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Background: Atrial fibrillation (AF), the most common cardiac arrhythmia, is a major risk factor for stroke. AF is often asymptomatic, making it difficult to diagnose. Globally, stroke is a leading cause of morbidity and mortality. Opportunistic AF screening has been recommended in clinical practice within the Republic of Ireland (RoI) and internationally, though the optimal mode and location remains under investigation. Currently, there is no formal AF screening programme. Primary care has been proposed as a suitable setting. Aim: To identify the facilitators and barriers to AF screening in primary care from the perspective of GPs. Design & setting: A qualitative descriptive study design was adopted. Fifty-four GPs were invited from 25 practices in the RoI to participate in individual interviews at their practices. Participants were from both rural and urban locations. Method: A topic guide was developed to guide the interview content towards identification of facilitators and barriers to AF screening. The interviews were conducted in person, audio-recorded, transcribed verbatim, and analysed using framework analysis. Results: Eight GPs from five practices participated in an interview. Three GPs, two male and one female, were recruited from two rural practices and five GPs, two male and three female, were recruited from three urban practices. All eight GPs expressed a willingness to engage in AF screening. Time pressures and the need for additional staff to support were identified as barriers. Programme structure and patient awareness campaigns and education were identified as facilitators. Conclusion: The findings will help to anticipate barriers to AF screening and aid the development of clinical pathways for people with or at risk of AF. The results have been integrated into a pilot primary care-based screening programme for AF.

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

Objectives To examine the characteristics of paediatric attendances to the emergency department (ED) in Cork University Hospital (CUH) before and after the expansion of free general practitioner (GP) care to children under the age of 6 years.Design This is a retrospective observational study that used a large administrative dataset.Setting The study was conducted in major Irish tertiary referral centre that serves a total population of over 1.1 million. It is a public hospital, owned and managed by the health service executive.Participants Children aged 0–15 years who attended CUH ED during the study period of 6 years (2012–2018) were included in this study (n=76 831).Interventions Free GP care was expanded to all children aged 0–5 years in July 2015.Main outcome measures Paediatric attendances to CUH ED were examined before (Time Period 1: July 2012–June 2015) and after (Time Period 2: July 2015–June 2018) the expansion of free GP care to children under 6. Changes in GP referral rates and inpatient hospital admissions were investigated.Results Paediatric presentations to CUH ED increased from 35 819 during the Time Period 1 to 41 012 during the Time Period 2 (14.5%). The proportion of the CUH ED attendances through GP referrals by children under 6 increased by over 8% in the Time Period 2 (from 10 148 to 14 028). Although the number of all children who attended CUH ED and were admitted to hospital increased in Time Period 2 (from 8704 to 9320); the proportion of children in the 0–5 years group who attended the CUH ED through GP referral and were subsequently admitted to hospital, decreased by over 3%.Conclusion The expansion of free GP care has upstream health service utilisation implications, such as increased attendances at ED, and should be considered and costed by policy-makers.

Abstract Background In the context of rising dementia prevalence, the workload of general practitioners (GPs) in dementia care is set to increase. However, there are many aspects of dementia care that GPs find challenging. Behavioural and psychological symptoms of dementia (BPSD) affect the majority of people with dementia and is an aspect of dementia care that GPs find particularly difficult to manage. The aim of this mixed methods systematic review is to undertake a synthesis of qualitative and quantitative studies on GPs’ knowledge, attitudes and experiences of managing BPSD. Methods Seven electronic bibliographic databases will be searched from inception to present. All qualitative or quantitative studies that explore the knowledge, attitude or experiences of GPs towards the management of BPSD in community and/or residential settings will be eligible for inclusion. A meta-ethnography will be conducted to synthesise included studies. Primary outcome measures will include GPs’ experiences of managing BPSD, GPs’ knowledge of BPSD and their attitude to different approaches to the management of BPSD, in particular their attitude to non-pharmacological approaches. All included papers will be independently assessed for methodological validity by two reviewers using the following tools: the Joanna Briggs Institute checklist for qualitative research, the Effective Public Health Practice Project (EPHPP) tool for intervention studies and the National Institute of Health (NIH) quality assessment tool for observational and analytical cross-sectional studies. As there is no agreed quality assessment tool for descriptive cross-sectional studies, an original tool will be developed. Two independent reviewers will apply the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) tool to the review findings. The results will be reported in line with the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement. Discussion This study will be the first systematic review that synthesises the existing literature of GPs’ knowledge, attitudes and experiences of managing BPSD in community and residential care. This review will improve our understanding of GPs’ perspectives on the management of BPSD, and the results will be used to inform the development of an intervention to improve the management of BPSD in general practice. Systematic review registration PROSPERO CRD42017054916.

Cider quality and consumer acceptance are greatly influenced by its aroma. With the continued expansion of the craft cider industry, cider producers are employing techniques such as dry hopping to develop unique flavor profiles. Few studies, however, have explored the VOCs of dry-hopped cider. Herein, we monitor the development of VOCs from pressed apple juice, through fermentation and dry hopping by HS–SPME–GC–MS, to elucidate when and how aroma compounds arise in cider production. In all, 89 VOCs were detected, spanning eight classes of organic compounds. Racking events decreased ester concentrations by 10 ± 1%, but resting on the lees allowed these pleasant, fruity aromas to be reestablished. Dry hopping was conducted with three types of hops (Citra, Galaxy, and Mosaic). The varied development of terpenes and esters between hop varieties supports the use of this technique to diversify the aroma profiles of ciders. Herein, we report that both the variety of hops and the timing of key processing steps including racking and hop addition significantly alter the identity and concentration of aroma-important VOCs in dry-hopped cider.

Medicines reconciliation is a way to identify and act on discrepancies in patients’ medical histories and it is found to play a key role in patient safety. This review focuses on discrepancies and medical errors that occurred at point of discharge from hospital. Studies were identified through the following electronic databases: PubMed, Sciences Direct, EMBASE, Google Scholar, Cochrane Reviews and CINAHL. Each of the six databases was screened from inception to end of January 2014. To determine eligibility of the studies; the title, abstract and full manuscript were screened to find 15 articles that meet the inclusion criteria. The median number of discrepancies across the articles was found to be 60%. In average patient had between 1.2–5.3 discrepancies when leaving the hospital. More studies also found a relation between the numbers of drugs a patient was on and the number of discrepancies. The variation in the number of discrepancies found in the 15 studies could be due to the fact that some studies excluded patient taking more than 5 drugs at admission. Medication reconciliation would be a way to avoid the high number of discrepancies that was found in this literature review and thereby increase patient safety.

OBJECTIVES:To review the empirical evidence on approaches used by Primary Care Physicians (PCPs) in fitness to drive (FtD) consultations with people living with cognitive impairment. DESIGN:Scoping review of empirical literature focused on primary studies of any design. SETTING:Primary care practice. PARTICIPANTS:PCPs or their equivalent and/ or individuals with cognitive impairment across the spectrum of mild cognitive impairment to dementia. MEASUREMENTS:Systematic search of Medline, Cinahl, PsychINFO, Academic Search Complete, Psychological and Behavioural Sciences Collection, SocIndex and Social Sciences FT were conducted. Records screened by two reviewers against agreed inclusion criteria. Mixed studies (qualitative and quantitative) were synthesized within overarching themes. RESULTS:Eighteen studies met our inclusion criteria. Synthesized data showed PCPs have mixed feelings on the appropriateness of their role in FtD assessments, with many feeling particularly uncomfortable and lacking confidence in the context of possible cognitive impairment. Reasons include lack of familiarity with legal requirements and local resources; fear of damaging the doctor-patient relationship; and impact on the patient's quality of life. Patients voiced their desire to maintain agency in planning their driving cessation. Studies evaluating pragmatic educational programmes suggest these can improve physician confidence in FtD consultations. CONCLUSION:The increasing number of older people affected by cognitive impairment, for whom driving may be a concern, has implications for primary care practice. Addressing the reasons for PCPs lack of comfort in dealing with this issue is essential in order for them to better engage in, collaborative discussion with patients on plans and preferences for driving cessation.

Undergraduate medical education has been criticised for failing to adequately prepare doctors for the task of prescribing. Pharmacists have been shown to improve medication use in hospitals. This study aims to elicit the views of intern doctors on the challenges of prescribing, and to suggest changes in education to enhance prescribing practice and potential role of the pharmacist. Semi-structured, qualitative interviews were conducted with intern doctors in their first year post qualification in an Irish hospital. Data collection was conducted until no new themes emerged and thematic analysis was performed. Thirteen interviews took place. Interns described training in practical prescribing as limited and felt the curriculum failed to convey the reality of actual prescribing. Pharmacists were perceived to be a useful, but underutilised, information source in the prescribing process. They requested an earlier introduction, and repeated exposure, to prescribing, and suggested the involvement of peers and pharmacists in this teaching. Intern doctors reported difficulties in applying knowledge gained in medical school to clinical practice. New strategies are needed to enhance the clinical relevance of the medical curriculum by rethinking the learning outcomes regarding prescribing practice and the involvement of pharmacists in prescribing education.

As the majority of prescribing in hospital is undertaken by intern doctors, the aims of this systematic review were to compile the evidence of the qualitative literature on the views and experiences of intern doctors and to examine the role of the pharmacist in assisting in prescribing by interns. A systematic review of the qualitative literature was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. The findings were synthesized using thematic analysis. Seven publications were included. Factors influencing prescribing behaviour were related to the environment; collaboration in medical teams; hierarchical structures; and patient and individual factors. This review confirmed that interns’ prescribing behaviour is influenced by multiple factors, and further highlighted the need for an educational intervention that supports the intern completing the prescribing task in a complex environment, and not just addresses the presumed knowledge gap(s).

AimsTo describe trends in the incidence of non-traumatic amputations among people with and without diabetes and estimate the relative risk of an individual with diabetes undergoing a lower extremity amputation compared to an individual without diabetes in the Republic of Ireland.MethodsAll adults who underwent a nontraumatic amputation during 2005 to 2009 were identified using HIPE (Hospital In-patient Enquiry) data. Participants were classified as having diabetes or not having diabetes. Incidence rates were calculated using the number of discharges for diabetes and non-diabetes related lower extremity amputations as the numerator and estimates of the resident population with and without diabetes as the denominator. Age-adjusted incidence rates were used for trend analysis.ResultsTotal diabetes-related amputation rates increased non-significantly during the study period; 144.2 in 2005 to 175.7 in 2009 per 100,000 people with diabetes (p = 0.11). Total non-diabetes related amputation rates dropped non-significantly from 12.0 in 2005 to 9.2 in 2009 per 100,000 people without diabetes (p = 0.16). An individual with diabetes was 22.3 (95% CI 19.1-26.1) times more likely to undergo a nontraumatic amputation than an individual without diabetes in 2005 and this did not change significantly by 2009.DiscussionThis study provides the first national estimate of lower extremity amputation rates in the Republic of Ireland. Diabetes-related amputation rates have remained steady despite an increase in people with diabetes. These estimates provide a base-line and will allow follow-up over time.