Factors Influencing Ambulance Usage in Acute Coronary Syndrome.

Aims The aims of this study are to identify the proportion of ACS patients using an ambulance to transport to hospital and to explore the factors influencing mode of transport. Methods A retrospective, observational cohort design was utilised in this study. Data concerning cases of ACS in a university hospital over a 9-year period was obtained from the Coronary Heart Attack Ireland Register. Descriptive statistics were used to detail demographic and clinical data, as well as to establish the proportion of ambulance usage among ACS patients. Chi-square and t-tests were used to differentiate between groups at baseline. Factors influencing mode of transport were analysed by binary logistic regression. Results 4,229 cases were obtained. Exclusion and inclusion criteria were applied, leaving 1,964 cases for overall analysis. 533 (27%) patients directly used an ambulance, 1,098 (56%) patients presented initially to their GP while 333 (17%) went directly to A&E. Logistic regression showed that age, clinical factors, smoking status and diagnosis each had a statistically significant effect on ambulance usage. Conclusions Ambulance services are underutilised by ACS patients, despite clear benefits of their use. Several factors impacted patients' mode of transport. Knowledge of these is essential in guiding future awareness campaigns to promote ambulance usage in ACS.

The healthcare system and the provision of oral healthcare in European Union member states. Part 7: Republic of Ireland.

The Irish oral healthcare system is a hybrid model with a public/private mix of service provision, predominantly organised on the basis of fee-per-item remuneration. The system is structured around three long standing publicly funded schemes: the Public Dental Service (PDS) for all children and adults with special needs and provided by salaried dentists, the Dental Treatment Services Scheme (DTSS) for low income adults, and the Dental Treatment Benefit Scheme (DTBS) for insured persons, the latter two both provided by private independent dental practitioners. Ireland introduced systemic water fluoridation in 1963 and currently 73% of the population has access to fluoridated water. Ireland currently has a dentist density ratio of 6.1 dentists per 10,000 inhabitants and on average, 43% of the population (30% for those aged 70+ years) visit a dentist annually. In 2014, 83% of expenditure on oral healthcare was from out-of-pocket payments by patients, with less than 1% of overall government expenditure on healthcare allotted to oral healthcare. After the economic downturn of 2008 and the severe recession that followed in Ireland, substantial cutbacks in government expenditure resulted in extensive cuts to the public sector supply of dental services and to the extent of cover provided by the publicly funded schemes. The Department of Health has recognised the major post recessionary challenges facing the Irish health system, not least, significantly reduced budgets and capacity deficits, and acknowledges the need for change in Ireland's health service. In 2014, a three-year project commenced at the Department of Health, to develop a new national oral health policy for Ireland.

Factors influencing the variation in GMS prescribing expenditure in Ireland.

BACKGROUND: Pharmaceutical expenditure growth is a familiar feature in many Western health systems and is a real concern for policymakers. A state funded General Medical Services (GMS) scheme in Ireland experienced an increase in prescription expenditure of 414 % between 1998 and 2012. This paper seeks to explore the rationale for this growth by investigating the composition (Anatomical Therapeutic Chemical (ATC) Group level 1 & 5) and drivers of GMS drug expenditure in Ireland in 2012. METHODS: A cross-sectional study was carried out on the Health Service Executive-Primary Care Reimbursement Service (HSE-PCRS) population prescribing database (n = 1,630,775). Three models were applied to test the association between annual expenditure per claimant whilst controlling for age, sex, region, and the pharmacology of the drugs as represented by the main ATC groups. RESULTS: The mean annual cost per claimant was €751 (median = €211; SD = €1323.10; range = €3.27-€298,670). Age, sex, and regions were all significant contributory factors of expenditure, with gender having the greatest impact (ß = 0.107). Those aged over 75 (ß =1.195) were the greatest contributors to annual GMS prescribing costs. As regards regions, the South has the greatest cost increasing impact. When the ATC groups were included the impact of gender is diluted by the pharmacology of the products, with cardiovascular prescribing (ATC 'C') most influential (ß = 1.229) and the explanatory power of the model increased from 40 % to 60 %. CONCLUSION: Whilst policies aimed at cost containment (co-payment charges; generic substitution; reference pricing; adjustments to GMS eligibility) can be used to curtail expenditure, health promotional programs and educational interventions should be given equal emphasis. Also policies intended to affect physicians' prescribing behaviour include guidelines, information (about price and less expensive alternatives) and feedback, and the use of budgetary restrictions could yield savings in Ireland and can be easily translated to the international context.

Parents' Experiences of Toothbrushing with Children: A Qualitative Study.

Globally, dental caries is one of the most prevalent diseases and is more common in children living in deprived areas. Dental caries is preventable, and guidance in the United Kingdom recommends parental supervised brushing (PSB): a collection of behaviors-including twice-daily toothbrushing with fluoridated toothpaste-that should begin upon eruption of the first tooth (approximately 6 to 12 mo of age) and for which children need to be helped or supervised by an adult until at least 7 y of age. The aim of this study was to explore parents' experiences of toothbrushing with their young children and to establish barriers and facilitators to PSB at individual, interpersonal, and environmental levels according to the theoretical domains framework. Qualitative semistructured interviews guided by the framework were conducted with 27 parents of young children (<7 y) in 2 deprived areas of the United Kingdom. Framework analysis was used. Parents were not aware of national guidance concerning their active involvement in toothbrushing; however, they did have detailed knowledge of toothbrushing practices for children, and their intentions were to brush their children's teeth themselves twice every day as part of a family routine. Nonetheless, parents' difficulties experienced in managing their children's challenging behavior and the environmental context of their stressful lives meant that many parents adopted a role of simply reminding their children to brush or watching them brush. As such, the main barriers to PSB among parents living in deprived areas were skills in managing their children's behavior and environmental influences on family life. The results of our study have clear implications for the development of appropriate interventions to address the modifiable barriers to improve parental adoption of PSB. Knowledge Transfer Statement: The results of this study will be used to develop a behavior change intervention to encourage parental supervised brushing. The intervention-which is likely to be delivered through health practitioners rather than dental teams-will be developed to reduce dental caries among young children and will require evaluation in terms of its clinical and cost effectiveness.

Computerised cognitive behavioural therapy for alcohol use disorder: a pilot randomised control trial.

BACKGROUND: Cognitive behavioural therapy (CBT) has been used in the treatment of alcohol use disorder (AUD), generally in individual or group therapy, but not via computer. Aim This study examined the effectiveness of an interactive, personalised, computer-based CBT therapy in a randomised control trial. METHODS: We studied a group of 55 patients with AUD, randomised to either 5-hour-long computerised CBT sessions or a placebo cognitive-stimulating session, together with a 4-week inpatient rehabilitation treatment, and followed them for 3 months. RESULTS: There was a high degree of patient adherence to the protocol. Both groups did well, with a significant fall in alcohol outcome measures including number of drinks per drinking day, and number of drinking days, and an increase in abstinence rates in both groups to an equivalent level. The CBT group attended alcoholics anonymous groups more frequently, and had significant alterations in their alcohol self-efficacy outcomes, which correlated with their drinking outcomes. We concluded that computerised CBT is a potentially useful clinical tool that warrants further investigation in different treatment settings for AUD.

Visualization at supercomputing centers: the tale of little big iron and the three skinny guys.

Supercomputing centers are unique resources that aim to enable scientific knowledge discovery by employing large computational resources-the "Big Iron." Design, acquisition, installation, and management of the Big Iron are carefully planned and monitored. Because these Big Iron systems produce a tsunami of data, it's natural to colocate the visualization and analysis infrastructure. This infrastructure consists of hardware (Little Iron) and staff (Skinny Guys). Our collective experience suggests that design, acquisition, installation, and management of the Little Iron and Skinny Guys doesn't receive the same level of treatment as that of the Big Iron. This article explores the following questions about the Little Iron: How should we size the Little Iron to adequately support visualization and analysis of data coming off the Big Iron? What sort of capabilities must it have? Related questions concern the size of visualization support staff: How big should a visualization program be-that is, how many Skinny Guys should it have? What should the staff do? How much of the visualization should be provided as a support service, and how much should applications scientists be expected to do on their own?

Anaesthetic specialist registrars in Ireland: current teaching practices and perceptions of their role as undergraduate teachers.

BACKGROUND AND OBJECTIVES: Teaching is an important responsibility of non-consultant hospital doctors. In Ireland, specialist registrars (SpRs) in anaesthesia are contractually obliged to teach medical students, other doctors and nurses. Both medical students and fellow non-consultant hospital doctors attribute between 30 and 40% of their knowledge gain to non-consultant hospital doctors. METHODS: We carried out a confidential telephone survey of anaesthetic SpRs in Ireland regarding their current teaching practices and the perceptions of their role as undergraduate teachers. All the SpRs currently working in clinical practice in Ireland were eligible. RESULTS: Fifty-five of the 79 (70%) SpRs responded to the questionnaire. Only 7 (12.7%) of the respondents said they had been well trained as a teacher. The majority of the respondents stated that they would attend a learning-to-teach course/workshop if one was available, and felt that such a course would improve their ability as a teacher. Only 8 (14.5%) agreed that adequate emphasis is placed on commitment to teaching in the assessment of SpRs, both by individual departments and by the College of Anaesthetists. Anaesthetic SpRs in Ireland spend a considerable amount of time each day teaching undergraduate medical students, the majority (68.9%) stated that they had inadequate time to prepare for teaching. CONCLUSION: The majority of the respondents stated that they enjoy teaching, feel that they play an important role in undergraduate teaching but have inadequate time to prepare for teaching. An adequate emphasis is not placed on their commitment to teaching.

[Are academic radiologists evaluating the professional ethics of their residents?]. / Les radiologues enseignants évaluent-ils l'éthique professionnelle de leurs internes?

PURPOSE: Ethics is a challenging topic to teach and calls for competencies complex to pin point. Nevertheless, evaluation of ethics is a milestone on the way to autonomous medical practice. Our objectives were 1; To describe the "hidden knowledge" of academic radiologists evaluating the ethics of their residents; 2; To look for common denominators by comparing the evaluative practice of academic radiologists from France and Quebec. METHOD: 8 academic radiologists were interviewed on a critical episode of ethics evaluation of residents. The 8 transcripts were coded then co-coded using a USA reference from the radiology literature. RESULTS: 8/8 radiologists referred to 8 common issues of ethics, 7/8 shared an extra one, related to the teaching setting and 3/8 added the specific issue of consent to radiological procedure. CONCLUSION: The same ethical issues are shared by radiologists working in USA, France and Quebec. There are great similarities in evaluating ethics of residents among academic radiologists from France and Quebec, the diffusion of which being potentially useful to medical ethics training.

Physiological responses to repeated bouts of high-intensity ultraendurance cycling--a field study case report.

The present study aimed to 1) examine the relationship between laboratory-based measures and high-intensity ultraendurance (HIU) performance during an intermittent 24-h relay ultraendurance mountain bike race (approximately 20 min cycling, approximately 60 min recovery), and 2) examine physiological and performance based changes throughout the HIU event. Prior to the HIU event, four highly-trained male cyclists (age = 24.0 +/- 2.1 yr; mass = 75.0 +/- 2.7 kg; VO2peak = 70 +/- 3 ml x kg(-1) x min(-1)) performed 1) a progressive exercise test to determine peak volume of oxygen uptake (VO2peak), peak power output (PPO), and ventilatory threshold (T(vent)), 2) time-to-fatigue tests at 100% (TF100) and 150% of PPO (TF150), and 3) a laboratory simulated 40-km time trial (TT40). Blood lactate (Lac(-)), haematocrit and haemoglobin were measured at 6-h intervals throughout the HIU event, while heart rate (HR) was recorded continuously. Intermittent HIU performance, performance HR, recovery HR, and Lac(-) declined (P < 0.05), while plasma volume expanded (P < 0.05) during the HIU event. TF100 was related to the decline in lap time (r = -0.96; P < 0.05), and a trend (P = 0.081) was found between TF150 and average intermittent HIU speed (r = 0.92). However, other measures (VO2peak, PPO, T(vent), and TT40) were not related to HIU performance. Measures of high-intensity endurance performance (TF100, TF150) were better predictors of intermittent HIU performance than traditional laboratory-based measures of aerobic capacity.

H pylori infection is associated with downregulation of E-cadherin, a molecule involved in epithelial cell adhesion and proliferation control.

Extracellular matrix proteins and proteins involved in epithelial adhesion are essential for maintenance of tissue structure. Helicobacter pylori is the major aetiological agent in peptic ulcer disease and has been shown to increase gastric cancer risk up to ninefold. In this study, changes induced by H pylori on the expression of extracellular matrix proteins (collagen IV, fibronectin, and laminin) as well as two essential proteins for cell-basement and cell-cell adhesion (alpha 6-integrin and E-cadherin) were assessed. Immunohistochemistry was performed in antral biopsy sections obtained from infected and non-infected patients, and light microscopy was used to determine the distribution and intensity of specific staining. The results showed that the infection was significantly associated with downregulation of E-cadherin, an essential protein for maintenance of solid tissues and differentiation, but did not induce changes in the expression of alpha 6-integrin or the extracellular matrix proteins.

Changes in the carboxyl-terminal domain of metabotropic glutamate receptor 1 by alternative splicing generate receptors with differing agonist-independent activity.

The metabotropic glutamate receptors (mGluRs) share no sequence homology and show different structural features compared with most other G protein-coupled receptors (GPCRs). In particular, some isoforms of the phospholipase C (PLC)-coupled mGluRs (mGluR1a, mGluR5a, and mGluR5b) have a surprisingly long carboxyl-terminal intracellular domain of more than 350 residues, whereas the splice variants mGluR1b and mGluR1c have a much shorter carboxyl terminus. In the current study, the different splice variants of mGluR1 were expressed in porcine kidney epithelial (LLC-PK1) or the human embryonic kidney (HEK 293) cells, and their levels of expression were examined with the use of Western blot analysis. Expression of the short isoforms mGluR1b and mGluR1c did not modify the basal inositol phosphate production. In contrast, expression to similar levels of mGluR1a resulted in a 2-fold increase in the basal inositol phosphate formation. This increase in basal PLC activity was due to neither the presence of a low concentration of glutamate in the incubation medium nor a modification of the PLC pathway, resulting, for example, from the constant activation of mGluR1a++ by glutamate during the culture. Surprisingly none of the known competitive antagonists of mGluR1 inhibited the basal PLC activity, indicating that none of these molecules act as inverse agonists. Taken together, these results indicate that the long carboxyl-terminal domain confers a small agonist-independent activity to mGluR1. This indicates that, as already observed for other GPCRs, little constitutive activity of wild-type mGluRs can be detected. Our results also add to the splice variants and further suggest that the long carboxyl-terminal domain of mGluR1a confers better coupling efficiency to the G proteins.

The use of alcohol home delivery services by male problem drinkers: a preliminary report.

Alcohol home delivery services (AHDS) provide convenient and confidential access to alcohol, yet little is known about their use. The purpose of this report is to present preliminary data describing the use of AHDS by problem drinkers. We surveyed 174 males regarding social and demographic characteristics, alcohol use history, and use of AHDS. Use of AHDS was most common among problem drinkers. When statistically controlling for the effects of demographic and social characteristics, regular drinkers without a history of alcohol problems were significantly less likely to have had alcohol delivered than problem drinkers, p = .0036. Contrary to expectation, medically ill alcoholics with advanced and disabling medical complications of heavy drinking were not more likely than other problem drinkers to have alcohol delivered. Living in an urban area and not having a vehicle available were associated with the use of AHDS. The public health and safety considerations of alcohol availability via home delivery are discussed.

Clean intermittent catheterization: safe, cost-effective bladder management for male residents of VA nursing homes.

OBJECTIVES: To compare the safety and cost of clean versus sterile intermittent bladder catheterization in male nursing home residents. To provide evidence to support the hypothesis that intermittent catheterization is a valid, alternative method of bladder management in male residents of long-term care in whom urinary retention is a documented problem. DESIGN: Randomized clinical trial. SETTING: Three long-term care sites having predominantly male populations. PARTICIPANTS: Eighty male veterans, residents of three long-term care facilities, ranging in age from 36 to 96 years with a mean age of 72. INTERVENTIONS: Standardized procedures for clean and sterile intermittent catheterization (IC) were implemented by staff nurses at each site. Patients were randomized into clean and sterile IC groups. Nursing time and catheterization equipment usage were recorded using bar code readers. Clinical data were collected from the medical chart. Treatment of urinary tract infection was prescribed by the medical personnel responsible for each individual resident. MEASUREMENTS: We compared the number of treatment episodes for symptomatic bacteriuria between groups randomized to receive either clean or sterile intermittent catheterization. Laboratory analysis of blood and urine was done on predetermined days. Control variables were research site and patient history of urinary tract infection within the last 6 months. A cost comparison of nursing time and equipment usage for the two catheterization techniques was also performed. RESULTS: No significant differences were found between clean and sterile groups with regard to number of treatment episodes, time to first infection, type of organism cultured, or cost of antibiotic treatment. The cost of sterile technique was considerably higher both in terms of nursing time and supplies. CONCLUSIONS: Findings from this study demonstrate that clean technique intermittent catheterization is a safe and cost-effective bladder management technique with male, nursing home residents, despite the frailty of this high risk population. An annual savings of approximately $1460 per patient in nursing time and catheterization supplies could be anticipated if a patient were catheterized an average of four times per day substituting clean IC technique for sterile IC technique.

enabled, a dosage-sensitive suppressor of mutations in the Drosophila Abl tyrosine kinase, encodes an Abl substrate with SH3 domain-binding properties.

Genetic screens for dominant second-site mutations that suppress the lethality of Abl mutations in Drosophila identified alleles of only one gene, enabled (ena). We report that the ena protein contains proline-rich motifs and binds to Abl and Src SH3 domains, ena is also a substrate for the Abl kinase; tyrosine phosphorylation of ena is increased when it is coexpressed in cells with human or Drosophila Abl and endogenous ena tyrosine phosphorylation is reduced in Abl mutant animals. Like Abl, ena is expressed at highest levels in the axons of the embryonic nervous system and ena mutant embryos have defects in axonal architecture. We conclude that a critical function of Drosophila Abl is to phosphorylate and negatively regulate ena protein during neural development.

Regulation of human tissue factor expression by mRNA turnover.

Tissue factor serves as the cellular receptor for circulating blood coagulation factor VII and is the principal physiological initiator of blood coagulation. Tissue factor is not normally expressed in cells that contact blood, such as endothelial cells and monocytes, but can be induced in these cells by tumor necrosis factor or tumor-promoting phorbol esters. Following induction, the human tissue factor mRNA is degraded with a half-life of approximately 0.75-1.5 h. The cellular mechanisms responsible for this rapid mRNA turnover were investigated with chimeric tissue factor.beta-globin constructs expressed in stably transfected mouse NIH/3T3 cells. These constructs were expressed with the transiently inducible c-fos promoter which eliminated the need to use transcriptional inhibitors to determine mRNA half-lives. Sequences capable of conferring rapid turnover to the normally stable beta-globin transcript were localized to the last 600 nucleotides of the tissue factor mRNA. The 3' end of this fragment is similar to previously described AU-rich mRNA destabilizing elements. Activity of the tissue factor element was dependent on its specific sequence and not simply a high AU nucleotide content. The degradation of unstable chimeric tissue factor.beta-globin mRNAs was prevented by inhibition of transcription with actinomycin D. Chimeric tissue factor.beta-globin mRNAs were superinduced by the protein synthesis inhibitor cycloheximide, and this superinduction may be due in part to stabilization of the mRNA.

Complex health problems. Clinically assessing self-management abilities.

Assessment of self-care abilities by staff nurses is critical to planning post-hospitalization care. Assessment instruments must be comprehensive and yet usable by busy nurses. Orem's three categories of self-care deficits (universal, developmental, and therapeutic) provided a basis for the development of a Self-Management Inventory.

Structure of the gene for human plasminogen activator inhibitor-2. The nearest mammalian homologue of chicken ovalbumin.

Plasminogen activator inhibitor-2 (PAI-2) can regulate the formation of plasmin by inhibiting urokinase and tissue plasminogen activator. PAI-2 is induced in monocytes and endothelium by inflammatory mediators, and it is made in the placenta during pregnancy. PAI-2 is a member of the serine protease inhibitor gene family, and it is particularly similar to chicken ovalbumin. Like ovalbumin, PAI-2 is secreted without cleavage of a signal peptide. To determine the structure of the PAI-2 gene, two bacteriophage lambda human genomic DNA libraries were screened with PAI-2 cDNA probes. Characterization of three positive clones shows that the human PAI-2 gene spans 16.5 kilobases and has eight exons. The 5'-untranslated sequence of the PAI-2 mRNA is 77 base pairs in length as suggested by primer extension and S1 nuclease mapping. The eukaryotic consensus sequence TATAAAA is found 22 base pairs 5' of the proposed cap site. The PAI-2 gene is on chromosome 18q21-23 as determined by hybridization to flow-sorted chromosomes and by in situ hybridization. There appear to be two common PAI-2 alleles that differ by six nucleotides in exons 1, 4, and 8. The structure of the PAI-2 gene is quite different from that of PAI-1 although these two inhibitors have common target protease specificity. In contrast, the structure of the PAI-2 gene is very similar to that of the chicken ovalbumin gene. When protein sequences are aligned to obtain maximal identity, six of the seven intron positions in the PAI-2 gene are identical to those in the chicken ovalbumin gene. We conclude that PAI-2 is the closest mammalian homologue of avian ovalbumin.