Quantifying the impact of regional variations in COVID-19 infections and hospitalizations across Ireland.

BACKGROUND: As most COVID-19 transmission occurs locally, targeted measures where the likelihood of infection and hospitalization is highest may be a prudent risk management strategy. To date, in the Republic of Ireland, a regional comparison of COVID-19 cases and hospitalizations has not been completed. Here, we investigate (i) the variation in rates of confirmed infection and hospital admissions within geographical units of the Republic of Ireland and (ii) frequency of deviations in risk of infection or risk of hospitalization. METHODS: We analyzed routinely collected, publicly available data available from the National Health Protection and Surveillance Centre and Health Service Executive from nine geographical units, known as Community Health Organization areas. The observational period included 206 14-day periods (1 September 2020-15 April 2021). RESULTS: A total of 206 844 laboratory-confirmed cases and 7721 hospitalizations were reported. The national incidence of confirmed infections was 4508 [95% confidence interval (CI) 4489-4528] per 100 000 people. The risk of hospital admission among confirmed cases was 3.7% (95% CI 3.5-3.9). Across geographical units, the likelihood that rolling 14-day risk of infection or hospitalization exceeded national levels was 9-86% and 0-88%, respectively. In the most affected regions, we estimate this resulted in an excess of 15 180 infections and 1920 hospitalizations. CONCLUSIONS: Responses to future COVID-19 outbreaks should consider the risk and harm of infection posed to people living in specific regions. Given the recent surges of COVID-19 cases in Europe, every effort should be made to strengthen local surveillance and to tailor community-centred measures to control transmission.

Medicine, media and the law: The effect on training in obstetrics and gynaecology.

The inextricable link between medicine and the legal profession has flourished in the 21st century, with countless newspaper articles and social media content on medical cases visible at every juncture. This is particularly true in the speciality of obstetrics and gynaecology, with one of the highest rates of litigation of all medical specialities. We aimed to evaluate the influence of media and the legal environment on the career of trainees in obstetrics and gynaecology. Under the auspices of the Irish national training body, we distributed a 26-item questionnaire to doctors-in-training (DIT) working in obstetrics and gynaecology in the Republic of Ireland. Descriptive statistics and Chi-squared analyses were performed on the anonymised data. 151 DIT responded to the questionnaire, with a response rate of 86.2 % (sample size = 175). The majority were female (79.9 %, n = 121), Irish (85.5 %, n = 106) and had no children (67.0 %, n = 83). 86.7 % (n = 131) felt that the media did not have a positive impact on patients receiving care, and, further, unfairly represented the speciality (94.1 %; n = 142). Additionally, DIT felt that medico-legal issues had a negative impact on issues such as retention and recruitment. These two areas were implicated in over three quarters of DIT considering leaving the speciality. This study demonstrates that DIT perceive media scrutiny and litigation to have a negative effect on the speciality of obstetrics and gynaecology. Further support integrated into specialist training, is needed to ensure that trainees are adequately equipped to deal with both mainstream and social media as well as interactions they may have with the legal profession as they progress through their career.

Survey of Irish general practitioners' preferences for continuing professional development.

BACKGROUND: Doctors' continuing professional development (CPD) training needs are known to be strongly influenced by national and local contextual characteristics. Given the changing national demographic profile and government-mandated changes to primary care health care provision, this study aimed to investigate Irish General Practitioners' (GPs) perceptions of, and preferences for, current and future CPD programmes. METHODS: A cross-sectional questionnaire, using closed- and open-ended questions, was administered to Irish GPs, focusing on training needs analysis; CPD course content; preferred format and the learning environment. RESULTS: The response rate was 719/1000 (71.9%). GPs identified doctor-patient communication as the most important and best-performed GP skill. Discrepancies between perceived importance (high) and current performance (low) emerged for time/workload management, practice finance and business skills. GPs identified clinically-relevant primary care topics and non-clinical topics (stress management, business skills, practice management) as preferences for future CPD. Flexible methods for CPD delivery were important. Gender and practice location (urban or rural) significantly influenced CPD participation and future course preference. CONCLUSION: The increasing diversity of services offered in the Irish primary care setting, in both clinical and non-clinical areas, should be tailored based to include GP practice location and structure.

Incidence of respiratory viral infection in infants with respiratory symptoms evaluated for late-onset sepsis.

OBJECTIVE: To determine the frequency, etiology and impact of respiratory viral infection (RVI) on infants evaluated for late-onset sepsis (LOS), defined as sepsis occurring >72 h of life, in the neonatal intensive care unit. STUDY DESIGN: Prospective observational study conducted from 6 March 2014 to 3 May 2016 on infants evaluated for LOS. PCR viral panel performed on nasopharyngeal specimens among infants with clinical suspicion for RVI. Sequence analysis was performed to determine viral subtypes. Fisher's exact or χ2 tests were done to determine the impact of RVI. RESULTS: During the 26-month study, there were 357 blood cultures obtained for LOS evaluations, 29 (8%) had a respiratory virus detected. Only 88 (25%) of infants evaluated for LOS also had clinical suspicion for a respiratory viral infection. RSV (14 of 29; 48%) was the predominant virus detected. Almost all infants (13 of 14; 93%) with RSV required increased respiratory support. Antimicrobial therapy was withheld or discontinued on most infants with a virus detected (18 of 29; 62%) and in the majority where there was no confirmed bacterial co-infection (18 of 20; 90%). CONCLUSION: The incidence of RVI in infants being evaluated for LOS is about 8%. RVI should be considered in LOS evaluation to prevent unnecessary antibiotic therapy.

Patients Accessing Ambulatory Care for HIV-infection: Epidemiology and Prevalence Assessment.

This study describes the demographics and treatment status of HIV-infected adults accessing ambulatory care in the Republic of Ireland and estimates diagnosed HIV prevalence rates. 3254 HIV-infected adults attended 1 of the 6 specialist HIV centres in the 12- month period 1st July 2009 to 30th June 2010. 2023/3254 (62%) were male, 1761/3133 (56%) Irish and 1048/3133 (34%) African. 1924/3098 (62%) resided in the Dublin area. The mean age was 39.8 years (SD 9.3); probable route of acquisition was available for 2898/3254 (89%); heterosexual acquisition accounted for 1442 (50%), MSM 777 (27%) and IDU 598 (21%). 2574/3202 (80%) were on highly active antiretroviral therapy (HAART). Of these 87% had HIV-RNA levels < 50cpm and 94% < 500cpm. The HIV diagnosed prevalence rate is estimated at 1.09/1000 nationally and at 2.25/1000 in the Dublin area for 15-59 year olds.

Prevention of postnatal growth restriction by the implementation of an evidence-based premature infant feeding bundle.

OBJECTIVE: To develop an evidence-based feeding bundle to safely decrease the rate of PNGR in VLBW infants. STUDY DESIGN: The bundle was developed and implemented in January 2010, followed by 3 years of monitoring bundle compliance and infant outcomes (days to first feed (FD), days to reach full feeds (FF), and birth-discharge growth trajectories (delta z-score)). RESULTS: Data were collected on 482 infants (119 pre-bundle). PNGR decreased from 35% to 19% (P<0.01) and weight delta z-score improved from -0.82 to -0.45 (P<0.001). Percentage of infants with head circumference (HC) below 10th percentile at discharge decreased from 21% to 9% (P<0.01) and HC delta z-score improved from -0.65 to -0.17 (P<0.001). FD and FF also decreased significantly. Rates of necrotizing enterocolitis, peak alkaline phosphatase and peak direct bilirubin levels all trended downward. CONCLUSIONS: An evidence-based, standardized feeding bundle was safe and effective in reducing the rate of PNGR and in improving head growth in VLBW infants.

Exodus? The training paths and plans of postgraduate medical trainees, under the Royal College of Physicians of Ireland.

BACKGROUND: In 2006, the Buttimer report highlighted the paucity of demographic data on those applying for and entering postgraduate medical education and training (PGMET) in Ireland. Today, concerns that there is an "exodus" of graduates of Irish medical schools are at the forefront of national discussion, however, published data on PGMET remains inadequate. AIMS: The objectives of this study were to collate existing data relating to trainees and training programmes at three stages of training and to examine the career plans of junior trainees. METHODS: Data from application forms for training programmes, commencing July 2012, under the Royal College of Physicians of Ireland (n = 870), were integrated with data from other existing sources. Candidates entering basic specialist training were surveyed with regard to career plans. Descriptive and comparative analysis was performed in SPSS version 18. RESULTS: Graduates of Irish medical schools made up over 70 % of appointees. Over 80 % of BST trainees aspired to work as consultants in Ireland, but 92.5 % planned to spend time working abroad (response rate 77 %). Decisions to leave the Irish system were linked to lifestyle, but also to failure to be appointed to higher specialist training. Significant numbers of trainees return to Ireland after a period abroad. CONCLUSIONS: The trainee "exodus" is more complex than is often portrayed. The desire to spend time working outside Ireland must be accounted for in workforce planning and configuration of training programmes. Expansion of HST is a potential solution to reduce the numbers of graduates leaving Ireland post-BST.

Enhanced research assessment performance in graduate vs. undergraduate-entry medical students: implications for recruitment into academic medicine.

BACKGROUND: Studies investigating variance between the academic performance of direct-entry (DEM) versus graduate-entry (GEM) medical students have yielded conflicting results, but their performance in undergraduate research-based assessments has not been compared to-date. AIM: We aimed to compare the results of DEM and GEM students with respect to their senior research dissertation module. METHODS: This retrospective study examined the final year results between 2011-2012 in DEM, (n = 219) and GEM (n = 84) students. Between-group comparisons of dissertation module marks were conducted using independent t-tests. Correlations between marks in dissertation module and in other disciplines assessed during the final year were attained using Pearson's correlation. Multiple regression analysis was employed to adjust for potential confounding factors such as student age and gender. RESULTS: No apparent difference was apparent between the DEM and GEM students with respect to results achieved across the clinical disciplines examined. However, GEM students performed significantly better than DEMs in their senior research dissertation assessment (Mean = 66.81% vs. 65.00%, fully adjusted p = 0.048). The variable which remained influential in regression analysis was nationality, where North American and Asian students were demonstrated to score lower than their Irish counterparts in the dissertation module (B coefficient = -1.90, SE = 0.94, P = 0.045 and B coefficient = -4.88, SE = 1.00, P < 0.001 respectively). CONCLUSIONS: Performance in the research-based module was significantly better in GEM relative to their DEM colleagues. This finding may have implications for future recruitment into academic medicine, as aptitude and interest in research at undergraduate level has been shown to be associated with increased likelihood of an academic career in medicine.

Postgraduate training in Ireland: expectations and experience.

BACKGROUND: Postgraduate medical training in Ireland has been compared unfavourably with training abroad and blamed for an "exodus" of graduates of Irish medical schools. Exploration of features of a good training environment and development of tools to measure it have been the focus of much published research. There have been no Irish studies examining training environment using such validated tools. AIM: The aim of this study was to use a validated tool, to examine the expectations and experience of training, amongst those training under the Royal College of Physicians of Ireland (RCPI). METHOD: The Dutch Residency Education Climate Test (D-RECT) is a 50 item tool to measure postgraduate learning environments. D-RECT was sent to all new entrants to RCPI training programmes in July 2012 (n = 527) and completed in regard to expectations of training (response rate 80.6 %). In March 2013, D-RECT was sent to all RCPI trainees (n = 1,246) to complete in relation to the post held on 1 March (response rate 32.6 %). Data were analysed in SPSS version 18. RESULTS: Experience fell short of expectations for basic specialist training, however, scores for experience rose with greater seniority to match expectations. Positive aspects were teamwork, consultant willingness to discuss patients and respectful treatment of trainees. Areas of weakness were provision of feedback and time to learn new skills. CONCLUSION: Measurement of learning environment at a national level using a quantitative tool provides useful information for quality assurance and improvement of training.

Trends in genital chlamydia infection in the Mid-West of Ireland, 2001-2006.

Genital Chlamydia trachomatis (GCT) infection is the most common bacterial sexually transmitted infection (STI) in Ireland. A retrospective analysis of 2,087 laboratory-confirmed GCT patient episodes from 2001 to 2006 in the Mid-West of Ireland was undertaken in conjunction with statutorily notifiable data that were reported by the Sexually Transmitted Disease/Genito-Urinary Medicine (STD/GUM) services in the region and used in national surveillance. Data were analysed by year, source, sex and age. The annual incidence of GCT in the Mid-West is increasing. A substantial proportion of GCT infections were diagnosed in the non-STD/GUM setting. The issue of sexually active young people seeking STI screening is a sensitive one, and delays increase the potential for transmission and the possibility of long-term complications when the disease is not treated. Based on this sample, national surveillance would significantly underestimate the burden of disease in Ireland, due to under-reporting. This would have implications for any national chlamydia screening programme. Among those who sought testing, women aged 15 to 19 years are five times more likely to be found positive than men in the same age group. Of those diagnosed in the non-STD/GUM setting, 83% were women. General practitioners and clinicians might consider targeting those aged 15 to 29 years for opportunistic screening and sexual health advice. Contact tracing and follow-up in the non-STD/GUM setting, as well as access for general practitioners to ongoing education on STIs are challenges to be addressed.

Mastery motivation in children with Down syndrome.

Mastery motivation refers to the intrinsic motivation children have to interact with their environments in order to learn about them. It appears early in life, and has been regarded by many researchers as a key motivator for development. It has also been suggested that young school age children with Down syndrome show lowered motivation to perform tasks. It is important to know if this low motivation is present from the start, or develops as a result of environmental experiences; studies of mastery motivation have been one way of investigating this issue. However definitions of mastery motivation, and hence empirical studies, have varied. Thus this paper starts by revisiting the issues surrounding definition and measurement. There is general agreement on some issues: that mastery motivation is intrinsic, that it is manifest in different behaviours as the child develops, that there are individual differences in mastery behaviour, and that these are affected by environmental factors. There is also current agreement that it is essential to remove the confound of differing levels of developmental competence by using individualized measurement. However there is disagreement about which behaviours best index mastery motivation. Some empirical work with infants with Down syndrome is reviewed, and results from a recent longitudinal study on the development of mastery motivation are presented. The results concurred with most others in the recent literature, suggesting that low mastery motivation is not inevitable in infancy in Down syndrome. Infants with Down syndrome showed similar patterns of development as typically developing children, with slight delays. It is argued that longitudinal studies are needed to demonstrate such patterns of development. As the children developed from 6 to 24 months mental age there was no evidence for decreasing levels of mastery motivation. Thus there was no support for the view that more failure experiences impact on levels of mastery motivation. In contrast caregivers did see their young children with Down syndrome as less object mastery oriented than did caregivers of typically developing children. The caregivers of children with Down syndrome were also significantly more directive in their interactions with their children, and there was some suggestion that individual differences in mastery behaviours were related to levels of mastery behaviours in their children. The final section speculates on reasons for these results, and makes suggestions for future work.

Acoustic neuroma surgery outcomes.

OBJECTIVE: The outcomes of surgery for acoustic neuromas have improved dramatically since the development of modern surgical techniques, the operating microscope, magnetic resonance imaging (MRI), and cranial nerve monitoring. The goals of acoustic neuroma surgery are now preservation of facial nerve function and, when feasible, hearing preservation. Many large series do not report standardized hearing and facial function grading, and they include patients who did not benefit from the most modern techniques. The purpose of this study was to present the results of acoustic neuroma surgery using the most modern techniques and equipment, using standardized grading systems. STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. PATIENTS: 97 patients who underwent surgical removal of acoustic neuromas from 1992 to 1998. INTERVENTION: All patients underwent acoustic neuroma surgery and had preoperative audiograms and MRI with contrast. In addition, all patients had preoperative and postoperative facial function graded by the House-Brackmann scale and intraoperative facial nerve monitoring. Hearing preservation was attempted in patients with tumors of any size who had preoperative function of grade A or B according to the Committee on Hearing and Equilibrium guidelines for reporting results of acoustic neuroma surgery. MAIN OUTCOME MEASURES: Hearing preservation was considered successful if the patient retained serviceable hearing grade A or B. House-Brackmann grade 1 or 2 was considered excellent facial function. Complications were recorded. RESULTS: Facial nerve integrity was preserved in 96 of 97 patients (99%). Eight of 8 (100%) patients with intracanalicular tumors had excellent facial nerve function (HB 1-2). Fifty-two of 55 (95%) of patients with small tumors had excellent facial nerve function, and 15 of 24 (63%) with medium tumors had HB grade 1-2. Hearing was preserved in 29% of patients with tumors under 2 cm. The overall complication rate was 20%; cerebrospinal fluid leak was the most common. CONCLUSION: These results show that with modern imaging and surgical techniques, acoustic neuroma surgery is extremely safe and outcomes are very good. Surgery remains the treatment of choice for most tumors until alternative therapies, such as gamma knife, use uniform grading scales and show long-term facial and hearing results.

National guidelines for the active management of HIV in pregnancy.

The number of HIV positive women becoming pregnant in Ireland is increasing, with many pregnancies occurring in women from countries of high HIV prevalence. The management of such patients offers the challenge of reducing the risk of maternal-fetal transmission of HIV infection, avoiding fetal-infant toxicities, and maintaining future maternal antiretroviral options. Guidelines for the optimal management of HIV disease in pregnancy have been produced by a subgroup of the Irish Infection Society consisting of GenitoUrinary Medicine and Infectious Diseases Consultants. They are based on currently available international data and guidelines. The national guidelines offer a broad management outline for HIV positive pregnant patients. Ultimately, each patient is assessed individually by a multidisciplinary team, and a careful plan for antenatal, intrapartum, and postpartum care is determined.