article in this month’s IMJ, p.102 - 104
Title: Paediatric Type 1 Diabetes in Ireland – Results of the First National Audit
 

Irish Medical Journal ■ April 2014 ■ Volume 107 ■ Number 4
Official Journal of the Irish Medical Organisation

Research suggests extending Free GP Visit Cards to Children could lead to 750,000 extra GP visits a year.

The Government’s plans to extend Free GP Visit Cards to Children Under Six could lead to as many as 750,000 additional visits to GPs a year according to research published in the April edition of the Irish Medical Journal (IMJ). The research examined GP visiting patterns involving children under six in different payment categories. It found that average consultation rates for Children with Free GP Visit Cards was over 5 per annum while the comparable rate for Children for which fees would be paid was just 2 per annum.

Speaking in response to the research findings, Dr. Ray Walley, Chairman of the GP Committee of the IMO, said such an increase in visitor numbers would “overwhelm” surgeries and lead to waiting lists for GP visits for the first time in this country. He said; “this research confirms our worst fears and highlights the lack of planning and thought that has gone into the Government’s plans.”

The study set out to determine consultation rates relating to Children Under the Age of Six by interrogating data from GPs' practice management systems. The study population was all children aged under six years who had first attended the practice more than 12 months previously and hadalso attended more than once in their lifetime.

A total of 1,931 children aged under six were eligible for inclusion in a cross sectional study of six General Practices. Of these, 1,277(66%) were private' patients, 583(30%) were GMS eligible and 71(4%) had Doctor Visit' cards. The 1,931 children were responsible for 5,814 surgery consultations during 2013 (a mean annual consultation rate of 3.01).

The mean annual consultation rate by patient category was: 4.91 for GMS patients, 5.07 for ‘Doctor Visit' patients and 2.03 for private patients. The combined out of hours and telephone consultation rates in the main author's practice were an additional 0.69 p.a. for 256 private patients and 0.8 p.a. for 60 GMS patients. The figures quoted in the study relate to children that received treatment only and do not take into consideration additional figures for new services.

The authors note that although the results of this study are considerably higher than that reported in much larger studies (e.g. Ireland's longitudinal study of childhood), this study is based on documented clinical activity as opposed to recollection by patient / parents and more consistent with international data which adopts a similar approach.

While policy that enhances access to primary care by introducing free general practice care is welcome, Behan et al state that “this study highlights the need for accurate data to allow effective planning and establishment of sustainable models of healthcare. Maximising the use of clinical records for this purpose (to complement data from large population surveys) is a priority.”

All references and author names are contained in the full article in this month’s IMJ,
Title: Does Eliminating Fees at Point of Access Affect Irish General Practice Attendance Rates in the Under 6 Years Old Population? A Cross Sectional Study at Six General Practices.

Irish Medical Journal ■ March 2014 ■ Volume 107 ■ Number 3
Official Journal of the Irish Medical Organisation

Seasonal Influenza Vaccine Uptake in HSE-Funded Hospitals and Nursing Homes During the 2011/2012 Influenza Season

Achieving high uptake of influenza vaccination should be a priority and a marker of quality care in Irish health care settings. A study on the uptake of the influenza vaccine by HSE-Funded Hospitals and Nursing Homes during the 2011/2012 is presented in the March edition of the Irish Medical Journal.

The findings of the report indicate that substantial work is needed in Ireland to identify reasons for non-vaccination and where necessary, improve access to vaccination clinics through mobile units operating on-site, in the wards for all shifts; improve knowledge and attitudes to vaccination; organise timely reminders and incentives; and assign personnel dedicated to supporting the vaccination programme

The authors Ó Lorcain et al recommend that further analysis of future survey data, looking at uptake by different sectors of the health care system is required along with additional specific studies to identify factors associated with uptake in different settings e.g. organisational issues, role of vaccine administrators and monitoring staff uptake.

GPs have a major role to play in boosting influenza vaccination in the community and among community based staff. Involving local Departments of Public Health and infection control staff, both of which have particular expertise in the area of vaccination, prevention of infectious diseases and management of outbreaks, should be encouraged

Title: Seasonal Influenza Vaccine Uptake in HSE-Funded Hospitals and Nursing Homes During the 2011/2012 Influenza Season, p.72, Irish Medical Journal March 2014 ■ Volume 107 ■ Number 3

Comparison of Comorbidities in Patients with Pre-Diabetes to Those with Diabetes Mellitus Type 2
The first study performed in Ireland that looks at the prevalence of complications in pre-diabetes and compares this rate to that in type 2 diabetes is published in this month’s Irish Medical Journal. The study by authors Farrell et al highlights the fact that the prevalence of many diabetic complications is statistically the same in the pre-diabetic and type 2 diabetic populations.

The prevalence of ischaemic heart disease, renal disease, cerebrovascular disease and autonomic neuropathy is statistically the same in both groups and active management of these co-morbidities is required.

Title: Comparison of Comorbidities in Patients with Pre-Diabetes to Those with Diabetes Mellitus Type 2, p.72, Irish Medical Journal March 2014 ■ Volume 107 ■ Number 3

Irish Medical Journal ■ February 2014 ■ Volume 107 ■ Number 2
Official Journal of the Irish Medical Organisation

In 2011 the HSE announced that the care of patients with uncomplicated type 2 diabetes would shift from secondary care to General Practice (GP) by the end of 2012. An implementation plan has not yet been published. A new study by O’Connor et al in the February edition of the Irish Medical Journal examines the current care of patients with type 2 diabetes in General Practice and assesses how prepared it is to take on the proposed large burden of diabetes management.

There is increasing evidence that a primary care-led health system can provide improved health outcomes at affordable costs compared to a system centred on secondary and specialist care. In Ireland it is estimated that 4.5% of the Irish population have type 2 diabetes. Provision of structured diabetes care in general practice, has been shown to provide equivalent standards of care to that achieved by hospitals, with enhanced diabetes related quality of life
12 GP teaching practices affiliated to the University of Limerick General Practice Training Scheme (UL GP Scheme) and or the University of Limerick Graduate Entry medical School (UL GEMS) in the Mid-West of Ireland took part in this study.

Practices were asked if they used a protocol for diabetes care. The rates of recording of Albumin Creatinine Ratio (ACR), foot review, retinopathy screening, knowledge of smoking status and pneumococcal vaccination in practices using a protocol were compared with those not using one
For the purposes of this study a protocol was defined as “evidence that the patient was seen in a structured way using any type of protocol”. Information was collected on 842 patients from 12 different geographical areas in the Mid-West of Ireland. Of the participants in the study, 522 (62%) were males and 320 (38%) were females.

The average age was 65 years. 625(74.2%) of the study population had medical cards, whereas 211 (25.1%) were private patients. Information on the presence of Medical Card eligibility (GMS status) was missing on 6(0.7%) of the 842 patients. A practice protocol for the management of type 2 diabetes was in place for 596 patients (70.8% of the total). Known prevalence of diabetes was measured in 5 practices. This varied from 1.4% to 3.9%, with a mean of 2.48%. The mean interval since the previous full diabetes review in all the practices studied was 308 days (95% C/I was 216 –400).

From the data presented in this study the authors have established that when GPs are given adequate resources, as in the Midlands Structured Diabetes Care Programme, their management of type 2 diabetes is of an equivalent standard to that of secondary care and patients also experience a better quality of life. These resources include not only financial resources to enable practices to employ additional medical and administrative staff, but also community resources such as clinical nurse specialists in diabetes care with an organisational as well as a clinical role. Timely access to dieticians, community education programmes such as DESMOND (Diabetes Education and Self-Management for On-going and Newly Diagnosed) and retinopathy screening needs to be available to all GPs in an equitable way.

In a related qualitative study, the authors have shown that lack of financial incentive, lack of access to secondary resources, lack of staff and increased workload were the main barriers to GPs taking full responsibility of their patients with type 2 diabetes. The study indicates that when unresourced GPs and their practice staff review patients with diabetes in the normal clinical setting, many of the national targets are reached. This is especially true of certain key parameters such as measurement of blood pressure, creatinine, total cholesterol and HbA1c levels. However other important measures such as calculation of Body mass Index (BMI), administering annual influenza vaccine and once off pneumococcal vaccine, checking for microalbuminuria and diabetic foot disease and ensuring retinopathy screening are occurring at substantially below current best practice guidelines.

The authors note that the fact that there is a statistically significant difference in the frequency of some measures between those practices using a protocol and those who don’t again shows the benefits of providing some form of structured care within general practice. The authors conclude that “The management of type 2 diabetes in unresourced general practices is suboptimal. This needs to be addressed before handover of routine care of diabetes to general practice.”

All references and author names are contained in the full article in this month’s IMJ, p.43
Title: Care of Type 2 Diabetes in Unresourced General Practice: Current Practice in the Mid-West
 

Irish Medical Journal ■ February 2014 ■ Volume 107 ■ Number 2
Official Journal of the Irish Medical Organisation

A study of Anorexia Nervosa in Inpatients at a Children’s Hospital (2005-2011)

Anorexia Nervosa (AN) is a serious mental illness best treated in the community. Those with critically low weight require hospitalisation. The 2002 Census estimated there were 2,400 adolescent females with AN with an average age of onset of 14 years. In Ireland there is little published research on Anorexia Nervosa. The aim of this audit by O’Reilly et al, published in the latest edition of the Irish Medical Journal was to review the demographics of all inpatients admitted with AN over a seven year period between 2005 and 2011 in the Children’s University Hospital.

In the Children’s University Hospital the Maudsley treatment approach to AN is employed. This treatment approach acknowledges the importance of the parents and child in recovery. Patients are initiated on a non-negotiable meal plan with total bed rest and supervision usually implemented. MDT community based therapy is recommended in treating the complex needs of the patient and family. The need for acute hospital admission is usually indicated in poor physical health or poor response/lack of access to outpatient treatment

Presentation age in this study was estimated at 13.5 years of age which is 6 months earlier than 2002 estimates suggesting AN is presenting at an earlier age. All patients presented (100%) through A&E. The majority (60%) were self-referral with the remaining referred via G.P. Boys represented 6/20 (30%) of admissions. On admission girls were more underweight than boys (0.4th centile V 9th centile for BMI). This was despite girls presenting to hospital sooner than boys post onset of symptoms. Aside from low weight, over-exercising and food restricting were the most common presenting features.
On admission, it was noted that 5/20 (25%) of patients were known to have been vomiting and 13/20 (65%) were overexercising. All patients were food restricting. All the girls who had reached menarche had amenorrhea.

The large increase in admissions to CUH over the past decade mirrors UK figures indicating AN is an area of evolving and increasing service needs particularly in the paediatric setting. The relatively high male showing corroborates recent research indicating increased male prevalence. Girls are presenting to hospital sooner post onset than boys which could suggest better awareness and detection of AN in girls. The authors say that “It is a concern that the overall mean age of onset was estimated at 6 months prior to seeking treatment.” Onset of AN in childhood without prompt intervention may worsen prognosis and weight restoration is more challenging as energy requirements can be greater at low weight. Early detection and treatment in the community would be preferable to later hospitalisation.

The authors of this study noted that a number of patients had commenced orthodontic treatment prior to onset of AN. When braces are fitted and frequently adjusted, the teeth loosen and move causing pain. Oral pain must be considered in cases of unintentional weight loss which could later precipitate disordered eating. Sometimes dental professionals may discourage certain foods if they interfere with treatment which the “perfectionist” child may over-interpret. Although no Irish figures are available on the prevalence of orthodontic treatment there is UK data estimating that 14% of all 15 year olds have orthodontics. Future research should explore the relationship of orthodontics to weight loss.

The average length of hospital stay is more than 5 weeks. Inpatient stay is expensive and requires much resource in terms of staff training and MDT input. Education sessions have been arranged for staff to raise awareness of the strict nature of caring for a child with AN on the ward. The ill child with AN may try to manipulate the meal plan with less experienced or new members of staff. The authors state that “It is vital that the child not feel they are colluding and thus controlling aspects of their care.”
While AN is best treated in the community it is most successful when the illness is treated in the early stage. In this study, onset of illness does appear to significantly predate hospitalisation. Awareness at a community level of the signs and symptoms of AN may facilitate earlier treatment and negate the need for hospitalisation. It is important to be aware of the trend towards younger onset of AN and also the increasing incidence in boys. AN may look different nowadays and we must be ahead of the curve given its’ high mortality rate. The dramatic increase in AN presentations in CUH in the past decade may be mirrored nationally and this will have implications on community and acute services. The authors conclude that provisions will certainly need to be made in the planning of the new paediatric hospital for dedicated beds and also specialist medical, nursing and dietetic posts.

All references and author names are contained in the full article in this month’s IMJ, p.43
Title: Anorexia Nervosa (AN) in Inpatients a Children’s Hospital (2005 – 2011)
 

Irish Medical Journal ■ January 2014 ■ Volume 107 ■ Number 1
Official Journal of the Irish Medical Organisation

A study in the January edition of the Irish Medical Journal examines the introduction of Organ Donation following the Circulatory determination of Death in Beaumont Hospital during a two year period. DCD is a process in which death has been diagnosed on the basis of cardio-respiratory criteria. O’Rourke et al present the organ donor data on 9 patients who died and detail the disease processes that led to patients being considered for DCD.

Donation after the Circulatory Determination of Death, Donation after Circulatory Death and Non Heart Beating Organ Donation(DCDD, DCD, NHBD) are synonymous terms. They refer to the process whereby organs for transplantation are recovered from a person whose death has been diagnosed on the basis of cardiorespiratory criteria. Potential DCD donors may be divided into five categories.
• Category I patients are pronounced dead on arrival to hospital.
• Categories II and V are patients in whom resuscitation has been attempted, but are pronounced dead following either out-of-hospital cardiac arrest (category II), or in-hospital cardiac arrest (category V).
• Category III patients have devastating neurological injury, withdrawal of life-sustaining therapy (WLT) is anticipated and end of life care planned.
• Category IV are patients who suffer cardiac arrest during or after brainstem testing

O’Rourke et al set out that DCD is necessary for a number of reasons; Ireland has had an extremely successful transplantation program, however organ donation rates fluctuate. Within the Council of European Countries, the Republic of Ireland’s organ donation rates moved from 6th in 2006 to 22nd in 2010 (13 organ donors per million population – pmp). Though rates improved markedly in 2011 (20 pmp), a comparison with Spanish figures (34 pmp) places this improvement in context. DCD is necessary because BSD is being diagnosed less frequently. Road deaths have decreased by greater than 50% within the past 14 years, a statistic known to correlate closely with organ donation rates. Organ donor patients who have died as a result of trauma from any cause are decreasing, from 44% (2000-2005) to 33% (2006-2011).5 Finally advances in neurocritical care such as the endovascular management of subarachnoid haemorrhage and decompressive craniectomy have also decreased the numbers of patients who progress to BSD.

The lack of a widely accepted clinical practice guideline dedicated to DCD has heretofore precluded this possibility and denied these patients and families their wish to donate. The DCD practice guideline upon which these results are based has been reviewed extensively and approved by learned groups both locally and nationally.

Patients in the study came from two level-3 intensive care units in two hospitals. Beaumont hospital is one of two national neurological tertiary referral centres. The data from eleven potential organ donor patients and seventeen renal transplant recipients were reviewed and simple descriptive statistics compiled.

Each of the eighteen kidneys were transplanted into seventeen patients One patient had a nephron-dosing transplant, i.e. both donor kidneys were transplanted into a single recipient
The authors note that although the data demonstrate that outcomes from recipients are very good, we observed a significant incidence of DGF. DGF is defined as the need for dialysis within the first seven days post transplantation. Though the rate of DGF in this case series is 70% and higher than that reported by others, the presence of DGF does not adversely affect the longer-term viability of these kidneys.

The authors of the study determine that careful planning will ensure the successful implementation of DCD in any hospital. The presence of a locally accepted policy governing the process, a period of staff education and a clear path of audit and governance are essential. In Beaumont Hospital DCD has been incorporated into ongoing education, “after event reviews” allow staff the opportunity to voice concerns and will improve sustainability over time.
The authors present this case series of eleven organ donor patients, and of eighteen transplant recipients thanks to the generosity of these patients.

All references and author names are contained in the full article in this month’s IMJ, p.11
Title: Organ Donation Following the Circulatory Determination of Death (DCD): An Audit of Donation and Outcomes Following Renal Transplantation