Evaluation of a national clinical programme for the management of self-harm in hospital emergency departments: impact on patient outcomes and the provision of care.

BACKGROUND: Emergency departments are important points of intervention, to reduce the risk of further self-harm and suicide. A national programme to standardise the management of people presenting to the emergency department with self-harm and suicidal ideation (NCPSHI) was introduced in Ireland in 2014. The aim of this study was to evaluate the impact of the NCPSHI on patient outcomes and provision of care. METHODS: Data on self-harm presentations were obtained from the National Self-Harm Registry Ireland from 2012 to 2017. The impacts of the NCPSHI on study outcomes (3-month self-harm repetition, biopsychosocial assessment provision, admission, post-discharge referral, and self-discharge) were examined at an individual and aggregate (hospital) level, using a before and after study design and interrupted time series analyses, respectively. The 15 hospitals that implemented the programme by January 2015 (of a total of 24 between 2015 and 2017) were included in the analyses. RESULTS: There were 31,970 self-harm presentations during the study period. In hospitals with no service for self-harm (n = 4), risk of patients not being assessed reduced from 31.8 to 24.7% following the introduction of the NCPSHI. Mental health referral in this hospital group increased from 42.2 to 59.0% and medical admission decreased from 27.5 to 24.3%. Signs of a reduction in self-harm repetition were observed for this hospital group, from 35.1 to 30.4% among individuals with a history of self-harm, but statistical evidence was weak. In hospitals with a pre-existing liaison psychiatry service (n = 7), risk of self-discharge was lower post-NCPSHI (17.8% vs. 14.8%). In hospitals with liaison nurse(s) pre-NCPSHI (n = 4), medical admission reduced (27.5% vs. 24.3%) and there was an increase in self-harm repetition (from 5.2 to 7.8%. for those without a self-harm history). CONCLUSION: The NCPSHI was associated with improvements in the provision of care across hospital groups, particularly those with no prior service for self-harm, highlighting the need to consider pre-existing context in implementation planning. Our evaluation emphasises the need for proper resourcing to support the implementation of clinical guidelines on the provision of care for people presenting to hospital with self-harm.

Sun-related risks and risk reduction practices in Irish outdoor workers.

BACKGROUND: Ultraviolet radiation (UVR) is an occupational hazard for outdoor workers. AIMS: This descriptive study aimed to describe the solar UVR risk, and explore associations between demographic characteristics and sun-safety knowledge, risks and practices, in golf-course maintenance workers on the island of Ireland. METHODS: A survey, designed to collect demographic and occupational information, measures of skin cancer knowledge and sun protection practices, was completed by 154 male outdoor workers in the golf-course maintenance industry. Statistical analysis included tests of association and non-parametric tests. RESULTS: Less than 10% of this mainly male worker group had received education/training on solar UVR risks (sun safety) and two-thirds were more concerned about workplace injury. While a majority used routine precautionary measures, those with greater knowledge of skin cancer, senior grades and workers under 45 years were significantly more likely to use sunscreen and/or sunglasses. CONCLUSIONS: Findings indicate that these workers were a high risk group for skin cancer, with good knowledge of the risk, but limited training or education in risk reduction. While the prevalence of sunscreen and sunglasses use is relatively good, it was better among younger workers and those in senior grades, and could be improved if they were routinely provided as a control measure by the employer.

Temporal macrodynamics and microdynamics of the postoperative impedance at the tissue-electrode interface in deep brain stimulation patients.

OBJECTIVE: To study the temporal dynamics of tissue impedance after deep brain stimulation (DBS). BACKGROUND: DBS therapy commonly employs a constant voltage approach, and current delivery to the tissue is a function of electrode-tissue impedance. It is presumed that impedance fluctuates early postimplantation, with implications for variations in current delivery and therapeutic efficacy. We hypothesised that the largest variation will be recorded early after surgery, followed by stabilisation. METHODS: Review of impedance checks of implanted DBS systems at standard parameters during the first five months postimplantation. All measurement time points were binned into 1-week periods, and we used repeated measures analysis of variance with Tukey pairwise multiple comparisons correction. The analysis was repeated after normalising impedance values for each subject to that patient's baseline value. RESULTS: There was an initial (non-significant) drop in impedance at week 1, followed by significant increase at week 3 (p=0.0002). There were no further significant differences in impedance values at subsequent time points. Analysis of normalised data showed a significant difference between the initial measurement in postoperative week 1 (normalised value 1) and week 3 (normalised value 1.73, p<0.0001), with no further difference among the subsequent weekly points during the 5-month follow-up. No significant hourly variations were found at any time points. CONCLUSIONS: We found major changes in impedance within the first month postimplantation, with no further variation. This is an important confirmation in patients of this temporal dynamics of the impedance of implanted DBS hardware, with potential therapeutic implications.

Obesogenic island: the financial burden of private transport on low-income households.

BACKGROUND: The physical and social environment influences access to a healthy lifestyle, of which transport is one determining factor. This paper estimates the cost of transport on the island of Ireland. METHODS: Budget standards were developed on the basis of costs of baskets of core goods and services required for daily living. The transport budget was based on the needs of an urban living family. Financial capacity of the family relative to transport basket costs was determined. RESULTS: Transport costs vary depending on family type and car ownership. The motoring costs for a family with two unemployed adults, with a weekly financial capacity of 388.28 euros and 427.70 euros, respectively, for the Republic of Ireland and Northern Ireland, amount to 94.78 euros and 74.68 euros, representing 18 and 10% of the family's weekly income. CONCLUSION: The prohibitive costs of private transport present an opportunity for policy makers to consider creating supportive environments incorporating the more cost-effective and environmentally friendly options of public transport. Without such measures, dependence on private transport will exacerbate the incidence of food poverty and the health inequalities consequent upon it.

Empirically derived weights for GMS capitation payments to General Practitioners.

AIM: Unlike other weighted capitation schemes used in Irish health service financing and in health systems internationally, the GMS capitation payments scheme for General Practitioners lacks transparency in both the data used and the model employed. In this study, evidence-based weights were generated and compared to current payment weights. METHODS: Four datasets on GP utilisation were interrogated. RESULTS: Evidence-based weights indicated that over 70s had higher payments per consultation than other groups. Considerable intra-age band differences in capitation payment were detected. DISCUSSION AND CONCLUSION: The results suggest that there is a need for a comprehensive review of the current payments system. Current age bands should be narrowed. The implications for the efficiency and equity of general practice in Ireland are discussed.

Patient level costing in Ireland: process, challenges and opportunities.

BACKGROUND: In 2013, the Department of Health released their policy paper on hospital financing entitled Money Follows the Patient. A fundamental building block for the proposed financing model is patient level costing. AIM: This paper outlines the patient level costing process, identifies the opportunities and considers the challenges associated with the process in the Irish hospital setting. METHODS: Methods involved a review of the existing literature which was complemented with an interview with health service staff. RESULTS: There are considerable challenges associated with implementing patient level costing including deficits in information and communication technologies and financial expertise as well as timeliness of coding. In addition, greater clinical input into the costing process is needed compared to traditional costing processes. However, there are long-term benefits associated with patient level costing; these include empowerment of clinical staff, improved transparency and price setting and greater fairness, especially in the treatment of outliers. These can help to achieve the Government's Health Strategy. CONCLUSIONS: The benefits of patient level costing need to be promoted and a commitment to investment in overcoming the challenges is required.

The clinical spectrum of anti-GAD antibody-positive patients with stiff-person syndrome.

OBJECTIVE: To evaluate the clinical spectrum of anti-GAD-positive patients with stiff-person syndrome (SPS) and provide reproducible means of assessing stiffness. BACKGROUND: SPS can be difficult to diagnose. Delineation of the clinical spectrum in a well defined population will increase diagnostic sensitivity. METHODS: In 20 anti-GAD-positive patients with SPS (six men, 14 women), screened among 38 referred patients, the authors assessed symptoms and signs, degree of disability, associated conditions, and immunogenetic markers. Degree of bending, distribution of stiff areas, timed activities, and magnitude of heightened sensitivity were examined monthly for 4 months in five patients. RESULTS: Average age at symptom onset was 41.2 years. Time to diagnosis was delayed from 1 to 18 years (mean 6.2). Stiffness with superimposed episodic spasms and co-contractures of the abdominal and thoracic paraspinal muscles were characteristic. All had stiff gait and palpable stiffness in the paraspinal muscles. Stiffness was asymmetric or prominent in one leg in 15 patients (stiff-leg syndrome) and involved facial muscles in 13. In one patient spasms lasted for days (status spasticus). Twelve patients needed a cane and seven a walker due to truncal stiffness and frequent falls (average three to four per month). Distribution of stiffness and degree of heightened sensitivity were two reproducible indices of stiffness and spasms. Autoimmune diseases or autoantibodies were noted in 80% and an association of with DRss(1) 0301 allele in 70%. CONCLUSIONS: SPS is 1) frequently misdiagnosed due to multifaceted presentations and asymmetric signs, 2) disabling if untreated, and 3) associated with other autoimmune conditions.

Treatment of chronic symptomatic supraventricular bradyarrhythmias with transdermal scopolamine.

The management of symptomatic bradyarrhythmias can be challenging in patients in whom cardiac pacing is not indicated, such as in the terminally ill or severely demented. We applied a transdermal scopolamine patch on one such patient with resultant substantial improvement in his supraventricular bradyarrhythmia.

The stability of L-glutamine in total parenteral nutrition solutions.

An assessment was made over a period of 14 days of the rate of glutamine degradation in different intravenous solutions kept at 22-24 degrees C, 4 degrees C, -20 degrees C and -80 degrees C. At room temperature (22-24 degrees C) degradation rates in mixed parenteral nutrition solutions and aminoacid/dextrose solutions ranged from 0.7-0.9%/day, in Perifusin 0.6%/day, and in dextrose alone as low as 0.15%/day. At 4 degrees C, glutamine degradation was <0.1-0.2%/day in all solutions examined, at -20 degrees C it was minimal (<0.04%/day) and at -80 degrees C, it was undetectable. Glutamine degradation was found to be associated with the formation of equimolar quantities of ammonia. No glutamate formation was detected. It is concluded that it is possible to store glutamine in parenteral nutrition solutions kept at 4 degrees C, with about 2% loss over a period of 14 days. The degradation is sufficiently slow to consider the use of intravenous glutamine in nutritional therapy.

A biomechanical evaluation of suture anchors in repair of the rotator cuff.

Repair of the rotator cuff requires secure reattachment, but large chronic defects cause osteoporosis of the greater tuberosity which may then have insufficient strength to allow proper fixation of the tendon. Recently, suture anchors have been introduced, but have not been fully evaluated. We have investigated the strength of suture-to-anchor attachment, and the use of suture anchors in repairs of the rotator cuff either to the greater tuberosity or the lateral cortex of the humerus. The second method gave a significant increase in the strength of the repair (p = 0.014). The repairs were loaded cyclically and failed at low loads by cutting into bone and tendon, casting doubt on the integrity of the repair in early mobilisation after surgery. Repairs with suture anchors did not perform better than those with conventional transosseous attachment.

The hidden cost of clinical audit: a questionnaire study of NHS staff.

OBJECTIVES: To determine the full cost of clinical audit in one health board area and extrapolate the result of Scotland. METHODS: A questionnaire was sent ot a representative sample of NHS staff to determine time spent on clinical audit. This was combined with cost data from clinical audit budgets and unit cost data for staff time. RESULTS: Seventy-two percent of staff participated in clinical audit at some point in time. Medical staff were significantly more likely to participate in audit than non medical staff (P <0.0001). Those who participated in clinical audit devoted only a small proportion of time to it. However, due to the high participation rates in clinical audit, this aggregated to a significant amount. In Forth Valley the total cost was estimated to be pound 1.72m (pound 1.37m-pound 2.10m) and in Scotland pound 36.3m (pound 29.6m-pound 44.0m). Staff time accounted for over 80% of the total cost of clinical audit. CONCLUSIONS: Clinical audit is widespread within the Scotish NHS and the total cost of staff time devoted to audit is substantial. Research is needed into the value of clinical audit and the potential cost implications of clinical governance need to be explicitly recognised.

An economic analysis of money follows the patient.

INTRODUCTION: As part of the proposed changes to re-design the Irish health-care system, the Department of Health (money follows the patient-policy paper on hospital financing, 2013b) outlined a new funding model for Irish hospitals-money follows the patient (MFTP). This will replace the existing system which is predominately prospective with hospitals receiving a block grant per annum. MFTP will fund episodes of care rather than hospitals. Thus, hospital revenue will be directly linked to activity [activity-based funding (ABF)]. THEORY AND LITERATURE REVIEW: With ABF there is a fundamental shift to a system where hospitals generate their own income and this changes incentive structures. While some of these incentives are intended (reducing cost per case and increasing coding quality), others are less intended and less desirable. As a result, there may be reductions in quality, upcoding, cream skimming and increased pressure on other parts of the health system. In addition, MFTP may distort health system priorities. There are some feasibility concerns associated with the implementation of MFTP. Data collection, coding and classification capacity are crucial for its success. While MFTP can build on existing systems, significant investment is required for its success. This includes investment in coding and classification, infrastructure, skills, IT, contracting, commissioning, auditing and performance monitoring systems. CONCLUSIONS: Despite the challenges facing implementers, MFTP could greatly improve the transparency and accountability of the system. Thus if the downside risks are managed, there is potential for MFTP to confer significant benefits to Irish hospital care.

Ethanol modulates mammalian circadian clock phase resetting through extrasynaptic GABA receptor activation.

Ethanol modulates the actions of multiple neurotransmitter systems, including GABA. However, its enhancing effects on GABA signaling typically are seen only at high concentrations. In contrast, although GABA is a prominent neurotransmitter in the circadian clock of the suprachiasmatic nucleus (SCN), we see ethanol modulation of clock phase resetting at low concentrations (<50 mM). A possible explanation is that ethanol enhances GABAergic signaling in the SCN through activating GABA(A) receptors that contain the delta subunit (GABA(Adelta) receptors), which are sensitive to low ethanol concentrations. Therefore, we investigated whether ethanol acts on GABA(Adelta) receptors in the SCN. Here we show that acute application of the GABA(Adelta) receptor antagonist, RO15-4513, to mouse hypothalamic slices containing the SCN prevents ethanol inhibition of nighttime glutamate-induced (photic-like) phase delays of the circadian clock. Diazepam, which enhances activity of GABA(A) receptors containing the gamma subunit (GABA(Agamma) receptors), does not modulate these phase shifts. Moreover, we find that RO15-4513 prevents ethanol enhancement of daytime serotonergic (non-photic) phase advances of the circadian clock. Furthermore, diazepam phase-advances the SCN circadian clock when applied alone in the daytime, while ethanol has no effect by itself at that time. These data support the hypothesis that ethanol acts on GABA(Adelta) receptors in the SCN to modulate photic and non-photic circadian clock phase resetting. They also reveal distinct modulatory roles of different GABA(A) receptor subtypes in circadian clock phase regulation.

Malaria prevention in The Gambia: patterns of expenditure and determinants of demand at the household level.

OBJECTIVE: To provide a better understanding of (1) the amounts households in The Gambia spend on a wide variety of malaria prevention measures, (2) how expenditure fluctuates throughout the year and (3) the main determinants of expenditure. METHODS: A random sample of 1700 households from the Farafenni region were interviewed about their expenditure on malaria prevention over the past 2 weeks. Interviews were staggered over 12 months. Expenditure was measured for bed nets, treating and repairing bed nets, aerosols, coils, indoor spraying, smoke and other prevention strategies such as drinking herbs and cleaning the outside environment. Results Expenditure on bed nets, including treatment and repair, constituted only 10% of total expenditure on malaria prevention. Every fortnight, households spent an average of 8.40 Dalasis (D) on coils, 4.20 D on indoor sprays, 3.09 D on smoke and 3.06 D on aerosols, together making up 81% of total fortnightly expenditure. Of the 442 households that did not own a bed net, 68% said it was because they could not afford one. Every 2 months, the same households spent an average of US 5 dollars, the equivalent to the cost of an insecticide treated bed net, on other forms of prevention. Total expenditure was 42% higher during the wet season than for the rest of the year. For every month of the year, coils were the dominant form of prevention expenditure. Wealth, age, occupation of household head, location of residence and month of the year were significant determinants of prevention expenditure. CONCLUSIONS: Households in The Gambia spend considerable amounts on a range of malaria prevention products and activities throughout the year. Bed nets represent a relatively small proportion of this expenditure even though they are perceived to be the most efficient and effective method of malaria control. A more concerted effort is needed to develop appropriate targeting strategies to encourage bed net use especially for children <5 years of age. Equal emphasis should be given to addressing barriers to purchasing nets such as their relative high upfront cost.

Basic principles for compounding all-in-one parenteral nutrition admixtures.

Parenteral nutrition admixtures are complex pharmaceutical entities. The more closely they are examined, the more physico-chemical interactions emerge that could potentially affect stability. The move towards large scale hospital or commercial preparation, with a requirement for extended shelf life, and the increasing use of admixtures as vehicles for drugs and pharmaconutrients have created new formulation challenges for pharmaceutical scientists.

The effects of electronic article surveillance systems on permanent cardiac pacemakers: an in vitro study.

UNLABELLED: Five Siemens Pacesetter cardiac pacemakers (PM) were subjected to in vitro testing with six different electronic article surveillance (EAS) devices. The PMs consisted of polarity programmable, dedicated bipolar, and dedicated unipolar types. EAS equipment included UHF, RF, Magnetic, and Magnetoacoustic (MA) devices from two manufacturers. Prior to testing, each PM was interrogated and normal operation confirmed. Each PM was attached to a heart simulator via an eight foot cable and then subjected to testing within the EAS field. The PMs were passed through the field in two axes, positioned stationary within the field, and, worst case (WC), placed directly against the transmitter. During testing the ECG was observed and PM behavior recorded. In one PM (Synchrony III), Event Records, and Event Histograms were utilized. At the conclusion of testing with each EAS device the PM was evaluated for normal operation. RESULTS: No PM was reprogrammed by the EAS devices. UHF produced no effect on the PMs. RF produced noise response in one unipolar PM while in the WC position. High frequency and multifrequency magnetic units produced positive results only in the WC position. Unipolar PMs were affected more often than bipolar. MA and older magnetic EAS units produced more positive responses than newer lower power devices. One incident of close coupled (400 msec) ventricular pacing was seen with the MA EAS unit. CONCLUSIONS: UHF, RF, high frequency, and dual frequency magnetic EAS produced few effects during in vitro testing. Except with the MA and low frequency magnetic devices, positive results occurred only in WC conditions.(ABSTRACT TRUNCATED AT 250 WORDS)

Circumvention of maximum tracking limitations with a rate modulated dual chamber pacemaker.

A patient having high grade AV block with intact sinus node function is presented in whom DDDR pacing provided the benefit of preventing 2:1 pacemaker block in response to exercise-induced sinus tachycardia. In paired treadmill tests with the patient blinded as to pacing mode, she was able to exercise longer (7.5 vs 6.6 METS) when programmed in DDDR than in DDDO. This is attributable to circumvention of 2:1 pacemaker block which had resulted in abrupt onset of fatigue and SOB (shortness of breath) when the sinus rate exceeded the maximum tracking rate of 130/min. Outpatient ambulatory electrocardiographic monitoring confirmed this phenomenon during relatively strenuous activity. The theoretic advantages of dual chamber rate modulated pacing compared to the DDDO and VVIR modes are discussed.

High-dose intravenous immune globulin for stiff-person syndrome.

BACKGROUND: Stiff-person syndrome is a disabling central nervous system disorder with no satisfactory treatment that is characterized by muscle rigidity, episodic muscle spasms, high titers of antibodies against glutamic acid decarboxylase (GAD65), and a frequent association with autoimmune disorders. Because stiff-person syndrome is most likely immune-mediated, we evaluated the efficacy of intravenous immune globulin. METHODS: We assigned 16 patients who had stiff-person syndrome and anti-GAD65 antibodies, in random order, to receive intravenous immune globulin or placebo for three months, followed by a one-month washout period and then by three months of therapy with the alternative agent. Efficacy was judged by improvements in scores on the distribution-of-stiffness index and heightened-sensitivity scale from base line (month 1) to the second and third month of each treatment phase. Direct and carryover effects of treatment were compared in the two groups. RESULTS: Among patients who received immune globulin first, stiffness scores decreased significantly (P=0.02) and heightened-sensitivity scores decreased substantially during immune globulin therapy but rebounded during placebo administration. In contrast, the scores in the group that received placebo first remained constant during placebo administration but dropped significantly during immune globulin therapy (P=0.01). When the data were analyzed for a direct and a first-order carryover effect, there was a significant difference in stiffness scores (P=0.01 and P<0.001, respectively) between the immune globulin and placebo groups, and immune globulin therapy had a significant direct treatment effect on sensitivity scores (P=0.03). Eleven patients who received immune globulin became able to walk more easily or without assistance, their frequency of falls decreased, and they were able to perform work-related or household tasks. The duration of the beneficial effects of immune globulin varied from six weeks to one year. Anti-GAD65 antibody titers declined after immune globulin therapy but not after placebo administration. CONCLUSIONS: Intravenous immune globulin is a well-tolerated and effective, albeit costly, therapy for patients with stiff-person syndrome and anti-GAD65 antibodies.