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  • The importance of taking a patient-centered, community-based approach to preventing and managing frailty: A public health perspective

    Adja, Kadjo Yves Cedric; Lenzi, Jacopo; Sezgin, Duygu; O'Caoimh, Rónán; Morini, Mara; Damiani, Gianfranco; Buja, Alessandra; Fantini, Maria Pia; Mercy University Hospital, Grenville Place, Cork, Ireland (Frontiers Media S.A., 2020-11-12)
    Across the world, life expectancy is increasing. However, the years of life gained do not always correspond to healthy life years, potentially leading to an increase in frailty. Given the extent of population aging, the association between frailty and age and the impact of frailty on adverse outcomes for older people, frailty is increasingly being recognized to be a significant public health concern. Early identification of the condition is important to help older adults regain function and to prevent the negative outcomes associated with the syndrome. Despite the importance of diagnosing frailty, there is no definitive evidence or consensus of whether screening should be routinely implemented. A broad range of screening and assessment instruments have been developed taking a biopsychosocial approach, characterizing frailty as a dynamic state resulting from deficits in any of the physical, psychological and social domains, which contribute to health. All these aspects of frailty should be identified and addressed using an integrated and holistic approach to care. To achieve this goal, public health and primary health care (PHC) need to become the fulcrum through which care is offered, not only to older people and those that are frail, but to all individuals, favoring a life-course and patient-centered approach centered around integrated, community-based care. Public health personnel should be trained to address frailty not merely from a clinical perspective, but also in a societal context. Interventions should be delivered in the individuals' environment and within their social networks. Furthermore, public health professionals should contribute to education and training on frailty at a community level, fostering community-based interventions to support older adults and their caregivers to prevent and manage frailty. The purpose of this paper is to offer an overview of the concept of frailty for a public health audience in order to raise awareness of the multidimensional aspects of frailty and on how these should be addressed using an integrated and holistic approach to care. © Copyright © 2020 Adja, Lenzi, Sezgin, O'Caoimh, Morini, Damiani, Buja and Fantini.
  • Evaluation of an emergency department falls pathway for older people: A patient chart review

    O'Keeffe, Anne; O'Grady, Sile; Cronin, Finola; Dolan, Clodagh; O'Hea, Ann; O'Shea, Katie Louise; Naughton, Corina; Mercy University Hospital (Elsevier BV, 2020-07)
    The number of older adults presenting to EDs following a fall continues to rise, yet falls management often ignores opportunities for secondary falls risk reduction. Advanced Nurse Practitioners (ANPs) in EDs have an important clinical leadership role in improving outcomes for this group of patients. Aim: This study describes the development of an ANP led falls pathway in an ED to improve safe discharge. It evaluates compliance with the pathway and referrals to community falls prevention services. It also draws comparison with baseline practice as recorded in 2014. Methods: The Falls Pathway involves four steps: 1) screening at triage (3 questions), 2) risk stratification (low, medium, high), 3) risk assessment (lying and standing blood pressure (B/P), timed-up and go (TUG), 4-AT for delirium screening, polypharmacy), and 4) referral to community falls services. We undertook a 12-month chart review of all patients aged 65 years or older presenting following a fall to the ANP service in 2018. We compared data to a baseline audit in 2014; descriptive and Chi squared statistics were used to examine the data. Results: The 2018 audit involved 77 patients representing 27% of ANP caseload. A repeat fall occurred in 42% (32/77) of cases and 35% (22/77) reported a fear of falling. The Falls Pathway was initiated in nearly 80% (62/77) of patients and compliance with falls risk assessment ranged from 42% for lying and standing B/P to 75% for TUG. In 2014, a review of 59 patient charts showed 27% (16/59) experienced a repeat fall, but other risk factors such as fear of falling were not recorded. In 2018, the majority of patients (88%) discharged home were referred to community falls prevention services compared to 22% in 2014. Conclusion: The Falls Pathway improved falls risk assessment in the ED, identified opportunities for risk reduction and optimised referral to community falls services. The pathway continues to be a valuable tool but requires resources for ongoing implementation among the wider ED team.
  • Irritant contact dermatitis in healthcare workers as a result of the COVID-19 pandemic: a cross-sectional study.

    Kiely, L F; Moloney, E; O'Sullivan, G; Eustace, J A; Gallagher, J; Bourke, J F (2020-09-05)
    COVID-19 healthcare workers (HCWs) require frequent handwashing and use of personal protective equipment (PPE) to prevent infection. However, evidence is emerging that these practices are causing adverse effects on their skin integrity. A single-centre, cross-sectional study of HCWs from an Irish hospital was undertaken to evaluate the degree of COVID-19-related irritant contact dermatitis (ICD) between April and May 2020. Of 270 participants surveyed, 223 (82.6%) reported symptoms of ICD. The hands were the most commonly affected site (76.47%) and the most frequently reported symptom was dry skin (75.37%). Nearly all (268; 99.26%) HCWs had increased hand-washing frequency, but 122 (45.35%) did not use emollients. In the ICD group, 24.7% cited a history of dermatitis compared with 4.3% of unaffected staff (P < 0.001). The ICD group recorded PPE usage for an average of 3.15 h compared with the non-ICD group at 1.97 h (P = 0.21). Promoting awareness of COVID-19-related ICD is vital to highlight prevention and treatment for frontline staff.
  • Youth mental health in the time of COVID-19.

    Power, Emmet; Hughes, S; Cotter, D; Cannon, M (2020-07-02)
    Youth mental health is a rapidly developing field with a focus on prevention, early identification, treatment innovation and service development. In this perspective piece, we discuss the effects of COVID-19 on young people's mental health. The psychosocial effects of COVID-19 disproportionately affect young people. Both immediate and longer-term factors through which young people are affected include social isolation, changes to the delivery of therapeutic services and almost complete loss of all structured occupations (school, work and training) within this population group. Longer-term mechanisms include the effects of the predicted recession on young people's mental health. Opportunities within this crisis exist for service providers to scale up telehealth and digital services that may benefit service provision for young people's mental health in the future.
  • Risk Factors for Respiratory Syncytial Virus Bronchiolitis Admissions

    Meenaghan, Samantha; Breatnach, C.; Smith, H. (Irish Medical Journal, 2020-01)
    AimDetermine the seasonal incidence of hospital Respiratory Syncytial Virus (RSV) bronchiolitis and explore the variables associated with admission to ward versus the Paediatric Intensive Care Unit (PICU).MethodRetrospective case-control study. Children, aged ≤2 years, between November and March, over a 3 year period with a positive RSV nasopharyngeal aspirate test.ResultsA total of 557 children were included; 19% (n=106) required PICU admission. Children admitted to the PICU were younger in age, median (IQR) 6.93 (3.96, 11.89) weeks compared to children who remained on the wards 11.00 (5.86, 24.14) weeks. Being underweight at the point of admission (adjusted odds ratio 3.15, 95% 1.46, 6.70, p=0.003) was associated with a PICU admission.ConclusionNumber of RSV bronchiolitis hospitalisations are increasing each year. Age, weight and the use of HFNC were independent predictors for PICU admission.
  • Social isolation due to the COVID-19 pandemic has led to worse outcomes in females with inflammatory arthritis.

    Maguire, Sinead; O'Shea, Finbar (2020-07-12)
    Background: Prolonged social isolation as a result of the COVID-19 global pandemic has been a source of considerable psychological distress for many people. This can manifest in many ways and if left undetected can impact negatively on general health. It is essential to understand the impact of these conditions on inflammatory arthritis (IA) patients, especially axial spondyloarthropathy (axSpA). Aim: To capture the level of psychological distress for patients with IA following prolonged social isolation. Methods: A survey was sent out to patients with a confirmed diagnosis of IA. This captured changes in sleep, mood, disease activity, employment and general health since the beginning of the social isolation period. A PHQ-4 (Patient Health Questionnaire) was included to determine level of psychological distress. Results: Females with IA reported significantly higher rates of decline in general health (40% vs 16%, p = 0.01), mood disturbance (43.4% vs 26%, p = 0.03) and increased disease activity (50% vs 16%, p = 0.01) compared to males. Evaluating the mean PHQ-4 scores, no significant difference was noted between genders (4.80 vs 3.44, p = 0.10). However, females demonstrated a non-significant trend toward increased rates of moderate to severe psychological distress (40% vs 30%, p = 0.13). Subanalysis of patients with axSpA found high rates of moderate to severe distress in both genders. Conclusions: Females with IA reported significantly higher rates of decline in general health, mood disturbance and increased disease activity during the period of social isolation. This was reflected in a trend towards greater levels of psychological distress.
  • Dual tasking interferes with dynamic balance in young and old healthy adults

    Sulaiman, Amal Al-Shaikh; Kelly, Marie; O'Connor, Mairead; Eva-Bamiou, Doris; Pavlou, Marousa (IOS Press, 2021-01-11)
    BACKGROUND:Functional mobility requires an ability to adapt to environmental factors together with an ability to execute a secondary task simultaneously while walking. A complex dual-tasking gait test may provide an indication of functional ability and falls risk among community-dwelling older adults. PURPOSE:The aim of this cross-sectional study is to investigate age-related differences in dual-tasking ability and to evaluate whether dual-tasking ability is related to executive function. METHODS:Forty-one community-dwelling healthy older and forty-one younger adults completed a dual-tasking assessment in which concurrent tasks were incorporated into the Functional Gait Assessment (FGA). The manual dual-task involved carrying a glass of water (FGA-M) while the cognitive dual-tasks involved numeracy (FGA-N) and literacy (FGA-L) related tasks. FGA scores under single (FGA-S) and dual-task conditions together with associated dual-task costs and response accuracy were determined. Executive function was assessed using The Behavioural Assessment of the Dysexecutive Syndrome (BADS). RESULTS:FGA-N and FGA-L scores were adversely affected in both groups compared to FGA-S (p≤0.001). However, score reductions and dual-task costs were significantly greater for older adults compared to younger adults on FGA-N (p≤0.05) and FGA-L (p≤0.001), with older adult performance on FGA-N associated with falls risk (p≤0.05). Executive function did not appear to be related to dual-tasking ability. CONCLUSION:Findings suggest that cognitively demanding tasks while walking, have a deleterious effect on dynamic balance and could place older adults at a greater risk of falls.
  • Uncomfortably numb: suicide and the psychological undercurrent of COVID-19.

    Hughes, H; Macken, M; Butler, J; Synnott, K (2020-05-21)
  • Estimation and consumption pattern of free sugar intake in 3-year-old Irish preschool children.

    Crowe, Michael; O'Sullivan, Michael; Cassetti, Oscar; O'Sullivan, Aifric (2019-07-19)
    Purposes: Dietary free sugars (FS) are the most important risk factor for dental caries and can contribute to excess energy intake. Measuring FS intake is limited by food composition databases and appropriate dietary assessment methods. The aim of this analysis was to estimate total sugar (TS) and FS intakes for Irish pre-schoolers and examine the proportion of dietary TS and FS captured using a short food questionnaire (SFQ). Methods: This is a secondary analysis of 3-year-old children from two national surveys; Growing Up in Ireland (GUI), N = 9793 of whom 49% were girls and the National Preschool Nutrition Survey (NPNS), N = 126 and 52% were girls. GUI used SFQs and NPNS used semi-weighed food diaries to collect dietary data from 3-year-old children. Dietary intake databases were linked using an established approach. Mean daily TS and FS intakes and frequency were calculated, and consumption patterns from foods and meals are presented. The proportion of foods that were covered or non-covered by the GUI SFQ was calculated by comparison with the NPNS food diary. Results: 75% of 3 year-olds had FS intake greater than the maximum recommended by WHO guidelines for free sugar intake, while 4% met the lower threshold. The median frequency of TS and FS consumption was 5.0 (4.0-6.0) and 4.0 (3.0-5.0) times/day. Less than one-quarter of TS intake (g/day) was non-covered by the GUI SFQ while less than one-third of FS intake was non-covered. Conclusions: A large majority of 3-year-old Irish children do not meet the WHO recommended guidelines for FS intake and almost none meet the desired conditional recommendation. SFQs only capture two-thirds of FS intake at this early age.
  • Storytelling and poetry in the time of coronavirus.

    Barrett, Elizabeth; Dickson, Melissa; Hayes-Brady, Clare; Wheelock, Harriet (2020-05-14)
    The coronavirus crisis occurs at a time when many clinicians have already experienced burnout. One in three Irish doctors were suffering from burnout in the 2019 National Study of Wellbeing of Hospital Doctors in Ireland; rates are also high in Irish Psychiatry. We present a perspective on the use of narrative in medicine and recognise that storytelling, and the patient history are very much at the heart of medicine. Clinician storytelling, such as Schwartz Rounds and Balint group work, has very much come to the fore in Irish Psychiatry and in training. Projects such as MindReading have explored overlaps between clinicians, humanities experts and experts by experience. We give an overview of some approaches from the movement around narrative in medicine to bolster this. We explore why clinicians write as ways to support identification, catharsis and a way to process experiences. Clinicians and patients may also use literature and poetry to promote coping. The historical context and practical strategies are highlighted, particularly with reference to poetry use during the current crisis.
  • Sepsis at ICU admission does not decrease 30-day survival in very old patients: a post-hoc analysis of the VIP1 multinational cohort study.

    Ibarz, Mercedes; Boumendil, Ariane; Haas, Lenneke E M; Irazabal, Marian; Flaatten, Hans; de Lange, Dylan W; Morandi, Alessandro; Andersen, Finn H; Bertolini, Guido; Cecconi, Maurizio; et al. (2020-05-13)
    Background: The number of intensive care patients aged ≥ 80 years (Very old Intensive Care Patients; VIPs) is growing. VIPs have high mortality and morbidity and the benefits of ICU admission are frequently questioned. Sepsis incidence has risen in recent years and identification of outcomes is of considerable public importance. We aimed to determine whether VIPs admitted for sepsis had different outcomes than those admitted for other acute reasons and identify potential prognostic factors for 30-day survival. Results: This prospective study included VIPs with Sequential Organ Failure Assessment (SOFA) scores ≥ 2 acutely admitted to 307 ICUs in 21 European countries. Of 3869 acutely admitted VIPs, 493 (12.7%) [53.8% male, median age 83 (81-86) years] were admitted for sepsis. Sepsis was defined according to clinical criteria; suspected or demonstrated focus of infection and SOFA score ≥ 2 points. Compared to VIPs admitted for other acute reasons, VIPs admitted for sepsis were younger, had a higher SOFA score (9 vs. 7, p < 0.0001), required more vasoactive drugs [82.2% vs. 55.1%, p < 0.0001] and renal replacement therapies [17.4% vs. 9.9%; p < 0.0001], and had more life-sustaining treatment limitations [37.3% vs. 32.1%; p = 0.02]. Frailty was similar in both groups. Unadjusted 30-day survival was not significantly different between the two groups. After adjustment for age, gender, frailty, and SOFA score, sepsis had no impact on 30-day survival [HR 0.99 (95% CI 0.86-1.15), p = 0.917]. Inverse-probability weight (IPW)-adjusted survival curves for the first 30 days after ICU admission were similar for acute septic and non-septic patients [HR: 1.00 (95% CI 0.87-1.17), p = 0.95]. A matched-pair analysis in which patients with sepsis were matched with two control patients of the same gender with the same age, SOFA score, and level of frailty was also performed. A Cox proportional hazard regression model stratified on the matched pairs showed that 30-day survival was similar in both groups [57.2% (95% CI 52.7-60.7) vs. 57.1% (95% CI 53.7-60.1), p = 0.85]. Conclusions: After adjusting for organ dysfunction, sepsis at admission was not independently associated with decreased 30-day survival in this multinational study of 3869 VIPs. Age, frailty, and SOFA score were independently associated with survival.
  • Mindfulness moments for clinicians in the midst of a pandemic.

    Hedderman, E; O'Doherty, V; O'Connor, S (2020-05-21)
    Clinicians are routinely subjected to intense and stressful working environments, and the current COVID-19 crisis increases their risk of psychological distress. Mindfulness has been shown to improve life satisfaction, resilience to stress, self-compassion, compassion and general well-being in healthcare workers. Based on their clinical experience, the authors present mindfulness moments for clinicians (MMFC), a selection of short, simple and accessible mindfulness practices to promote resilience and compassion among clinicians working in this pandemic. The practices can be used on the job and are accessible to both novice and experienced meditators. Most of these practices are extracted from evidence-based mindfulness programmes. Further research is indicated to assess the effectiveness of using MMFC to support clinicians in their work and to promote resilience.
  • Emerging treatments for inflammatory bowel disease.

    Hazel, Karl; O'connor, Anthony (2020-02-05)
    Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), is characterized by chronic inflammation, a relapsing and remitting clinical course, requirement for lifelong medication and often, significant morbidity. While multiple effective therapeutic options exist for the treatment of IBD, a proportion of patients will either fail to respond or lose response to therapy. Advances in therapeutics, such as the gut-specific anti-integrins, now offer patients an alternative option to systemic immunosuppression. Anti-interleukin 12 (anti-IL-12)/IL-23 agents offer new and effective treatment options for CD, while the oral small molecules now offer an oral alternative for the treatment of moderate-to-severe disease, previously requiring subcutaneous injection or intravenous infusion. Alternatives to pharmacological treatment such as stem-cell transplant and faecal microbiota transplant are also showing some promise in the treatment of both CD and UC.
  • Sepsis Associated Delirium.

    Atterton, Ben; Paulino, Maria Carolina; Povoa, Pedro; Martin-Loeches, Ignacio (2020-05-18)
    Sepsis is a potentially life-threatening condition caused by a systemic dysregulated host response to infection. The brain is particularly susceptible to the effects of sepsis with clinical manifestations ranging from mild confusion to a deep comatose state. Sepsis-associated delirium(SAD) is a cerebral manifestation commonly occurring in patients with sepsis and is thought to occur due to a combination of neuroinflammation and disturbances in cerebral perfusion, the blood brain barrier (BBB) and neurotransmission. The neurological impairment associated with SAD can persist for months or even longer, after the initial septic episode has subsided which may impair the rehabilitation potential of sepsis survivors. Early identification and treatment of the underlying sepsis is key in the management of SAD as once present it can be difficult to control. Through the regular use of validated screening tools for delirium, cases of SAD can be identified early; this allows potentially aggravating factors to be addressed promptly. The usefulness of biomarkers, neuroimaging and electroencephalopathy (EEG) in the diagnosis of SAD remains controversial. The Society of Critical Care Medicine (SCCM) guidelines advise against the use of medications to treat delirium unless distressing symptoms are present or it is hindering the patient’s ability to wean from organ support.
  • Down syndrome and oral health: mothers' perception on their children's oral health and its impact.

    AlJameel, AlBandary H; Watt, Richard G; Tsakos, Georgios; Daly, Blánaid (2020-06-16)
    Background: Individuals with Down syndrome exhibit particular oro-facial characteristics that may increase their risk of oral health problems. However, there is little research on the oral health of children and adults with Down syndrome and the way that oral health may affect Quality of Life (QoL). This study explored mothers' perceptions of the oral health problems experienced by their children with Down syndrome and how these reported problems impacted the lives of the children and their families. Methods: The study involved 20 in-depth, semi-structured interviews with mothers of children and adolescents aged 12-18 years with Down syndrome attending special care centres in Riyadh, Saudi Arabia. Results: The predominant oral-health related problem reported by mothers was difficulty in speaking. Mothers also reported that tooth decay and toothache were problems that had undesirable effects on different aspects of their children's QoL including: performing daily activities, emotional wellbeing, and social relationships. Poor oral health and functional problems had direct and indirect impacts on the family's QoL as well. Conclusion: Mothers perceived an array of QoL impacts from oral conditions, which affected their child with Down syndrome and the wider family.
  • A prospective cohort study of the conservative management of focal cervical intraepithelial neoplasia 2.

    McMahon, Gabriela; Griffin, Sinead; Curley, Jennifer; Hartel, Paul; Kilgallen, Clive; Kondaveeti, Nirmala; Sligo University Hospital (European Society of Gynaecology, 2020)
    Background and Purpose: Traditionally, cervical intraepithelial neoplasia 2 (CIN 2) is managed by the removal of affect-ed tissue in a procedure known as a large loop excision of the transformation zone (LLETZ). In our unit, pathology reports on LLETZ specimens done for a diagnosis of CIN 2 often are reported as CIN 1 or a normal result. So we wondered – are we over-managing CIN 2? Methods: This study was designed to assess the acceptability and outcomes of the conservative management of focal CIN 2. We wanted to establish if monitoring of the disease is sufficient in selected women. In this prospective cohort, women were selected for inclusion in the study by having a histological diagnosis of focal CIN 2 from a cervical biopsy and after discussion at the colposcopy multi-disciplinary team meeting. After explanation of CIN 2 and its future impli-cations, women were informed of the risks and benefits of conservative management versus LLETZ. Women who opted for conservative management were seen in the colposcopy clinic for colposcopy examination, cervical biopsy ± cervical smear and HPV testing at six monthly intervals for two years.Results: Over the two-year follow-up period, 20/31 women (64.5%) had regression of disease, 7/31 women (22.6%) had persistence of CIN 2 and 4/31 women (12.9%) had progression of disease to CIN 3. There were no reported cases of cervical carcinoma in situ or invasive cervical carcinoma. During the follow-up period, patients were offered treatment if there was progression to CIN 3 or worse, persistence of CIN 2 or if they wished to undergo treatment at any stage.Conclusions: Conservative management of CIN 2 may be considered in women who are under the age of 30 with focal CIN 2. However, larger studies should be carried out to define the safety or acceptability of changing this practice.
  • Involving Clients to Inform Development and Implementation of Combined Type 2 Diabetes and Chronic Kidney Disease Care Using Discovery Interview Technique.

    Blanchfield, Denise; O'Connor, Laserina (Innovational Publishers, 2020-10)
    The development of chronic kidney disease in persons with Type 2 diabetes has been described as an epidemic. Standard outpatient care for these associated conditions is routinely provided separately, resulting in missed opportunities to implement preventative and early management strategies. Historically, care delivery for these combined conditions has fallen within the remit of medical professionals, evidenced by a dearth of information pertaining to the contribution of advanced practice nursing for this cohort. Clients report an uncoordinated impersonal approach to care delivery for associated conditions, however incorporating their experience is vital to the delivery of patient centered care and will be included in this study through their stories. The primary aim of this participatory action research (PAR) study is to utilize the client care stories and health-care professional perspectives to inform development and implementation of a new combined Type 2 diabetes and chronic kidney disease service in the context of advanced practice nursing. Methodology: This study adopted a PAR approach informed by patient discovery interviews and key stakeholders focus groups. Transcripts will be developed from discovery interviews and focus groups and analyzed using thematic analysis. Results: The PAR will utilize thematic analysis outcomes to inform the primary aim and clinical outcomes from combined care will be evaluated after 9 months by retrospective chart review. Conclusion: The approach adopted in this study represents a departure from traditional medically led care strategies. Outcomes may elucidate potential challenges to the development and delivery of innovative care delivery for underserved patient cohorts in the context of advanced practice nursing.
  • Beaumont Hospital and National Ambulance Service: Pathfinder Service

    Corcoran, Grace; Kenna, Lawrence; Beaumont Hospital, National Ambulance Service (Beaumont Hospital, 2020-02-26)
    Presentation on integration of ambulance service and Beaumont Hospital ED.

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