Trends in incidence of ischaemic stroke in people with and without diabetes in Ireland 2005-2015.

AIMS: We aim to describe the epidemiology of ischaemic stroke and in-hospital mortality associated with stroke among men and women with and without diabetes from 2005 to 2015. METHODS: Secondary data analysis of national hospital discharge data from the Hospital Inpatient Enquiry database. Stroke incidence and in-hospital mortality rates in people with and without diabetes were calculated. Poisson regression models were used to estimate the incidence rate ratio (IRR) and assess trends over time. RESULTS: The age-adjusted incidence of stroke was twice as high in people with diabetes compared to those without diabetes (men IRR 2.0 [95% CI 1.95-2.06] and women IRR 2.2 [95% CI 2.12-2.27]). The incidence of ischaemic stroke decreased by an average 1.7% per year in men with diabetes and 3.3% per year in women with diabetes. In people without diabetes, the average annual reduction was smaller (0.2% per year in men and 1% per year in women). In-hospital mortality associated with admission with ischaemic stroke was approximately twice as high in those with diabetes compared to those without diabetes among men [IRR 1.81 (1.67-1.97)] and women [IRR 2 (95% CI 1.84-2.18)]. CONCLUSION: Despite decreases in incidence of ischaemic stroke and associated in-hospital mortality, there remains a twofold increased risk of ischaemic stroke and mortality in people with diabetes. Therefore, priority must be given to management of risk factors for ischaemic stroke in people with diabetes as well as continued development of targeted stroke prevention strategies.

Early diagnosis and better rhythm management to improve outcomes in patients with atrial fibrillation: the 8th AFNET/EHRA consensus conference.

Despite marked progress in the management of atrial fibrillation (AF), detecting AF remains difficult and AF-related complications cause unacceptable morbidity and mortality even on optimal current therapy. This document summarizes the key outcomes of the 8th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA). Eighty-three international experts met in Hamburg for 2 days in October 2021. Results of the interdisciplinary, hybrid discussions in breakout groups and the plenary based on recently published and unpublished observations are summarized in this consensus paper to support improved care for patients with AF by guiding prevention, individualized management, and research strategies. The main outcomes are (i) new evidence supports a simple, scalable, and pragmatic population-based AF screening pathway; (ii) rhythm management is evolving from therapy aimed at improving symptoms to an integrated domain in the prevention of AF-related outcomes, especially in patients with recently diagnosed AF; (iii) improved characterization of atrial cardiomyopathy may help to identify patients in need for therapy; (iv) standardized assessment of cognitive function in patients with AF could lead to improvement in patient outcomes; and (v) artificial intelligence (AI) can support all of the above aims, but requires advanced interdisciplinary knowledge and collaboration as well as a better medico-legal framework. Implementation of new evidence-based approaches to AF screening and rhythm management can improve outcomes in patients with AF. Additional benefits are possible with further efforts to identify and target atrial cardiomyopathy and cognitive impairment, which can be facilitated by AI.

Effects of the COVID-19 Pandemic on Prehospital Emergency Care for Adults with Stroke and Transient Ischaemic Attack: A Systematic Review and Meta-Analysis.

INTRODUCTION: COVID-19 has challenged global health care systems and resulted in prehospital delays for time-sensitive emergencies, like stroke and transient ischemic attacks (TIA). However, there are conflicting international reports on the level of effect of the pandemic on ambulance response intervals and emergency call volumes for these conditions. OBJECTIVES: The purpose of this study was to synthesize the international evidence on the effect of COVID-19 on ambulance response intervals and emergency call volume for suspected stroke and TIA. METHODS: Following a published protocol, we conducted a systematic search of six databases through May 31, 2022. We re-ran this search on April 14, 2023, to check for any new papers. We considered for inclusion peer-reviewed quantitative studies comparing prehospital emergency care for adults with suspected stroke/TIA before and during the COVID-19 pandemic. Two authors screened title/abstract and full text articles. One author carried out data extraction, with a random selection of articles being checked by another author. We calculated overall pooled estimates of ambulance intervals (activation, response, patient care, and total prehospital intervals) and stroke/TIA emergency call volume. Subgroup and sensitivity analyses included location and stroke/TIA diagnosis. Two authors assessed study quality using the appropriate Joanna Briggs Institute tool. We worked with patient and public involvement contributors and clinical and policy stakeholders throughout the review. RESULTS: Of 4,083 studies identified, 52 unique articles met the inclusion criteria. Mean response interval (-1.29 min [-2.19 to -0.38]) and mean total prehospital interval (-6.42 min [-10.60 to -2.25]) were shorter in the pre-COVID-19 period, compared to the COVID-19 period. Furthermore, there was a higher incidence rate of emergency call volume for suspected stroke/TIA per day pre-COVID-19 compared with the COVID-19 period (log IRR = 0.17 [0.02 to 0.33]). Ambulance response interval definitions and terminology varied between regions and countries. CONCLUSIONS: Our review indicates that prehospital delays for suspected stroke/TIA increased during the COVID-19 pandemic. Furthermore, emergency call volume for suspected stroke/TIA decreased during this period. In order to minimize delays in future pandemics or other health care emergencies future research may involve understanding the potential reasons for these delays.

Compliance with local travel restrictions and face masks during first phase of COVID-19 pandemic in Ireland: a national survey.

BACKGROUND: This study examines compliance with local travel restrictions and assesses early uptake of mask wearing, during the initial phase of the coronavirus disease of 2019 (COVID-19) pandemic in Ireland, to inform the ongoing outbreak response. METHODS: A series of four nationally representative telephone surveys were developed. Information was collected at a household level and from primary respondents. Multivariable logistic regression estimated the association between sociodemographic characteristics and compliance with the local travel restriction and with mask use in primary respondents. RESULTS: Household compliance with local travel restrictions was similar by region, household size and social position. 73.4% of all household members complied, with high levels maintained over time. Higher proportions reported travelling for non-permitted reasons with time. Older age, female gender and attending higher education were independently associated with compliance to local travel restrictions. Among primary respondents, no factors were independently associated with mask use. CONCLUSION: High compliance with local travel restrictions during the early stages of the pandemic demonstrates the engagement of the population with public health guidance. Although high compliance with local travel restrictions was generally maintained over time, non-permitted activities increased. Early adoption of mask use before required by national policy or legislation provides further evidence of the responsiveness of the population.

Implementing an integrated diabetic foot care programme in Ireland: podiatrists' experience.

BACKGROUND: International evidence suggests that an integrated multidisciplinary approach to diabetic foot management is necessary to prevent ulceration and progression to amputation. Many health systems have introduced policies or models of care supporting the introduction of this evidence into practice, but little is known about the experiences of those involved in implementation. This study addresses this gap by examining the experiences of podiatrists providing integrated diabetic foot care. METHODS: Between October 2017 and April 2018, an online survey comprising closed and open-ended questions on podiatrists' demographics, clinical activity, links with other services, continuous professional development activities and experiences of implementing the Model of Care was administered to podiatrists (n = 73) working for Ireland's Health Service Executive in the community and hospital setting. Data were analysed using descriptive statistics and qualitative content analysis. RESULTS: The response rate was 68% (n = 50), with 46% (n = 23), 38% (n = 19) and 16% (n = 8) working across hospital, community and both settings, respectively. Most reported treating high-risk patients (66%), those with active foot disease (61%) and educating people about the risk of diabetes to the lower limb (80%). Reported challenges towards integrated diabetic foot care include a perceived lack of awareness of the role of podiatry amongst other healthcare professionals, poor integration between hospital and community podiatry services, especially where new services had been developed, and insufficient number of podiatrists to meet service demands. CONCLUSION: Previous evidence has shown that there is often a gap between what is set out by a policy and what it looks like when delivered to service users. Results from the current study support this, highlighting that while most podiatrists work in line with national recommendations, there are specific gaps and challenges that need to be addressed to ensure successful policy implementation.

Exploring the psychological impact of contact tracing work on staff during the COVID-19 pandemic.

BACKGROUND: Contact tracing is a key control measure in the response to the COVID-19 pandemic. While quantitative research has been conducted on the psychological impact of the pandemic on other frontline healthcare workers, none has explored the impact on contact tracing staff. METHODS: A longitudinal study was conducted using two repeated measures with contact tracing staff employed in Ireland during the COVID-19 pandemic using two-tailed independent samples t tests and exploratory linear mixed models. RESULTS: The study sample included 137 contact tracers in March 2021 (T1) and 218 in September 2021 (T3). There was an increase from T1 to T3 in burnout related exhaustion (p < 0·001), post-traumatic stress disorder (PTSD) symptom scores (p < 0·001), mental distress (p < 0·01), perceived stress (p < 0·001) and tension and pressure (p < 0·001). In those aged 18-30, there was an increase in exhaustion related burnout (p < 0·01), PTSD symptoms (p < 0·05), and tension and pressure scores (p < 0·05). Additionally, participants with a background in healthcare showed an increase in PTSD symptom scores by T3 (p < 0·001), reaching mean scores equivalent to those of participants who did not have a background in healthcare. CONCLUSIONS: Contact tracing staff working during the COVID-19 pandemic experienced an increase in adverse psychological outcomes. These findings highlight a need for further research on psychological supports required by contact tracing staff with differing demographic profiles.

Limited transmission of SARS-CoV-2 in schools in Ireland during the 2020-2021 school year.

BackgroundThe role of schools in SARS-CoV-2 transmission has been a debated topic since the beginning of the COVID-19 pandemic.AimTo examine SARS-CoV-2 transmission in all schools in Ireland during the 2020-21 school year.MethodsIn a national descriptive cross-sectional study, we investigated PCR-confirmed cases of COVID-19 among students (aged < 20 years) and staff (aged ≥ 20 years) who attended school during their infectious period to identify school close contacts. SARS-CoV-2 PCR test results of all school close contacts were pooled to obtain an overall positivity rate and to stratify positivity rate by school setting and role (i.e. student or staff).ResultsIn total, 100,474 individuals were tested as close contacts in 1,771 schools during the 2020-21 school year. An overall close contact positivity rate of 2.4% was observed across all schools (n = 2,373 secondary cases). The highest positivity rate was seen in special schools (3.4%), followed by primary (2.5%) and post-primary schools (1.8%) (p < 0.001). Of the close contacts identified, 90.5% (n = 90,953) were students and 9.5% (n = 9,521) were staff. Overall, students had a significantly higher positivity rate than staff (2.4% vs 1.8%, p < 0.001).ConclusionThis study demonstrated that a low level of SARS-CoV-2 transmission occurred in Irish schools during the 2020-21 academic year. In the event of future pandemics, and as the COVID-19 pandemic continues, there is a need to carefully weigh up the harms and benefits associated with disrupted education to mitigate infectious disease transmission before reflexively closing classes or schools.

Facilitators and barriers to the introduction of atrial fibrillation screening in primary care: a qualitative descriptive study of general practitioners in primary care.

INTRODUCTION: Atrial fibrillation (AF), the most common cardiac arrhythmia, is a major risk factor for stroke. AF is often asymptomatic and, if identified, treatment can be offered that can reduce stroke risk by up to two thirds. AF screening meets many of the Wilson Jungner criteria for screening. While AF screening is recommended in clinical practice and internationally, the optimal mode and location for AF screening remains under investigation. Primary care has been identified as a potential setting. This study aimed to identify facilitators and barriers to AF screening from the perspective of GPs. METHODS: The study adopted a qualitative descriptive design conducted in the south of Ireland. 58 GPs were invited from the north Cork region to participate in individual interviews at their practices, rural and urban, with a view to recruiting a purposive sample of up to 12 GPs. The interviews were audio-recorded, transcribed verbatim and analysed using a framework analysis. RESULTS: Eight GPs (four male, four female) from five practices participated. Five GPs were from urban practices and three were from rural practices. Facilitators and barriers were sub-categorised into patient facilitators, practice facilitators, GP facilitators, patient barriers, practice barriers, GP barriers, attitudes to AF screening, willingness to facilitate and priority ranking. All eight participants expressed a willingness to engage in AF screening. Time was the barrier discussed most frequently by all participants along with the need for additional staff. Programme structure was the most discussed facilitator by all participants and patient awareness campaigns. DISCUSSION: Despite barriers to AF screening identified by GPs, there was a significant willingness to engage and identify potential facilitators to support such screening.

International comparison of glycaemic control in people with type 1 diabetes: an update and extension.

AIMS: To update and extend a previous cross-sectional international comparison of glycaemic control in people with type 1 diabetes. METHODS: Data were obtained for 520,392 children and adults with type 1 diabetes from 17 population and five clinic-based data sources in countries or regions between 2016 and 2020. Median HbA1c (IQR) and proportions of individuals with HbA1c < 58 mmol/mol (<7.5%), 58-74 mmol/mol (7.5-8.9%) and ≥75 mmol/mol (≥9.0%) were compared between populations for individuals aged <15, 15-24 and ≥25 years. Logistic regression was used to estimate the odds ratio (OR) of HbA1c < 58 mmol/mol (<7.5%) relative to ≥58 mmol/mol (≥7.5%), stratified and adjusted for sex, age and data source. Where possible, changes in the proportion of individuals in each HbA1c category compared to previous estimates were calculated. RESULTS: Median HbA1c varied from 55 to 79 mmol/mol (7.2 to 9.4%) across data sources and age groups so a pooled estimate was deemed inappropriate. OR (95% CI) for HbA1c < 58 mmol/mol (<7.5%) were 0.91 (0.90-0.92) for women compared to men, 1.68 (1.65-1.71) for people aged <15 years and 0.81 (0.79-0.82) aged15-24 years compared to those aged ≥25 years. Differences between populations persisted after adjusting for sex, age and data source. In general, compared to our previous analysis, the proportion of people with an HbA1c  < 58 mmol/l (<7.5%) increased and proportions of people with HbA1c ≥ 75 mmol/mol (≥9.0%) decreased. CONCLUSIONS: Glycaemic control of type 1 diabetes continues to vary substantially between age groups and data sources. While some improvement over time has been observed, glycaemic control remains sub-optimal for most people with Type 1 diabetes.

Epidemiology of COVID-19 and public health restrictions during the first wave of the pandemic in Ireland in 2020.

BACKGROUND: We describe the epidemiological trends and report and review the public health restrictions implemented during the first wave of the COVID-19 pandemic in Ireland. METHODS: The study reviewed confirmed cases of COVID-19 notified from 1 March to 18 July 2020. Data were obtained from the national COVID-19 Data Hub, the National Health Protection Surveillance Centre, the National Contact Management Programme and the European Centre for Disease Prevention and Control. RESULTS: A total of 25 617 cases were notified during the study period. Weekly cases and deaths peaked in mid-April 2020 at 5701 and 316, respectively. Mean number of close contacts per case was lowest at 0.7 in April, rising to 6.6 by July. Outbreak settings shifted from travel and workplace in March, to healthcare in April. Restrictions implemented on 12 March extended to full lockdown on 27 March. Phased relaxation of restrictions commenced 18 May. Effective suppression of community transmission of COVID-19 was achieved by June 2020. CONCLUSION: Lockdown is a crude population-level restriction effective in controlling COVID-19. Phased relaxation of restrictions in Ireland, however, led to an immediate increase in mean number of contacts per case, which facilitates viral transmission unless individual-level restrictions are adhered to. This demonstrates a limitation of lockdown as a long-term mechanism of pandemic control.

Numbers of close contacts of individuals infected with SARS-CoV-2 and their association with government intervention strategies.

BACKGROUND: Contact tracing is conducted with the primary purpose of interrupting transmission from individuals who are likely to be infectious to others. Secondary analyses of data on the numbers of close contacts of confirmed cases could also: provide an early signal of increases in contact patterns that might precede larger than expected case numbers; evaluate the impact of government interventions on the number of contacts of confirmed cases; or provide data information on contact rates between age cohorts for the purpose of epidemiological modelling. We analysed data from 140,204 close contacts of 39,861 cases in Ireland from 1st May to 1st December 2020. RESULTS: Negative binomial regression models highlighted greater numbers of contacts within specific population demographics, after correcting for temporal associations. Separate segmented regression models of the number of cases over time and the average number of contacts per case indicated that a breakpoint indicating a rapid decrease in the number of contacts per case in October 2020 preceded a breakpoint indicating a reduction in the number of cases by 11 days. CONCLUSIONS: We found that the number of contacts per infected case was overdispersed, the mean varied considerable over time and was temporally associated with government interventions. Analysis of the reported number of contacts per individual in contact tracing data may be a useful early indicator of changes in behaviour in response to, or indeed despite, government restrictions. This study provides useful information for triangulating assumptions regarding the contact mixing rates between different age cohorts for epidemiological modelling.

Estimation of the serial interval and proportion of pre-symptomatic transmission events of COVID- 19 in Ireland using contact tracing data.

BACKGROUND: The serial interval is the period of time between the onset of symptoms in an infector and an infectee and is an important parameter which can impact on the estimation of the reproduction number. Whilst several parameters influencing infection transmission are expected to be consistent across populations, the serial interval can vary across and within populations over time. Therefore, local estimates are preferable for use in epidemiological models developed at a regional level. We used data collected as part of the national contact tracing process in Ireland to estimate the serial interval of SARS-CoV-2 infection in the Irish population, and to estimate the proportion of transmission events that occurred prior to the onset of symptoms. RESULTS: After data cleaning, the final dataset consisted of 471 infected close contacts from 471 primary cases. The median serial interval was 4 days, mean serial interval was 4.0 (95% confidence intervals 3.7, 4.3) days, whilst the 25th and 75th percentiles were 2 and 6 days respectively. We found that intervals were lower when the primary or secondary case were in the older age cohort (greater than 64 years). Simulating from an incubation period distribution from international literature, we estimated that 67% of transmission events had greater than 50% probability of occurring prior to the onset of symptoms in the infector. CONCLUSIONS: Whilst our analysis was based on a large sample size, data were collected for the primary purpose of interrupting transmission chains. Similar to other studies estimating the serial interval, our analysis is restricted to transmission pairs where the infector is known with some degree of certainty. Such pairs may represent more intense contacts with infected individuals than might occur in the overall population. It is therefore possible that our analysis is biased towards shorter serial intervals than the overall population.

Case fatality ratios for serious emergency conditions in the Republic of Ireland: a longitudinal investigation of trends over the period 2002-2014 using joinpoint analysis.

BACKGROUND: In the past decade, the Republic of Ireland has undertaken significant reconfiguration programmes to improve emergency services. During this time the public healthcare system experienced a large real decrease in resources. This study assesses national and regional population outcomes over the period 2002-2014, and whether changes coincide with system reconfiguration and the financial restrictions imposed by the 2008 recession. METHODS: Case fatality ratios (CFRs) were constructed for emergency conditions for 2002-2014. Total emergency conditions and individual condition trends were analysed nationally using joinpoint analysis. National results informed the investigation of trends at a regional and county level using an inverse standard error weighted generalised linear model with a log link to construct funnel plots. County-level CFRs were compared for the first and last 3 years of the period to further investigate the changes to county results over the 13 year period, specifically in comparison to the national-level CFR. RESULTS: Nationally, there was an annual fall in CFRs (2.1%). The decline was faster from 2002 to 2007 (annual percentage change = - 3.4; 95% CI-4.4, - 2.4), compared to 2007-2014 (annual percentage change = - 1.2; 95% CI -1.9, - 0.5). The South-East had a lower rate of decrease and the West had a higher rate. Cross sectional analysis of two periods (2002-2004 and 2012-2014) showed high consistency in the counties performance relative to the national CFR in both periods. CONCLUSION: Change in the national trend coincided with the onset of economic stress on the public health system. Attributing the decline in CFR improvement to economic factors is weakened by the uneven nature of the trend change. No distinct pattern of change was identified among regions which underwent substantial reconfiguration of emergency services.

Energy drinks available in Ireland: a description of caffeine and sugar content.

OBJECTIVE: To describe the caffeine and sugar content of all energy drinks available on the island of Ireland. DESIGN: Two retail outlets were selected from each of: multinational, convenience and discount stores in Northern Ireland and the Republic of Ireland, and all available single-serve energy drinks were purchased. The cross-sectional survey was conducted in February 2015 and brand name, price, volume, caffeine and sugar content were recorded for each product. Descriptive analysis was performed. RESULTS: Seventy-eight products were identified on the island of Ireland (regular, n 59; diet/sugar-free/light, n 19). Caffeine and sugar content was in the range of 14-35 mg and 2·9-15·6 g per 100 ml, respectively. Mean caffeine content of 102·2 mg per serving represents 25·6 % of the maximum intake advised for adults by the European Food Safety Authority. Per serving, mean sugar content of regular energy drinks was 37 g. This exceeds WHO recommendations for maximum daily sugar intake of <5 % of total energy intake (25 g for adults consuming 8368 kJ (2000 kcal) diet). If displaying front-of-pack labelling, fifty-seven of the fifty-nine regular energy drinks would receive a Food Standards Agency 'red' colour-coded label for sugar. CONCLUSIONS: Energy drinks are freely available on the island of Ireland and all products surveyed can be defined as highly caffeinated products. This has potential health issues particularly for children and adolescents where safe limits of caffeine have not been determined. Energy drinks surveyed also contained high levels of sugar and could potentially contribute to weight gain and adverse dental health effects.

Epidemiology of diabetes and complications among adults in the Republic of Ireland 1998-2015: a systematic review and meta-analysis.

BACKGROUND: Accurate estimates of the burden of diabetes are essential for future planning and evaluation of services. In Ireland, there is no diabetes register and prevalence estimates vary. The aim of this review was to systematically identify and review studies reporting the prevalence of diabetes and complications among adults in Ireland between 1998 and 2015 and to examine trends in prevalence over time. METHODS: A systematic literature search was carried out using PubMed and Embase. Diabetes prevalence estimates were pooled by random-effects meta-analysis. Poisson regression was carried out using data from four nationally representative studies to calculate prevalence rates of doctor diagnosed diabetes between 1998 and 2015 and was also used to assess whether the rate of doctor diagnosed diabetes changed over time. RESULTS: Fifteen studies (eight diabetes prevalence and seven complication prevalence) were eligible for inclusion. In adults aged 18 years and over, the national prevalence of doctor diagnosed diabetes significantly increased from 2.2 % in 1998 to 5.2 % in 2015 (p trend ≤ 0.001). The prevalence of diabetes complications ranged widely depending on study population and methodology used (6.5-25.2 % retinopathy; 3.2-32.0 % neuropathy; 2.5-5.2 % nephropathy). CONCLUSIONS: Between 1998 and 2015, there was a significant increase in the prevalence of doctor diagnosed diabetes among adults in Ireland. Trends in microvascular and macrovascular complications prevalence could not be examined due to heterogeneity between studies and the limited availability of data. Reliable baseline data are needed to monitor improvements in care over time at a national level. A comprehensive national diabetes register is urgently needed in Ireland.

Preparedness of Hospitals in the Republic of Ireland for an Influenza Pandemic, an Infection Control Perspective.

BACKGROUND: When an influenza pandemic occurs most of the population is susceptible and attack rates can range as high as 40-50 %. The most important failure in pandemic planning is the lack of standards or guidelines regarding what it means to be 'prepared'. The aim of this study was to assess the preparedness of acute hospitals in the Republic of Ireland for an influenza pandemic from an infection control perspective. METHODS: This was a cross sectional study involving a questionnaire completed by infection control nurses, time period from June - July 2013, (3 weeks) from acute public and private hospitals in the Republic of Ireland. A total of 46 out of 56 hospitals responded to the questionnaire. RESULTS: From a sample of 46 Irish hospitals, it was found that Irish hospitals are not fully prepared for an influenza pandemic despite the 2009 Influenza A (H1N1) pandemic. In 2013, thirty five per cent of Irish hospitals have participated in an emergency plan or infectious disease exercise and have plans or been involved in local planning efforts to care for patients at non-health care facilities. Sixty per cent of Irish hospitals did not compile or did not know if the hospital had compiled a "lessons learned" from any exercise that were then used to revise emergency response plans. Fifty two per cent of hospitals have sufficient airborne isolation capacity to address routine needs and have an interim emergency plan to address needs during an outbreak. Fifty one percent of hospitals have taken specific measures to stockpile or have reserve medical supplies e.g. masks, ventilators and linen. CONCLUSIONS: This is the first study carried out in the Republic of Ireland investigating the current preparedness for an influenza pandemic from an infection control perspective. Deficits exist in the provision of emergency planning committees, testing of emergency plans, airborne isolation facilities, stockpiling of personal protective equipment (PPE) and medical supplies and organisational schemes/incentives for healthcare workers to continue to work in a pandemic. While Irish standards are comparable to findings from international studies, the health care service needs to continue to enhance preparedness for an influenza pandemic and implement standard preparedness guidance for all Irish hospitals.

Management of diabetic foot disease and amputation in the Irish health system: a qualitative study of patients' attitudes and experiences with health services.

BACKGROUND: Diabetes is an increasingly prevalent chronic illness that places a huge burden on the individual, the health system and society. Patients with active foot disease and lower limb amputations due to diabetes have a significant amount of interaction with the health care services. The purpose of this study was to explore the attitudes and experiences of foot care services in Ireland among people with diabetes and active foot disease or lower limb amputations. METHODS: A purposive sample of individuals who had either active foot disease or a lower limb amputation as a result of diabetes were recruited from the Prosthetic, Orthotic and Limb Absence Rehabilitation (POLAR) Unit of an Irish hospital. One-to-one interviews were conducted in the POLAR unit using a semi-structured topic guide. Thematic analysis was used to identify, analyse and describe patterns within the data. RESULTS: Ten males participated in the study. Most participants expressed a need for emotional support alongside the medical management of their condition. There were substantial differences between participants with regard to the level of education and information they appeared to have received regarding their illness. There were also variations in levels of service received. Transport and medication costs were considered barriers. Having a medical card, which entitles the holder to free medical care, eased the burden of the patient's illness. A number of participants attributed some of the problems they faced with services to the health care system as a whole rather than health care professionals. CONCLUSION: Results suggest that rehabilitation services should place a strong focus on psychological as well as physical adjustment to active foot disease or lower limb amputations. The delivery of services needs to be standardised to ensure equal access to medical care and supplies among people with or at risk of lower extremity amputations. The wider social circumstances of patients should be taken into consideration by health care professionals to provide effective support while patients adjust to this potentially life changing complication. The patient's perspective should also be used to inform health service managers and health professionals on ways to improve services.

Social deprivation and diabetic kidney disease: A European view.

There is a large body of literature demonstrating a social gradient in health and increasing evidence of an association between social deprivation and diabetes complications. Diabetic kidney disease (DKD) increases mortality in people with diabetes. Socioeconomic deprivation is increasingly recognized as a modifier of risk factors for kidney disease but also an independent risk factor itself for kidney disease. This may not be truly appreciated by clinicians and warrants further attention and exploration. In this review we explore the literature to date from Europe on the relationship between social deprivation and DKD. The majority of the studies showed at least an association with microalbuminuria, an early marker of DKD, while many showed an association with overt nephropathy. This was seen across many countries in Europe using a variety of different measures of deprivation. We reviewed and considered the mechanisms by which deprivation may lead to DKD. Health related behaviors such as smoking and suboptimal control of risk factors such as hypertension, hyperglycemia and elevated body mass index (BMI) accounts for some but not all of the association. Poorer access to healthcare, health literacy, and stress are also discussed as potential mediators of the association. Addressing deprivation is difficult but starting points include targeted interventions for people living in deprived circumstances, equitable roll out of diabetes technology, and flexible outpatient clinic arrangements including virtual and community-based care.