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The aim of this study was to establish the utility of the NIH Toolbox as a cognitive screener of executive functions in the clinical context. Additionally, we aimed to investigate whether age and t...

Introduction and aims: Objective structured clinical examinations (OSCEs) play a pivotal role in medical education assessment. The Advanced Clinical Skills (ACS) OSCE examines clinical skills in psychiatry, general practice, obstetrics and gynaecology and paediatrics. This study examined if the 2020 ACS OSCE for fourth year medical students attending the National University of Ireland, Galway, was associated with any significant result differences compared to the equivalent 2019 OSCE. Additionally, we assessed students’ satisfaction and explored any organisational difficulties in conducting a face-to-face OSCE during the COVID-19 pandemic. Materials and methods: This study compared anonymised data between the 2019 and 2020 ACS OSCEs and analysed anonymised student feedback pertaining to the modified 2020 OSCE. Results: The mean total ACS OSCE result achieved in 2020 was statistically higher compared to the 2019 OSCE [62.95% (SD = 6.21) v. 59.35% (SD = 5.54), t = 6.092, p < 0.01], with higher marks noted in psychiatry (p = 0.001), paediatrics (p = 0.001) and general practice (p < 0.001) with more students attaining honours grades (χ2 = 27.257, df = 3, p < 0.001). No difference in failure rates were found. Students reported feeling safe performing the 2020 OSCE (89.2%), but some expressed face-mask wearing impeded their communication skills (47.8%). Conclusion: This study demonstrates that conducting a face-to-face OSCE during the pandemic is feasible and associated with positive student feedback. Exam validity has been demonstrated as there was no difference in the overall pass rate.

Aims Lifelong HIV infection has an unknown impact on bone health in children. In view of this, we aimed to improve management of vitamin D deficiency. Methods Three audits over 8 years (2009-2017) were performed with interventions introduced intermittently in an effort to improve vitamin D deficiency. The interventions included education, a change in vitamin D dose and brand to increase compliance and a shift to nursing led management. Results The most striking result was the eradication of patients with deficient vitamin D levels (25nmol/L) in 2017. In 2009 and 2015, 15% and 9% were deficient. In the earlier two studies, only 15% had ‘sufficient’ (50nmol) vitamin D levels. This increased to 71% in 2017. 10% of patients had levels greater than120nmol/L, increasing risk of vitamin D toxicity. 67% of patients with insufficient vit D (25-50nmol/L) were prescribed a stat high dose vitamin D (120,000 IU) to help avoid adherence issues. Conclusions Sequential audits along with a shift to nurse led management were the most likely reasons for sustained improvement. Similar projects in all medical departments could improve clinical outcomes.

Background Gonadoblastoma (GB) is a rare tumour of the gonads presenting in childhood or adolescence. It is a lesion composed of a mixture of germ cells at different stages of maturation, with low malignant potential. It is associated with disorders of sex development, most commonly Turner mosaic syndrome with Y chromosome material (TMSY), and 46XY gonadal dysgenesis (GD). Little is known about the natural history and incidence, however prophylactic gonadectomy is recommended. Objectives To determine the incidence and clinical features of GB presenting in childhood in the Irish Republic (RoI) from 1999–2018 inclusive. Methods A retrospective review of children and adolescents with a diagnosis of GB was undertaken using the records of the National Cancer Registry Ireland (NCRI) and the Departments of Endocrinology, Pathology and Surgery at the main children’s hospitals. Results Fifteen cases of gonadoblastoma were identified, all except one phenotypically female. Fourteen patients had prophylactic gonadectomy and one presented with an ovarian mass and raised tumour markers. Eight had TMSY (age at gonadectomy 2 weeks – 14 years). Seven were phenotypically female and one was male. Seven cases of 46 XY GD (all female phenotype) were diagnosed with gonadoblastoma with an age range of 4 months – 15 years at time of surgery. Four of these were unilateral. In the remaining three cases, one patient had bilateral gonadoblastoma, one had unilateral dysgerminoma and contralateral gonadoblastoma and the third had bilateral dysgerminoma with features of gonadoblastoma. Conclusions This is the first reported population incidence rate of GB in children with a 20 year incidence of gonadoblastoma in the Republic of Ireland of 1/100,000 live births. The data supports the recommendation for elective gonadectomy in high risk conditions. Due to the wide age range in presentations, however, the timing of gonadectomy should be individualised, based on underlying diagnosis and following multidisciplinary team discussion. The true rate of malignant transformation in early onset GB remains to be studied.

Aim This study aims to describe the perceptions of young adults’, parents of young adults’ and health care professionals’ (HCPs) of the transition process for young adults with Type 1 Diabetes in the West of Ireland. Methods Thematic analysis of semi-structured interviews conducted with the three stakeholder groups was performed. Results Young adults hardly noticed the transition, with many of them seeing it as a physical move, whereas parents were more anxious and felt their involvement was still needed but not accommodated. Both groups perceived the young adults’ ability to manage their diabetes as a facilitator, as well as the continuity of care provided by the diabetes nurse. Resource limitations and an inability of a young adult to self-manage were identified as barriers to smooth transition by parents, whilst HCPs were experiencing problems with non-attendance and a lack of a psychology service. Conclusion This study highlights the importance of encouraging adolescents’ autonomy in the years leading to transition. A key healthcare professional link between both services appears to facilitate smooth transition. Being flexible and supportive of both parents and adolescents including the provision of mental health services are other important considerations.

BackgroundWhen intubating newborns, clinicians aim to position the endotracheal tube (ETT) tip in the midtrachea. The depth to which ETTs should be inserted is often estimated using the infant’s weight. ETTs are frequently incorrectly positioned in newborns, most often inserted too far. Using the vocal cord guide (a mark at the distal end of the ETT) to guide insertion depth has been recommended.ObjectiveTo determine whether estimating ETT insertion depth using the vocal cord guide rather than weight results in more correctly positioned ETT tips.DesignSingle-centre randomised controlled trial.SettingLevel III neonatal intensive care unit (NICU) at a university maternity hospital (National Maternity Hospital, Dublin, Ireland).PatientsNewborn infants without congenital anomalies intubated in the NICU.InterventionsParticipants were randomised to have ETT insertion depth estimated using weight [insertion depth (cm) = weight (kg) +6] or vocal cord guide.Main outcome measureCorrect ETT position, that is, tip between the upper border of the first thoracic vertebra (T1) and the lower border of the second thoracic vertebra (T2) on a chest X-ray as determined by one paediatric radiologist masked to group assignment.Results136 participants were randomised. The proportion of correctly positioned ETTs was similar in both groups (weight 30/69 (44%) vs vocal cord guide 27/67 (40%), p=0.731). Most incorrectly positioned ETT (69/79, 87%) were too low.ConclusionEstimating ETT insertion depth using the vocal cord guide did not result in more correctly positioned ETT tips.Trial registration numberISRCTN39654846.

Acute intestinal failure (AIF) is defined as an inability to tolerate 80% of nutritional requirements delivered enterally for a minimum of 48 h. In surgical patients it commonly relates to abdominal sepsis, intestinal obstruction, or ileus. The prevalence of AIF in surgical units in Ireland has not previously been studied. We retrospectively audited the general surgical and ICU departments in St James’s Hospital over a 3-month period to identify patients with AIF and followed their management and outcomes focusing on the need for artificial nutrition and surgical intervention. Fifty-four surgical patients (11.4% of surgical emergency admissions) were diagnosed with AIF over the 3-month period. Of these, 30 (55.6%) required nutritional support; 26 (48.2%) had surgical ± radiological intervention and 6 (11.1%) had radiological intervention alone. Abdominal sepsis was present in 17 (31.5%) patients, a group that required significantly longer parenteral (14.6 vs. 6.7 days, p 0.029) and enteral (13.9 vs. 2.2 days, p 0.005) nutrition than AIF patients without abdominal sepsis. AIF also took longer to resolve in (5.8 vs. 4.2 days, p 0.024) in sepsis versus nonsepsis patients. The majority of patients (n = 43, 80%) were referred to clinical nutrition teams early after having symptoms for 3.77 days (range 1–21) and 72% had complete nutritional assessment clearly documented. AIF is common, and can often be treated conservatively. Early linkage with nutrition services is recommended. Early diagnosis of abdominal sepsis is important as this cohort of patients can be particularly difficult to manage.

Ireland has seen a steady increase in paediatric sickle cell disease (SCD). In 2005, only 25% of children with SCD were referred to the haemoglobinopathy service in their first year. A non-funded screening programme was implemented. This review aimed to assess the impact screening has had. All children referred to the haemoglobinopathy service born in Ireland after 2005 were identified. Data was collected from the medical chart and laboratory system. Information was analysed using Microsoft Excel. 77 children with SCD were identified. The median age at antibiotic commencement in the screened group was 56 days compared with 447 days in the unscreened group, p =0.0003. 22 (28%) of infants were born in centre's that do not screen and 17 (81%) were over 6 months old at referral, compared with 14 (21%) in the screened group. 6 (27%) of those in the unscreened group presented in acute crisis compared with 2 (3%) in the screened population. The point prevalence of SCD in Ireland is 0.2% in children under 15 yr of African and Asian descent. We identified delays in referral and treatment, which reflect the lack of government funded support and policy. We suggest all maternity units commence screening for newborns at risk of SCD. It is a cost effective intervention with a number needed to screen of just 4 to prevent a potentially fatal crisis.

Introduction Although children with painful sickle cell crises (PSCC) frequently present to the Emergency Department (ED), pain in sickle cell disease is often under-recognised, under-treated and treatment may be delayed. We aimed to evaluate pain assessment and management in children presenting to the ED with PSCC. Methods A 12-month prospective descriptive study of acute pain management of PSCC at an urban tertiary paediatric ED. Pain was assessed by the triage nurse or physician using a validated age appropriate pain scale (Faces, Legs, Activity, Cry, Consolability (FLACC) Scale; Manchester Pain Ruler). Results There were 96 presentations in 66 patients with PSCC (Table 1). Nineteen (19.7%) patients recieved no pre-hospital analgesia. Conclusion PSCC pain is under-treated, under-monitored and adequate treatment of pain is delayed in our ED. Patients with severe pain appear at highest risk for treatment guideline violation. This is predominantly related to lack of opiate administration. An educational intervention, with/without the inclusion of an easily administered, fast-onset and short-acting opiate e.g. intranasal fentanyl, may decrease the time from ED arrival to effective pain relief.

Objectives To understand and classify causal factors linked to medication errors and to define opportunities for systematic changes to improve the safety of prescription medication use. Design, Setting, and Participants All recipients of liver, kidney, and/or pancreas allografts followed up by an academic medical center and encountered in the acute care facility, outpatient clinic, or by telephone during 12 months (April 1, 2004, through March 31, 2005). Errors were sought by specific review of the expected and actual medication lists. Main Outcome Measure Proportion of medication errors in each of 5 classifications developed through iterative revision. Definitions included failure to provide a correct prescription (prescription error); deliver a prescribed medication to the patient (delivery error); possess enough medication for a 24-hour or greater supply (availability error); accurately use an available, prescribed medication (patient error); and identify the type, dosage, or frequency of a medication (reporting error). Results We identified 149 errors in 93 patients who were prescribed a mean of 10.9 medications each. Adverse events were associated with 48 errors (32%), including hospitalization (17 patients) or outpatient invasive procedure (3 patients) in 13%. Nine episodes of rejection and 6 failed allografts were identified. The most common error type was patient error in 83 errors (56%) with prescription errors in 20 errors (13%), delivery errors in 20 errors (13%), availability errors in 15 errors (10%), and reporting errors in 12 errors (8%). Root cause analysis identified the patient as the cause in 101 errors (68%) while pharmacies and other sectors of the health care team caused 41 errors (27%). Finances were linked to 7 errors (5%). Error frequency was estimated during 4 weeks of outpatient visits at 15 of 219 visits. Conclusions Outpatient medication errors are abundant, often occult, and associated with significant adverse events in a complex transplant population. The health care system is associated with nearly one third of errors.