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This chapter explores in detail what happens after a paper is published, in terms of the ways in which papers have an impact, the importance of subsequent citations, and how the importance of a paper to its parent field can be eventually judged. This is illustrated by following the citation trends of several key historical scientific papers (e.g., Watson and Crick on DNA, the first report of the identification of Buckminsterfullerene) and exploring rates of citation, the peak citation times, the manner in which the papers were referred to at different times, and, in general, the way in which ripples of information transfer across the scientific community. Examples of papers to which reaction was negative (e.g., the report on cold fusion) or mixed (NASA’s report of possible fossil micro-organisms in Martian rock) are also discussed.

Today, a major consideration in scientific publishing is obviously ethical issues or those relating to research integrity, and key concepts around falsification, fabrication, and plagiarism are explored in this chapter, in terms of defining key principles for good research practice underpinned by the highest standards of integrity, as is expected of all researchers today. There have been many high-profile cases of controversies involving scientific papers, and key case studies are described. In addition, issues such as failure to acknowledge conflicts of interest for the authors (e.g., the Lancet study by Wakefield et al. on the link between the MMR vaccine and autism) are discussed. Likely future trends including the nature of the refereeing process and the access to experimental data are explored, and a key focus is on the rights and responsibilities of authors and coauthors.

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.

Many studies have reported astonishing statistics about the rate of introduction of new food products globally, with new products appearing probably at least every hour somewhere around the world, if not more frequently. If you could go into a food store anywhere in the world and somehow take a snapshot of the range of products on the shelf, then revisit it five years later and do a comparison of what you find, there would be a huge surprise in terms of the turnover. Many products will have disappeared, and many new ones will have appeared. For those that remain across this time span, there is a very high likelihood that they have changed in less visible ways, in terms of modifications to their formulation, package, or the process by which they are made. Even fresh foods like fruit, vegetables, meat, and fish are likely to have benefited from scientific advances in their production, quality, or transportation in an optimal state of quality and safety. Why is there such a high rate of change? There are two main drivers, one external to those who produce the food and that relates to the highly fluid and some­times unpredictable expectations and demand of consumers, and one more specific to the food producer that relates to new opportunities in technology, formulation, or scientific understanding. For any new product to be successful on the market requires two successful changes in behavior of consumers. The first is that, instead or as well as what they normally purchase, they need to buy to try a new product, and drop it into their basket or cart as a result of a planned or spontaneous decision to do so. To achieve this is primarily the responsibility of experts in marketing, who can divine what consumers want, develop a strategy accordingly, and then deploy the appropriate tools to bring the product to the attention of those who are most likely to buy the product, such as through promotions, advertisements, and probably, in today’s world, social media campaigns.

In the last chapter, yeast was mentioned a few times as one of the generally less-problematic microbial denizens of food systems, and in fact the roles of yeast in the production of two of our most common and popular food categories, alcoholic beverages and bakery products such as bread, are so critical that it is worth dedicating a whole chapter just to the consideration of the science of these products. The ability of yeast to grow in a wide range of raw materials and convert sugars to alcohol, carbon dioxide, and other interesting products is the basis for production of products such as wine and beer, as well as higher-alcohol-level spirits, and is a process that has been exploited for the purposes of human pleasure for thousands of years. The origins of alcoholic fermentations, like those of many food products, are somewhat murky, but it is thought that honey or fruit may have been the original basis for the fermentation of such products, and that wine arose because of accidental adventitious spoilage of grapes and their juice that turned out to have, well, interesting consequences. The Greeks and Romans had wine-making down to an art, and it features frequently in their art; it also makes many appearances in the Bible (including a nonscientifically verifiable production protocol based apparently solely on water). The main reason alcoholic fermentation became of interest was as a way to prevent bacteria or other undesirable microorganisms from growing in juice by allowing a different kind of microorganism to get there first, use up the goodies, and produce products that made conditions highly unsuitable for colonization by later invaders. We routinely associate the word “intoxicated” with a formal description of the result of overconsumption of the outputs of such fermentation, but the heart of that word is “toxic,” which reminds us that alcohol is a poison. It just happens to be one that humans can tolerate only up to certain levels, beyond which poisoning and death can readily occur, but at lower levels has a range of effects that need not be described here.

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.

In this work, we study the numerical performance of various common algorithms used to calculate the average of an array of half precision (FP16) floating point values. While the current generation of CPUs does not support native FP16 arithmetic, it is a planned feature in a number of next-generation CPUs. FP16 arithmetic was emulated via the half software library. Due to the limitations of the FP16 data type, some algorithms proved insufficient for arrays as small as 100 elements. We propose an algorithm that allows numerically stable FP16 computation of the average and compare it to the naive floating point (FP32) algorithm in terms of both numerical precision and runtime performance. We find that our algorithm offers comparable robustness, numerical precision, and SIMD performance to the higher precision computation.

Generalised linear regression models were used to identify factors associated with fatal/serious road traffic collision injuries for single- and multi-vehicle collisions. Single-vehicle collisions and multi-vehicle collisions occurring during the hours of darkness or on a wet road surface had reduced likelihood of a fatal/serious injury. Single-vehicle 'driver with passengers' collisions occurring at junctions or on a hill/gradient were less likely to result in a fatal/serious injury. Multi-vehicle rear-end/angle collisions had reduced likelihood of a fatal/serious injury. Single-vehicle 'driver only' collisions and multi-vehicle collisions occurring on a public/bank holiday or on a hill/gradient were more likely to result in a fatal/serious injury. Single-vehicle collisions involving male drivers had increased likelihood of a fatal/serious injury and single-vehicle 'driver with passengers' collisions involving drivers under the age of 25 years also had increased likelihood of a fatal/serious injury. Findings can enlighten decision-makers to circumstances leading to fatal/serious injuries.

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.

General practice makes a critical contribution to healthcare in Ireland. However, there is a weak understanding of the general practice workforce in Ireland. The aim of this study is to estimate the number of general practitioners (GPs) and practice nurses in Ireland. A variety of data sources was used to corroborate counts of general practitioners and practice nurses. Capture–recapture methods were used to estimate the hidden population of GPs not identified by the databases included. There are 2,954 general practitioners in Ireland, equivalent to 64.4 per 100,000 population. There are 1,700 practice nurses nationally, equivalent to 37.1 per 100,000 persons. There is substantial regional variation in the number of general practitioners and practice nurses per 100,000. To some extent, deficits in one discipline may be counterbalanced by a surplus in the other. In the absence of a centralised register, it is not possible to track the number of GPs or practice nurses working in Ireland at present. This is despite the fact that there are twice as many general practice visits per annum compared to hospital visits.

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.

Little is known about the relationship between infant temperament and breastfeeding. The few studies investigating this report mixed results. Some suggest that difficult infants are breastfed for shorter duration, others report opposing results or no association between the two.This study investigated associations between infant difficult temperament and breastfeeding duration in a nationally representative cohort of Irish 9-month-old infants.Breastfed, normal birth-weight singletons from The Infant Cohort of the Growing Up in Ireland Study (n = 5,955) were considered in this research. The Infant Characteristics Questionnaire (ICQ), completed by the mother, was used to assess four different dimensions of difficult temperament: fussy, unpredictable, unadaptable, and dull. Our main interest was the fussy dimension as this is captured best by the ICQ. Initially, a logistic regression (LR) model having the binary version, short (90 days) or long breastfeeding (≥90 days) as outcome variable, was constructed. Next, a proportional odds logistic regression (POLR) model examining the five-level categorical version (≤1 week, 2 weeks-1 month, 1-3 months, 3-6 months, and ≥6 months) of breastfeeding duration was developed. All regression models were adjusted for relevant sociodemographic data.A total of 3,119 infants were breastfed for less than 90 days, while 2,836 were breastfed for 90 days or longer. The LR and POLR models showed a mild inverse association between infant fussiness/difficultness and breastfeeding duration (LR: OR = 0.98, 95% CI: 0.97-0.99, POLR: OR = 0.98, 95% CI: 0.97-0.99). Higher infant unpredictability is associated with longer breastfeeding duration (LR: OR = 1.04, 95% CI: 1.02-1.07, POLR: OR = 1.04, 95% CI: 1.02-1.06).In this cross-sectional study, we found that breastfeeding duration was inversely associated with infant fussiness and positively associated with infant unpredictability.

Background: The baseline periodontal examination is reported to be a painful dental procedure, but currently there are limited practical techniques to reduce this pain. The objective of this study is to evaluate the efficacy of an intrapocket anesthetic gel in the reduction of pain on periodontal probing in a group of untreated patients with generalized chronic periodontitis (CP). Methods: This study is a randomized, double-masked, split-mouth,placebo-controlledtrial.Thirtyconsecutivepatients meetingtheinclusioncriteriahadfull-mouthperiodontalprobing performed in a split-mouth (right side/left side) manner. Before probing, both quadrants on each side were isolated and had a randomized gel (either placebo or test gel) placed in the periodontal pockets for 30 seconds. Pain was measured using two ungraded 100-mm horizontal visual analog scales (VAS) representing right and left sides of the mouth. Results: The mean – SD VAS for the test gel was 23.5 – 16.8 mm, and the mean – SD VAS for the placebo gel was 23.5 – 14.6 mm. The mean – SD difference in VAS was 51.6 – 28.11 mm in favor of the anesthetic gel, and only age was found to be a marginally significant predictor. Conclusions: The VAS pain scores showed favorable anesthetic efficacy of the test gel compared to a placebo gel in reducing patients’ pain on periodontal probing in a group of patients with generalized CP. It suggests that the gel may be used for patients who find the full-mouth periodontal probing experience particularly painful in view of other tested alternatives. J Periodontol 2012;83:1492-1498.

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.

To analyse small area variation in health status and outcomes, it is important to understand area type and the degree to which an area is urban or rural. The previous urban–rural classification for Ireland was based on a simple dichotomy which ignored the range of settlement and area types. Multiple data sources including population density, settlement size and land-use were used to develop a new urban–rural classification for small areas in Ireland. This classification provides better distinction between the variety of settlement types that exist than the simple dichotomous classification. Comparison using proxies for socio-economic and health status shows how the various classes are distinctive. This classification provides a useful new tool for Irish health research.

Background General practitioners (GPs) do not routinely check children9s weight, partly due to concern regarding parental/child response. The aim of this study is to compare GP concerns regarding weighing with parental/child responses. Objective Compare GP insights on weighing children with the experience of parents whose children had been weighed. Methods Part 1: postal survey of 20% sample of Irish GPs. Part 2: general practice-based study checking weight of 5–12 year olds attending 10 practices, with postconsultation parental survey. Setting Irish General Practice. Participants 393 GPs and 457 parents. Outcome measures GP (n=393) and parental (n=434) responses. Results Of 490 GPs surveyed, 393 responded (response rate 80.2%). Few GPs (3.56%) always checked children9s weight. Concern regarding parental response was often (52.2%) or always (19.0%) a concern that affected the likelihood of discussing a child9s weight. Among children (n=457), 14.9% were overweight and 10.9% obese. Almost all (98.6%) parents indicated checking weight was helpful. 4.4% of parents and just over 1 in 4 obese children responded negatively to weighing. Overweight children were more likely to respond negatively (χ 2 =62.6, df=4, p Conclusions GPs are conflicted regarding the acceptability of weighing the child but almost all parents believed it helpful. A minority of obese children responded negatively.

Ecological relationships between deprivation and forensic psychiatric admission rates may differ in urban and rural areas.The aim of the study was to compare the relationship between material deprivation and forensic admission rates in rural and urban areas for a whole-national service in Ireland over a 3-year period.All Irish forensic admissions from 1997 to 1999 were allocated to the appropriate small area. Material deprivation scores were calculated from census data. Mean annual admission rates and Bayesian standardised forensic admission ratios for small areas were aggregated by material deprivation score and population density.At small area level, there were significant non-linear increases in forensic admissions with increasing deprivation. The increases in urban areas (population density10/hectare) were absent in less densely populated areas.Deprivation alone may not be the key factor in predicting forensic service utilisation. Factors associated with specifically urban deprived areas may be of greater relevance in planning services.

This paper explores the potential use of grid technology in healthcare, from the perspective of a European health authority in a Regional Healthcare Network (RHCN) seeking to model the effects of a proposed hospital closure programme. The paper reviews the strategic implications of using a 'grid-based' application to enable the collation and analyses of public health information (PHI) to support healthcare planning and capital development. The paper also considers relevant issues in relation to the analysis of data extracted from Electronic Health Records (EHR) systems and Patient Management Systems (PMS), across many hospitals and Primary Healthcare Centres (PHCC) in a region, via a grid-based application. The potential for the use of the grid to support PHI in compute and data intensive tasks is discussed, together with a proposed way forward for the development of a grid-based RHCN PHI service.The paper is based on an earlier paper presented by David Piggott at the First European HealthGrid Conference held in Lyons, France on 17th January 2003, together with subsequent research undertaken by Trinity College Dublin into the use of the grid to support healthcare impact assessment and planning applications.

Objective:General psychiatric bed numbers in Ireland have reduced markedly in recent decades. In other jurisdictions such reductions have been accompanied by increases in the prevalence rates of severe mental illness among prisoners. We examined variations in per capita provision of local psychiatric beds and community residential places in Ireland for associations with forensic psychiatric service utilisation.Method:All admissions via the courts and prisons to the national forensic psychiatry service during the years 1997-1999 were assigned to the appropriate health board. Forensic admission and bed utilisation rates were compared with measures of general psychiatric service provision.Results:There were 476 admissions via the criminal justice system during the study period (0.74% of all psychiatric admissions in Ireland). A disproportionate number came from the most urbanised area. There were fivefold differences in overall bed and hostel place allocation between Irish health boards. Combined general psychiatric beds were inversely correlated with forensic bed utilisation (Spearman r = -0.75, p = 0.013). These differences showed a strong inverse correlation with forensic service utilisation.Conclusions:General psychiatric services are relatively under-resourced in areas of greatest predicted need in Ireland. This is associated with increased use of forensic psychiatric services and may reflect accumulation of the mentally ill in Irish prisons.

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

It is well known that adherence to anti-depressant therapy is often poor, but the literature describes little in the way of systematic analyses to determine co-relation between treatment discontinuation and possible contributing factors. We used a community dispensing database to review anti-depressant prescribing patterns and continuity of therapy over a period of 10 months among a population of community-based general practice patients. Some 109,228 anti-depressant prescriptions were dispensed to 24,073 patients, of whom 37.5% collected a single prescription only. Tricyclic anti-depressant prescribing declined significantly during the observation period (from 70% of prescriptions in month 1 to 66% in month 10) while that of selective serotonin reuptake inhibitors (SSRIs) increased (23% in month 1, 28% in month 10) ( p0.0001). Some 27% of those on tricyclics were prescribed50% of the defined daily dose (DDD) compared with 2% of those on SSRIs. Among patients new to therapy who collected1 prescription, adherence was poor and declined over time. The factors that influenced the extent to which patients failed to adhere to therapy included dosage level (% DDD) and age ( p0.0001 for both), but not drug class or sex. The findings suggest that low dosage is a contributory factor in treatment discontinuation, and that contrary to common perception, SSRIs are not necessarily associated with better adherence to therapy than tricyclics. Copyright (c) 2000 John WileySons, Ltd.

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

In 1985 the Committee for Safety of Medicines warned that cotrimoxazole was likely to cause adverse effects, particularly bone marrow suppression and death in patients over 65 years. Fears regarding the safety of cotrimoxazole received media attention in 1994 and by 1995 the indications for use of cotrimoxazole were restricted. We studied the prescribing patterns of cotrimoxazole and trimethoprim within the state-supported General Medical Services (GMS) scheme in Ireland to document the influence of media and regulatory advice on prescribing patterns. The decline in prescribing of cotrimoxazole (by some 70,000 prescriptions within a year) preceded the change in its licensed indications emphasizing the strong influence of media reports on prescribing patterns. At present the prescribing rates of cotrimoxazole appear greater than is warranted and is similar among children (18/1000 patients) and the elderly (15/1000 patients) which is in contrast to the prescribing rates for trimethoprim in children (17/1000 patients) and the elderly (101/1000 patients). The most common length of therapy for both antibiotics was 7 days despite evidence that shorter courses of these antibiotics are suitable for treating uncomplicated urinary tract infections. Cotrimoxazole is still being prescribed to a significant degree across all age groups despite its revised indications. The need for a continuous input by regulatory agencies is clear. Copyright (c) 2000 John Wiley & Sons, Ltd.

OBJECTIVE To quantify and compare the effect of two different hormone replacement therapy regimens on bone mineral density (BMD) and serum alkaline phosphate levels against a group of no treatment control volunteers. METHODS An open 104-week comparative study of 113 early postmenopausal women. Fifty volunteered for the no treatment arm; the remainder were randomized to tibolone (T) (n = 32) or conjugated estrogens plus sequential norgestrel (CEEP) (n = 31). BMD was measured at baseline and after 48 and 96 weeks by dual photon absorptiometry. RESULTS Baseline BMD was lower in nontherapy controls and with women assigned to CEEP compared with the T group. Statistical significance was not reached. By 96 weeks, increased BMD was observed with both therapies at all sites, whereas controls had lost bone compared with baseline. Changes from baseline with both preparations were significantly different (p < 0.05) from changes in controls for all sites, except femoral neck where the change was significant only with CEEP (p < 0.05). Alkaline phosphatase was significantly reduced in both treatment groups compared with controls (p < 0.05) at 48 and 96 weeks. CONCLUSIONS The significant increases in BMD with T and CEEP confirm both regimens are effective in preventing osteoporosis. Without treatment, BMD declines postmenopausally.

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.

A quota-controlled nationally representative sample of 1401 Irish adults completed an interview-assisted questionnaire on beliefs about health priorities and attitudes about eating. Fifty-seven percent believed that eating a healthy diet was a health priority. When shown five statements on attitudes about eating, 39% selected “I don’t worry too much as long as I eat enough healthy things such as fruit and vegetables” and 30% selected “I eat and drink the things I enjoy and don’t worry about it.” A simple logistic regression model on the belief that diet is a health priority showed that although, in general, males were less likely than females to select “eat a healthy diet,” there were significant sex/education interactions, and males with tertiary level education had the highest probability overall in selecting diet as a health priority. An ordinal logistic regression model on attitudes about eating demonstrated that subjects who were young and those with low education levels were significantly the most likely to be least concerned about nutrition, with no significant interactions between the sociodemographic variables. Social class was not found to be significant in any of the models when other sociodemographic variables were controlled for. The results suggest that a primary target group for nutrition education are young males with minimal education.

Small cell carcinoma of the oesophagus is an uncommon malignancy. Only 272 cases have been reported to date. Inconsistency in therapeutic approaches reflects the paucity of individual experience and the unsatisfactory response to current management strategies. We report 11 cases drawn from a series of 1012 cases of oesophageal malignancy and perform a statistical analysis on treatment and survival data of 189 cases drawn from the world literature. Small cell carcinoma of the oesophagus was seen to have an incidence of 1%. Seven of 11 patients were female. A variety of therapeutic modalities were employed, and the median survival was 6.6 months. Statistical analysis of these and worldwide data showed a significant survival advantage for patients who received multimodality therapy.

A survey of dental schools in the European Union was carried out for two main reasons. Firstly to promote the exchange of information in respect of curriculum objectives in the different countries and secondly to ascertain the differences in the interpretation of the 1978 EU sectoral directives for dental education and training. Out of 127 schools, only 30 responded, yet the information provided is of considerable importance. It demonstrates wide divergence in the interpretation of the 1978 Directives and methods of assessment of clinical competence. There is a considerable difference throughout Europe in hours devoted to the various subjects included in the Dental Directives. There is little evidence of convergence in methods of assessment or quality assurance. The survey demonstrates the difference in resources, levels of staff, availability of clinical training places, output in research and patient treatments throughout the European Union. The results question the effectiveness of the 1978 Dental Directives in promoting convergence of standards. As there is free movement of dentists throughout the European Union, it is concluded that a different approach may be necessary to ensure that all European Union dental graduates achieve comparable standards in their education and training.

Objectives The objective of this study was to investigate the impact of moderate and severe hypodontia and amelogenesis imperfecta on the quality of life and self-esteem of affected adult patients. Methods Forty one adult patients (aged 18–45 years) with clinical and radiological diagnoses of moderate to severe hypodontia and twenty seven patients diagnosed with amelogenesis imperfecta were age and gender matched with a control group of patients attending for routine dental care. Subjects completed the Oral Health Impact Profile [OHIP-49] and Rosenberg Self Esteem Scale. A paired t-test was used to analyse data; the test alpha level was set at P ≤ 0.05. Results The results for hypodontia patients were significantly different from controls in six out of the seven OHIP-49 domains, the exception being the Handicap domain. Total scores were also significantly different between the two groups (P = 0.003). Self-esteem was not significantly different between the two groups (P = 0.98). For amelogenesis imperfecta patients the results were significantly different from control patients in four out of the seven domains of the OHIP-49 and also in the total scores (P = 0.01). When self-esteem was investigated there was no significant differences between the two groups (P = 0.92). Conclusions Moderate to severe hypodontia and amelogenesis imperfecta have marked negative impacts on the Oral Health Related quality of life of this patient population relative to controls. However, self-esteem was not significantly affected.

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

There is no established safe level of alcohol consumption in pregnancy. Studies from Ireland have consistently shown lower abstention and higher binge drinking rates in pregnancy than other countries, indicating a high potential for foetal alcohol-related disorders. There has been little research on alcohol in pregnancy in primary care.To determine the prevalence of alcohol consumption amongst pregnant women attending their GP for antenatal care, and to compare this to use in the year prior to conception.Prospective cross-sectional study was carried out in fifteen teaching practices in the greater Dublin area. Women were recruited at their antenatal visits. Data were gathered by self-completed questionnaire in the practice, or researcher-administered telephone questionnaire. The questionnaire was based on the AUDIT, a WHO-validated data collection instrument designed for use in primary care.Two hundred and forty valid questionnaires were returned (80 % recruitment rate). Alcohol intake and binge drinking levels were much lower during pregnancy compared to the year prior to pregnancy (p0.001). There was a marked reduction in the prevalence of alcohol use in pregnancy compared to previous research. Over 97 % drink no more than once a week, including almost two-thirds of women who abstain totally from alcohol in pregnancy. Non-pregnant Irish women drink alcohol more frequently, and with higher rates of binge drinking, than women of other nationalities.Primary care is a suitable setting to research alcohol use in pregnancy. Alcohol use in pregnancy in Ireland has decreased markedly compared to previous research from this jurisdiction.

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

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.

OBJECTIVES: To investigate the significance of the undergraduate dental curriculum on the medium- to long-term attitudes of the clinician to life-long learning, and to identify demographical and professional characteristics which may influence this attitude. METHODS: A specially designed questionnaire targeted 12 cohorts of dentists who qualified from Dublin Dental School and Hospital between 1994 and 2005. The curricula of the cohorts varied from fully didactic, exclusively Problem Based Learning or a hybrid for the oldest, youngest and middle graduates, respectively. Participants were questioned about current professional activities, postgraduate training, practice type, hospital affiliation, use of information services and time dedicated to continuing dental education (CDE), etc. A number of dental scenarios were proposed to determine if participants were adherent to current clinical guidelines. Additionally, a visual analogue scale assessed the overall satisfaction of dentists with their undergraduate programme and determined their opinion regarding its influence on subsequent ability to practice dentistry and keep up-to-date with scientific developments. RESULTS: Contingency analysis of the association between curriculum and continuous educational data did not produce statistical significance. Dentists who work in a hospital environment spend more time on CDE (chi(2), Pearson's, P = 0.001), are more adherent to current guidelines (chi(2), Pearson's, P = 0.005) and found their undergraduate studies more enjoyable (Wilkoxon/Kruskal-Wallis, P = 0.01). CONCLUSIONS: Undergraduate curriculum type was found to have very little or no effect on the graduate's attitude towards life-long learning or confidence in their ability to practice dentistry. However, these attitudes did appear to be influenced by certain family, demographical and professional characteristics.

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.

The decline in incidence of tuberculosis in Ireland has led Peamount Hospital to reconfigure its services towards the needs of general practice.To ascertain views of local GPs on their current use of Peamount, and how the hospital might best serve their future needs.Self-administered postal questionnaires sent to 151 GPs practicing in Peamount's catchment area, to determine their current use of services, and likely future use of proposed services. Total valid response rate 64% (n = 84).Responses indicated a lack of awareness of many services currently available, with a concomitant under-use of these services. The majority of GPs would use planned future services, particularly expanded radiology services.This survey promoted awareness among GPs of services available at Peamount. It informed the planning of future services and promoted a culture of involving local GPs in the planning of services of which they will be the users.

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.