280 PERCEIVED NEED FOR A CLINICAL ETHICS SUPPORT SERVICE AT AN IRISH UNIVERSITY HOSPITAL

Background

Ethics are the set of moral principles that guide a person’s behaviour. Ethical issues are a key component of healthcare and frequently arise in the management of hospitalized older patients. To improve decision-making and reduce burden on individual hospital staff, Clinical Ethics Support Services (CESS) have been widely-integrated into care pathways internationally. However, the need for CESS has received little attention in Irish hospitals.

Methods

A cross-sectional analysis of the ethical situation and CESS readiness at a tertiary hospital in Ireland was collected from July-October 2021 and in February 2022 via hard copies and online collection (SurveyMonkey). Both clinical (medicine, nursing other patient care role) and non-clinical (administrative, clerical, ICT, HR, general support staff and management) staff participated. Descriptive statistics were assessed taking the valid percentages, mean 5-item Likert scores and Friedman Test mean rank for ten ranked statements.

Results

In total, 199 people (13% response rate) completed the survey. Staff were largely (76%) clinical and the majority were qualified >10 years (57%). In all, 78% reported that ethical issues arise in the role (83% clinical staff, 59% non-clinical staff). Most (63%) were unsure who to contact about ethical concerns, instead seeking informal advice from colleagues (>90%). The majority of participants were interested in additional ethical training, especially on decision-making capacity (mean interest 4.18 out of 5), strategies for working with challenging patient/family situations (4.07 out of 5) and end-of-life care (4.06 out of 5). Out of ten options assessed, participants preferenced the development of a formal clinical ethics committee over education and training or the provision of educational materials.

Conclusion

Ethical issues commonly arise when caring for older hospitalized patients. This study found a perceived need and widespread interest in additional education as well as formal approaches to develop a hospital-based CESS, centred around a formal committee structure.

Irritant contact dermatitis in healthcare workers as a result of the COVID-19 pandemic: a cross-sectional study

COVID‐19 healthcare workers (HCWs) require frequent handwashing and use of personal protective equipment (PPE) to prevent infection. However, evidence is emerging that these practices are causing adverse effects on their skin integrity. A single‐centre, cross‐sectional study of HCWs from an Irish hospital was undertaken to evaluate the degree of COVID‐19‐related irritant contact dermatitis (ICD) between April and May 2020. Of 270 participants surveyed, 223 (82.6%) reported symptoms of ICD. The hands were the most commonly affected site (76.47%) and the most frequently reported symptom was dry skin (75.37%). Nearly all (268; 99.26%) HCWs had increased hand‐washing frequency, but 122 (45.35%) did not use emollients. In the ICD group, 24.7% cited a history of dermatitis compared with 4.3% of unaffected staff (P < 0.001). The ICD group recorded PPE usage for an average of 3.15 h compared with the non‐ICD group at 1.97 h (P = 0.21). Promoting awareness of COVID‐19‐related ICD is vital to highlight prevention and treatment for frontline staff.

Irish Psychiatric Association survey of psychiatric services in Ireland

Aims and Method

The Irish Psychiatric Association conducted a national survey of psychiatric services in Ireland to examine clinical resources in relation to the relative affluence of catchment areas. A consultant psychiatrist from each catchment area was sent a postal survey form (August 2002) and the data received were cross-referenced with measures of relative affluence.

Results

There was a 72% response rate. A negative relationship emerged between indices of need and both the number of acute beds and the number of consultant psychiatrists per head of the population.

Clinical Implications

The results of this survey indicate that clinical resources in mental health in Ireland are not concentrated in areas of greatest need, but paradoxically have been best developed in areas of greatest affluence.

The Efficacy of COPD Outreach in Reducing Length of Stay and Improving Quality of Life

COPD exacerbations results in prolonged hospitalisation, re-admissions, reduces health-related quality of life (HRQoL) and increases mortality. The study aimed to assess the efficacy of a COPD Outreach service in reducing average length of stay (ALOS), reducing readmissions within 90 days of admission, improving HRQoL and reducing mortality among COPD patients with acute exacerbations (AECOPD). AECOPD data for a 2 year period commencing September 2011 was analysed. The COPD Assessment test (CAT) quantified HRQoL at enrolment and 6 weeks post Outreach. COPD Outreach had an ALOS of 2.47 days compared to ALOS 8.59 days and 8.5 days for all AECOPD before and during an operational COPD Outreach. Re-admission rates among patients enrolled in COPD Outreach were 36.3%. CAT improved from mean 19.3 to 13.5. Mortality was 4.9% among Outreach patients and 2.5% for overall AECOPD in 2012-2013. COPD Outreach reduced ALOS and improved HRQoL for selected patients with AECOPD. It did not reduce re-admissions or mortality.

Pulmonary Langerhans cell histiocytosis

We report the case of a 57 year old man who presented with increased shortness of breath together with increased pulmonary nodules in his upper lobes over a two year period. His strong smoking history and pattern of distribution makes Langerhans cell Histiocytosis a likely diagnosis that was confirmed on biopsy.

Sleep apnoea and its relationship with cardiovascular, pulmonary, metabolic and other morbidities

Sleep apnoea (OSAS) is a multisystem disorder. There is a high prevalence of cardiovascular and metabolic morbidities in patients investigated for sleep apnoea. We aim to evaluate any association between cardiovascular, metabolic and pulmonary co morbidities in patients investigated for OSAS and whether clinical findings based on Epworth sleep score (ESS) and snoring helps in diagnosing sleep apnoea. 258 consecutive patients who were electively admitted for sleep assessment in Peamount Hospital, Dublin from Sept 2009 to Aug 2011 were retrospectively reviewed. 139/258 were diagnosed as OSAS. Cardiovascular, metabolic and pulmonary co morbidities were 46.12%, 37.2% and 29% respectively. There is no correlation found between ESS, Snoring with Apnoea Hypopnoea Index in OSAS group. Screening for OSAS should be considered in patients with certain cardiovascular and metabolic disorders. PSG is so far considered the gold standard investigation to diagnose OSAS and better clinical evaluating tools need to be formulated.

The potential lost hospital income from miscoded emergency department boarders in Ireland

BACKGROUND

Emergency department (ED) boarders, namely patients who have been admitted under an in-patient service but remain on a trolley in the ED, have long been a problem in the Irish healthcare system.

METHODS

We conducted a retrospective analysis of all ED boarders in Cork University Hospital (CUH) for a 6-month period from January to July 2011. Data were obtained from the Hospital In-Patient Enquiry Office (HIPE). The income generated by the hospital for a subset of these patients (January and February attendances) was obtained from the Finance Office in the hospital, based on diagnoses as recorded on the HIPE system. A convenience sample of two-thirds of the 39 acute hospitals nationally was surveyed to ascertain whether ED boarders were coded by individual HIPE offices as hospital in-patients or as ED attendees.

RESULTS

A total of 806 patients were admitted to an in-patient service from January to July 2011 in CUH and subsequently discharged, having completed their entire stay in the ED. The income generated by a sub-sample of 228 patients (January and February ED boarders) was determined. The hospital was remunerated by <euro>685,111 for these patients, i.e. an average income of <euro>3,098 per patient. Only 8 hospitals of the 27 surveyed hospitals coded overnight ED Boarders as in-patients and were thus able to request income for these patients appropriately.

CONCLUSION

Discrepancies in coding of ED boarders may result in significant revenue losses for certain hospitals.

The use of computerised tomography guided percutaneous fine needle aspiration in the evaluation of solitary pulmonary nodules

The evaluation of a solitary pulmonary nodule (SPN) has changed over the years with increased access to percutaneous computerised tomography (CT) guided fine needle aspiration (FNA), where bronchoscopy is unhelpful. The aim of our study was to evaluate the sample adequacy, diagnostic and complication rate of CT-FNA of a SPN at our academic teaching hospital over an 18 month period. CT-FNA was performed by a radiologist, with a cytopathologist in attendance to confirm the adequacy of the sample obtained. The size of the nodule, sample material and adequacy, diagnosis and complications were recorded. A total of 101 patients were included, 54 male and the mean age was 68 +/- 11 years. The mean size of the SPN was 2.3 cm (range 1-11 cm). 56 (56%) patients had a right SPN, 45 (45%) had a left SPN. CT-FNA was diagnostic in 80 (80%) patients and non-diagnostic in 21 (20%) patients. The sample was insufficient for immunocytochemistry, although the morphological appearance was diagnostic in 20 (25%) of the 80 patients. Pneumothorax occurred in 26/101 (26%) patients post CT-FNA, of these 7 (27%) required chest drain insertion, while 19 (73%) were managed conservatively. CT FNA is a useful tool for the diagnosis of a SPN, with our diagnostic accuracy comparable to that reported in the literature. However, CT-FNA may not provide adequate sample volume to perform ancillary testing and has a moderate complication rate.

An unusual cause of spontaneous pneumothorax: the Mounier-Kuhn syndrome

We present the case of a 54-year old woman referred to our service with an unusual presentation of an under-diagnosed condition. A life-long non-smoker, she was referred to respiratory services by our emergency department with a left sided pneumothorax, progressive dyspnoea on exertion, and recurrent chest infections. Subsequent investigation yielded findings consistent with Mounier-Kuhn syndrome (Tracheobronchomegaly), a condition characterised by marked dilatation of the proximal airways, recurrent chest infection, and consequent emphysema and bronchiectasis. Although rarely diagnosed, some degree of Mounier-Kuhn syndrome may occur in up to 1 in 500 adults.

Spontaneous pneumothorax management

Guidelines for the management of spontaneous pneumothorax were published by the British Thoracic Society (BTS) in 2003. The aim of our study was to assess compliance with the BTS guidelines. A retrospective review was performed on all spontaneous pneumothoraces admitted to our hospital between June 2006 and December 2007. There were 29 pneumothoraces during the study period, 20 of which were primary spontaneous pneumothoraces (PSPs). All 15 (100%) large PSPs had an intercostal drain (ICD) inserted with a mean calibre of 20Fr, however only 1 of the 15 (6.7%) had a prior attempt at aspiration. High flow oxygen was used in 3/20 (15%) PSPs and 1/9 (11%) secondary spontaneous pneumothoraces (SSPs). 5/6 (83%) of large SSPs had ICDs placed with a mean calibre of 23.3Fr. Compliance with BTS guidelines was suboptimal. In particular, simple aspiration was underutilised with an over-reliance on unnecessary tube thoracostomy. Moreover, the calibre of intercostal drains used was in excess of BTS recommendations. This study highlights the need to formally adopt BTS guidelines, thereby establishing a more standardised practice which should improve management of spontaneous pneumothoraces.

Nocturnal nasal intermittent positive pressure ventilation (NIPPV) therapy for chronic respiratory failure: long-term effects

The development of positive pressure ventilation delivered through a nasal or face mask has greatly expanded the use of non-invasive ventilation in patients with chronic respiratory insufficiency, particularly during sleep. Disorders ranging from neurologic and neuromuscular, such as polio and muscular dystrophy, central alveolar hypoventilation, thoracic cage disorders such as kyphoscoliosis, and pulmonary disorders such as COPD, particularly of the blue-bloater type. The relative hypoventilation that is common to each condition is due to varying combinations of an inadequate respiratory drive and an increase in the work of breathing. Previous studies have shown sustained reversal of awake hypercapnia in patients with alveolar hypoventilation syndrome using nocturnal NIPPV. We analysed 10 consecutive patients with chronic respiratory insufficiency due to diverse aetiologies over a period of time using long-term domiciliary nocturnal NIPPV. Awake hypercapnia and hypoxaemia improved in nine patients over time and deteriorated in one patient. There was no significant change in pulmonary function apart from one patient with progressive muscular dystrophy who deteriorated. A considerable reduction in the need for subsequent hospital admission was noted in the group as a whole following institution of NIPPV. We conclude that nocturnal NIPPV improves awake gas exchange in patients with chronic respiratory failure.

Test of Xq26.3-28 linkage in bipolar and unipolar affective disorder in families selected for absence of male to male transmission

BACKGROUND

There have been several reports of linkage between genetic markers on the X chromosome at Xq26.3-28 and bipolar affective disorder in family samples obtained from distinct ethnic and geographical origins. As part of a genome search in a series of 23 UK and Icelandic families, specifically selected for their large size and power to resolve the issue of linkage heterogeneity, we have tested the hypothesis that there is a locus for a genetic subtype of bipolar affective disorder which is linked to this region.

METHOD

In families selected on the basis of absent male to male transmission for affective disorder, we performed two-point and FASTMAP multipoint linkage analyses with markers spanning the region between the genetic loci DXS102 and F8.

RESULTS

We found negative lod scores for several models of affection status in families selected under stringent and relaxed criteria for the absence of male to male transmission.

CONCLUSIONS

In the family sample we have obtained, our study provides no support for the presence of a locus increasing genetic susceptibility to bipolar affective disorder in this region of the X chromosome. It is likely that our finding reflects heterogeneity of linkage for bipolar and genetically related unipolar disorder that exists in specific ethnic populations. Alternatively the X-linked subtype of the disorder may have been present only in a few of our small families resulting in loss of power to detect the Xq26.3-28 linked subtype.

Two-locus admixture linkage analysis of bipolar and unipolar affective disorder supports the presence of susceptibility loci on chromosomes 11p15 and 21q22

Following a report of a linkage study that yielded evidence for a susceptibility locus for bipolar affective disorder on the long arm of chromosome 21, we studied 23 multiply affected pedigrees collected from Iceland and the UK, using the markers PFKL, D21S171, and D21S49. Counting only bipolar cases as affected, a two-point LOD of 1.28 was obtained using D21S171 (theta = 0.01, alpha = 0.35), with three Icelandic families producing LODs of 0.63, 0.62, and 1.74 (all at theta = 0.0). Affected sib pair analysis demonstrated increased allele sharing at D21S171 (P = 0.001) when unipolar cases were also considered affected. The same set of pedigrees had previously been typed for a tyrosine hydroxylase gene (TH) polymorphism at 11p15 and had shown some moderate evidence for linkage. When information from TH and the 21q markers was combined in a two-locus admixture analysis, an overall admixture LOD of 3.87 was obtained using the bipolar affection model. Thus the data are compatible with the hypothesis that a locus at or near TH influences susceptibility in some pedigrees, while a locus near D21S171 is active in others. Similar analyses in other datasets should be carried out to confirm or refute our tentative finding.

Further tests for linkage of bipolar affective disorder to the tyrosine hydroxylase gene locus on chromosome 11p15 in a new series of multiplex British affective disorder pedigrees

OBJECTIVE

This study was undertaken to confirm or refute previous reports that link bipolar affective disorder to polymorphic DNA markers at or near the gene for tyrosine hydroxylase.

METHOD

A previous linkage analysis, which used a tetranucleotide repeat polymorphism at the tyrosine hydroxylase locus, of six Icelandic families was extended to include a new series of 17 multiply affected British families.

RESULTS

Overall lod scores under the assumption of locus heterogeneity were between 1.20 and 1.40 at zero recombination with tyrosine hydroxylase, and these scores persisted across three affective disorder models.

CONCLUSIONS

These results provide some support for linking affective disorder to this genetic region and suggest that additional linkage and association studies should be conducted to determine whether tyrosine hydroxylase or a nearby locus contributes to susceptibility to bipolar affective disorder in some families.

A linkage study of affective disorder with DNA markers for the ABO-AK1-ORM linkage group near the dopamine beta hydroxylase gene

Combining data from a number of studies has provided evidence for a susceptibility allele for affective disorder near to the ABO-AK1-ORM region on chromosome 9q34. The dopamine beta hydroxylase gene locus is also at 9q34. Five multigenerational families with bipolar and unipolar affective disorder were analyzed for linkage with highly polymorphic microsatellite markers from the candidate region. The segregation of the illness in these families was compatible with an autosomal dominant susceptibility allele. Linkage analyses using conservative parameters seemed to provide strong evidence against a major susceptibility allele in this region including the candidate gene dopamine beta hydroxylase in these families.

Genetic linkage analysis of manic depression in Iceland

Genetic linkage analysis has been used to study five Icelandic pedigrees multiply affected with manic depression. Genetic markers were chosen from regions which had been implicated by other studies or to which candidate genes had been localized. The transmission model used was of a dominant gene with incomplete penetrance and allowing for a large number of phenocopies, especially for unipolar rather than bipolar cases. Multipoint analysis with linked markers enabled information to be gained from regions spanning large distances. Using this approach we have excluded regions of chromosome 11p, 11q, 8q, 5q, 9q and Xq. Candidate genes excluded include those for tyrosine hydroxylase, the dopamine type 2 receptor, proenkephalin, the 5HT1A receptor and dopamine beta hydroxylase. Nevertheless, we remain optimistic that this approach will eventually identify at least some of the genes predisposing to manic depression.

Segregation and linkage analysis in five manic depression pedigrees excludes the 5HT1a receptor gene (HTR1A)

Five kindreds selected through probands attending an Icelandic hospital were recruited for linkage studies of manic depression. The rates of affection were equal for males and females and the age of onset appeared to be predominantly in early adult life, since prevalence did not rise appreciably with age. A complex segregation analysis was performed using the computer program POINTER to obtain maximum likelihood estimates of the contributions to liability from multifactorial transmission and a single major locus. Likelihood ratios between models supported a role for a single major locus which was dominant and had moderately high penetrance with, in the case of unipolar illness, additional multifactorial transmission. The best-fitting parameters were used to devise a transmission model for linkage analysis. Three markers on chromosome 5 were studied, at D5S76, D5S6 and D5S39. Strongly negative lod scores were obtained which were less than -2 over a distance of 40 cM, which included the region to which the gene for the 5HT1a receptor has been mapped.

Blunted prolactin responses to d-fenfluramine in sociopathy. Evidence for subsensitivity of central serotonergic function

Using a neuroendocrine probe we studied nine male offenders in a forensic hospital, convicted of murder, with a diagnosis of antisocial personality disorder, who had been behaviourally 'quiescent' for varying periods and who had not recently been abusing drugs. Nine healthy age-matched men also participated. All subjects received 30 mg d-fenfluramine (d-FEN), a 5-HT releasing agent, orally, after an overnight fast, and serial samples for prolactin estimation were taken hourly for five hours. Responses were significantly impaired in the patients, suggesting a subsensitivity of certain 5-HT systems in antisocial personality disorder, regardless of recent or ongoing behavioural disturbance.

Role of Drugs and Alcohol in Patients with Head Injury

In an effort to define the role that substance abuse has to play in head injuries, a prospective study of 204 patients presenting to the Accident and Emergency (A&E) Department over a 10-week period was carried out. Urine samples were collected and assayed for the presence of common drugs of abuse and alcohol. One or other substance (drugs or alcohol) was detected in 43% of patients. The association between alcohol and head injuries has been confirmed and the importance of drugs in this area has been addressed and found to be of some significance. More rapid and accurate methods of assaying these substances may improve our management of head injury patients.

Pyomyositis in a temperate climate. Presentation, diagnosis, and treatment

The cases of eighteen patients who were treated for pyomyositis between 1970 and 1988 were evaluated. The diagnosis was often delayed because other primary diagnoses were considered, including muscle strain, synovitis, thrombophlebitis, and neoplasm, and because the symptoms were vague and prolonged (maximum duration, one year). The muscles around the hip and thigh were most commonly involved (twelve patients), and Staphylococcus aureus most commonly grew on culture (twelve patients). Computed tomography aided in the accurate diagnosis of the infection and of the extent of involvement. Incision, drainage, and antibiotic therapy eradicated the infection in all patients, and they had no residual functional limitations and minimum residual symptoms.