Midland Regional Hospital Mullingar

BACKGROUND: Evidence suggests that schizophrenia may be a disorder with origins in early intrauterine mal-development. We have constructed a comprehensive anthropometric scale for the evaluation of dysmorphic features as an index of the nature and timing of developmental disturbance. METHOD: A detailed set of craniofacial and bodily measures was compiled and applied to 174 patients with schizophrenia and 80 matched control subjects. RESULTS: Patients had significantly higher scores on this scale and displayed multiple anomalies of the craniofacial region with an overall narrowing and elongation of the mid-face and lower face. Twelve craniofacial anomalies independently distinguished patients from controls and these variables correctly classified 95% of patients and 80% of control subjects. CONCLUSIONS: This new scale, while procedurally more exacting than the Waldrop scale, more clearly defines the topography of anomalies previously suspected in individuals with schizophrenia. These findings constitute direct evidence for disturbed craniofacial development in schizophrenia and indicate origins in the foetal period during which the characteristic human facial pattern evolves in close association with brain differentiation.

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.

OBJECTIVE: To evaluate the relative effectiveness of hysterectomy, endometrial destruction (both "first generation" hysteroscopic and "second generation" non-hysteroscopic techniques), and the levonorgestrel releasing intrauterine system (Mirena) in the treatment of heavy menstrual bleeding. DESIGN: Meta-analysis of data from individual patients, with direct and indirect comparisons made on the primary outcome measure of patients' dissatisfaction. DATA SOURCES: Data were sought from the 30 randomised controlled trials identified after a comprehensive search of the Cochrane Library, Medline, Embase, and CINAHL databases, reference lists, and contact with experts. Raw data were available from 2814 women randomised into 17 trials (seven trials including 1359 women for first v second generation endometrial destruction; six trials including 1042 women for hysterectomy v first generation endometrial destruction; one trial including 236 women for hysterectomy v Mirena; three trials including 177 women for second generation endometrial destruction v Mirena). Eligibility criteria for selecting studies Randomised controlled trials comparing hysterectomy, first and second generation endometrial destruction, and Mirena for women with heavy menstrual bleeding unresponsive to other medical treatment. RESULTS: At around 12 months, more women were dissatisfied with outcome with first generation hysteroscopic techniques than with hysterectomy (13% v 5%; odds ratio 2.46, 95% confidence interval 1.54 to 3.9, P<0.001), but hospital stay (weighted mean difference 3.0 days, 2.9 to 3.1 days, P<0.001) and time to resumption of normal activities (5.2 days, 4.7 to 5.7 days, P<0.001) were longer for hysterectomy. Unsatisfactory outcomes were comparable with first and second generation techniques (odds ratio 1.2, 0.9 to 1.6, P=0.2), although second generation techniques were quicker (weighted mean difference 14.5 minutes, 13.7 to 15.3 minutes, P<0.001) and women recovered sooner (0.48 days, 0.20 to 0.75 days, P<0.001), with fewer procedural complications. Indirect comparison suggested more unsatisfactory outcomes with second generation techniques than with hysterectomy (11% v 5%; odds ratio 2.3, 1.3 to 4.2, P=0.006). Similar estimates were seen when Mirena was indirectly compared with hysterectomy (17% v 5%; odds ratio 2.2, 0.9 to 5.3, P=0.07), although this comparison lacked power because of the limited amount of data available for analysis. CONCLUSIONS: More women are dissatisfied after endometrial destruction than after hysterectomy. Dissatisfaction rates are low after all treatments, and hysterectomy is associated with increased length of stay in hospital and a longer recovery period. Definitive evidence on effectiveness of Mirena compared with more invasive procedures is lacking.

The pathogenesis and complications of type 2 diabetes (T2DM) are closely linked with defective glucose metabolism, obesity, cardiovascular disease and an inability to mount an effective immune response to certain pathogenic organisms. Perturbations in key innate immune receptors known as Toll-like receptors (TLRs) and inflammatory mediators such as IL-6, TNFα and IL-1β have been linked with T2DM. Herein, we sought to establish whether patients with T2DM and underlying complications exhibit perturbations in cytokine and TLR expression. Serum cytokine and mRNA levels of cytokines/TLRs in monocytes (M) and neutrophils (N) were measured in a cohort of 112 diabetic patients: good glycaemic control without complications (GC), good glycaemic control with complications (GCC), poor glycaemic control without complications (PC) and poor glycaemic control with complications (PCC) and compared them with 34 non-diabetic volunteers (NGT). Serum cytokine levels were normal in all study participants. In the GC group, cytokine and TLR gene expression were enhanced compared to NGT. In contrast, suppressed cytokine and TLR gene expression were evident in PC, GCC & PCC groups when compared to the GC. In conclusion, whereas serum pro-inflammatory cytokine levels are unaltered in T2DM patients, differences in inflammatory gene profiles exist among the T2DM patient groups.

OBJECTIVE: To examine whether low birth weight (LBW) children are at greater risk for behavioural and emotional problems than normal birth weight children. METHODS: Electronic databases (PubMed, Google) were searched. Key search terms (LBW, emotional behavioural outcome) were used to identify possible studies. Selection of studies was limited to those including detailed assessment of behavioural and/or emotional outcome of very low birth weight or very preterm infants with normal term infants as controls, published from the year 2000 to date. A total of 20 studies were identified for inclusion in our review. RESULTS: Overall studies showed a significant increase in behavioural problems in particular poor attention span, withdrawn behaviour and poorer adaptive functioning. Rates of a clinically significant neurobehavioural impairment in cases ranged from 25% to 55% with controls displaying a relatively constant rate of around 7%. Attention problems without hyperactivity (ADD) were more common than 'classical attention deficit/hyperactivity disorder' in LBW children. Only 4% of the LBW children had previously been referred to a consultant psychiatric suggesting that at present these problems are being under-recognised. CONCLUSION: VLBW or very preterm infants are at significant risk of behavioural and emotional problems. The risk is further increased when cognitive or motor difficulties are present or when social circumstances are poor.

We describe a study of 312 subjects in 71 families near related to a proband with type II hyperprolinaemia. The subjects were Irish travellers (nomads) among whom consanguineous marriage and high fertility are common. Thirteen additional cases of type II hyperprolinaemia were discovered; all were offspring of consanguineous unions. A further 50 subjects were found to have mild hyperprolinaemia. We found a strong association between type II hyperprolinaemia and seizures during childhood but no significant association with mental handicap. Most adults with type II hyperprolinaemia enjoyed normal health and there was no evidence that maternal hyperprolinaemia compromised fetal development. The documented association between type II hyperprolinaemia and seizures may be related to the neuromodulatory or reducing-oxidising effects of proline and pyrroline-5-carboxylate, respectively, that has been shown in vitro. Alternatively, another genetic defect closely linked to the type II hyperprolinaemia allele could be the explanation.

Chondroitin sulfate (CS), as a popular material for cartilage tissue engineering scaffolds, has been extensively studied and reported for its safety and excellent biocompatibility. However, the rapid degradation of pure CS scaffolds has brought a challenge to regenerate neo-tissue similar to natural articular cartilage effectively. Meanwhile, the poly(ethene glycol) (PEG) -based biopolymer is frequently applied as a structural constituent material because of its remarkable mechanical properties, long-lasting in vivo stability, and hypo-immunity. Here, we report that the combination of CS and hyperbranched multifunctional PEG copolymer (HB-PEG) could synergistically promote cartilage repair. The thiol functionalised CS (CS-SH)/HB-PEG hydrogel scaffolds were fabricated via thiol-ene reaction, which exhibits rapid gelation, excellent mechanical properties and prolonged degradation properties. We found that rat adipose-derived mesenchymal stem cells presented great cell viability and improved chondrogenesis in CS-SH/HB-PEG hydrogels. Moreover, the injectable hydrogel scaffolds reduced stem cell inflammatory response, consistent with the well-documented anti-inflammatory activities of CS.

BACKGROUND: Compulsory admission procedures of patients with mental disorders vary between countries in Europe. The Ethics Committee of the European Psychiatric Association (EPA) launched a survey on involuntary admission procedures of patients with mental disorders in 40 countries to gather information from all National Psychiatric Associations that are members of the EPA to develop recommendations for improving involuntary admission processes and promote voluntary care. METHODS: The survey focused on legislation of involuntary admissions and key actors involved in the admission procedure as well as most common reasons for involuntary admissions. RESULTS: We analyzed the survey categorical data in themes, which highlight that both medical and legal actors are involved in involuntary admission procedures. CONCLUSIONS: We conclude that legal reasons for compulsory admission should be reworded in order to remove stigmatization of the patient, that raising awareness about involuntary admission procedures and patient rights with both patients and family advocacy groups is paramount, that communication about procedures should be widely available in lay-language for the general population, and that training sessions and guidance should be available for legal and medical practitioners. Finally, people working in the field need to be constantly aware about the ethical challenges surrounding compulsory admissions.

SUMMARY: High bone mineral density on routine dual energy X-ray absorptiometry (DXA) may indicate an underlying skeletal dysplasia. Two hundred fifty-eight individuals with unexplained high bone mass (HBM), 236 relatives (41% with HBM) and 58 spouses were studied. Cases could not float, had mandible enlargement, extra bone, broad frames, larger shoe sizes and increased body mass index (BMI). HBM cases may harbour an underlying genetic disorder. INTRODUCTION: High bone mineral density is a sporadic incidental finding on routine DXA scanning of apparently asymptomatic individuals. Such individuals may have an underlying skeletal dysplasia, as seen in LRP5 mutations. We aimed to characterize unexplained HBM and determine the potential for an underlying skeletal dysplasia. METHODS: Two hundred fifty-eight individuals with unexplained HBM (defined as L1 Z-score ≥ +3.2 plus total hip Z-score ≥ +1.2, or total hip Z-score ≥ +3.2) were recruited from 15 UK centres, by screening 335,115 DXA scans. Unexplained HBM affected 0.181% of DXA scans. Next 236 relatives were recruited of whom 94 (41%) had HBM (defined as L1 Z-score + total hip Z-score ≥ +3.2). Fifty-eight spouses were also recruited together with the unaffected relatives as controls. Phenotypes of cases and controls, obtained from clinical assessment, were compared using random-effects linear and logistic regression models, clustered by family, adjusted for confounders, including age and sex. RESULTS: Individuals with unexplained HBM had an excess of sinking when swimming (7.11 [3.65, 13.84], p < 0.001; adjusted odds ratio with 95% confidence interval shown), mandible enlargement (4.16 [2.34, 7.39], p < 0.001), extra bone at tendon/ligament insertions (2.07 [1.13, 3.78], p = 0.018) and broad frame (3.55 [2.12, 5.95], p < 0.001). HBM cases also had a larger shoe size (mean difference 0.4 [0.1, 0.7] UK sizes, p = 0.009) and increased BMI (mean difference 2.2 [1.3, 3.1] kg/m(2), p < 0.001). CONCLUSION: Individuals with unexplained HBM have an excess of clinical characteristics associated with skeletal dysplasia and their relatives are commonly affected, suggesting many may harbour an underlying genetic disorder affecting bone mass.

The data presented are those from a two-year prospective study of 69 patients identified in the Nottingham field centre of the WHO Study of Determinants of Outcome of Severe Mental Disorders. Premorbid personality, childhood adjustment and adolescent adjustment were assessed at the patients' first presentation to psychiatric services with a psychotic illness. Ratings were made blind to diagnosis. Premorbid explosive and paranoid traits were commoner in patients with schizophrenia than in patients with other non-organic psychoses, and these traits were associated with later onset of schizophrenia. Premorbid schizoid traits were significantly commoner in patients with schizophrenia compared to patients with other psychoses, but only in those patients for whom a parent was the informant. Schizoid traits were no commoner in men with schizophrenia than in women, and were not associated with earlier age of onset. The findings suggest that premorbid personality, in men and women, may shape the expression of symptoms produced during an illness episode.

BACKGROUND: As a result of the essential role of oestrogens in epiphyseal closure, aromatase inhibitors have been trialled as an intervention to improve height outcomes in male children and adolescents by inhibiting the conversion of testosterone to oestradiol. OBJECTIVES: To assess the effects of aromatase inhibitors in male children and adolescents with short stature. SEARCH METHODS: To identify relevant trials, we searched the Cochrane Library (2014, Issue 7), MEDLINE, EMBASE, and the World Health Organization (WHO) ICTRP trial register from their inception until August 2014. In addition, we conducted citation searches and screened reference lists of included trials. SELECTION CRITERIA: We included randomised controlled trials (RCTs) if they compared use of an aromatase inhibitor with placebo in male children and adolescents with short stature. DATA COLLECTION AND ANALYSIS: Two authors independently screened titles and abstracts for relevance. Both authors carried out screening for inclusion, data extraction, and risk of bias assessment, with any disagreements resolved following discussion. We assessed trials for quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) instrument. We contacted study authors regarding missing information. Primary outcomes were final or near-final height, adverse events, and health-related quality of life. Secondary outcomes included all-cause mortality, cognitive outcomes, socioeconomic effects, laboratory measures, short-term growth parameters, and assessment of effects on bone health. Meta-analysis was not appropriate due to the substantial clinical heterogeneity between trials; we presented the findings of the review in narrative format. MAIN RESULTS: We included four RCTs involving 207 participants (84 on interventions) in the review. Trials included males with constitutional delay of growth and puberty (CDGP), idiopathic short stature (ISS), and growth hormone (GH) deficiency. Three of the trials had an overall low or unclear risk of bias for primary outcomes. Short-term growth outcomes, such as predicted adult height, improved in all trials. Just one trial reported the primary outcome of final and near-final height as an extension under non-randomised conditions. None of the trials assessed health-related quality of life. One publication provided detailed information regarding the incidence of adverse events. A significant proportion (45%) of prepubertal boys with ISS treated with letrozole developed mild morphological abnormalities of their vertebrae, compared with none in the placebo group. AUTHORS' CONCLUSIONS: Available evidence suggested that aromatase inhibitors improved short-term growth outcomes. There was no evidence to support an increase in final adult height, based on limited data, with only one of four trials publishing final height data under non-randomised conditions.

Background: stroke is a leading cause of death and disability globally. The economic costs of stroke are high but not often fully quantified. This paper estimates the economic burden of stroke and transient ischaemic attack (TIA) in Ireland in 2007. Methods: a prevalence-based approach using a societal perspective is adopted. Both direct and indirect costs are estimated. Results: total stroke costs are estimated to have been 489-805 million in 2007, comprising 345-557 million in direct costs and 143-248 million in indirect costs. Nursing home care and indirect costs together account for the largest proportion of total stroke costs (74-82%). The total cost of TIA was approximately 11.1 million in 2007, with acute hospital care accounting for 90% of the total.

Neurodegenerative diseases are an increasing cause of global morbidity and mortality. They occur in the central nervous system (CNS) and lead to functional and mental impairment due to loss of neurons. Recent evidence highlights the link between neurodegenerative and inflammatory diseases of the CNS. These are typically associated with several neurological disorders. These diseases have fundamental differences regarding their underlying physiology and clinical manifestations, although there are aspects that overlap. The endocannabinoid system (ECS) is comprised of receptors (type-1 (CB1R) and type-2 (CB2R) cannabinoid-receptors, as well as transient receptor potential vanilloid 1 (TRPV1)), endogenous ligands and enzymes that synthesize and degrade endocannabinoids (ECBs). Recent studies revealed the involvement of the ECS in different pathological aspects of these neurodegenerative disorders. The present review will explore the roles of cannabinoid receptors (CBRs) and pharmacological agents that modulate CBRs or ECS activity with reference to Alzheimer's Disease (AD), Parkinson's Disease (PD), Huntington's Disease (HD) and multiple sclerosis (MS).

The sources of passive intermodulation (PIM) on matched uniform microstrip lines have been investigated. The results of PIM measurements and SEM analysis of the conductor traces fabricated on the PCB laminates coated by copper foils of different grades suggest that PIM sources on the printed transmission lines are of non-local nature being distributed along the signal path. Quality of the copper foil and roughness of its surface proved to critically affect PIM performance of the microstrip lines on the low loss PTFE based dielectric substrates.

To test the hypothesis that the infecting meningococcal serogroup modulates the presentation, course, and outcome of invasive meningococcal disease (IMD), we performed a retrospective review of cases of IMD in 407 children from 2 tertiary referral centers and 2 regional centers in Ireland. Patients infected with serogroup C meningococci ( ) were older than those infected with serogroup B ( ; median, 2.5 vs. 1.5 n p 104 n p 303 years;

BACKGROUND: In several countries, respiratory syncytial virus prophylaxis is offered to late preterm infants who are at escalated risk of respiratory syncytial virus hospitalization (RSVH). However, targeted prophylaxis should be informed by country-specific data. This study, which uniquely includes 36 weeks of gestational age (GA) infants, aims to establish the risk factors for RSVH in 32-36 weeks of GA infants in Ireland. METHODS: A prospective observational study at 13 hospitals of laboratory-confirmed RSVH in nonprophylaxed 32-36 weeks of GA infants was conducted from July 2011 to February 2014. Baseline and first-year clinical data were analyzed by using SPSS software Version 22 (IBM Corp, Armonk, NY). Significant (P < 0.05) variables were entered into multiple logistic regression to determine the independent risk factors for RSVH. RESULTS: Sixty-three percent of eligible infants (1825 of 2877) were recruited. The RSVH rate was 3.6% (65 of 1807 analyzed infant records). There was no RSV-attributable mortality. Twelve infants required intensive care. Of the 15 variables correlating to RSVH, 5 independent risk factors were identified: older siblings [odds ratio (OR): 3.8; 95% confidence interval (CI): 1.97-7.41], being Caucasian (OR: 2.3; 95% CI: 1.04-5.29), neonatal respiratory morbidity (OR: 2.2; 95% CI: 1.28-3.94); birth July 15 to December 15 (OR: 2.1; 95% CI: 1.09-3.92) and family history of asthma (OR: 1.9; 95% CI: 1.01-3.39). Birth from 36 weeks to 36 + 6 days mitigated RSVH risk (relative risk: 0.58; 95% CI: 0.34-0.99); however, risk factors were similar to the 32-35 weeks of GA cohort. CONCLUSION: Neonatal respiratory morbidity or being Caucasian were the population-specific independent risk factors for RSVH in 32-36 weeks of GA in Ireland, whereas the other identified independent risk factors mirrored those established in previous studies.

This article discusses the issue of prosecution of mentally disordered patients particularly in relation to assaults or acts of violence in health care settings. The arguments for prosecuting those responsible for committing acts of dangerous behaviour are discussed, as are the arguments against prosecution and some of the possible reasons why this is a contentious area of discussion. There are significant risks to the integrity of mental health services if the consideration of prosecution as a strategy to reduce risk of violence in hospitals does not become an area of meaningful discussion at all levels. The risk of violence is real, but the risks of accepting it without taking measures to reduce the frequency or severity of violence is no less acceptable than accepting that burglary is inevitable and leaving one's front door ajar every day. Health care professionals may wish to consider that in the absence of a clinically based solution or ownership of the problem, the risk of an organizational response to this sensitive area, perhaps guided or driven by political concerns is likely, as has happened in areas such as risk assessment, treatability and compliance with treatment.

The electrocardiogram (ECG) is essential for the diagnosis of some potentially life-threatening and time sensitive conditions, such as ST-elevation in myocardial infarction (MI). It is therefore imperative that healthcare professionals responsible for performing and interpreting ECGs are alert to the features of lead misplacement, as these can alter the ECG appearance dramatically, resulting in unnecessary investigations, admission to hospital, and treatment. ECG lead misplacement can result in significant harm to the patient if essential treatment is withheld or if the incorrect treatment is delivered solely on the basis of ECG findings. Case report: An unusual and previously unreported case of misplacement of all 12 ECG leads is presented, which would have resulted in significant harm to the patient had it not been identified so early. Conclusion: The ECG is one of the most important and most frequently requested investigations in the management of the acutely ill patient. A review of ECG lead misplacement is presented.

Following publication of the British Society for Haematology (BSH) transfusion guidelines for fetuses, neonates and older children,1 there have been a number of changes requiring this addendum, prior to full revision of the guideline. For each update in the addendum, the relevant section number in the main guideline is given. The PlaNeT-2/MATISSE study was a multicentre randomised controlled trial of prophylactic platelet transfusions in preterm neonates (660 babies, <34 weeks’ gestation). The results showed that babies with severe thrombocytopenia randomised to receive platelet transfusions to maintain a platelet count threshold of 50 × 109/l had a significantly higher rate of mortality or major bleeding within 28 days of randomisation than those transfused to maintain a platelet count threshold of 25 × 109/l.2 The possible reasons for this evidence of harm of platelet transfusions are not clear and are the subject of further investigation.3 The PlaNeT-2/MATISSE results support strengthening the current BSH guideline restrictive recommendation on prophylactic platelet transfusion thresholds. New additional wording is shown in italics: For preterm neonates with very severe thrombocytopenia (platelet count below 25 × 109/l) platelet transfusions should be administered in addition to treating the underlying cause of the thrombocytopenia (2C). For non-bleeding neonates platelet transfusions should not be routinely administered if platelet count is ≥25 × 109/l (1B). Suggested threshold counts for platelet transfusions in different situations are given in Table 2 (2C). The requirement to import plasma for treatment of individuals born on or after 1 January 1996 or with TTP was introduced in 2004 in the UK, as part of variant Creuzfeldt–Jacob disease (vCJD) risk reduction measures. In September 2019, the Department of Health and Social Care withdrew this requirement and approved the use of UK-sourced plasma and pooled platelets for these individuals (https://www.parliament.uk/business/publications/written-questions-answers-statements/written-statement/Commons/2019-09-09/HCWS1821/). This followed publication of advice and a comprehensive updated assessment of the vCJD risk by the Advisory Committee for the Safety of Blood, Tissues and Organs (SaBTO) (https://www.gov.uk/government/publications/risk-reduction-measures-for-variant-creutzfeldt-jakob-disease-pcwg-report). For details on the use of plasma for treatment of patients with TTP also refer to the relevant BSH guideline.4 The Joint UK Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee (JPAC) subsequently agreed that UK plasma for those born on or after 1 January 1996 does not need to be pathogen inactivated, similar to UK plasma for all other age groups (Oct 2019, https://www.transfusionguidelines.org/about/minutes-of-jpac-meetings). Helen V. New and Simon J. Stanworth wrote the initial manuscript, all authors critically reviewed it and approved the final version. We gratefully acknowledge the comments of the BSH Transfusion Task Force and review by paediatric haematology and neonatology expert colleagues.

OBJECTIVES: To describe a home-based treatment (HBT) service. To profile the patient population using HBT. To determine why HBT was used and to record disposal. METHOD: All patients treated by HBT during the first two years of this new service were identified from the HBT logbook. A checklist recording demographic, diagnostic, presenting complaint data and details of HBT contact was used to analyse the patients' charts. A statistical package JMP was used to analyse the data. RESULTS: Two hundred and six patients (275 episodes) were treated using HBT. These were 101 (49.1 %) males and 105 (50.9%) females. Of these, 89 (43.2%) were single. Forty-eight (19.4%) lived alone and 53 (25.7%) were unemployed. The most common presenting complaint was severe depression (39.3%). A depressive disorder was the most frequent diagnosis (28.7%). Twenty six (13%) episodes of HBT ended in admission. One hundred and eighty five (67.3%) were referred to outpatients and 26 (9.5%) were discharged to the GP. CONCLUSIONS: Home-based treatment is feasible for a wide range of patients with an array of presenting complaints. This model of service delivery is viable in a rural setting. Admission will still be required for some patients. Further work is needed to examine its sustainability and its generalisability to other Irish settings.