The effect of patient characteristics upon uptake of the influenza vaccination: a study comparing community-based older adults in two healthcare systems.

BACKGROUND: the uptake of influenza vaccination represents a simple marker of proactive care of older people. However, many still do not receive the vaccine. To understand this challenge better, we investigated the relationship between patient characteristics (demographic, physical and psychological health and health service use) and vaccination uptake in a sample of community-dwelling older people in two adjacent but differently structured healthcare systems (Northern Ireland (NI) and the Republic of Ireland (RoI)). METHODS: a total of 2,033 randomly selected community-dwelling older adults (65 years and older) were interviewed in their homes. RESULTS: rates of uptake were 78% in NI and 72% in RoI. The uptake was greater with older age (odds ratio (OR) 1.6, 95% confidence interval (CI) = 1.3-2.1, P < 0.0005), widowhood (OR = 1.5, 95% CI = 1.1-2.3, P = 0.02), living in NI (OR = 0.77, 95% CI = 0.6-0.9, P = 0.04), greater functional impairment (OR RoI 2.0, 95% CI = 0.8-3.5, P = 0.03), more frequent use of family doctor (OR RoI 0.5, 95% CI = 0.3-0.6, P = 0.0001; NI 0.6, 95% CI = 0.4-0.9, P = 0.01) and greater use of services such as chiropody (OR NI 0.6, 95% CI = 0.4-0.9, P = 0.01), meals-on-wheels (OR RoI 1.3, 95% CI = 0.4-2.2, P = 0.03), social work (OR RoI 1.2, 95% CI = 0.3-1.9, P = 0.05) and occupational therapy (OR RoI 1.3, 95% CI = 0.5-2.5, P = 0.02). CONCLUSION: the uptake rates in both healthcare systems exceeded targets. Higher rates of vaccination were found among older people, those who were married and those who made greater use of hospital and community services. Increased exposure to health services may enhance trust in health care leading to higher vaccination uptake.

"Murder or mercy?" An innovative module helping UK medical students to articulate their own ethical viewpoints regarding end-of-life decisions.

This module was designed to equip UK medical students to respond ethically and sensitively to requests encountered as qualified doctors regarding euthanasia and assisted dying. The aim was to expose students to relevant opinions and experiences and provide opportunities to explore and justify their own views and rehearse ethical decision making in a safe learning environment.The module is delivered by a multidisciplinary team, providing students with the working knowledge to actively discuss cases, articulate their own views and practice ethical reasoning. Visits to intensive care units, palliative care wards and hospices are integrated with theory. Student assessment comprises a dissertation, debate and reflection. Module impact was evaluated by analysis of student coursework and a questionnaire.Students greatly appreciated the clinical context provided by the visits and opportunities to apply ethical reasoning to cases and debate issues with peers. They reported increased discernment of the ethical and legal position and practical considerations and greater awareness of the range of professional and lay viewpoints held. Many participants were less strongly in favor of euthanasia and assisted dying on module completion than at the outset, but all of them believed they were better equipped to justify their own viewpoint and respond to patient requests. The multi-disciplinary nature of this course helps to prepare students to deal effectively and sensitively with ethical dilemmas they will encounter in their medical career. Use of an integrated, learner-centred approach equips students to actively engage with their peers in discussion of such issues and to formulate and defend their own position.

Wholeness of healing: an innovative Student-Selected Component introducing United Kingdom medical students to the spiritual dimension in healthcare.

OBJECTIVE: This Student Selected Component (SSC) was designed to equip United Kingdom (UK) medical students to engage in whole-person care. The aim was to explore students' reactions to experiences provided, and consider potential benefits for future clinical practice. METHODS: The SSC was delivered in the workplace. Active learning was encouraged through facilitated discussion with and observation of clinicians, the palliative team, counselling services, hospital chaplaincy and healing ministries; sharing of medical histories by patients; and training in therapeutic communication. Assessment involved reflective journals, literature appraisal, and role-play simulation of the doctor-patient consultation. Module impact was evaluated by analysis of student coursework and a questionnaire. RESULTS: Students agreed that the content was stimulating, relevant, and enjoyable and that learning outcomes were achieved. They reported greater awareness of the benefit of clinicians engaging in care of the "whole person" rather than "the disease." Contributions of other professions to the healing process were acknowledged, and students felt better equipped for discussion of spiritual issues with patients. Many identified examples of activities which could be incorporated into core teaching to benefit all medical students. CONCLUSION: The SSC provided relevant active learning opportunities for medical students to receive training in a whole-person approach to patient care.

Stroke presentation and hospital management: comparison of neighboring healthcare systems with differing health policies.

BACKGROUND AND PURPOSE: Acute stroke care is shaped by healthcare policies. Differing policies in similar populations allow for assessment of policy impact on health and healthcare outcomes. The purpose of this study was to compare stroke presentation and hospital care in two adjacent healthcare systems with differing healthcare policies. METHODS: Interviews and chart review of consecutive acute stroke admissions in Northern Ireland (n=103) and the Republic of Ireland (n=100). RESULTS: Marked regional contrasts were evident for key aspects of hospital care. Northern Ireland performed significantly better on 15 of 16 quality of care (Sentinel Audit) items. Delivery on standards was significantly better in Northern Ireland for early assessment (Northern Ireland 72%; Republic of Ireland 54%, P<0.01), multidisciplinary review (Northern Ireland 69%; Republic of Ireland 31%, P<0.001), medications review (Northern Ireland 54%; Republic of Ireland 19%, P<0.001), and for discharge-rehabilitation planning (Northern Ireland 83%; Republic of Ireland 8%, P<0.001). Preadmission prescription of advised cardiovascular medications was similar between regions for antihypertensives and anticoagulants but significantly higher in Northern Ireland for antiplatelets (Northern Ireland 65%; Republic of Ireland 38%, P=0.001) and lipid-regulating medication (Northern Ireland 44%; Republic of Ireland 26%; P=0.006). Prescribing levels increased in both regions and all medication categories by discharge but with significantly lower levels in Northern Ireland for antihypertensives (Northern Ireland 60%; Republic of Ireland 75%, P=0.025). Northern Ireland patients were more functionally dependent (mean Barthel Index 10.5 versus 12.7 [Republic of Ireland], P=0.013) and less aphasic (mean Frenchay Aphasia Screening Test 17.8 versus 16.8 [Republic of Ireland], P=0.022). CONCLUSIONS: In similar neighboring acute stroke populations, differing healthcare policies were associated with significant differences in processes of patient care. Policy reform is an important tool in ensuring optimal stroke care delivery.

Angiographically confirmed coronary heart disease and periodontal disease in middle-aged males.

BACKGROUND: The aim of this study was to investigate whether an association could be demonstrated between coronary heart disease (CHD) and chronic periodontitis in a population of middle-aged males in Northern Ireland. METHODS: A case-control design was used. Cases were men aged over 40 years with angiographically proven CHD. Controls were age-matched males, with no evidence of CHD, randomly drawn from the same locality as the cases. Each subject had a clinical periodontal examination and completed a detailed sociodemographic questionnaire. High sensitivity C-reactive protein (CRP) was measured in serum by immunoturbidimetry. RESULTS: There were 92 cases (mean age 56.7 years; SD = 6.3) and 79 controls (mean age 58.2 years; SD = 6.7). The CHD cases had an average of three teeth less than the controls (P <0.0001). A higher proportion of sites examined in cases than controls had plaque (P = 0.004), bleeding on probing (P = 0.013), and probing depths of > or = 4 mm (P = 0.006) or > or = 6 mm (P = 0.03). Subjects with > or = 4 mm pocketing in more than 20% of their interproximal sites and those with deep pocketing (> or = 6 mm) were classified as having poor periodontal status. A total of 35 cases (38%), compared to only 13 controls (16%), had a poor periodontal status (P = 0.0017). Men with a poor periodontal condition had higher levels of CRP (median 2.19 mg/l) than those with good periodontal health (median 1.42 mg/l), P = 0.007. After adjusting for smoking, academic achievement, alcohol consumption, unemployment, ability to maintain body weight, regular exercise, ability to relax daily, having a hobby or pastime, plaque, and CRP, logistic regression analysis showed that poor periodontal status was significantly associated with CHD, with an adjusted odds ratio of 3.06 and 95% confidence intervals of 1.02 to 9.17, P = 0.046. CONCLUSIONS: There was an association between coronary heart disease and poor periodontal status in the middle-aged males investigated. This association was independent of diabetes and all other cardiovascular risk factors investigated.

Home heating and respiratory symptoms among children in Belfast, Northern Ireland.

In this study, the authors assessed whether home heating with a glass-fronted solid fuel fire (GFF) affected the respiratory health of children in Belfast, Northern Ireland. Questionnaires were mailed to 2,480 households within 4 medical general practice areas of the city. Respiratory symptoms, tobacco exposure, socioeconomic status, and crowding were studied. The authors found statistically significant relationships (p < 0.001) between GFF heating and wheeze, cough, and asthma diagnosis (odds ratios [ORs] = 3.23, 2.91, and 1.83, respectively). After controlling for tobacco exposure, social deprivation, and crowding, GFF heating remained associated with wheeze, cough, and asthma diagnosis (ORs = 2.47, 2.20, and 1.81, respectively). Respiratory symptoms were triggered 6 times more often when GFF heating was turned on, compared with when it was off. A pilot environmental study of 19 homes determined that levels of particulate matter with diameters < or = 10 microm (PM10) were significantly higher when GFF heating was on. Home heating with GFF is associated with respiratory symptoms in children; in fact, PM10 levels may be the causal link.

Management of varicella contacts in pregnancy: VZIG or vaccination?

BACKGROUND: Varicella infection during pregnancy poses a serious risk for both foetus and mother. It has been suggested that it would be more cost-effective to screen antenatally with post-partum vaccination, which occurs in the US, than the current policy of checking immune status post varicella exposure, with VZIG administration where necessary. Additionally, it is doubtful whether the current policy provides best patient care, when a vaccine is available. OBJECTIVES: The study aims to retrospectively compare the cost of the current policy with a cost estimate for antenatal screening with post-partum vaccination in NI. STUDY DESIGN: A cost estimate of antenatal screening of primigravidas, with post-partum vaccination, was calculated for two models: (1) verbal screening, with serological testing of those with no history of varicella infection and (2) serological screening of all primigravidas. RESULTS: The cost of VZIG issued to pregnant women in 2006 was pound100,800; 43% of births were to primigravidas therefore the estimated cost of VZIG issued to multigravidas was pound58,100. The cost of verbal screening with post-partum vaccination is estimated at pound23,750 p.a., saving pound34,350 over current policy. The estimated cost of screening all primigravidas with post-partum vaccination is pound43,000, saving pound15,100. CONCLUSIONS: This retrospective study suggests that in NI either of the proposed antenatal screening strategies would be less costly than current practice. This finding supports the suggestion that varicella immunity testing should be included in the Antenatal Infectious Diseases Screening Programme, either as part of the universal vaccination programme or solely as an antenatal programme.

Institutional care for elderly people in North and West Belfast. A decade of change from 1989-1999.

BACKGROUND AND AIMS: We wished to document the pattern of institutional care for dependent elderly people during a period of altered provision of care, namely a shift from National Health Service long-term hospital care provision to residential and nursing home provision in the private sector. METHODS: We systematically studied all Institutionalized people aged 65+ years in a single geographic area in 1989, 1992, 1995 and 1999. Subjects' physical and mental function was assessed using the Barthel Index and the Abbreviated Mental Test. Descriptive and statistical comparisons between years and care facilities were made. RESULTS: There were large changes in facilities providing for care between 1989 and 1999, with an 84% increase in nursing home placements and an 89% decrease in hospital admissions. Smaller reductions in residential and psychogeriatric placements were observed together with a large increase in Elderly Mentally Infirm (EMI) placements. We found significant increases in the physical dependency and mental impairment of those receiving nursing, psychogeriatric and long-term hospital care. Residential homes are now caring for people who are significantly less physically dependent, and there have been no changes in the dependency level of residents in EMI homes. CONCLUSIONS: There has been an overall mean reduction from 4.3 to 3.9% in the percentage of elderly people aged 65 and over receiving institutional care between 1989 and 1999. This trend has included a radical shift in care from hospital-based provision to nursing home care and undoubtedly an increase in support for people wishing to remain in their own homes. The increased dependency found in institutional care is believed to be due to the higher threshold now necessary for provision of care, which may be due to fiscal constraints.

Seasonal changes in platelets, fibrinogen and factor VII in elderly people.

BACKGROUND: an increase in mean platelet volume and a decrease in platelet total have been reported following stroke and increased mean platelet volume in acute myocardial infarction has been shown to be predictive of mortality. OBJECTIVE: given the established seasonal variation in morbidity and mortality from cardiovascular disease and various risk factors for the disease, we explored the seasonal variation in mean platelet volume and platelet total. METHODS: we assessed levels of platelet count, platelet volume, fibrinogen, factor VII, core body and ambient temperatures in 54 healthy community dwelling elderly volunteers over a period of 1 year. We used cosinor rhythmometry to quantify and compare the seasonal rhythms. RESULTS: we found significant seasonal variation in fibrinogen, mean platelet volume and core body temperature all of which peaked synchronously in May/June, in a year with an atypically mild winter and hot summer. Platelet total and factor VII did not exhibit a seasonal rhythm. CONCLUSIONS: we conclude that the synchrony between peak size of platelets and peak level of fibrinogen will significantly increase the likelihood of thrombotic events. These results provide further evidence of a seasonal pro-thrombotic state, which has a complex relationship with temperature.

Factors influencing prescription of CNS medications in different elderly populations.

Factors influencing the use of neuroleptic and other CNS-acting medications ('antidepressants' and 'hypnotics/anxiolytics') were examined in different elderly populations (> 65 years): long-stay care hospital subjects (n = 381), nursing home subjects (n = 1247), private residential home subjects (n = 321), statutory residential home subjects (n = 525), old age psychiatry facility subjects (n = 48), community dwellers (n = 97), in different geographical areas (urban n = 1223 and rural n = 1396). Neuroleptics were prescribed in 28% of the individuals, hypnotics/anxiolytics in 33% and antidepressants in 12%. Prescription of neuroleptics was significantly predicted by institutional placement (other than long-stay care hospital facility), lower cognitive function and rural geographical area. Age greater than 75 years and lower functional score (lower dependency) significantly decreased the likelihood of receipt of neuroleptics. Antidepressant use was significantly less likely in male subjects, patients with cognitive impairment and patients greater than 85 years. Institutional placement (other than long-stay care hospital facility and old age psychiatry facility) and rural locality predicted increased likelihood of antidepressant prescription. Institutional placement (other than long-stay care hospital facility) and geographical (rural) location were significant independent predictors of hypnotic/anxiolytic use. Prescription of hypnotic/anxiolytic drug class was significantly less likely in those individuals with lower cognitive status. In this representative elderly cohort, patient characteristics: age, sex, cognitive score, functional score, place of residence and geographical location markedly influenced drug utilisation.