Essential Public Health Functions in Ireland: Perspectives to strengthen capacities and stewardship

Background

COVID-19 has caused unprecedented disruptions to health, social and economic systems in countries worldwide including Ireland. Weaknesses in Public Health capacities have undermined health system resilience compounding the effects of the pandemic. The Essential Public Health Functions (EPHFs) provide a comprehensive, cost-effective approach to operationalising public health and a means to build health systems resilience. As Ireland looks to recovery, the Department of Health engaged the World Health Organization (WHO) to undertake a mapping of the current state of delivery of EPHFs to identify opportunities for improvement and support wider health system strengthening towards resilience.

Methods

A strategic review of the delivery of EPHFs in Ireland was conducted with respect to policy, infrastructure, service provision and coordination and integration. Findings were reported in the context of international lessons identified through experience with COVID-19 and major health system challenges within the Irish context.

Results

There are significant capacities present within the Irish context to support the delivery of the EPHFs though they are limited in strategic cohesion, coordination and implementation. These include a high level of Public Health expertise, an agile and resourceful workforce, a strongly engaged community and significant evidence generation and synthesis capacities. Gaps recognised included ICT infrastructure and capacity, workforce resourcing and support, pandemic planning and public health governance, visibility, legislation, strategy and resourcing. COVID-19 has led to the development and strengthening of mechanisms to leverage a whole-of-government and -society approach to health that should be sustained to tackle ongoing and future stressors.

Conclusions

The use of the EPHFs within the Irish setting provides a comprehensive approach to strengthening capacities for public health and enhanced population health and wellbeing.

239 IS ORTHOSTATIC HYPOTENSION ASSOCIATED WITH ALTERED CEREBRAL PERFUSION DURING ACTIVE STANDING?

Background

Orthostatic Hypotension (OH) is associated with poor health outcomes in later life including depression, cognitive impairment, frailty and falls. Whilst it is hypothesised that OH compromises cerebral autoregulation leading to hypoperfusion, this has not been robustly demonstrated to date. This study investigated the association between OH and cerebral perfusion during orthostasis using a non-invasive surrogate of cerebral perfusion, Near Infrared Spectroscopy (NIRS).

Methods

Four hundred and ninety one participants (58% female, median age 65, IQR 38–92) attending a falls and syncope service underwent measurement of beat-to-beat blood pressure (BP) by finometry and real-time frontal lobe perfusion (% TSI: Tissue Saturation Index) by NIRS during the active stand manoeuvre. We examined the association between OH and change in cerebral perfusion (delta TSI) using mixed-effects linear regression, with adjustment for important clinical covariates.

Results

Nearly two-fifths of the sample (189/491,38.5%) met criteria for OH occurring between 30 and 120 seconds after standing. Using mixed effects linear regression models, we observed a significant relationship between OH and TSI at the same timepoint (β −0.53, −0.59 to −0.46, p < 0.001) which persisted following adjustment for confounders including age, sex, baseline blood pressure, cerebrovascular and cardiovascular disease, depression/anxiety, diabetes, systolic blood pressure, antihypertensives, and antidepressants (β −0.51, −0.58 to −0.44, p < 0.001). Cerebral perfusion levels differed for those with OH compared to those without.

Conclusion

OH is independently associated with lower frontal lobe cerebral perfusion. This association may indicate disruption to dynamic cerebral autoregulation and explain the significant link between OH and poor health outcomes.

Real-time assessment of learning curve for robot-assisted laparoscopic prostatectomy

INTRODUCTION

The learning curves analysed to date for robot-assisted laparoscopic prostatectomy are based on arbitrary cut-offs of the total cases.

METHODS

We analysed a large dataset of robot-assisted laparoscopic prostatectomies from a single centre between 2008 and 2019 for assessment of the learning curve for perioperative outcomes with respect to time and individual cases.

RESULTS

A total of 1,406 patients were evaluated, with mean operative time 198.08 minutes and mean console time 161.05 minutes. A plot of operative time and console time showed an initial decline followed by a near-constant phase. The inflection points were detected at 1,398 days (308th case) for operative time and 1,470 days (324th case) for console time, with a declining trend of 8.83 minutes and 7.07 minutes, respectively, per quarter-year (p<0.001). Mean estimated blood loss showed a 70.04% reduction between the start (214.76ml) and end (64.35ml) (p<0.001). The complication rate did not vary with respect to time (p=0.188) or the number of procedures (p=0.354). There was insufficient evidence to claim that the number of operations (p=0.326), D'Amico classification (p=0.114 for intermediate versus low; p=0.158 for high versus low) or time (p=0.114) was associated with the odds of positive surgical margins.

CONCLUSIONS

It takes about 300 cases and nearly 4 years to standardise operative and console times, with a requirement of around 80 cases per annum for a single surgical team in the initial years to optimise the outcomes of robot-assisted laparoscopic prostatectomy.

The association between benzodiazepine use and falls, and the impact of sleep quality on this association: data from the TILDA study

BACKGROUND

Benzodiazepines (BZD) are associated with adverse effects, particularly in older adults.

AIM

This study assesses the association between BZD use and falls, and the impact of sleep quality on this association, in community dwelling adults aged over 50.

DESIGN

Cross-sectional analysis of data from wave 1 of The Irish Longitudinal Study on Ageing.

METHODS

Participants were classed as BZD users or non-users and asked if they had fallen in the last year, and whether any falls were unexplained. Sleep quality was assessed via self-reported trouble falling asleep, daytime somnolence and early-rising. Logistic regression assessed for an association between BZD use and falls, and the impact of sleep quality on this association was assessed by categorizing based on BZD use and sleep quality variables.

RESULTS

Of 8175 individuals, 302 (3.69%) reported taking BZDs. BZD use was associated with falls, controlling for confounders [Odds Ratio (OR) 1.40; 1.08, 1.82; P-value 0.012]. There was no significant association between BZDs and unexplained falls, controlling for confounders [OR 1.41; 95% Confidence Interval (CI) 0.95, 2.10; P-value 0.09]. Participants who use BZDs and report daytime somnolence (OR 1.93; 95% CI 1.12, 3.31; P-value 0.017), early-rising (OR 1.93; 95% CI 1.20, 3.11; P-value 0.007) or trouble falling asleep (OR 1.83; 95% CI 1.12, 2.97; P-value 0.015), have an increased odds of unexplained falls.

CONCLUSION

BZD use is associated with falls, with larger effect size in those reporting poor sleep quality in community dwelling older adults. Appropriate prescription of medications such as BZDs is an important public health issue.

Subpubic cartilaginous cyst: an unusual cause of urinary tract infection

It is important to consider alternative causes when treating refractory cases of urinary tract infection in the elderly population.

Is orthostatic hypotension more common in individuals with atrial fibrillation?-Findings from The Irish Longitudinal Study on Ageing (TILDA)

Introduction

atrial fibrillation (AF) and orthostatic hypotension (OH) share common risk factors such as age, hypertension and cardiovascular (CV) disease. The autonomic nervous system (ANS) also plays a role in the pathogenesis of both AF and OH. The aim of this study is to assess whether individuals with AF are more likely to have OH than those without AF.

Methods

data from wave 1 of The Irish Longitudinal Study on Ageing were used. Beat-to-beat blood pressure was measured during active stand lasting 110 s. OH, defined as a drop in systolic blood pressure (SBP) ≥20 mmHg or a drop in diastolic blood pressure ≥10 mmHg at 30, 60 and 90 s was assessed. Initial OH (IOH) was assessed as a drop in SBP ≥40 mmHg or a drop in diastolic BP≥20 mmHg.

Results

in total 4,408 participants aged ≥50 had active stand and electrocardiogram data suitable for analysis. AF was identified in 101 of these. Logistic regression found participants with AF were more likely to have OH at 30 (odds ratio (OR) 1.95, 95% confidence interval (CI) 1.24-3.06) and 60 (OR 2.13, 95% CI 1.18-3.87) seconds, and IOH (OR 1.81, 95% CI 1.21-2.70). The association between IOH and OH at 30 s remained significant following adjustment for confounders (age, sex, baseline HR, education, BP, smoking, frailty, beta blocker (BB) use, anti-hypertensive use (excluding BBs) and number of CV conditions).

Conclusion

OH is more common in individuals with AF, this may reflect the role of the ANS in both AF and OH.

The management of vasovagal syncope

Vasovagal syncope, or the "common faint", is the most common cause of syncope. Although it is considered a benign condition, there is a significant economic burden and significant impact on quality of life in patients with recurrent syncope, particularly in older adults. Typical vasovagal syncope usually occurs in young adults, and can often be diagnosed on the basis of history, in the absence of structural heart disease. Atypical vasovagal syncope, which is more common in older adults, can be more difficult to diagnose, however. In atypical vasovagal syncope, there is often a short or absent prodrome, and amnesia for loss of consciousness is common and it can, therefore, often be misdiagnosed, for example as falls. A more standardized approach to the diagnosis and management of patients presenting with syncope or unexplained falls is required, and it is anticipated that the number of Syncope Units will increase. Treatment of vasovagal syncope is largely conservative; however, medical or device therapy may be required when syncope is severe and refractory to conservative treatment, as there is significant impact on quality of life and it can be associated with injury. The aim of this article is to provide an overview of the diagnosis and management of vasovagal syncope.

Integrative review on the non-invasive management of lower urinary tract symptoms in men following treatments for pelvic malignancies

AIM

To develop a non-invasive management strategy for men with lower urinary tract symptoms (LUTS) after treatment for pelvic cancer, that is suitable for use in a primary healthcare context.

METHODS

PubMed literature searches of LUTS management in this patient group were carried out, together with obtaining a consensus of management strategies from a panel of authors for the management of LUTS from across the UK.

RESULTS

Data from 41 articles were investigated and collated. Clinical experience was sought from authors where there was no clinical evidence. The findings discussed in this paper confirm that LUTS after the cancer treatment can significantly impair men's quality of life. While many men recover from LUTS spontaneously over time, a significant proportion require long-term management. Despite the prevalence of LUTS, there is a lack of consensus on best management. This article offers a comprehensive treatment algorithm to manage patients with LUTS following pelvic cancer treatment.

CONCLUSION

Based on published research literature and clinical experience, recommendations are proposed for the standardisation of management strategies employed for men with LUTS after the pelvic cancer treatment. In addition to implementing the algorithm, understanding the rationale for the type and timing of LUTS management strategies is crucial for clinicians and patients.

Screening for carcinoma of the prostate: a GP based study

OBJECTIVE

To examine the feasibility and acceptability of screening for cancer of the prostate by digital rectal examination (DRE), prostate specific antigen (PSA) determination and subsequent transrectal ultrasound (TRUS) in selected patients in a single general practice in Hertfordshire.

SUBJECTS AND METHODS

A total of 568 of 856 men aged 55 to 70 accepted an invitation for a health check which included screening for prostate cancer. Of these, 80 individuals with either a raised PSA level or an abnormal DRE underwent TRUS. In 29 individuals biopsies were taken, 11 of which confirmed the presence of adenocarcinoma of the prostate giving an overall detected prevalence of 2%. Of the 11 tumours identified by screening, two were T1M0, four were T2M0, two were T3M0 and three were T3M1.

RESULTS

To assess the acceptability of the screening exercise a postal questionnaire was sent to all 568 participants: 83% replied and 69% reported no concern. Of the 67 individuals who had undergone TRUS, 69% reported discomfort. A total of 448 (95%) of respondents declared that they would be prepared to undergo the screening exercise again.

CONCLUSION

Screening for prostate cancer would seem to be technically feasible and generally acceptable. However, there is a considerable false positive rate in the PSA range 4 ng/ml to 10 ng/ml, particularly among men with clinical evidence of benign prostatic hyperplasia. To establish the true benefit of screening a large-scale prospective controlled study will be necessary.

Endoscopic application of lasers in urology

Urology is an increasingly endoscopic surgical specialty. The unique physical characteristics of lasers lend themselves to a range of urological applications at present in specialist centres but increasingly in more general urological practice.

Intramural rupture and intramural haematoma of the oesophagus

We report on two cases of spontaneous intramural rupture and haematoma formation in the oesophagus. This is an unusual and often misdiagnosed condition. Its diagnosis relies on the history and a barium swallow. Instrumentation can result in further damage to the oesophagus and should be avoided. Treatment is conservative and results in resolution of the haematoma and a return to normal swallowing.

Lymphoid polyps of the rectum

In children lymphoid polyps of the rectum are uncommon benign lesions with a good prognosis following local treatment. We report a girl in whom a cluster of lymphoid polyps occurred 9 months following removal of a single lymphoid polyp. All of the polyps, including the original lesion, displayed a monoclonal nature on immunocytochemical examination.