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... more
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. prospective cohort study. university teaching hospital. 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). 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). 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 < 0.00...
Research Interests: Psychology, Mass Spectrometry, Clostridium difficile, Adolescent, Diarrhea, and 24 moreUniversity Teaching, Disease Outbreaks, Prospective studies, Humans, Age, Female, Male, Course design, Cohort Study, Disease Severity, Incidence, Risk factors, Logistic Regression Analysis, Clinical Sciences, Colitis, Aged, Middle Aged, Spectrum, Cognitive impairment, Adult, Public health systems and services research, Time Factors, Risk Factors, and Functional Disability
As the prevalence of dementia increases, more people will need dementia palliative and end-of-life (EOL) care in acute hospitals. Published literature suggests that good quality care is not always provided. To evaluate the prescription of... more
As the prevalence of dementia increases, more people will need dementia palliative and end-of-life (EOL) care in acute hospitals. Published literature suggests that good quality care is not always provided. To evaluate the prescription of antipsychotics and performance of multidisciplinary assessments relevant to palliative care for people with dementia, including those at EOL, during hospital admission. As part of a national audit of dementia care, 660 case notes were reviewed across 35 acute hospitals. In the entire cohort, many assessments essential to dementia palliative care were not performed. Of the total sample, 76 patients died, were documented to be receiving EOL care, and/or were referred for specialist palliative care. In this cohort, even less symptom assessment was performed (eg, no pain assessment in 27%, no delirium screening in 68%, and no mood or behavioral and psychological symptoms of dementia in 93%). In all, 37% had antipsychotic drugs during their admission and 71% of these received a new prescription in hospital, most commonly for &amp;amp;amp;amp;amp;amp;amp;amp;quot;agitation.&amp;amp;amp;amp;amp;amp;amp;amp;quot; This study suggests a picture of poor symptom assessment and possible inappropriate prescription of antipsychotic medication, including at EOL, hindering the planning and delivery of effective dementia palliative care in acute hospitals.
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Elder abuse is an under-recognised cause of morbidity in the elderly. The frail elderly with multiple physical and psychiatric problems living with a relative who may also have a physical or psychiatric problem are particularly at risk.... more
Elder abuse is an under-recognised cause of morbidity in the elderly. The frail elderly with multiple physical and psychiatric problems living with a relative who may also have a physical or psychiatric problem are particularly at risk. Although increased awareness of the problem and a high index of suspicion are necessary factors to diagnose the condition, clinical pointers towards diagnosis are available. Treatment for both victim and "carer" should be on the basis of multi-disciplinary assessment, and may result in admission of the elderly patient to an extended-care facility.
A range of neurological sequelae of intensive care have been described, including myopathy/neuropathy of critical illness which has been shown to hinder physical rehabilitation. Swallow disorders have not yet been described as a... more
A range of neurological sequelae of intensive care have been described, including myopathy/neuropathy of critical illness which has been shown to hinder physical rehabilitation. Swallow disorders have not yet been described as a complication of critical care, although transient changes have been described following endotracheal intubation. We report a series of cases of unexplained persistent dysphagia following critical illness which have led to significant morbidity and, in one case, mortality.
ABSTRACT The use of standardised assessments and outcome measures is important for establishing the effectiveness of physiotherapy intervention in clinical practice. This article presents the results of a survey undertaken to establish... more
ABSTRACT The use of standardised assessments and outcome measures is important for establishing the effectiveness of physiotherapy intervention in clinical practice. This article presents the results of a survey undertaken to establish current trends and practices in physiotherapy in Ireland.
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From 2005 to 2006 a professional orchestra (the Irish Chamber Orchestra) performed in a university teaching hospital with the aims of bringing live music to patients who could not access traditional concert venues and of improving quality... more
From 2005 to 2006 a professional orchestra (the Irish Chamber Orchestra) performed in a university teaching hospital with the aims of bringing live music to patients who could not access traditional concert venues and of improving quality of life for patients and staff. This was the first time an orchestra was resident in a hospital in the Republic of Ireland. An independent contemporaneous evaluation was carried out to assess the benefit of live music for patients. Live music in hospital was found to enhance the quality of the aesthetic environment of the hospital, with both patients and staff stating that listening to live music helped them to relax, feel happier and more positive. Patients' perception of the hospital was affected positively by live music in waiting areas. Music was found to have strong emotional effect and the individual preferences and experiences of patients need to be carefully taken into account when programming music in hospital. Listening to live music ...
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It has become part of conventional wisdom that medical students experience a clear separation between the explicit ethics curriculum of the lecture room and the implicit curriculum of the clinic. This paper outlines and critiques some... more
It has become part of conventional wisdom that medical students experience a clear separation between the explicit ethics curriculum of the lecture room and the implicit curriculum of the clinic. This paper outlines and critiques some important assumptions made about the teaching of ethics in medical schools. It identifies the need for close collaboration between clinical and non-medical ethics teachers to advance the teaching of ethics in medical training.
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An accurate assessment of stroke severity and the ability to predict prognosis is important for determining rehabilitation needs and long term management of patients after stroke. The Orpington Prognostic Score (OPS) is a clinically... more
An accurate assessment of stroke severity and the ability to predict prognosis is important for determining rehabilitation needs and long term management of patients after stroke. The Orpington Prognostic Score (OPS) is a clinically derived stroke severity scale that can be used to stratify patients into different severity groups. The aim of this study was to validate the Orpington Prognostic Score (OPS) in an Irish in-patient stroke population. Fifty 'first stroke' patients (21 male, median age 72.5 [range 31-93] years) were assessed within two weeks following stroke onset. Subjects were stratified into mild, moderate and severe groups using previously established cut-offs for the OPS. Outcomes were determined prospectively and compared to initial severity groups. Patients in the severe group had a significantly increased chance of dying (Odds ratio [95%CI] 2.16 [1.72-2.72] and this persisted after adjustment for age and gender. Length of stay increased significantly with i...
Research Interests: Ireland, Irish medical history, Stroke, Humans, Female, and 5 moreMale, Aged, Middle Aged, Prognosis, and Inpatients
Gait abnormalities are common in older people but relatively under-diagnosed. We investigated the prevalence of gait abnormalities among patients presenting to a geriatric medicine day hospital, classified them according to whether they... more
Gait abnormalities are common in older people but relatively under-diagnosed. We investigated the prevalence of gait abnormalities among patients presenting to a geriatric medicine day hospital, classified them according to whether they were lower, middle or higher level gait disorders and compared inter-professional (physician and physiotherapist) assessments for this classification. Prospective independent assessment by a physician and a senior physiotherapist of 50 consecutive patients presenting to a day hospital. Presence of a gait abnormality was determined and then classified. Levels of agreement were determined between the two professions. There was 98% agreement that a gait abnormality existed in 43 people. In classifying the gait abnormality there was complete agreement in over two-thirds of cases (67.4%). There was further agreement of higher level gait disorders (but disagreement in the sub-classification) in 11.6% of cases. Given the high prevalence of gait abnormality ...
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Chronic kidney disease has been shown to be associated with significant increases in mortality and morbidity even in early stages. Despite this it is rarely diagnosed, actively investigated or managed in the elderly. We set out to... more
Chronic kidney disease has been shown to be associated with significant increases in mortality and morbidity even in early stages. Despite this it is rarely diagnosed, actively investigated or managed in the elderly. We set out to establish the prevalence of CKD and identify causative factors in a consecutive series of referrals to a geriatric medical clinic. We calculated glomerular filtration rates (GFR) for 101 patients attending a geriatric medical clinic using the Cockroft and Gault formula, and collected data on medications and relevant past medical history. Mild CKD (GFR <60ml/min) was present in 80% of the group. Only 10% of these patients had serum creatinine >130(mmol/L. hypertension was present in 50% and only 9% were diabetic. Almost one third were on inappropriate drugs or dosages; most commonly non-steroidal anti-inflammatory drugs (99%). Chronic kidney disease is extremely common in older people attending a geriatric medical clinic and carries significant risks....
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Older people are a significant source of emergency admissions to general hospitals relative to their proportion of the population. Little is known of the acuity of these admissions, aspects of which this study aims to determine. A... more
Older people are a significant source of emergency admissions to general hospitals relative to their proportion of the population. Little is known of the acuity of these admissions, aspects of which this study aims to determine. A prospective survey of 1 in 10 acute general takes in a university teaching hospital over 11 months. Age, sex, acuity of presentation, premorbid functional status and cognitive impairment were recorded. Of 332 admissions, 127 (38%) patients were aged 65 years or over and 205 under 65. Of > or =65's, 53 (42 ) presented <2 days of symptoms compared to 117 (57%) <65's. Mean delay between onset of primary symptom and presentation was 8.76 days (> or =65's) and 6.77 days (<65's). Previous functional loss was present in 42% of > or =65's. On admission, 36% of > or =65's were deemed cognitively impaired. Acute on chronic illness represents a significant proportion of 'acute general take'. Older patients admitted...
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Health and social services in Ireland tend to be relatively poorly coordinated. Surveys confirm the perceptions of older people with disability that access to and availability of both health and social services are limited.... more
Health and social services in Ireland tend to be relatively poorly coordinated. Surveys confirm the perceptions of older people with disability that access to and availability of both health and social services are limited. Multi-disciplinary geriatric medical clinics may provide a focus for better utilization and coordination of these services. The purpose of this study was to measure not only the existing service use but also the potential for community and social-care intervention with older people living in the community when using multi-disciplinary geriatric medical clinics. A sample of 60 consecutive patients aged over 65, attending our geriatric medical OPD for the first time, were interviewed using a semistructured questionnaire on the current and potential use of community and social care services. Our service arranged for 229 interventions or referral to services, an average of 3.8 interventions per patient. Ninety-six services were already in place (an average of 1.6 per...
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The provision of extended care facilities in urban Ireland has lagged behind the growth in the numbers of older people. A final pathway for placement is often through the general hospital and the attendant delay results in a diversion of... more
The provision of extended care facilities in urban Ireland has lagged behind the growth in the numbers of older people. A final pathway for placement is often through the general hospital and the attendant delay results in a diversion of resources. We developed a database of the long-term care waiting lists for the years 1994-present and this was analysed for the six years 1994-1999. We calculated the number of bed-days consumed by elderly patients awaiting placement in long-term care facilities and thus the hospital resources consumed during these periods. The total number of bed-days consumed over the study period was 51,923, the mean being 8653.8 days. Approximately 23.9% of patients die in hospital while awaiting long-term placement. Translating these bed-days into opportunity cost losses in areas relevant to the general hospital we found that 560 extra elective orthopaedic procedures and 1,212 extra transurethral prostatectomies could have been performed per year. The problem o...
Research Interests: Long Term Care, Health Services Research, Ireland, Irish medical history, Humans, and 11 moreNeeds Assessment, Human Resources for Health, Nursing Homes, Construction Project Financing, Life Expectancy, Length of Stay, Waiting lists, Aged, Hospital Mortality, Orthopedic Procedures, and Bed Occupancy
Road traffic accidents (RTA's) are the leading cause of fatal trauma in Ireland. Although older drivers are the safest group of drivers in the population, once involved in a crash they are more likely to sustain a severe injury or... more
Road traffic accidents (RTA's) are the leading cause of fatal trauma in Ireland. Although older drivers are the safest group of drivers in the population, once involved in a crash they are more likely to sustain a severe injury or death. The experiences of Irish elderly RTA victims has not been previously documented. We studied older RTA patients admitted to two Irish trauma centres in 1995. Of 525 patients, 39 (7%) were aged over 65. We compared 38 patients aged 16-64 years for comparison and reviewed the notes in detail. Elderly patients were mostly pedestrians (23/38 - 61%) though 21% (8/38) were drivers with 8% (3/38) on public transport. Younger patients were mostly drivers (14/37 - 38%), cyclists (9/37 - 24%) or motorcyclists (7/37 - 19%). Older patients had a higher median Injury Severity Score, p < 0.05, were more likely to be female (p<0.01), involved in RTA's between 9am-5pm (p<0.05) and have pre-existing medical conditions (p<0.01). The following were ...
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Research Interests: Depression, Dementia, Irish medical history, Stroke, Humans, and 3 moreHemiplegia, Aged, and Middle Aged
Acute stroke is associated with a high morbidity and mortality: up to 24% of patients may not survive their hospital admission. Stroke unit care has been shown in a meta-analysis to reduce this morbidity and mortality. We present a... more
Acute stroke is associated with a high morbidity and mortality: up to 24% of patients may not survive their hospital admission. Stroke unit care has been shown in a meta-analysis to reduce this morbidity and mortality. We present a three-year audit of the first acute stroke service in an Irish teaching hospital. The audit was carried out prospectively on 193 patients admitted to the acute stroke service, from July 1996 to end of June 1999. Details regarding patients, type and severity of stroke, length of stay and outcome were collected prospectively on a standard pro-forma. We observed a reduction in mortality from 19% to 15% to 9%, and an increasing percentage of patients discharged home from 55% to 64% to 68%, in year 1, year 2 and year 3 respectively. A trend towards a greater number of patients, younger age and improved outcome with lower mortality was observed from year to year, without significant change in length of stay. This study confirms the value to patients of organise...
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to determine whether the age and medical condition of a patient influences hospital-based doctors' decision making when advising patients to stop smoking cigarettes. we presented 142 doctors from four grades (consultant, registrar,... more
to determine whether the age and medical condition of a patient influences hospital-based doctors' decision making when advising patients to stop smoking cigarettes. 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. 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). the advice given to patients about their cigarette smoking habits by hospital doctors is strongly influenced not only by the patient...
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1. J Am Geriatr Soc. 2000 Mar;48(3):345-6. ERT and cognitive decline. Cunningham C, O'Neill D, Rowan M. Comment on J Am Geriatr Soc. 1999 May;47(5):518-23. PMID: 10733070 [PubMed - indexed for MEDLINE]. Publication Types: Comment;... more
1. J Am Geriatr Soc. 2000 Mar;48(3):345-6. ERT and cognitive decline. Cunningham C, O'Neill D, Rowan M. Comment on J Am Geriatr Soc. 1999 May;47(5):518-23. PMID: 10733070 [PubMed - indexed for MEDLINE]. Publication Types: Comment; Letter. MeSH Terms. ...
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UK PubMed Central (UKPMC) is an archive of life sciences journal literature.
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ABSTRACT To the Editor,Baxter et al. provide a helpful review on the impact of work-related challenges that may be associated with elderly anesthesiologists. The authors also offer proposed assessments and possible solutions to ensure... more
ABSTRACT To the Editor,Baxter et al. provide a helpful review on the impact of work-related challenges that may be associated with elderly anesthesiologists. The authors also offer proposed assessments and possible solutions to ensure patient care is not compromised.1 This paper reflects broader concerns over a lack of preparedness among professional bodies associated with a range of liberal professions where their members may continue practice into later life without support from formal occupational health services.2 This is particularly important for medical specialities where there is a heavy reliance on psychomotor skills and rapid responses to emergent situations and where senior specialists are frequently required to attend out of hours to deal with complex clinical cases.For this reason, it is essential that professional and regulatory bodies draw on emerging developments in research on older workers from the field of occupational health.3 The concept of “promotion of work ability” pione ...
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An adapted Folstein Mini-Mental State Examination was applied to 244 consecutive admissions to an acute geriatric medical unit to determine the prevalence of cognitive impairment. At a cut-off point of 23/30, 109 (44%) were rated as... more
An adapted Folstein Mini-Mental State Examination was applied to 244 consecutive admissions to an acute geriatric medical unit to determine the prevalence of cognitive impairment. At a cut-off point of 23/30, 109 (44%) were rated as normal and 44 (19%) were unable to perform the test. Of the 85 (36%) who scored less than 23, 63 were suffering from dementia, nine were delirious, and 12 had normal cognitive function, a false positive rate of 14%. The most common dementia was senile dementia of the Alzheimer type. Cognitive impairment was not noted by the admitting doctor in 57% of affected cases. The need for increased awareness of cognitive impairment in the elderly is emphasized, and the more widespread use of formal mental test scores is recommended.
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Research Interests: Humans, Female, Male, Lancet, Aged, and 4 moreMiddle Aged, Adult, Intelligence tests, and Education Continuing
1. Ir Med J. 2002 Oct;95(9):281-2. Stroke associated with amphetamine use. Miranda J, O'Neill D. PMID: 12470006 [PubMed - indexed for MEDLINE]. Publication Types: Case Reports; Letter. MeSH Terms. Adult; Amphetamines ...
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ABSTRACT Objective: To investigate changes in attitudes, resources and practices of GPs towards evaluating medical fitness to drive (MFTD) following the publication of national guidelines and an extensive educational programme in traffic... more
ABSTRACT Objective: To investigate changes in attitudes, resources and practices of GPs towards evaluating medical fitness to drive (MFTD) following the publication of national guidelines and an extensive educational programme in traffic medicine. Method: Postal questionnaire-survey to GPs (n = 1,000) in November 2013. Results: The final response rate was 46%. GPs are confident (57%) or very confident (14%) in assessing MFTD. There is a high awareness of the new Irish guidelines with 86% of GPs using them for assistance in assessing MFTD. GPs are divided as to whether GPs (49%) or practitioners specially trained for assessing MFTD (44%) should be primarily responsible for assessing MFTD. GPs expressed interest in traffic medicine educational programmes, most notably a resource pack for CME Small Group learning (87%), MFTD software (71%) and an online moodle (68%). Many remain (68%) concerned about their liability in regard to MFTD assessments. Conclusion: Irish GPs are confident in assessing MFTD and show a high level of awareness of the new guidelines. There is a clear interest among GPs in further educational supports and training in traffic medicine, particularly MFTD assessments.
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Although cognitive impairment and delirium are highly prevalent in older patients who present to the emergency department, multiple studies have highlighted inadequate detection by doctors. This study investigated potential reasons... more
Although cognitive impairment and delirium are highly prevalent in older patients who present to the emergency department, multiple studies have highlighted inadequate detection by doctors. This study investigated potential reasons underlying this. A 14-item self-administered questionnaire was distributed to all medical, surgical and emergency department physicians involved in the care of older patients in the emergency department of an urban university teaching hospital between January and March 2012. The questionnaire was completed by 76/97 (78%) of eligible respondents. Respondents reported screening an average of one in four older patients that they reviewed. Almost one-third (22/76, 29%) felt they lacked the relevant expertise to perform cognitive screening: those with training in geriatrics were less likely to cite lack of expertise as a factor. While the majority felt screening for cognition in the emergency department-setting was important (59/76, 78%), several limiting factors were identified: lack of a screening tool; lack of privacy; too much noise; and time constraints. There was no consensus on who should perform screening. Doctors reviewing patients in the emergency department-setting reported several important factors limiting their ability to screen older patients for cognitive impairment. Respondents to this questionnaire did not feel the emergency department environment was conducive towards the assessment of cognition in older patients. Clarification of each discipline&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s responsibility in the detection, assessment and management of delirium and/or dementia, and the implementation of emergency department cognitive screening instruments more suited to this setting would likely improve detection and management.
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Asymptomatic hemorrhagic transformation of infarction (AHTI) is common, but its risk factors and relationship with functional outcome are poorly defined. The analyses used data from the Tinzapararin in Acute Ischaemic Stroke Trial, a... more
Asymptomatic hemorrhagic transformation of infarction (AHTI) is common, but its risk factors and relationship with functional outcome are poorly defined. The analyses used data from the Tinzapararin in Acute Ischaemic Stroke Trial, a randomized controlled trial assessing tinzaparin (low molecular weight heparin) versus aspirin in 1484 patients with acute ischemic stroke. CT head scans (baseline, day 10) were adjudicated for the presence of hemorrhagic transformation. Stroke subtype was classified according to modified Trial of Org 10172 in Acute Stroke Treatment (small vessel, large vessel, cardioembolic) and the Oxfordshire Community Stroke Project (total anterior, partial anterior, lacunar, and posterior circulatory syndromes). Modified Rankin scale and Barthel Index were measured at 3 and 6 months. Analyses were adjusted for age, sex, severity, blood pressure, infarct volume, and treatment. Symptomatic hemorrhage was excluded. At day 10, AHTI did not differ between aspirin (300 mg; 32.8%) and medium-dose (100 IU/kg; 36.0%) and high-dose (175 IU/kg; 31.4%) tinzaparin groups (P = 0.44). Relative to lacunar stroke, AHTI on follow-up CT was significantly increased in total anterior circulation syndrome (odds ratio, 11.5; 95% CI, 7.1 to 18.7) and partial anterior circulation syndrome (odds ratio, 7.2; 95% CI, 4.5 to 11.4) stroke. Similarly, relative to small vessel disease, AHTI was increased in large vessel (odds ratio, 15.1; 95% CI, 9.4 to 24.3) and cardioembolic (odds ratio, 14.1; 95% CI, 8.5 to 23.5) stroke. After adjustment for infarct volume, the presence of AHTI was not associated with outcome at 3 or 6 months as measured by the modified Rankin Scale and Barthel Index. AHTI is increased in ischemic stroke with cortical syndromes and of large vessel or cardioembolic etiology. Heparin does not increase AHTI. AHTI is not associated with functional outcome.
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In the spring of 1910, Oskar Kokoschka painted a portrait of the eminent Swiss psychiatrist, neuroanatomist, temperance champion, and myrmecologist Auguste Forel. The painting is a remarkable psychological portrait but also appears to... more
In the spring of 1910, Oskar Kokoschka painted a portrait of the eminent Swiss psychiatrist, neuroanatomist, temperance champion, and myrmecologist Auguste Forel. The painting is a remarkable psychological portrait but also appears to predict the strokes and right hemiparesis that affected Forel more than a year later. Although it is possible that Kokoschka shared a gift of psychic prediction with his mother and grandmother, a more likely explanation can be ascribed to a combination of the artist&amp;amp;#39;s acute perception and the presence of subclinical signs of stroke disease.