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Taking oral antibiotics during childhood has been linked with an increased risk of childhood obesity. This study assessed any potential association in number of courses of antibiotics taken between 2–3 and 4–5 years of age and body mass trajectory up to age 5. The study was a secondary analysis of 8186 children and their parents from the infant cohort of the Irish National Longitudinal Study of Children. Antibiotic use was measured by parental recall between ages 2–3 and 4–5. Longitudinal models described the relationship between antibiotic exposure and body mass index (BMI) standard deviation scores and binary outcomes, and examined interactions between covariates, which included socioeconomic status, diet assessed by food frequency questionnaires and maternal BMI. Any antibiotic usage between 2 and 3 years did not predict risk of overweight or obesity at age 5. Four or more courses of antibiotics between 2 and 3 years were independently associated with obesity at age 5 (odds ratio 1.6, 95% confidence interval 1.11–2.31). Effect size was modest (coefficient + 0.09 body mass SD units, standard error 0.04, P = 0.037). Maternal BMI modified the relationship: ≥ 4 courses of antibiotics between 2 and 3 years were associated with a + 0.12 body mass SD units increase in weight at age 5 among children of normal-weight mothers (P = 0.035), but not in children of overweight mothers. Number of antibiotic courses, rather than antibiotic use, may be an important factor in any link between early antibiotic exposure and subsequent childhood obesity. Research is needed to confirm differential effects on babies of normal versus overweight/obese mothers independent of socioeconomic factors.

Patients with severe coronavirus disease 2019 (COVID-19) develop a febrile pro-inflammatory cytokinemia with accelerated progression to acute respiratory distress syndrome (ARDS). Here we report the results of a phase 2, multicenter, randomized, double-blind, placebo-controlled trial of intravenous (IV) plasma-purified alpha-1 antitrypsin (AAT) for moderate to severe ARDS secondary to COVID-19 (EudraCT 2020-001391-15).Patients (n = 36) were randomized to receive weekly placebo, weekly AAT (Prolastin, Grifols, S.A.; 120 mg/kg), or AAT once followed by weekly placebo. The primary endpoint was the change in plasma interleukin (IL)-6 concentration at 1 week. In addition to assessing safety and tolerability, changes in plasma levels of IL-1β, IL-8, IL-10, and soluble tumor necrosis factor receptor 1 (sTNFR1) and clinical outcomes were assessed as secondary endpoints.Treatment with IV AAT resulted in decreased inflammation and was safe and well tolerated. The study met its primary endpoint, with decreased circulating IL-6 concentrations at 1 week in the treatment group. This was in contrast to the placebo group, where IL-6 was increased. Similarly, plasma sTNFR1 was substantially decreased in the treatment group while remaining unchanged in patients receiving placebo. IV AAT did not definitively reduce levels of IL-1β, IL-8, and IL-10. No difference in mortality or ventilator-free days was observed between groups, although a trend toward decreased time on ventilator was observed in AAT-treated patients.In patients with COVID-19 and moderate to severe ARDS, treatment with IV AAT was safe, feasible, and biochemically efficacious. The data support progression to a phase 3 trial and prompt further investigation of AAT as an anti-inflammatory therapeutic.ECSA-2020-009; Elaine Galwey Research Bursary.

Background and objectives An environmental trigger has been proposed as an inciting factor in the development of anti-GBM disease. This multicenter, observational study sought to define the national incidence of anti-GBM disease during an 11-year period (2003–2014) in Ireland, investigate clustering of cases in time and space, and assess the effect of spatial variability in incidence on outcome. Design, setting, participants, & measurements We ascertained cases by screening immunology laboratories for instances of positivity for anti-GBM antibody and the national renal histopathology registry for biopsy-proven cases. The population at risk was defined from national census data. We used a variable-window scan statistic to detect temporal clustering. A Bayesian spatial model was used to calculate standardized incidence ratios (SIRs) for each of the 26 counties. Results Seventy-nine cases were included. National incidence was 1.64 (95% confidence interval [95% CI], 0.82 to 3.35) per million population per year. A temporal cluster ( n =10) was identified during a 3-month period; six cases were resident in four rural counties in the southeast. Spatial analysis revealed wide regional variation in SIRs and a cluster ( n =7) in the northwest (SIR, 1.71; 95% CI, 1.02 to 3.06). There were 29 deaths and 57 cases of ESRD during a mean follow-up of 2.9 years. Greater distance from diagnosis site to treating center, stratified by median distance traveled, did not significantly affect patient (hazard ratio, 1.80; 95% CI, 0.87 to 3.77) or renal (hazard ratio, 0.76; 95% CI, 0.40 to 1.13) survival. Conclusions To our knowledge, this is the first study to report national incidence rates of anti-GBM disease and formally investigate patterns of incidence. Clustering of cases in time and space supports the hypothesis of an environmental trigger for disease onset. The substantial variability in regional incidence highlights the need for comprehensive country-wide studies to improve our understanding of the etiology of anti-GBM disease.

A mesh improvement methodology is pre- sented which aims to improve the quality of the worst elements in 3D meshes with non-planar surfaces which cannot be improved using traditional methods. A nu- merical optimisation algorithm, which specifically tar- gets the worst elements in the mesh, but is a smooth function of nodal positions is introduced. A method of moving nodes on curved surfaces whilst maintaining the domain geometry and preserving mesh volume is proposed. This is shown to be very effective at improv- ing meshes for which traditional mesh improvers do not perform well.

People with type 2 diabetes frequently have a variety of related and unrelated chronic conditions. These additional conditions have implications for patient education, treatment burden and disease management.The aim of this study was to examine the nature of multimorbidity, and its impact on GP visits, polypharmacy and glycaemic control as measured by HbA1c, in a cohort of patients with type 2 diabetes attending general practice in Ireland.A cohort of 424 patients with type 2 diabetes enrolled in a cluster randomized controlled trial based in Irish general practice was examined. Patient data included: medical conditions, HbA1c, health service utilization, socio-economic status and number of prescribed medications.90% of patients had at least one additional chronic condition and a quarter had four or more additional chronic conditions. 66% of patients had hypertension; 25% had heart disease; and 16% had arthritis. General practitioner visits and polypharmacy increased significantly with increasing numbers of chronic conditions. When comparing patient self-report with medical records, patients who reported a higher proportion of their conditions had better glycaemic control with a significantly lower HbA1c score.There was a high prevalence of multimorbidity in these patients with type 2 diabetes and the results suggest that glycaemic control is related to patients' awareness of their chronic conditions. The variety of conditions emphasizes the complexity of illness management in this group and the importance of maintaining a generalist and multidisciplinary approach to their clinical care.

While co-design methods are becoming more popular in healthcare, there is a gap within the peer-reviewed literature on how to do co-design in practice. This paper addresses this gap by delineating the approach taken in the co-design of a collective leadership intervention to improve healthcare team performance and patient safety culture. Over the course of six workshops healthcare staff, patient representatives and advocates, and health systems researchers collaboratively co-designed the intervention. The inputs to the process, exercises and activities that took place during the workshops and the outputs of the workshops are described. The co-design method, while challenging at times, had many benefits including grounding the intervention in the real-world experiences of healthcare teams. Implications of the method for health systems research are discussed.

Ninety-one patients were studied serially for chimeric status following allogeneic stem cell transplantation (SCT) for severe aplastic anaemia (SAA) or Fanconi Anaemia (FA). Short tandem repeat polymerase chain reaction (STR-PCR) was used to stratify patients into five groups: (A) complete donor chimeras (n = 39), (B) transient mixed chimeras (n = 15) (C) stable mixed chimeras (n = 18), (D) progressive mixed chimeras (n = 14) (E) recipient chimeras with early graft rejection (n = 5). As serial sampling was not possible in Group E, serial chimerism results for 86 patients were available for analysis. The following factors were analysed for association with chimeric status: age, sex match, donor type, aetiology of aplasia, source of stem cells, number of cells engrafted, conditioning regimen, graft-versus-host disease (GvHD) prophylaxis, occurrence of acute and chronic GvHD and survival. Progressive mixed chimeras (PMCs) were at high risk of late graft rejection (n = 10, P < 0.0001). Seven of these patients lost their graft during withdrawal of immunosuppressive therapy. STR-PCR indicated an inverse correlation between detection of recipient cells post-SCT and occurrence of acute GvHD (P = 0.008). PMC was a bad prognostic indicator of survival (P = 0.003). Monitoring of chimeric status during cyclosporin withdrawal may facilitate therapeutic intervention to prevent late graft rejection in patients transplanted for SAA.

BackgroundScan statistics have been used extensively to identify temporal clusters of health events. We describe the temporal cluster detection methodology adopted by the EUROCAT (European Surveillance of Congenital Anomalies) monitoring system.MethodsSince 2001, EUROCAT has implemented variable window width scan statistic for detecting unusual temporal aggregations of congenital anomaly cases. The scan windows are based on numbers of cases rather than being defined by time.The methodology is imbedded in the EUROCAT Central Database for annual application to centrally held registry data. The methodology was incrementally adapted to improve the utility and to address statistical issues. Simulation exercises were used to determine the power of the methodology to identify periods of raised risk (of 1 to 18 months).ResultsIn order to operationalize the scan methodology, a number of adaptations were needed, including: estimating date of conception as unit of time; deciding the maximum length (in time) and recency of clusters of interest; reporting of multiple and overlapping significant clusters; replacing the Monte Carlo simulation with a lookup table to reduce computation time; and placing a threshold on underlying population change and estimating the false positive rate by simulation. Exploration of power found that raised risk periods lasting 1 month are unlikely to be detected except when the relative risk and case counts are high.ConclusionsThe variable window width scan statistic is a useful tool for the surveillance of congenital anomalies. Numerous adaptations have improved the utility of the original methodology in the context of temporal cluster detection in congenital anomalies.

Background: Helicobacter pylori eradication regimens have failure rates under 10%, however little information is available on the effect of treatment success in reducing the subsequent prescription of anti-ulcer medications in primary care. Aims: To determine, using a large prescription database in eastern Ireland, the success of presumptive eradication therapy in improving symptoms of dyspepsia in primary care, as judged by a reduction in the subsequent prescription of anti-ulcer medications. Methods: In a cross-sectional study, we identified 3847 patients who received a prescription for eradication therapy for Helicobacter pylori, including 826 who were followed for 9–11 months. Those who subsequently received anti-ulcer medications were deemed failures to obtain symptom relief. Results: For 3847 patients with a median follow-up of 8 months, the failure rate was 49%. Of 826 patients, followed for a longer period (9–11 months), the overall failure rate was 56% (range 44–62% depending on the eradication regimen used). Age over 65 years (hazard ratio=1.57, 95% confidence interval= 1.29–1.91, P

Background: Heparin therapy may be effective in steroid resistant inflammatory bowel disease. Aim: A randomized pilot study, to compare unfractionated heparin as a first-line therapy with corticosteroids in colonic inflammatory bowel disease. Methods: Twenty patients with severe inflammatory bowel disease (ulcerative colitis, n=17; Crohn’s colitis, n=3) were randomized to either intravenous heparin for 5 days, followed by subcutaneous heparin for 5 weeks (n=8), or high-dose intravenous hydrocortisone for 5 days followed by oral prednisolone 40 mg daily, reducing by 5 mg per day each week (n=12). After 5 days, non-responders in each treatment group were commenced on combination therapy. Response to therapy was monitored by: clinical disease activity (ulcerative colitis: Truelove and Witt Index; Crohn’s colitis: Harvey and Bradshaw Index), stool frequency, serum C-reactive protein and α1 acid glycoprotein, endoscopic and histopathological grading. Results: The response rates were similar in both treatment groups: clinical activity index (heparin vs. steroid; 75% vs. 67%; P=0.23), stool frequency (75% vs. 67%; P=0.61), endoscopic (75% vs. 67%; P=0.4) and histopathological grading (63% vs. 50%; P=0.67). Both treatments were well-tolerated with no serious adverse events. Conclusion: Heparin as a first line therapy is as effective as corticosteroids in the treatment of colonic inflammatory bowel disease. Large multicentre randomized comparative studies are required to determine the role of heparin in the management of inflammatory bowel disease.

Aims To develop an index of quality prescribing in general practice by investigating the incidence of potential drug interactions when medicines were coprescribed within the State supported General Medical Services (GMS) in Ireland. Methods We determined an odds ratio (OR), as a measure of the relative risk of being exposed to a potential interaction, comparing the use of the H2-receptor antagonist, cimetidine, with that of the noninteracting agents ranitidine, famotidine and nizatidine in users and nonusers of warfarin, phenytoin and theophylline. Results and conclusions In 86 510 prescriptions for the H2–receptor antagonists potentially interacting drugs were dispensed to 8188 (9%) patients in the Eastern Health Board Region of the GMS. We found that prescribers were significantly less likely to use cimetidine (OR = 0.20,95% CI 0.17–0.21, P

Objective: toxigenic Clostridium difficile is responsible for a spectrum of disease severity ranging from mild diarrhoea to fulminant colitis. This study attempts to determine the proportion of patients in each category of severity and evaluate the risk factors for a more prolonged and complicated course. Design: prospective cohort study. Setting: university teaching hospital. Subjects: all patients with symptomatic C. difficile infection during 4 months of an outbreak (January‐April 1995); n = 73; median age 74 years (range 17‐91). Measurements: incidence of C. difficile-associated disease (CDAD); severity of disease; percentage of patients in each category of severity; risk factors for severe disease/prolonged symptoms (univariate and multivariable analyses). Results: the incidence of CDAD was 0.93%. Of the cases identified, 18 (24.7%) had mild, self-limiting disease; 26 (35.6%) had moderately severe disease; 23 (31.5%) had prolonged symptoms and six (8.2%) had a complicated course. Although CDAD was more common in older patients (P < 0.001), increasing age was not a risk factor for severity. Significant risk factors for severe CDAD included low Barthel and abbreviated mental test scores (P < 0.01, P < 0.001 respectively) and recent endoscopy (P = 0.03). Logistic regression analysis revealed the following independent predictors of severe CDAD: endoscopy [odds ratios (OR) 4.0, P = 0.03] and cognitive impairment (OR 11.0, P < 0.01). A trend towards significance was noted for nasogastric tube insertion (OR 3.1, P = 0.08). Complications of infection included dehydration, malnutrition and faecal incontinence (which was statistically significantly associated with more severe disease; P < 0.01). Conclusion: risk factors for severity of CDAD include functional disability, cognitive impairment, and recent endoscopy. Anticipation of severe CDAD may limit morbidity and mortality.

More and more citizens urge public health authorities to investigate reports of disease excess in their neighbourhood. These environmental concerns are legitimate and it is part of good public health practice to respond to these complaints. However, the methodological and practical problems are severe and a lot of controversy exists about the usefulness of these investigations. To clarify the possibilities and limitations in this situation, this paper proposes a typology of cluster studies. According to this framework, cluster response is distinguished from two other types of cluster studies: Cluster monitoring. screening proactively for clusters to act as an early warning system, and cluster research, scrutinizing clustering to generate and test aetiological hypotheses. To each of these three types of cluster studies corresponds a different public health context; respectively public health action, public health surveillance and public health research. Probably, part of the controversy mentioned stems from not acknowledging sufficiently the corresponding intrinsic differences in rationality and practical constraints. Cluster response is crisis management and not scientific research. In a relatively short time, an informed decision should be taken by a multidisciplinary team of experts using readily available information and knowledge. In accordance with this point of view, cluster reports should be handled stepwise and the role of statistics is to quantify a cluster exploring different points of view as an input to the decision process.

Summaryobjective To assess the impact of screening and intervention based on maternal height, prepregnancy weight and weight during weeks 16–19 or 24–27 in reducing adverse pregnancy outcomes (IUGR, preterm birth and assisted delivery) in developing country settings.methods Decision analysis based on a recent multicentre WHO collaborative study of maternal anthropometry and pregnancy outcomes and meta-analyses of controlled clinical trials of balanced energy/protein supplementation (for IUGR and preterm birth) and support from caregivers during labour (for assisted delivery). Subjects for the analysis comprised pregnant women from Cali, Colombia (1989, n= 4598); urban and rural Pune, India (1990, n= 4307); and urban and rural Myanmar (1981–82, n= 3542) followed until delivery.results Seven to 45% of pregnant women had positive screens, with preventive fractions (PFs) ranging from 0.034 to 0.109 for IUGR, 0.027–0.082 for preterm birth and 0.011–0.105 for assisted delivery. Screening prevention ratios (SPRs = ratios of the number of women treated to the number of cases of adverse outcome prevented) are high in all three study settings for preterm birth and assisted delivery (range 22.8–115.7) and low in settings with a high prevalence of the adverse outcome and high specificity of the anthropometric measure (India for IUGR, range 7.0–8.0). Sensitivity analyses demonstrate a marked linear fall in PF and an exponential rise in the SPR as the relative risk associated with intervention increases (i.e. as the protective benefit of intervention decreases) from 0.60 to 0.95.conclusions A maternal anthropometry-based ‘risk approach’ is unlikely to result in a major reduction in adverse pregnancy outcomes in developing country settings. For risk-free and inexpensive interventions (e.g. caregiver support during labour), a better strategy would be to forego screening and instead treat all pregnant women.

Background Early childhood caries (ECC) is a public health problem due to its impact on children’s health, development and well being. Little is known about early childhood oral health in the West Indies or the influence of social and behavioural factors on the prevalence and severity of early childhood caries in this preschool population. The aims of this study were to describe the prevalence and severity of ECC in preschool children in a region of central Trinidad and to explore its relationship with social and behavioural factors. Method A cross-sectional survey was undertaken on children aged 3-5 years-old from a random sample of preschools in central Trinidad. Oral health examinations were conducted for children for whom parental consent was given, using WHO criteria (visual diagnosis / cavitation at d3). A self-reported questionnaire was distributed to all parents and caregivers. Variables included socio-demographics, oral health knowledge, attitudes and behaviours, visible caries experience and treatment need. Results 251 children were examined, 50.2% were male with a mean age of 3.7 years (SD 0.67) and 71% were of Indian ethnicity. The prevalence of ECC was 29.1% and the prevalence of severe early childhood caries (S-ECC) was 17.5%. 29.9% of children had some treatment need, with 12% in need of urgent care or referral. Poisson generalized linear mixed model analysis found a higher rate of visible caries experience for children who ate sweet snacks more than twice a day (p

To increase public awareness about mouth cancer, the Dublin Dental University Hospital (DDUH) hosted an awareness day and free mouth check-up in September 2010. The messages of information, self-examination and risk management, and the importance of early detection, were available to all attendees. The role of general dental and medical practitioners in examination of the mouth was stressed.A questionnaire regarding knowledge about the causes of and risk factors for mouth cancer, and a clinical check-up, were completed.A total of 1,661 individuals (675 male, 986 female) were examined. The mean age was 59.6 years. Just over one-third (36.5%) of those examined required no action, and slightly less (30%) were advised to return to their general dental or medical practitioner (GDP/GMP). Some 21% were advised about self-examination of the mouth, and 8% about smoking cessation. Of the remainder, 52 people (3.5%) were sent for a second opinion. Of these, 30 individuals were referred for further investigation, including biopsy in 27 cases. Following biopsy, five individuals were diagnosed with carcinoma in situ or carcinoma.The diagnosis of five people with mouth cancers, who may not otherwise have been identified for early treatment, highlights the need for regular mouth examination. It is inappropriate that such an exercise would remain the preserve of the dental teaching hospitals, and it is vital that all dentists take on the responsibility for regular mouth checks for all of their patients. More should be done to encourage those identified as high risk to visit their dentist. There is a need for recognition of the additional resources required for the detection and timely management of such cancers.

Background Although the Irish farming population is a significant occupational group, analysis of their mortality patterns is limited. This study compared mortality trends with other occupational groups and assessed the impact of socio-economic factors. Methods Population and mortality data (2000–06) were obtained to calculate standardized mortality ratios (SMRs) by cause of death and matched with socio-economic data. The extent to which variation in mortality was explained by variations in the socio-economic data was determined using multiple regression. Results Farmers and agricultural workers experienced the highest levels of mortality for all causes of death (2000–06). Farmers are 5.14 times more likely and agricultural workers are 7.35 times more likely to die from any cause of death than the lowest risk group. Circulatory disease is a significant cause of mortality among farmers [SMR = 215.91, 95% confidence interval (CI) = 201.83–229.98]. Other significant causes include cancers (SMR = 156.60, CI = 146.73–166.48) and injuries and poisonings (SMR = 149.69, CI = 135.44–163.93). Agricultural workers have similar mortality trends: circulatory disease (SMR = 226.27; CI = 192.45–260.08), cancers (SMR = 221.44; CI = 193.88–249.00), and injuries and poisonings (SMR = 353.90; CI = 302.48–405.32). From 2000 to 2006, SMRs increased incrementally. Multiple regression identified farm size and income poverty risk as predictors of mortality. Conclusion Irish farmers and agricultural workers have experienced a reversal of mortality trends compared to the 1980s and 1990s. Policies should target them as a high-risk group.

Aims: We sought to examine the fall in age of first drinking in Ireland and to determine whether there were gender differences. We also aimed to determine whether there was a relationship between the per capita alcohol consumption evident when people entered later adolescence and their age of drinking onset. Methods: Information on age of first drinking was based on retrospective recall of 9832 interviewees from the pooled samples obtained from two population surveys. We examined the change in age of first drinking, by birth cohort and by gender, utilizing survival analysis. We utilized Pearson's correlation to explore the relationship between median age of first drinking within each birth cohort and the mean per capita alcohol consumption when that birth cohort was aged 16 years. Results: The average age of first drinking fell steadily and significantly across birth cohorts from the late 1930s to the early 1990s. This change was significantly greater in females. Per capita alcohol consumption was very highly negatively correlated with the median age at which each birth cohort commenced drinking ( r = −0.96, P

To evaluate the effectiveness of a psychological, family-based intervention to improve diabetes-related outcomes in patients with poorly controlled type 2 diabetes.This study was a randomized controlled trial of a psychological family-based intervention targeted at individuals with poorly controlled type 2 diabetes. Recruitment and follow-up occurred at specialist diabetes clinics. Patients were randomly allocated to an intervention group (n=60) or a control group (n=61). Poor control was defined as at least 2 of the patient's last 3 glycated hemoglobin (A1C) readings at8.0%. The intervention consisted of 2 sessions delivered by a health psychologist to the patient and a family member in the patient's home, with a third session involving a 15-minute follow-up telephone call.At 6-month follow-up, the intervention group reported significantly lower mean A1C levels than the control group (8.4% [SD=0.99%] vs 8.8% [SD=1.36%]; P=.04). The intervention was most effective in those with the poorest control at baseline (A1C9.5%) (intervention 8.7% [SD=1.16%, n=15] vs control 9.9% [SD=1.31%, n=15]; P=.01). The intervention group also reported statistically significant improvements in beliefs about diabetes, psychological well-being, diet, exercise, and family support.After participating in a family-based intervention targeting negative and/or inaccurate illness perceptions, patients with poorly controlled type 2 diabetes showed improvements in A1C levels and other outcomes. Our results suggest that adding a psychological, family-based component to usual diabetes care may help improve diabetes management.

Objective: To test the effectiveness of peer support for patients with type 2 diabetes. Design: Cluster randomised controlled. Setting: 20 general practices in the east of the Republic of Ireland. Participants: 395 patients (192 in intervention group, 203 in control group) and 29 peer supporters with type 2 diabetes. Intervention: All practices introduced a standardised diabetes care system. The peer support intervention ran over a two year period and contained four elements: the recruitment and training of peer supporters, nine group meetings led by peer supporters in participant¿s own general practice, and a retention plan for the peer supporters. Main outcome measures: HbA1c; cholesterol concentration; systolic blood pressure; and wellbeing score. Results: There was no difference between intervention and control patients at baseline. All practices and 85% (337) of patients were followed up. At two year follow-up, there were no significant differences in HbA1c (mean difference '0.08%, 95% confidence interval '0.35% to 0.18%), systolic blood pressure ('3.9 mm Hg, '8.9 to 1.1 mm Hg)'total cholesterol concentration ('0.03 mmol/L, '0.28 to 0.22 mmol/L), or wellbeing scores ('0.7, '2.3 to 0.8). While there was a trend towards decreases in the proportion of patients with poorly controlled risk factors at follow-up, particularly for systolic blood pressure (52% (87/166) >130 mm Hg in intervention v 61% (103/169) >130 mm Hg in control), these changes were not significant. The process evaluation indicated that the intervention was generally delivered as intended, though 18% (35) of patients in the intervention group never attended any group meetings. Conclusions: A group based peer support intervention is feasible in general practice settings, but the intervention was not effective when targeted at all patients with type 2 diabetes. While there was a trend towards improvements of clinical outcomes, the results do not support the widespread adoption of peer support. Trial registration: Current Controlled Trials ISRCTN42541690 peer-reviewed

The general medical services (GMS) scheme provides care free at the point of use for the 30% most economically deprived section of the population and the elderly. Almost all people of over-70-year olds are eligible for the GMS scheme potentially directing resources away from those most in need. The aim of this study is to analyse the relationship between practice GMS income and deprivation amongst Dublin-based general practitioners (GPs). The practice GMS income in Dublin was analysed in relation to practice characteristics including the number of GPs, catchment area population, proportion of over-70-year olds in the catchment area, catchment deprivation, number of GMS GPs within 2 km, and average GMS practice income within 2 km. Practice GMS income was highest in deprived areas but is also a valuable source of income in the least deprived areas. The capitation rate for over-70-year olds provides an incentive for GPs to locate in affluent areas and potentially directs resources away from those in greater need.

This paper demonstrates that by understanding how energy is consumed in the manufacturing of reinforced concrete, designers can significantly reduce the overall embodied energy of structures. Embodied energy of products can vary from country to country. Therefore, to accurately estimate the embodied energy of reinforced concrete structures, data specific to the country where they are being constructed must be used. This paper presents the assessment of embodied energy in typical RC building structures in Ireland.The most common methods used to calculate EE are evaluated in this paper and the most suitable method was applied to reinforced concrete. The EE of a typical 30 MPa concrete mix in Ireland is calculated to be 1.08 MJ/kg. Notably cement is credited with 68% of the total EE. The major contributors of energy consumption are identified, which should aid to minimise energy consumption and optimise efficiency.A case study is presented which compares the EE of a typical reinforced concrete structure in Ireland using two concrete mix designs. The first uses Ordinary Portland Cement, while the second uses GGBS replacing half of the cement content. As expected, the EE of the GGBS mix is significantly lower (30%) than that of its counterpart. (C) 2009 Elsevier B.V. All rights reserved. peer-reviewed

OBJECTIVE: to determine whether the age and medical condition of a patient influences hospital-based doctors' decision making when advising patients to stop smoking cigarettes. METHODS: we presented 142 doctors from four grades (consultant, registrar, senior house officer and house officer) and four specialities (medicine, surgery, psychiatry and anaesthetics), based in a Dublin teaching hospital, with 20 clinical vignettes. Each vignette described a patient from one of five age groups with one of four levels of health. The vignettes were randomly mixed. We asked doctors to say whether they would advise the patient in each case to quit smoking. RESULTs: hospital-based doctors are significantly less likely to advise patients aged over 65 years than younger patients of the hazards of cigarette smoking, irrespective of the person's physical or mental health (P < 0.001). CONCLUSION: The advice given to patients about their cigarette smoking habits by hospital doctors is strongly influenced not only by the patient's health, but also by the patient's chronological age. Comment in Smoking cessation in old age: closing the stable door? [Age Ageing. 2000]

The aim of this study was to describe the distribution of GP services in Ireland with respect to deprivation. Seven percent of rural inhabitants live within walking distance of the nearest GP compared to 89% of city dwellers. The longest average travel times occur in the most deprived rural areas. The variation in travel times across deprivation scores was modest, particularly in city, town and village areas. The highest workloads were observed in the most deprived urban areas. The current distribution of GPs in Ireland is relatively equitable although the most deprived practices have high workloads or appear to be overstretched. Incentives may be required to increase service provision in these highly deprived areas.

To estimate the effect of a consultation charge on the health-seeking behaviour of patients.Cross-sectional survey of patients carried out in Northern Ireland, where services are free at the point of delivery, and the Republic of Ireland, where 70% of the population are charged a consultation fee to see the general practitioner (GP).There were 11 870 respondents to the survey (response rate 52%). In the Republic of Ireland, 18.9% of patients (4.4% of non-paying patients and 26.3% of paying patients) had a medical problem in the previous year but had not consulted the doctor because of cost; this compares with only 1.8% of patients in Northern Ireland. Because those in the Republic of Ireland on low income are entitled to free care, the effects of the consultation charge were most marked in the middle of the income distribution, with such patients being over four times as likely to have been deterred as those in the most affluent group. However, amongst paying patients, it was the poorest and those with the worst health who were most affected. Compared to the most affluent patients and those without depression, the likelihood of not having seen the GP due to cost was 6.75 (95% confidence interval [CI] 3.79, 11.09) for the poorest patients and 2.01 (95% CI 1.53, 2.52) for those with depression.Even in countries with exemptions for the poor and more vulnerable, a consultation charge can deter a large proportion of poorer and less healthy patients from seeing their GP.

A study of the dietary intake of 115 male and 217 female mentally handicapped persons aged 15–64 years in five long-stay institutions was carried out using a semi-weighed technique over 4 d. Nineteen per cent of males and 5% of females were classified as being underweight and 15% of males and 27% of females were classified as being obese. The average daily intakes of nutrients were: energy 8.8 MJ, protein 92 g, carbohydrate 218 g, fat 101 g, dietary fibre 18 g, calcium 1024 mg, iron 12.5 mg, vitamin B6 1.4 mg, vitamin B12 10.8 μg, ascorbic acid 68 mg. The distribution of energy between protein, carbohydrate and fat was 18, 39 and 43% respectively. Energy intakes were not related to ambulatory status, degree of mental handicap, the level of drug usage or body mass index. Energy intakes varied significantly between hospitals and between the sexes.

Objectives: Most Organisation for Economic Co-operation and Development (OECD) countries have introduced cost-sharing. This study compares the views of patients who are used to a service that is free at the point of delivery with those who are used to a system where 70% of patients pay for consultations. Methods: Secondary analysis of survey data from a random sample of 11,870 patients in Northern Ireland and the Republic of Ireland. Results: A 52% response rate was achieved, though respondents were representative of the two populations. Attitudes generally reflected the national status quo with little support for co-payments where there was currently no charging, but broad support where charging was established. Charging for missed appointments would be supported where there were delays in getting an appointment. Conclusions: More research is needed to understand what underlies support for, or opposition to, charges. However, it is apparent that patients' opinions need to be considered when formulating health care policy.

Background Research and policy related to reducing health inequalities has progressed separately within Ireland and Northern Ireland. This paper describes the first exploration of the socio-economic influences on health on the island of Ireland since 1922. Methods Postal survey. Results The response rate was 52%; 11,870 respondents. Men reported more long-standing illness (LLTI) or poor general health (PGH); depression was more common amongst women. Socio-economic gradients in health were evident in both jurisdictions, with the effects of household income being particularly marked. Overall, morbidity levels were significantly better in Ireland than in Northern Ireland: adjusted odds ratio Of 0.79 (95% Cl 0.71- 0.88) for LLTI; 0.64 (0.57 - 0.72) for PGH; 0.90 (0.82 - 0.99) for depression. Conclusions There is evidence of strong and similar socio-economic gradients in health throughout the island of Ireland. This would suggest joint policy approaches or at least further comparative evaluation of the initiatives in each jurisdiction.

Ecological studies are increasingly being used to monitor changes in status over time or as a way of evaluating area based policy interventions1 and as a method of examining for widening inequalities in health.2 The principle is to apply the same assessment instruments to the same areas at two points in time and to compare the changes. However, most of these studies ignore the possible contribution of population change.3This paper aims to compare the inter-censal changes in the mortality experience of the two capital cities in the North and South of Ireland with the rest of the country to see if these changes are related to population movement. Each country was divided into three areas; capital city, hinterland and the rest of the country. For the South of Ireland the first two of these were respectively Dublin City Borough (which is nested within Dublin County) and the remainder of Dublin County. The equivalent divisions for Northern Ireland were Belfast City (defined by the Belfast …

Uncontrolled studies suggest that a combination of chemotherapy and radiotherapy improves the survival of patients with esophageal adenocarcinoma. We conducted a prospective, randomized trial comparing surgery alone with combined chemotherapy, radiotherapy, and surgery.Patients assigned to multimodal therapy received two courses of chemotherapy in weeks 1 and 6 (fluorouracil, 15 mg per kilogram of body weight daily for five days, and cisplatin, 75 mg per square meter of body-surface area on day 7) and a course of radiotherapy (40 Gy, administered in 15 fractions over a three-week period, beginning concurrently with the first course of chemotherapy), followed by surgery. The patients assigned to surgery had no preoperative therapy.Of the 58 patients assigned to multimodal therapy and the 55 assigned to surgery, 10 and 1, respectively, were withdrawn for protocol violations. At the time of surgery, 23 of 55 patients (42 percent) treated with preoperative multimodal therapy who could be evaluated had positive nodes or metastases, as compared with 45 of the 55 patients (82 percent) who underwent surgery alone (P0.001). Thirteen of the 52 patients (25 percent) who underwent surgery after multimodal therapy had complete responses as determined pathologically. The median survival of patients assigned to multimodal therapy was 16 months, as compared with 11 months for those assigned to surgery alone (P=0.01). At one, two, and three years, 52, 37, and 32 percent, respectively, of patients assigned to multimodal therapy were alive, as compared with 44, 26, and 6 percent of those assigned to surgery, with the survival advantage favoring multimodal therapy reaching significance at three years (P=0.01).Multimodal treatment is superior to surgery alone for patients with resectable adenocarcinoma of the esophagus.

Editor—The paper by de Abajo et al raises the possibility of an increased risk of upper gastrointestinal bleeding associated with selective serotonin reuptake inhibitors.1 The authors excluded patients with cancer, oesophageal varices, Mallory-Weiss disease, alcoholism, liver disease, and coagulopathies, but it is not clear if they excluded patients who were coprescribed antiulcer treatments. They do mention antecedents of upper gastrointestinal disorders as potential cofounders that were adjusted for. To investigate this issue further we examined a large prescription database provided by the general medical services in the Republic of Ireland. For November 1998 we determined the odds ratios to estimate the relative risk for the coprescription of antiulcer drugs (including H2 antagonists, proton pump inhibitors, and prostaglandin analogues but excluding antacids) with selective serotonin reuptake inhibitors and other antidepressants (table). We excluded people who were coprescribed aspirin, non-steroidal anti-inflammatory agents, or corticosteroids as this may have been cytoprotective coprescribing. This left a total of 95 929 patients for analysis, of whom 8921 received prescriptions for antiulcer drugs. There was a significant correlation between the prescribing of antidepressants of all types and antiulcer drugs. In the past, tricyclic antidepressants were used to treat peptic ulcer disease because of their antimuscarinic effects, but because of poor efficacy they are now not used for this. The newer selective serotonin reuptake inhibitors may have fewer antimuscarinic side effects, although they have gastrointestinal side effects such as vomiting, dyspepsia, and abdominal pain. Paradoxically, antidepressants (in particular, selective serotonin reuptake inhibitors) have been recommended in functional dyspepsia.2 Coprescribing of antiulcer drugs with antidepressants may indicate patients with depression who have dyspeptic symptoms, an increased prevalence of peptic ulcer disease in patients with depression, or an increased prevalence of depression in patients with peptic ulcer disease. Whatever the true association between these conditions, an increased risk of bleeding from peptic ulcer disease would be expected on the basis of these data.

The vitamin B12 and folate content of human platelets have been determined. The B12 concentration was sixfold that in red cells and one-sixth that in leukocytes. In normal whole blood, with a platelet count of 300,000 per cu. mm., the B12 activity contributed by platelets would be 6-21 pg. per ml. The contribution of platelets to the folate activity of normal whole blood averaged 0.4-1.7 ng. per ml. The folate activity in platelets was one-fifth that in an equal volume of red cells, but unlike red cell folate, was not increased by incubating platelet extracts with plasma.

A rapid, reproducible coated charcoal assay for vitamin B12 in erythrocytes is described. Results are almost identical to those of microbiologic assay.