Antimicrobial stewardship in Ireland, with a focus on long term care facilities

Background: Antimicrobial resistance is a major public health concern, and its increasing incidence in the Long Term Care Facility (LTCF) setting warrants attention (1). The prescribing of antimicrobials in this setting is often inappropriate and higher in Ireland than the European average (2). The aim of the study was to generate an evidence base for the factors influencing antimicrobial prescribing in LTCFs and to investigate Antimicrobial Stewardship (AMS) strategies for LTCFs. Methods: An initial qualitative study was conducted to determine the factors influencing antimicrobial prescribing in Irish LTCFs. This allowed for the informed implementation of an AMS feasibility study in LTCFs in the greater Cork region. Hospital AMS was also investigated by means of a national survey. A study of LTCF urine sample antimicrobial resistance rates was conducted in order to collate information for incorporation into future LTCF AMS initiatives. Results: The qualitative interviews determined that there are a multitude of factors, unique to the LTCF setting, which influence antimicrobial prescribing. There was a positive response from the doctors and nurses involved in the feasibility study as they welcomed the opportunity to engage with AMS and audit and feedback activities. While the results did not indicate a significant change in antimicrobial prescribing over the study period, important trends and patterns of use were detected. The antimicrobial susceptibility of LTCF urine samples compared to GPs samples found that there was a higher level of antimicrobial resistance in LTCFs. Conclusion: This study has made an important contribution to the development of AMS in LTCFs. The complexity of care and healthcare organisation, and the factors unique to LTCFs must be borne in mind when developing quality improvement strategies.

A facilities maintenance management process based on degradation prediction using sensed data

Energy efficiency and user comfort have recently become priorities in the Facility Management (FM) sector. This has resulted in the use of innovative building components, such as thermal solar panels, heat pumps, etc., as they have potential to provide better performance, energy savings and increased user comfort. However, as the complexity of components increases, the requirement for maintenance management also increases. The standard routine for building maintenance is inspection which results in repairs or replacement when a fault is found. This routine leads to unnecessary inspections which have a cost with respect to downtime of a component and work hours. This research proposes an alternative routine: performing building maintenance at the point in time when the component is degrading and requires maintenance, thus reducing the frequency of unnecessary inspections. This thesis demonstrates that statistical techniques can be used as part of a maintenance management methodology to invoke maintenance before failure occurs. The proposed FM process is presented through a scenario utilising current Building Information Modelling (BIM) technology and innovative contractual and organisational models. This FM scenario supports a Degradation based Maintenance (DbM) scheduling methodology, implemented using two statistical techniques, Particle Filters (PFs) and Gaussian Processes (GPs). DbM consists of extracting and tracking a degradation metric for a component. Limits for the degradation metric are identified based on one of a number of proposed processes. These processes determine the limits based on the maturity of the historical information available. DbM is implemented for three case study components: a heat exchanger; a heat pump; and a set of bearings. The identified degradation points for each case study, from a PF, a GP and a hybrid (PF and GP combined) DbM implementation are assessed against known degradation points. The GP implementations are successful for all components. For the PF implementations, the results presented in this thesis find that the extracted metrics and limits identify degradation occurrences accurately for components which are in continuous operation. For components which have seasonal operational periods, the PF may wrongly identify degradation. The GP performs more robustly than the PF, but the PF, on average, results in fewer false positives. The hybrid implementations, which are a combination of GP and PF results, are successful for 2 of 3 case studies and are not affected by seasonal data. Overall, DbM is effectively applied for the three case study components. The accuracy of the implementations is dependant on the relationships modelled by the PF and GP, and on the type and quantity of data available. This novel maintenance process can improve equipment performance and reduce energy wastage from BSCs operation.

Issues in the prescribing of psychotropic and psychoactive medication for persons with learning disability: quantitative and qualitative perspectives

The administration of psychotropic and psychoactive medication for persons with learning disability and accompanying mental illness and/or challenging behaviour has undergone much critical review over the past two decades. Assessment and diagnosis of mental illness in this population continues to be psychopharmacological treatment include polypharmacy, irrational prescription procedures and frequent over-prescription. It is clear that all forms of treatment including non-pharmacological interventions need to be driven by accurate and appropriate diagnoses. Where a psychiatric diagnosis has been identified, it greatly aides the selection of appropriate medication, although a specific medication for each diagnosis, as was once hoped, is simply no longer a reality in practice. Part one of the present thesis seeks to address many of the current issues in mental health problems and pharmacological treatment to date. The author undertook a drug prevalence study within both residential and community facilities for persons with learning disability within the Mid-West region of Ireland in order to ascertain the current level of prescribing of psychotropic and psychoactive medications for this population. While many attempts have been made to account for the variation in prescribing, little systematic and empirical research has been undertaken to investigate the factors thought to influence such prescribing. While studies investigating the prescribing behaviours of General Practitioners (GP's) have illustrated the complex nature of the decision making process in the context of general practice, no similar efforts have yet been directed at examining the prescribing behaviours of Consultant Psychiatrists. Using The Critical Incident Technique, the author interviewed Consultant Psychiatrists in the Republic of Ireland to gather information relating not only to their patterns of prescribing for learning disabled populations, but also to examine reasons influencing their prescribing in addition to several related factors. Part two of this thesis presents the findings from this study and a number of issues are raised, not only in relation to attempting to account for the findings from part one of the thesis, but also with respect to implications for improved management and clinical practice.

Genteel revolutionaries: the lives of Anna and Thomas Haslam

The lives of Thomas and Anna Haslam were dedicated to the attainment of women's equality. They were feminists before the word was coined. In an era when respectable women were not supposed to know of the existence of prostitutes, Anna became empowered to do the unthinkable, not only to speak in public but to discuss openly matters sexual and to attack the double standard of sexuality which was enshrined in the official treatment of prostitutes. Their life-long commitment to the cause of women's suffrage never faltered, despite the repeated discouragement of the fate of bills defeated in the House of Commons. The Haslams represented an Ireland which did not survive them. While they were dedicated to the union with Westminster, they worked happily with those who applied themselves to its destruction. Although in many ways they exemplified the virtues of their Quaker backgrounds, they did not subscribe to any organised religion. Despite living in straitened circumstances, they were part of an urban intellectual elite and participated in the social and cultural life of Dublin for over fifty years. It is tempting to speculate how the Haslams would have fared in post independence Ireland. Hanna Sheehy Skeffington who had impeccable nationalist credentials, was effectively marginalised. It is likely that they would have protested against discriminatory legislation in their usual law abiding manner but, in a country which quickly developed an overwhelmingly Roman Catholic ethos, would they have had a voice or a constituency? Ironically, Thomas's teaching on chastity would have found favour with the hierarchy; his message was disseminated in a simple and more pious manner in numerous Catholic Truth Society pamphlets. The Protestant minority never sought to subvert the institutions of the state, was careful not to criticise and kept its collective head down. Dáil Éireann was not bombarded with petitions for the restoration of divorce facilities or the unbanning of birth control. Those who sought such amenities obtained them quietly 'in another jurisdiction.' Fifty years were to pass before the condom wielding 'comely maidens' erupted on to the front pages of the Sunday papers. They were, one imagines, the spiritual descendants of the militant rather than the constitutional suffrage movement. "Once and for all we need to commit ourselves to the concept that women's rights are not factional or sectional privileges, bestowed on the few at the whim of the many. They are human rights. In a society in which the rights and potential of women are constrained no man can be truly free." These words spoken by Mary Robinson as President of Ireland are an echo of the principles to which the Haslams dedicated their lives and are, perhaps, a tribute to their efforts.

The Queen's College, Cork: its origins and early history, 1803-1858

This work examines the origins and early history of the Queen's College, Cork. Designedly there is as much stress on the origins as on the early history, for it is the contention of the work that the College was something more than a legislative mushroom. It was very much in the tradition of the civic universities which added an exciting new dimension to academic life in these islands in the nineteenth century. The first chapter surveys university practice and thinking at the opening of the century, relying exclusively on published sources. The second chapter is devoted specifically to the state of learning in Cork during the period, and makes extensive use of hitherto unpublished manuscript material in relation to the Royal Cork Institution. The third chapter deals with the highly significant evidence on education embodied in the Report of the Select Committee on Irish Education of 1838. This material has not previously been published. In chapter four an extended study is made of relevant letters in the manuscript correspondence of Sir Robert Peel - even the most recent authoritative biography has ignored this material. The remaining three chapters are devoted more specifically to the College, both in the formulation or policy and in its practical working. In chapter six there is an extended survey of early College life based exclusively on hitherto unpublished manuscript material in the College Archives. All of these sources, together with incidental published material, are set out at the end of each chapter.

Impact of the smoke-free workplace legislation on smoking behaviour, risk perception & stigmatisation

The Republic of Ireland became the first European country to implement nationwide smoke-free workplace legislation. Aims: To determine prevalence of smoking among bar workers and estimate the impact of the smoke-free workplace legislation on their smoking behaviour to that of a comparable general population sample. To approximate the influence of tobacco control measures on risk perception of second-hand smoke (SHS) among the general population. To explore the de-normalisation of smoking behaviour and the potential increased stigmatisation of smokers and their smoking. Methods: Prevalence estimates and behavioural changes were examined among a random sample of bar workers before and 1 year after the smoke-free legislation; comparisons made with a general population sub-sample. Changes in risk knowledge related to SHS exposure were based on general population data. Qualitative interviews were conducted among a purposive sample of smokers and non-smokers four years after the implementation of the legislation. Results: Smoking prevalence was extremely high among bar workers. Smoking prevalence dropped in bar workers and significantly among the general population 1 year post ban while cigarette consumption dropped significantly among bar workers. Disparity in knowledge between smokers and non-smoker of risk associated with SHS exposure reduced. Lack of understanding of the risk of ear infections in children posed by SHS exposure was notable. Evidence for advanced de-normalisation of smoking behaviour and intensification of stigma because of the introduction of the legislation was dependent on many factors, quality of smoking facilities played a key role. Conclusions: Ireland’s smoke-free legislation was associated with a drop in prevalence and cigarette consumption. Disparity in knowledge between smokers and non-smokers of the risk posed by SHS exposure reduced however the risk of ear infections in children needs to be effectively disseminated. The proliferation of ‘good’ smoking areas may diminish the potential to reduce smoking behaviour and de-normalise smoking.

College adjustment, depressive symptoms and peer support among undergraduate university students

Background: College adjustment is a developmental milestone that can be stressful and may lead to mental health problems such as depression. Support during this adjustment period is seen as essential, however it is unknown if informal peer support from fellow students has any impact on either college adjustment or depressive symptoms. Aim: To identify levels of social and personal college adjustment, depressive symptoms and peer support among students, and to examine the relationship between the variables. Design: A quantitative correlational design was used Instruments: Data were collected using two subscales of the Student Adaptation to College Questionnaire; the Centre for Epidemiology Depressive Symptoms Scale and a subscale of the Peer Support Evaluation Inventory. Sample: The sample consisted of 417, first (n=188), second (n=134) and fourth (n=94) year nursing and midwifery students from one University in Ireland. Findings: The findings indicated that 20% of participants were poorly personally adjusted and 9% poorly socially adjusted. Furthermore, 34% of participants experienced significant depressive symptoms. Most students had good levels of peer support. Statistically significant relationships were found between all key variables, the strongest of which were between personal adjustment and depressive symptoms and social adjustment and depressive symptoms. Differences in adjustment and depressive symptom scores were found based on year of study, with second year students experiencing more depressive symptoms and having poorer personal adjustment scores. Participants who had poor relationships with their father’s experienced greater depressive symptoms and had more difficulties personally and socially adjusting to college. The alcohol consumption of participants had a statistically significant correlation with college adjustment, depressive symptoms and peer support, with higher consumption having a positive impact on the variables.

Climate and energy scenarios for Ireland to 2050 using the Irish TIMES energy systems model

Due to growing concerns regarding the anthropogenic interference with the climate system, countries across the world are being challenged to develop effective strategies to mitigate climate change by reducing or preventing greenhouse gas (GHG) emissions. The European Union (EU) is committed to contribute to this challenge by setting a number of climate and energy targets for the years 2020, 2030 and 2050 and then agreeing effort sharing amongst Member States. This thesis focus on one Member State, Ireland, which faces specific challenges and is not on track to meet the targets agreed to date. Before this work commenced, there were no projections of energy demand or supply for Ireland beyond 2020. This thesis uses techno-economic energy modelling instruments to address this knowledge gap. It builds and compares robust, comprehensive policy scenarios, providing a means of assessing the implications of different future energy and emissions pathways for the Irish economy, Ireland’s energy mix and the environment. A central focus of this thesis is to explore the dynamics of the energy system moving towards a low carbon economy. This thesis develops an energy systems model (the Irish TIMES model) to assess the implications of a range of energy and climate policy targets and target years. The thesis also compares the results generated from the least cost scenarios with official projections and target pathways and provides useful metrics and indications to identify key drivers and to support both policy makers and stakeholder in identifying cost optimal strategies. The thesis also extends the functionality of energy system modelling by developing and applying new methodologies to provide additional insights with a focus on particular issues that emerge from the scenario analysis carried out. Firstly, the thesis develops a methodology for soft-linking an energy systems model (Irish TIMES) with a power systems model (PLEXOS) to improve the interpretation of the electricity sector results in the energy system model. The soft-linking enables higher temporal resolution and improved characterisation of power plants and power system operation Secondly, the thesis develops a methodology for the integration of agriculture and energy systems modelling to enable coherent economy wide climate mitigation scenario analysis. This provides a very useful starting point for considering the trade-offs between the energy system and agriculture in the context of a low carbon economy and for enabling analysis of land-use competition. Three specific time scale perspectives are examined in this thesis (2020, 2030, 2050), aligning with key policy target time horizons. The results indicate that Ireland’s short term mandatory emissions reduction target will not be achieved without a significant reassessment of renewable energy policy and that the current dominant policy focus on wind-generated electricity is misplaced. In the medium to long term, the results suggest that energy efficiency is the first cost effective measure to deliver emissions reduction; biomass and biofuels are likely to be the most significant fuel source for Ireland in the context of a low carbon future prompting the need for a detailed assessment of possible implications for sustainability and competition with the agri-food sectors; significant changes are required in infrastructure to deliver deep emissions reductions (to enable the electrification of heat and transport, to accommodate carbon capture and storage facilities (CCS) and for biofuels); competition between energy and agriculture for land-use will become a key issue. The purpose of this thesis is to increase the evidence-based underpinning energy and climate policy decisions in Ireland. The methodology is replicable in other Member States.

Investment incentives and valuation of power sector infrastructure assets with increasing interconnection, intermittency and decarbonisation

This dissertation applies a variety of quantitative methods to electricity and carbon market data, utility company accounts data, capital and operating costs to analyse some of the challenges associated with investment in energy assets. In particular, three distinct research topics are analysed within this general theme: the efficiency of interconnector trading, the optimal sizing of intermittent wind facilities and the impact of carbon pricing on the cost of capital for investors are researched in successive sections.

The use of fault detection and diagnostics to reduce air handling unit energy consumption

The contribution of buildings towards total worldwide energy consumption in developed countries is between 20% and 40%. Heating Ventilation and Air Conditioning (HVAC), and more specifically Air Handling Units (AHUs) energy consumption accounts on average for 40% of a typical medical device manufacturing or pharmaceutical facility’s energy consumption. Studies have indicated that 20 – 30% energy savings are achievable by recommissioning HVAC systems, and more specifically AHU operations, to rectify faulty operation. Automated Fault Detection and Diagnosis (AFDD) is a process concerned with potentially partially or fully automating the commissioning process through the detection of faults. An expert system is a knowledge-based system, which employs Artificial Intelligence (AI) methods to replicate the knowledge of a human subject matter expert, in a particular field, such as engineering, medicine, finance and marketing, to name a few. This thesis details the research and development work undertaken in the development and testing of a new AFDD expert system for AHUs which can be installed in minimal set up time on a large cross section of AHU types in a building management system vendor neutral manner. Both simulated and extensive field testing was undertaken against a widely available and industry known expert set of rules known as the Air Handling Unit Performance Assessment Rules (APAR) (and a later more developed version known as APAR_extended) in order to prove its effectiveness. Specifically, in tests against a dataset of 52 simulated faults, this new AFDD expert system identified all 52 derived issues whereas the APAR ruleset identified just 10. In tests using actual field data from 5 operating AHUs in 4 manufacturing facilities, the newly developed AFDD expert system for AHUs was shown to identify four individual fault case categories that the APAR method did not, as well as showing improvements made in the area of fault diagnosis.

Human interfaces to structured documents

This research investigates some of the reasons for the reported difficulties experienced by writers when using editing software designed for structured documents. The overall objective was to determine if there are aspects of the software interfaces which militate against optimal document construction by writers who are not computer experts, and to suggest possible remedies. Studies were undertaken to explore the nature and extent of the difficulties, and to identify which components of the software interfaces are involved. A model of a revised user interface was tested, and some possible adaptations to the interface are proposed which may help overcome the difficulties. The methodology comprised: 1. identification and description of the nature of a ‘structured document’ and what distinguishes it from other types of document used on computers; 2. isolation of the requirements of users of such documents, and the construction a set of personas which describe them; 3. evaluation of other work on the interaction between humans and computers, specifically in software for creating and editing structured documents; 4. estimation of the levels of adoption of the available software for editing structured documents and the reactions of existing users to it, with specific reference to difficulties encountered in using it; 5. examination of the software and identification of any mismatches between the expectations of users and the facilities provided by the software; 6. assessment of any physical or psychological factors in the reported difficulties experienced, and to determine what (if any) changes to the software might affect these. The conclusions are that seven of the twelve modifications tested could contribute to an improvement in usability, effectiveness, and efficiency when writing structured text (new document selection; adding new sections and new lists; identifying key information typographically; the creation of cross-references and bibliographic references; and the inclusion of parts of other documents). The remaining five were seen as more applicable to editing existing material than authoring new text (adding new elements; splitting and joining elements [before and after]; and moving block text).

Development of low-cost sensing and separation devices based on macro, micro and nano technology for health applications

The work presented in this thesis described the development of low-cost sensing and separation devices with electrochemical detections for health applications. This research employs macro, micro and nano technology. The first sensing device developed was a tonerbased micro-device. The initial development of microfluidic devices was based on glass or quartz devices that are often expensive to fabricate; however, the introduction of new types of materials, such as plastics, offered a new way for fast prototyping and the development of disposable devices. One such microfluidic device is based on the lamination of laser-printed polyester films using a computer, printer and laminator. The resulting toner-based microchips demonstrated a potential viability for chemical assays, coupled with several detection methods, particularly Chip-Electrophoresis-Chemiluminescence (CE-CL) detection which has never been reported in the literature. Following on from the toner-based microchip, a three-electrode micro-configuration was developed on acetate substrate. This is the first time that a micro-electrode configuration made from gold; silver and platinum have been fabricated onto acetate by means of patterning and deposition techniques using the central fabrication facilities in Tyndall National Institute. These electrodes have been designed to facilitate the integration of a 3- electrode configuration as part of the fabrication process. Since the electrodes are on acetate the dicing step can automatically be eliminated. The stability of these sensors has been investigated using electrochemical techniques with excellent outcomes. Following on from the generalised testing of the electrodes these sensors were then coupled with capillary electrophoresis. The final sensing devices were on a macro scale and involved the modifications of screenprinted electrodes. Screen-printed electrodes (SPE) are generally seen to be far less sensitive than the more expensive electrodes including the gold, boron-doped diamond and glassy carbon electrodes. To enhance the sensitivity of these electrodes they were treated with metal nano-particles, gold and palladium. Following on from this, another modification was introduced. The carbonaceous material carbon monolith was drop-cast onto the SPE and then the metal nano-particles were electrodeposited onto the monolith material

The biodiversity, control and genetic characterisation of the lactococcal 936 group phages

Phages belonging to the 936 group represent one of the most prevalent and frequently isolated phages in dairy fermentation processes using Lactococcus lactis as the primary starter culture. In recent years extensive research has been carried out to characterise this phage group at a genomic level in an effort to understand how the 936 group phages dominate this particular niche and cause regular problems during large scale milk fermentations. This thesis describes a large scale screening of industrial whey samples, leading to the isolation of forty three genetically different lactococcal phages. Using multiplex PCR, all phages were identified as members of the 936 group. The complete genome of thirty eight of these phages was determined using next generation sequencing technologies which identified several regions of divergence. These included the structural region surrounding the major tail protein, the replication region as well as the genes involved in phage DNA packing. For a number of phages the latter genomic region was found to harbour genes encoding putative orphan methyltransferases. Using small molecule real time (SMRT) sequencing and heterologous gene expression, the target motifs for several of these MTases were determined and subsequently shown to actively protect phage DNA from restriction endonuclease activity. Comparative analysis of the thirty eight phages with fifty two previously sequenced members of this group showed that the core genome consists of 28 genes, while the non-core genome was found to fluctuate irrespective of geographical location or time of isolation. This study highlights the continued need to perform large scale characterisation of the bacteriophage populations infecting industrial fermentation facilities in effort to further our understanding dairy phages and ways to control their proliferation.