Child Health Care in Ireland

The Irish health care system is based on a complex and costly mix of private, statutory, and voluntary provisions. The majority of health care expenditure comes from the state, with a significant proportion of acute hospital care funded from private insurance, but there are relatively high out-of-pocket costs for most service users. There is free access to acute hospital care, but not for primary care, for all children. About 40% of the population have free access to primary care. Universal preventive public health services, including vaccination and immunization, newborn blood spot screening, and universal neonatal hearing screening are free. Major health challenges include poverty, obesity, drug and alcohol use, and mental health. The health care system has been dominated for the last 5 years by the impact of the current recession, which has led to very sharp cuts in health care expenditure. It is unclear if the necessary substantial reform of the system will happen. Government policy calls for a move toward a patient-centered, primary care-led system, but without very substantial transfers of resources and investment in Information and Communication Technology, this is unlikely to occur. The paper has been published as part of an overall report of Child Health in Europe: Diversity of Child Health Care in Europe: A Study of the European Paediatric Association/Union of National European Paediatric Societies and Associations http://www.jpeds.com/issue/S0022-3476(16)X0010-8 . (J Pediatr 2016;177S:S87-106).  

Economic evaluations of clinical pharmacy services in Ireland, 2007-2015

Introduction The concept of this thesis was driven by stagnation within the Irish healthcare system. Multiple reports from pharmacy organisations had outlined possible future directions for the profession but progress was minimal, especially in comparison with other countries. The author’s directive was to evaluate the economic impact of a series of clinical pharmacy services (CPS) in hospital and community settings. Methods A systematic review of economic evaluations of clinical pharmacy services in hospital patients was undertaken to gain insight into recent research in the field. Eligible studies were evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS), to establish the quality, consistency and transparency of relevant research. A retrospective analysis of an internal hospital pharmacy interventions database was conducted. A method first described by Nesbit et al. was implemented to estimate the level of cost avoidance achieved. A cost-effectiveness analysis based on data from a randomised controlled trial of a pharmacist-supervised patient self-testing (PST) of warfarin therapy is presented. Outcome measure was the incremental cost associated with six months of intervention management. A similar cost-effectiveness analysis based on previously published RCT data was used to evaluate a novel structured pharmacist review of medication in older hospitalised patients. Cost-effectiveness analysis was presented in the form of an incremental cost-effectiveness ratio (ICER). An ICER is an additional cost per unit effect, in the case of this study, the cost of preventing an additional non-trivial ADR in hospital. A method described by Preaud et al. was adapted to estimate the clinical and economic benefit gained from vaccination of patients by a community pharmacist in Ireland in 2013/14. Sample demographic data was obtained from a national chain of community pharmacies and applied to overall national vaccination data. Results Systematic review identified twenty studies which were eligible for inclusion. Overall, pharmacist interventions had a positive impact on hospital budgets. Only three studies (15%) were deemed to be “good-quality” studies. No ‘novel’ clinical pharmacist intervention was identified during the course of this review. Analysis of internal hospital database identified 4,257 interventions documented on 2,147 individual patients over a 12 month period. Substantial cost avoidance of €710,000 was generated over a 1 year period from the perspective of the health care provider. Mean cost avoidance of €166 per intervention was generated. The cost of providing these interventions was €82,000. Substantial net cost-benefits of €626,279 and a cost-benefit ratio of 8.64 : 1 were generated based on this evaluation of pharmacist interventions. Results from an evaluation of a novel pharmacist-led form of warfarin management indicated indicated that on a per patient basis, PST was slightly more expensive than established anticoagulant management. On a per patient basis over a six month period, PST resulted in an incremental cost of €59.08 in comparison with routine care. Overall cost of managing a patient through pharmacist-supervised PST for a six month period is €226.45. However, for this increase in cost a clinically significant improvement in care was provided. Patients achieved a significantly higher time in therapeutic range during the PST arm in comparison with routine care, (72 ± 19.7% vs 59 ± 13.5%). Difference in overall cost was minimal and PST was the dominant strategy in some scenarios examined during sensitivity analysis. Structured pharmacist review of medication was determined to be dominant in comparison to usual pharmaceutical care. Even if the healthcare payer was unwilling to pay any money for the prevention of an ADR, the intervention strategy is still likely to be cost-effective (probability of being determined cost-effective = 0.707). Implementation of pharmacist-led influenza vaccination has resulted in substantial clinical and economic benefits to the healthcare system. The majority of patients (64.9%) who availed of this service had identifiable influenza-related risk factors. Of patients with influenza-related risk factors, age ≥65 year was the most commonly cited risk factor. Pharmacist vaccination services averted a total of 848 influenza cases across all age groups during the 2013/2014 influenza season. Due to receipt of vaccination in a pharmacy setting, 444 influenza-related GP visits were prevented. In terms of more serious influenza-associated events, 11 hospitalisations and five influenza-related deaths were averted. Costs averted were approximately €305,000. These were principally wider societal-related costs associated with lost productivity. Conclusion Overall, clinical pharmacy services are adding value to the Irish healthcare system in both hospital and community settings, but provision of additional funding for new services would enable them to offer a great deal more.

A kingdom near lost: English military recovery in Ireland, 1600-03

Ireland was rarely a peaceful realm for Elizabeth I, but Hugh O’Neill, Earl of Tyrone and his allies brought the edifice of English power in Ireland to the brink of collapse. The war in Ireland at the end of the sixteenth century devoured money, lives and reputations at a prodigious rate. However seven years of Irish success ended when in 1600 the Queen appointed Charles Blount, Lord Mountjoy as Lord Deputy. Success replaced failure, but only after the new Lord Deputy transformed English strategy and rebuilt the army into an instrument fit for purpose.

Occurrence of OsHV-1 in Crassostrea gigas cultured in Ireland during an exceptionally warm summer. Selection of less susceptible oysters

The occurrence of OsHV-1, a herpes virus causing mass mortality in the Pacific oyster Crassostrea gigas was investigated with the aim to select individuals with different susceptibility to the infection. Naïve spat transferred to infected areas and juveniles currently being grown at those sites were analyzed using molecular and histology approaches. The survey period distinguishes itself by very warm temperatures reaching up to 3.5°C above the average. The virus was not detected in the virus free area although a spread of the disease could be expected due to high temperatures. Overall mortality, prevalence of infection and viral load was higher in spat confirming the higher susceptibility in early life stages. OsHV-1 and oyster mortality were detected in naïve spat after 15 days of cohabitation with infected animals. Although, infection was associated with mortality in spat, the high seawater temperatures could also be the direct cause of mortality at the warmest site. One stock of juveniles suffered an event of abnormal mortality that was significantly associated with OsHV-1 infection. Those animals were infected with a previously undescribed microvariant whereas the other stocks were infected with OsHV-1 μVar. Cell lesions due to the infection were observed by histology and true infections were corroborated by in situ hybridization. Survivors from the natural outbreak were exposed to OsHV-1 μVar by intramuscular injection and were compared to naïve animals. The survival rate in previously exposed animals was significantly higher than in naïve oysters. Results derived from this study allowed the selection of animals that might possess interesting characteristics for future analysis on OsHV-1 resistance.

Patterns of psychotropic prescribing and polypharmacy in older hospitalized patients in Ireland: the influence of dementia on prescribing

Neuropsychiatric Symptoms (NPS) are ubiquitous in dementia and are often treated pharmacologically. The objectives of this study were to describe the use of psychotropic, anti-cholinergic, and deliriogenic medications and to identify the prevalence of polypharmacy and psychotropic polypharmacy, among older hospitalized patients in Ireland, with and without dementia. All older patients (≥ 70 years old) that had elective or emergency admissions to six Irish study hospitals were eligible for inclusion in a longitudinal observational study. Of 676 eligible patients, 598 patients were recruited and diagnosed as having dementia, or not, by medical experts. These 598 patients were assessed for delirium, medication use, co-morbidity, functional ability, and nutritional status. We conducted a retrospective cross-sectional analysis of medication data on admission for 583/598 patients with complete medication data, and controlled for age, sex, and co-morbidity. Of 149 patients diagnosed with dementia, only 53 had a previous diagnosis. At hospital admission, 458/583 patients experienced polypharmacy (≥ 5 medications). People with dementia (PwD) were significantly more likely to be prescribed at least one psychotropic medication than patients without dementia (99/147 vs. 182/436; p < 0.001). PwD were also more likely to experience psychotropic polypharmacy (≥ two psychotropics) than those without dementia (54/147 vs. 61/436; p < 0.001). There were no significant differences in the prescribing patterns of anti-cholinergics (23/147 vs. 42/436; p = 0.18) or deliriogenics (79/147 vs. 235/436; p = 0.62). Polypharmacy and psychotropic drug use is highly prevalent in older Irish hospitalized patients, especially in PwD. Hospital admission presents an ideal time for medication reviews in PwD.

Alcohol consumption among university students in Ireland and the United Kingdom from 2002 to 2014: a systematic review

Background: Alcohol is a leading cause of global suffering. Europe reports the uppermost volume of alcohol consumption in the world, with Ireland and the United Kingdom reporting the highest levels of binge drinking and drunkenness. Levels of consumption are elevated among university students. Thus, this literature review aims to summarise the current research on alcohol consumption among university students in the Republic of Ireland and the United Kingdom. Methods: MEDLINE, CINAHL, EMBASE and PsychInfo were systematically searched for literature from January 2002 until December 2014. Each database was searched using the following search pillars: alcohol, university student, Ireland or the United Kingdom and prevalence studies. Results: Two thousand one hundred twenty eight articles were retrieved from electronic database searching. These were title searched for relevance. 113 full texts were retrieved and assessed for eligibility. Of these, 29 articles were deemed to meet inclusion criteria for the review. Almost two thirds of students reported a hazardous alcohol consumption score on the AUDIT scale. Over 20 % reported alcohol problems over their lifetime using CAGE while over 20 % exceed sensible limits each week. Noteworthy is the narrowing of the gender gap throughout the past decade. Conclusion: This is the first review to investigate consumption patterns of university students in Ireland and the United Kingdom. A range of sampling strategies and screening tools are employed in alcohol research which preclude comparability. The current review provides an overview of consumption patterns to guide policy development.

Sexually transmitted infection incidence among adolescents in Ireland

Objective: The burden of sexually transmitted infections (STIs) rests with young people, yet in Ireland there has been very little research into this population. The purpose of this study was to determine the incidence rate and establish risk factors that predict STI occurrence among adolescents in Ireland. Design: Routine diagnostic, demographic and behavioural data from first-time visits to three screening centres in the southwest of Ireland were obtained. Univariate and multivariable logistic regression models were used to assess risk factors that predict STI occurrence among adolescents. Results: A total of 2784 first-time patients, aged 13–19 years, received 3475 diagnoses between January 1999 and September 2009; 1168 (42%) of adolescents had notifiable STIs. The incidence rate of STIs is 225/100 000 person-years. Univariate analysis identified eligible risk factors (p<0.2) for inclusion in the multivariable model. Multivariable logistic regression showed the dominant risk factors for STI diagnosis to be: males who sometimes [odds ratio (OR) 2.02] or never (OR 1.83) use condoms; and females 18–19 years (OR 2.26) and 16–18 years (OR 1.8), with 2 (OR 1.33) or 3+ (OR 1.56) partners in the last 12 months, who are non-intravenous drug users (OR 0.72), are most likely to receive a positive STI diagnosis. Conclusions: STI diagnosis has become increasingly common in Ireland. The proportion of notifications among those aged under 20 years is increasing. These data illustrate the significance of age, condom use and number of sexual partners as risk factors for STI diagnosis. Furthermore, providing data for the first time, we report on the high incidence rate of STIs among adolescents in Ireland. The high levels of risk-taking behaviour and STI acquisition are highlighted and suggest that there is a need for an integrated public health approach to combat this phenomenon in the adolescent population.

Hazardous alcohol consumption among university students in Ireland: a cross-sectional study

Objective: There is considerable evidence of a cultural shift towards heavier alcohol consumption among university students, especially women. The aim of this study is to investigate the prevalence and correlates of hazardous alcohol consumption (HAC) among university students with particular reference to gender and to compare different modes of data collection in this population. Setting: A large Irish university. Design: A cross-sectional study using a classroom distributed paper questionnaire. Participants: A total of 2275 undergraduates completed the classroom survey, 84% of those in class and 51% of those registered for the relevant module. Main outcome measures: Prevalence of HAC measured using the Alcohol Use Disorders Identification Test for Consumption (AUDIT-C) and the proportion of university students reporting 1 or more of 13 adverse consequences linked to HAC. HAC was defined as an AUDIT-C score of 6 or more among males and 5 or more among females. Results: In the classroom sample, 66.4% (95% CI 64.4 to 68.3) reported HAC (65.2% men and 67.3% women). In women, 57.4% met HAC thresholds for men. Similar patterns of adverse consequences were observed among men and women. Students with a hazardous consumption pattern were more likely to report smoking, illicit drug use and being sexually active. Conclusions: The findings highlight the high prevalence of HAC among university students relative to the general population. Public policy measures require review to tackle the short-term and long-term risks to physical, mental and social health and well-being.

Diageo's 'Stop Out of Control Drinking' campaign in Ireland: an analysis

Background: It has been argued that the alcohol industry uses corporate social responsibility activities to influence policy and undermine public health, and that every opportunity should be taken to scrutinise such activities. This study analyses a controversial Diageo-funded ‘responsible drinking’ campaign (“Stop out of Control Drinking”, or SOOCD) in Ireland. The study aims to identify how the campaign and its advisory board members frame and define (i) alcohol-related harms, and their causes, and (ii) possible solutions. Methods: Documentary analysis of SOOCD campaign material. This includes newspaper articles (n = 9), media interviews (n = 11), Facebook posts (n = 92), and Tweets (n = 340) produced by the campaign and by board members. All material was coded inductively, and a thematic analysis undertaken, with codes aggregated into sub-themes. Results: The SOOCD campaign utilises vague or self-defined concepts of ‘out of control’ and ‘moderate’ drinking, tending to present alcohol problems as behavioural rather than health issues. These are also unquantified with respect to actual drinking levels. It emphasises alcohol-related antisocial behaviour among young people, particularly young women. In discussing solutions to alcohol-related problems, it focuses on public opinion rather than on scientific evidence, and on educational approaches and information provision, misrepresenting these as effective. “Moderate drinking” is presented as a behavioural issue (“negative drinking behaviours”), rather than as a health issue. Conclusions: The ‘Stop Out of Control Drinking’ campaign frames alcohol problems and solutions in ways unfavourable to public health, and closely reflects other Diageo Corporate Social Responsibility (CSR) activity, as well as alcohol and tobacco industry strategies more generally. This framing, and in particular the framing of alcohol harms as a behavioural issue, with the implication that consumption should be guided only by self-defined limits, may not have been recognised by all board members. It suggests a need for awareness-raising efforts among the public, third sector and policymakers about alcohol industry strategies

Suicide among young people and adults in Ireland: method characteristics, toxicological analysis and substance abuse histories compared

Objective: Information on factors associated with suicide among young individuals in Ireland is limited. The aim of this study was to identify socio-demographic characteristics and circumstances of death associated with age among individuals who died by suicide. Methods: The study examined 121 consecutive suicides (2007–2012) occurring in the southern eastern part of Ireland (Cork city and county). Data were obtained from coroners, family informants, and health care professionals. A comparison was made between 15-24-year-old and 25-34-year-old individuals. Socio-demographic characteristics of the deceased, methods of suicide, history of alcohol and drug abuse, and findings from toxicological analysis of blood and urine samples taken at post mortem were included. Pearson’s χ2 tests and binary logistic regression analysis were performed. Results: Alcohol and/or drugs were detected through toxicological analysis for the majority of the total sample (79.5%), which did not differentiate between 15-24-year-old and 25-34-year-old individuals (74.1% and 86.2% respectively). Compared to 25-34-year-old individuals, 15-24-year-old individuals were more likely to engage in suicide by hanging (88.5%). Younger individuals were less likely to die by intentional drug overdose and carbon monoxide poisoning compared to older individuals. Younger individuals who died between Saturday and Monday were more likely to have had alcohol before dying. Substance abuse histories were similar in the two age groups. Conclusion: Based on this research it is recommended that strategies to reduce substance abuse be applied among 25-34-year-old individuals at risk of suicide. The wide use of hanging in young people should be taken into consideration for future means restriction strategies.

O "ser português" e o "outro": Revisitar a história de Portugal no diálogo com a civilização chinesa - O caso Tomás Pereira

Tese de Doutoramento em Ciências da Cultura - Especialidade em Culturas do Extremo Oriente

Appartenances en fête: entre l'ordinaire et le spectaculaire

Résumé Alors que les pratiques religieuses régulières diminuent et que les groupes religieux majoritaires perdent des membres formellement enregistrés, une évènementisation de l'appartenance religieuse peut être observée depuis environ deux décennies. Dans un premier exemple, l'auteure montre que le réseau transnational de la confrérie soufie des Mourides resserre les liens entre adeptes dans un contexte migratoire qui tend à fragiliser les relations sociales. La confrérie y fait face à travers une spectacularisation de la pratique religieuse, occupant l'espace public à Harlem ou, dans une moindre mesure, à Paris. Le second exemple traite du pèlerinage aux Saintes et Saints d'Afrique dans la ville valaisanne de Saint Maurice. Ce dernier fut inventé par l'Église catholique suisse afin d'attirer des migrants africains, mais aussi afin de redynamiser une pratique religieuse ordinaire en perte de vitesse. L'évènement a lieu en même temps que le pèlerinage de Namugongo en Ouganda, réunissant plus d'un demi-million de personnes. Les communautés évènementielles ainsi créées sont-elles durables ou plutôt liquides ? Abstract While regular religious practice is decreasing and the major religious groups are losing formally registered members, a 'spectacularization' of religious belonging can be observed over the last two decades. The author presents two examples to support this argument. In the first, the transnational network of the Murids, a Sufi brotherhood, has tried to reinforce the relations between its members, which become fragile during migration. The brotherhood occupies a public space in Harlem, and, to a lesser extent, in Paris, in a spectacularization of religious belonging, in order to remain attractive to migrants. The second example deals with the pilgrimage dedicated to African Saints in the Swiss town of Saint Maurice. This event was invented by the missionary service of the Swiss Catholic Church in order to attract African migrants, but also in order to make ordinary religious practice more appealing. The event takes place at the same time as the Ugandan pilgrimage of Namugongo, which assembles more than half a million people. However, are these 'event communities' sustainable or ephemeral?

Niagara Postcards, 1902, 1908, 1910, undated.

Consists of 33 postcards featuring various scenes and landmarks in the Niagara region. The postcards feature the Great Gorge Route, the Niagara River and Falls, Queenston Heights, Ridley College, military camps in Niagara-on-the-Lake, and a Catholic Church in Port Colborne. Most of the postcards are blank, but four have been postmarked. One of these is addressed to Miss Ada Misner, Espanola, Ont., from M.G. and is postmarked August 18, 1908. Another postcard is addressed to Mr. Alfred H. Smith, Stamford Hill, London N., from Hedley Smith, France and is postmarked 1902. Another is addressed to Miss Annabel Bishop, Buffalo, N.Y. from Irene Lalour(?), and is postmarked April 30, 1908. The last postcard is addressed to Miss Edna Lackie, Toronto, from R.M. and is postmarked August 1, 1910.

Systématisation du contenu théologique de l’expression « nouvelle évangélisation » à la lumière de la théologie pastorale de Jean-Paul II

Polarisé par l’événement du jubilé de l’an 2000, Jean-Paul II, tout au long de son pontificat, achemine l’Église catholique dans un long pèlerinage vers le IIIe millénaire de l’humanité. À l’aube du XXIe siècle, avec le contenu théologique du concile Vatican II pour boussole fiable, le pape polonais arbore une vision pastorale originale marquée par l’expression « nouvelle évangélisation ». Reprise de l’épiscopat d’Amérique latine, cette expression devient ainsi son emblème et son fer de lance durant les quelque 27 années de son pontificat. Largement récupérée par maints milieux ecclésiaux, l’expression méritait qu’on en produise une étude systématique à la lumière de la théologie pastorale de celui qui en a été le divulgateur privilégié. Pour ce faire, nous avons choisi comme texte fondateur à notre étude sa lettre apostolique Tertio Millennio Adveniente publiée en 1994, en raison de la vision pastorale qui s’en dégage à l’aube de l’an 2000. Ce texte, qui couvre la période du concile Vatican II jusqu’à l’entrée de l’Église catholique dans le IIIe millénaire, définit le cadre temporel de notre recherche. Par ailleurs, il nous permet de retenir trois référents théologiques pour conduire notre étude. Nous les analysons et nous en conduisons une synthèse théologique à travers trois regards synoptiques qui acheminent progressivement la thèse vers sa conclusion. Le premier référent théologique retenu est l’exhortation apostolique Evangelii Nuntiandi du pape Paul VI ; le deuxième référent est l’ouvrage de Karol Wojtyla Aux sources du renouveau ; le troisième référent est l’exhortation postsynodale Ecclesia in America. Avec une démarche herméneutique justifiée, et par la synthèse de ces référents théologiques, trois aboutissants voient le jour. Le premier regarde l’application pastorale du concile Vatican II : dans un regard pastoral justifié par une anthropologie définie, le pasteur articule les constitutions Lumen Gentium et Gaudium et Spes pour proposer une praxis pastorale. Le second aboutissant parle alors de la notion de la créativité de la foi. Cette créativité de la foi se décline, elle, dans les médiations culturelles – troisième aboutissant – qui s’articulent elles-mêmes autour des concepts d’attitudes et de dialogue wojtylien. La critique proposée en conclusion de thèse porte directement sur l’anthropologie proposée par Jean-Paul II sous-jacente à chacun de ces trois aboutissants.