Lorraine Kyne - Academia.edu (original) (raw)

Papers by Lorraine Kyne

Journal of Hospital Infection, 1998

Stroke, 2012

Introduction Accurate health economics data is essential for service planning and clinical guidel... more Introduction Accurate health economics data is essential for service planning and clinical guideline development. Stroke associated with atrial fibrillation (AF) is characteristically more severe and disabling than non-AF stroke. Few data exist on the economic impact of AF-stroke compared to non-AF-stroke in population-based samples. Methods The North Dublin Population Stroke Study is a population-based prospective study of incident stroke in Dublin, Ireland. Both direct (healthcare-related) and indirect costs were calculated over a 2-year post-stroke period for individual patients, using data for survival and disability, discharge destination, outpatient and family practitioner visits, community supports, and ongoing treatment. Acute inpatient care was costed using the casemix approach, measuring the resource use per hospitalization (index stroke plus post-stroke admissions). Length of stay was used to cost rehabilitation and nursing home admissions. Indirect costs of illness were ...

Age and Ageing, 2019

Background In Ireland, the Assisted Decision-Making (ADM) (Capacity) Act and emerging Codes of Pr... more Background In Ireland, the Assisted Decision-Making (ADM) (Capacity) Act and emerging Codes of Practice provide a legal framework for Healthcare Professionals (HCPs) to enable ADM for patients with impaired capacity. ADM ensures that a person’s will and preference is at the centre of all decisions related to their care. This study conducted a realist evaluation and developed a Programme Theory (PT) to highlight how ADM for older people can be operationalised within an Acute Care (AC) context. Methods Key informants with interest in ADM informed this evaluation. Interviews were conducted in two Acute Care (AC) sites with multidisciplinary HCPs working within older person services (n=20). Interviews with informants that recently received care within an AC setting involved older people (n=3) people with dementia (n=4) and family carers (n=5). Ethnographic observations from AC multidisciplinary team meetings also informed the review. The framework that guided the qualitative analysis wa...

Age and Ageing, 2019

Background Clear and effective communication is central to all aspects of healthcare. Discussions... more Background Clear and effective communication is central to all aspects of healthcare. Discussions centred on advance care planning are vital to ensure the person with dementia receives the support and care they need in the future based on their will and preferences. The aim of this study was to ascertain from those provided with information on advance care planning if it met their needs and assisted their understanding on planning for the future. Methods This study centred on eliciting the views of older persons diagnosed with dementia and their carers on the provision of an information booklet titled ‘I have dementia ... How do I plan for the future’. Ethical approval was sought and provided to conduct this study. Participants presenting to an acute hospital day ward for older persons were identified and recruited through the medicine for older person’s team. 42 people consented to participate with 20 people returning questionnaires, a 48% response rate. Thematic analysis was appl...

Age and Ageing, 2019

Background Ireland’s Assisted Decision-Making (Capacity) Act 2015 breaks from traditional views o... more Background Ireland’s Assisted Decision-Making (Capacity) Act 2015 breaks from traditional views of capacity to consider the uniqueness of each decision with relation to topic, time and place for those with impaired or fluctuating capacity. It has yet to be commenced, however codes of practice and educational strategies are in development to support health and social care professionals (HSCPs) to practice in accordance with the Act. This study set out to examine barriers and enablers to the adoption of assisted decision making (ADM) involving older people in acute hospitals from multiple perspectives. It describes a pre-implementation formative evaluation informed by the perspectives of relevant stakeholders in ADM practice. Methods In total, 12 key informant interviews and two validation groups were conducted with family carers and older people with and without a diagnosis of dementia in two acute hospitals. In addition, 20 interviews and two validation groups were conducted with HS...

HRB Open Research, 2018

Background: The Assisted Decision-Making (ADM) (Capacity) Act 2015 was enacted by Dáil Éireann in... more Background: The Assisted Decision-Making (ADM) (Capacity) Act 2015 was enacted by Dáil Éireann in December 2015. The purpose of the act, as it applies to healthcare, is to promote the autonomy of persons in relation to their treatment choices, to enable them to be treated according to their will and preferences, and to provide healthcare professionals with important information about persons and their choices in relation to treatment. In practice, those patients with cognitive impairment, particularly dementia, and those with complex needs requiring composite decisions present the greatest challenge to healthcare professionals practicing in accordance with this legislation. Patients with complex needs requiring multifaceted decisions are often over 70 years of age and present in acute hospitals experiencing some form of cognitive impairment. Objectives: The aim of this project is to develop an educational tool which will promote understanding of ADM among healthcare professionals wo...

Irish journal of medical science, Jan 24, 2018

Few population-based studies have assessed lipid adherence to international guidelines for primar... more Few population-based studies have assessed lipid adherence to international guidelines for primary and secondary prevention in stroke/transient ischaemic attack (TIA) patients. This study aims to evaluate adherence to lipid-lowering therapy (LLT) guidelines amongst patients with ischaemic stroke/TIA. Using hot and cold pursuit methods from multiple hospital/community sources, all stroke and TIA cases in North Dublin City were prospectively ascertained over a 1-year period. Adherence to National Cholesterol Education Programme (NCEP) III guidelines, before and after index ischaemic stroke/TIA, was assessed. Amongst 616 patients (428 ischaemic stroke, 188 TIA), total cholesterol was measured following the qualifying event in 76.5% (471/616) and low-density lipoprotein (LDL) in 60.1% (370/616). At initial stroke/TIA presentation, 54.1% (200/370) met NCEP III LDL goals. Compliance was associated with prior stroke (odds ratio [OR] 2.19, p = 0.02), diabetes (OR 1.91, p = 0.04), hypertensi...

Journal of Comorbidity, 2016

Background: Patients with multimorbidity (two or more chronic conditions) are now the norm in cli... more Background: Patients with multimorbidity (two or more chronic conditions) are now the norm in clinical practice, and place an increasing burden on the healthcare system. Management of these patients is challenging, and requires doctors who are skilled in the complexity of multiple chronic diseases. Objective: To perform a systematic review of the literature to ascertain whether there are education and training formats which have been used to train postgraduate medical doctors in the management of patients with multimorbidity in primary and/or secondary care, and which have been shown to improve knowledge, skills, attitudes, and/or patient outcomes. Methods: Overall, 75,110 citations were screened, of which 65 full-text articles were then independently assessed for eligibility by two reviewers, and two studies met the inclusion criteria for the review. Results: The two included studies implemented and evaluated multimorbidity workshops, and highlight the need for further research addressing the learning needs of doctors tasked with managing patients with multimorbidity in their daily practice. Conclusion: While much has been published about the challenges presented to medical staff by patients with multimorbidity, published research regarding education of doctors to manage these problems is lacking. Further research is required to determine whether there is a need for, or benefit from, specific training for doctors to manage patients with multimorbidity. PROSPERO registration number: CRD42013004010.

International journal of stroke : official journal of the International Stroke Society, Jan 3, 2016

Few studies have directly compared stroke recurrence rates after stroke and transient ischemic at... more Few studies have directly compared stroke recurrence rates after stroke and transient ischemic attack, and the risk factors underlying early recurrence are poorly understood. We aimed to investigate risk factors for recurrent stroke after first stroke and transient ischemic attack in a population-based study. The North Dublin Population Stroke Study applied multiple overlapping hot and cold pursuit methods, to ascertain hospital- and community-treated stroke and transient ischemic attack patients over a 12-month period. Inclusion criteria were: (1) Stroke-physician confirmed transient ischemic attack/ischemic stroke; (2) first-stroke/transient ischemic attack event within the ascertainment period. Patients were prospectively followed at 72 h, 7, 28 and 90 days. A total of 584 patients met eligibility criteria (172 transient ischemic attack, 412 stroke). More transient ischemic attack than stroke patients presented to medical attention with recurrent stroke (8.24% vs. 0.24%, p = 0.00...

The Clinical Teacher, 2012

Many advantages to community-oriented medical education have already been described. Responding t... more Many advantages to community-oriented medical education have already been described. Responding to reforms in undergraduate medical education policy, our medical school reconfigured its clinical curriculum to include a module with a broad community focus, based in primary and secondary care. We describe our initial experience developing, implementing and evaluating this module. The aim of the module was to provide students with an understanding of medicine as practised, and health care as delivered, in the community. The 6-week module is delivered four times annually in the final stage of the medical degree programme, with 40-50 students attending each time. Learning experiences encompass clinical attachments, lectures, workshops, seminars and group presentations, with multifaceted assessment and formal student feedback at the end of the module (Ramsden's Module/Course Experience Questionnaire, and student self-assessment of specified learning objectives, using a five-point Likert scale). RESULTS OF STUDENT FEEDBACK: A total of 104 out of 181 (57.5%) students completed the evaluation. Of these, 69.3 per cent were satisfied with the course (with a mean Likert score of 3.7). More than 75 per cent of the students agreed or strongly agreed that they had attained 12 of 13 specified learning objectives, and 64.6 per cent (95% CI 55.0-74.2%) agreed that they could use common diagnostic/therapeutic equipment. The mean Likert scores for Ramsden questionnaire subscales were: good teaching, 3.5; clarity of goals, 3.1; appropriate assessment, 3.6; appropriate workload, 3.7; and generic skills development, 3.4. The most positive scores were attained for teachers' ability to explain (3.95; 77.5% agreed or strongly agreed) and effort at making subjects interesting (3.83; 73.5% agreed or strongly agreed). Our experience shows a community-based module with a strong combined primary care and elderly care focus is feasible, and enables the achievement of valuable learning objectives.

Stroke, 2009

Background and Purpose— Transient ischemic attack (TIA) diagnosis is frequently difficult in clin... more Background and Purpose— Transient ischemic attack (TIA) diagnosis is frequently difficult in clinical practice. Noncerebrovascular symptoms are often misclassified as TIA by nonspecialist physicians. Clinical prediction rules such as ABCD 2 improve the identification of patients with TIA at high risk of early stroke. We hypothesized that the ABCD 2 score may partly improve risk stratification due to improved discrimination of true TIA and minor ischemic stroke (MIS) from noncerebrovascular events. Methods— Consecutive patients with TIA were identified within a prospective population-based cohort study of stroke and TIA. The cohort was expanded by inclusion of patients with MIS and noncerebrovascular events referred to a daily TIA clinic serving the population. Diagnosis was assigned by a trained stroke physician independent of ABCD 2 score. Results— Five hundred ninety-four patients were included (292 [49.2%] TIA, 45 [7.6%] MIS, and 257 [43.3%] noncerebrovascular). The mean ABCD 2 s...

Stroke, 2011

Background and Purpose— Statins improve infarct volume and neurological outcome in animal stroke ... more Background and Purpose— Statins improve infarct volume and neurological outcome in animal stroke models. We investigated the relationship between statin therapy and ischemic stroke outcome in the North Dublin Population Stroke Study. Methods— A population-based prospective cohort study was performed using rigorous ascertainment methods. Prestroke and acute (≤72 hours) poststroke medications were recorded. Modified Rankin score and fatality were assessed at 7, 28, and 90 days and 1 year. Results— Of 448 ischemic stroke patients, statins were prescribed before stroke onset in 30.1% (134/445) and were begun acutely (≤72 hours) in an additional 42.5% (189/445). On logistic regression analysis, adjusting for age, prestroke disability (modified Rankin scale), NIHSS score, hypertension, and aspirin, new poststroke statin therapy was independently associated with improved early and late survival (compared with statin untreated patients: OR for death, 0.12; CI, 0.03–0.54 at 7 days; OR, 0.19;...

Journal of Vascular Surgery, 2012

At this point, vascular surgeons are not likely to be involved with the selection of patients for... more At this point, vascular surgeons are not likely to be involved with the selection of patients for TAVI. However, TAVI will become more widely performed in the U.S. during the next few years as approved devices are gradually disseminated to selected hospitals. Because the devices can require large introducer sheaths (up to 24F) and the transapical approach appears to be associated with higher mortality, vascular surgeons may be involved with selection of access for placement of these devices and treatment of the complications of transfemoral or trans-subclavian access. At this point, major vascular complications in patients undergoing TAVI via the transfemoral approach appear to occur in about 5.5% of the cases. It also appears that in Europe, patients are increasingly opting for TAVI rather than open aortic valve replacement, and there are suggestions of a high rate of off-label use of the device (Zahn R et al, Eur Heart J 2011;32:198-204). Vascular surgeons should be aware of the complexity of these patients, access options, and the complications and outcomes of TAVI.

Journal of the Neurological Sciences, 2013

cognitive decline, cerebral haemorrhages and TIA like episodes. Early diagnosis is important to a... more cognitive decline, cerebral haemorrhages and TIA like episodes. Early diagnosis is important to avoid catastrophic bleeding with antiplatelet or anticoagulant medication. Objective: To demonstrate practical difficulties in diagnosis and management of CAA in patients with vascular risk factors. Patients and methods: We present a case of pathologically proved CAA. Clinical presentation and investigation results are discussed. Results: This gentleman initially presented to psychiatric services with memory problems at the age of 76. Brain MRI showed evidence of small vessel disease. Other vascular risk factors included hypertension, previous smoking and IHD. His medication included aspirin, clopidogrel, citalopram and ramipril. At the age of 79 he had a brief episode of language difficulties lasting for a few hours. One month later he developed a similar but longer episode. CT of the brain showed a right frontal subarachnoid haemorrhage. MRI of the brain 2 days later showed a further left superficial parietotemporal bleeding. Antiplatelets were stopped and the patient made a good recovery. Further fatal intracranial bleeding occurred 2 months later. Pathological examination confirmed CAA. Conclusion: CAA is common in older patients who may have other vascular risk factors. Cognitive impairment and changes on CT or MRI are often attributed to ischemic small vessel disease. This case demonstrates the importance of obtaining specialised MRI sequences in older patients before decisions are made on the use of several antiplatelet agents or oral anticoagulation.

Journal of Medical Microbiology, 2011

Clostridium difficile is the most common cause of nosocomial bacterial diarrhoea in the Western w... more Clostridium difficile is the most common cause of nosocomial bacterial diarrhoea in the Western world. Diarrhoea and colitis are caused by the actions of toxins A and B released by pathogenic strains of C. difficile. Adaptive immune responses to these toxins influence the outcomes of C. difficile infection (CDI). Symptomless carriers of toxinogenic C. difficile and those with a single episode of CDI without recurrence show more robust antitoxin immune responses than those with symptomatic and recurrent disease. Immune-based approaches to CDI therapy and prevention have been developed using active vaccination or passive immunotherapy targeting C. difficile toxins. Innate immune responses to C. difficile and its toxins are also central to the pathophysiology of CDI. An acute intestinal inflammatory response with prominent neutrophil infiltration and associated tissue injury is characteristic of CDI. Furthermore, inhibiting this acute inflammatory response can protect against the intestinal injury that results from exposure to C. difficile toxins in animal models. Studies examining host risk factors for CDI have led to validated clinical prediction tools for risk of primary and of recurrent disease. Risk factors associated with severe CDI with poor clinical outcomes have also been identified and include marked elevation of the peripheral white blood cell count and elevated creatinine. However, further work is needed in this area to guide the clinical application of new approaches to disease prevention and treatment including new antimicrobials as well as passive and active immunization.

Clinical Gastroenterology and Hepatology, 2008

Background & Aims: Recent studies of Clostridium difficile infection (CDI) have indicated a drama... more Background & Aims: Recent studies of Clostridium difficile infection (CDI) have indicated a dramatic increase in metronidazole failure. The aims of this study were to compare current and historical rates of metronidazole failure and to identify risk factors for metronidazole failure. Methods: Eighty-nine patients with CDI in 2004 to 2006 were followed for 60 days and were compared with a historical cohort of 63 CDI patients studied prospectively in 1998. Metronidazole failure was defined as persistent diarrhea after 10 days of therapy or a change of therapy to vancomycin. Stool samples were analyzed for the presence of the North American pulsed-field gel electrophoresis type-1 (NAP-1) strain. Results: Metronidazole failure rates were 35% in both cohorts. There was no difference in the median time to resolution of diarrhea (8 vs 5 d; P ‫؍‬ .52) or the proportion with >10 days of diarrhea (35% vs 29%; P ‫؍‬ .51). Risk factors for metronidazole failure included recent cephalosporin use (odds ratio [OR], 32; 95% confidence interval [CI], 5-219), CDI on admission (OR, 23; 95% CI, 3-156), and transfer from another hospital (OR, 11; 95% CI, 2-72). The frequency of NAP-1 infection in patients with and without metronidazole failure was similar (26% vs 21%; P ‫؍‬ .67). Conclusions: We found no difference in metronidazole failure rates in 1998 and 2004 to 2006. Patients with recent cephalosporin use, CDI on admission, and transfer from another hospital were more likely to metronidazole failure. Infection with the epidemic NAP-1 strain was not associated with metronidazole failure in endemic CDI.

BioDrugs, 1998

Clostridium difficile diarrhoea and colitis is a new disease that is attributable to broad spectr... more Clostridium difficile diarrhoea and colitis is a new disease that is attributable to broad spectrum antibiotic therapy. During the past 2 decades C. difficile has become one of the most common nosocomial pathogens in the developed world. As changing demographics create an increasingly elderly population and the use of broad spectrum antimicrobials continues to expand, C. difficile is likely to become increasingly problematic. Disease caused by this organism is caused by the inflammatory actions of its 2 toxins, A and B, on the intestinal mucosa. Human antibody responses to these toxins are common in the general population and in patients with C. difficileassociated disease. There is substantial, albeit inconclusive, evidence to indicate that antitoxin antibodies provide protection against severe, prolonged or recurrent C. difficile diarrhoea. Immunity induced by oral or parenteral passive administration of antibody is protective in animal models of C. difficile infection. In humans, intravenous passive immunisation with pooled human immunoglobulin has been successful in the treatment of recurrent and severe C. difficile colitis. Human trials of oral passive immunotherapy with bovine immunoglobulin therapy are in progress. Formalin-inactivated culture filtrate from toxigenic C. difficile, as well as purified and inactivated toxins, have been used to successfully immunise animals. Similar preparations are under investigation as possible human vaccines. Antibiotic therapy is effective in treating most individual patients with C. difficile diarrhoea, but has proven ineffective in reducing the overall incidence of nosocomial infection. Active immunisation is probably the most promising approach to long term control of this difficult iatrogenic disease.

Journal of Hospital Infection, 1998

Stroke, 2012

Introduction Accurate health economics data is essential for service planning and clinical guidel... more Introduction Accurate health economics data is essential for service planning and clinical guideline development. Stroke associated with atrial fibrillation (AF) is characteristically more severe and disabling than non-AF stroke. Few data exist on the economic impact of AF-stroke compared to non-AF-stroke in population-based samples. Methods The North Dublin Population Stroke Study is a population-based prospective study of incident stroke in Dublin, Ireland. Both direct (healthcare-related) and indirect costs were calculated over a 2-year post-stroke period for individual patients, using data for survival and disability, discharge destination, outpatient and family practitioner visits, community supports, and ongoing treatment. Acute inpatient care was costed using the casemix approach, measuring the resource use per hospitalization (index stroke plus post-stroke admissions). Length of stay was used to cost rehabilitation and nursing home admissions. Indirect costs of illness were ...

Age and Ageing, 2019

Background In Ireland, the Assisted Decision-Making (ADM) (Capacity) Act and emerging Codes of Pr... more Background In Ireland, the Assisted Decision-Making (ADM) (Capacity) Act and emerging Codes of Practice provide a legal framework for Healthcare Professionals (HCPs) to enable ADM for patients with impaired capacity. ADM ensures that a person’s will and preference is at the centre of all decisions related to their care. This study conducted a realist evaluation and developed a Programme Theory (PT) to highlight how ADM for older people can be operationalised within an Acute Care (AC) context. Methods Key informants with interest in ADM informed this evaluation. Interviews were conducted in two Acute Care (AC) sites with multidisciplinary HCPs working within older person services (n=20). Interviews with informants that recently received care within an AC setting involved older people (n=3) people with dementia (n=4) and family carers (n=5). Ethnographic observations from AC multidisciplinary team meetings also informed the review. The framework that guided the qualitative analysis wa...

Age and Ageing, 2019

Background Clear and effective communication is central to all aspects of healthcare. Discussions... more Background Clear and effective communication is central to all aspects of healthcare. Discussions centred on advance care planning are vital to ensure the person with dementia receives the support and care they need in the future based on their will and preferences. The aim of this study was to ascertain from those provided with information on advance care planning if it met their needs and assisted their understanding on planning for the future. Methods This study centred on eliciting the views of older persons diagnosed with dementia and their carers on the provision of an information booklet titled ‘I have dementia ... How do I plan for the future’. Ethical approval was sought and provided to conduct this study. Participants presenting to an acute hospital day ward for older persons were identified and recruited through the medicine for older person’s team. 42 people consented to participate with 20 people returning questionnaires, a 48% response rate. Thematic analysis was appl...

Age and Ageing, 2019

Background Ireland’s Assisted Decision-Making (Capacity) Act 2015 breaks from traditional views o... more Background Ireland’s Assisted Decision-Making (Capacity) Act 2015 breaks from traditional views of capacity to consider the uniqueness of each decision with relation to topic, time and place for those with impaired or fluctuating capacity. It has yet to be commenced, however codes of practice and educational strategies are in development to support health and social care professionals (HSCPs) to practice in accordance with the Act. This study set out to examine barriers and enablers to the adoption of assisted decision making (ADM) involving older people in acute hospitals from multiple perspectives. It describes a pre-implementation formative evaluation informed by the perspectives of relevant stakeholders in ADM practice. Methods In total, 12 key informant interviews and two validation groups were conducted with family carers and older people with and without a diagnosis of dementia in two acute hospitals. In addition, 20 interviews and two validation groups were conducted with HS...

HRB Open Research, 2018

Background: The Assisted Decision-Making (ADM) (Capacity) Act 2015 was enacted by Dáil Éireann in... more Background: The Assisted Decision-Making (ADM) (Capacity) Act 2015 was enacted by Dáil Éireann in December 2015. The purpose of the act, as it applies to healthcare, is to promote the autonomy of persons in relation to their treatment choices, to enable them to be treated according to their will and preferences, and to provide healthcare professionals with important information about persons and their choices in relation to treatment. In practice, those patients with cognitive impairment, particularly dementia, and those with complex needs requiring composite decisions present the greatest challenge to healthcare professionals practicing in accordance with this legislation. Patients with complex needs requiring multifaceted decisions are often over 70 years of age and present in acute hospitals experiencing some form of cognitive impairment. Objectives: The aim of this project is to develop an educational tool which will promote understanding of ADM among healthcare professionals wo...

Irish journal of medical science, Jan 24, 2018

Few population-based studies have assessed lipid adherence to international guidelines for primar... more Few population-based studies have assessed lipid adherence to international guidelines for primary and secondary prevention in stroke/transient ischaemic attack (TIA) patients. This study aims to evaluate adherence to lipid-lowering therapy (LLT) guidelines amongst patients with ischaemic stroke/TIA. Using hot and cold pursuit methods from multiple hospital/community sources, all stroke and TIA cases in North Dublin City were prospectively ascertained over a 1-year period. Adherence to National Cholesterol Education Programme (NCEP) III guidelines, before and after index ischaemic stroke/TIA, was assessed. Amongst 616 patients (428 ischaemic stroke, 188 TIA), total cholesterol was measured following the qualifying event in 76.5% (471/616) and low-density lipoprotein (LDL) in 60.1% (370/616). At initial stroke/TIA presentation, 54.1% (200/370) met NCEP III LDL goals. Compliance was associated with prior stroke (odds ratio [OR] 2.19, p = 0.02), diabetes (OR 1.91, p = 0.04), hypertensi...

Journal of Comorbidity, 2016

Background: Patients with multimorbidity (two or more chronic conditions) are now the norm in cli... more Background: Patients with multimorbidity (two or more chronic conditions) are now the norm in clinical practice, and place an increasing burden on the healthcare system. Management of these patients is challenging, and requires doctors who are skilled in the complexity of multiple chronic diseases. Objective: To perform a systematic review of the literature to ascertain whether there are education and training formats which have been used to train postgraduate medical doctors in the management of patients with multimorbidity in primary and/or secondary care, and which have been shown to improve knowledge, skills, attitudes, and/or patient outcomes. Methods: Overall, 75,110 citations were screened, of which 65 full-text articles were then independently assessed for eligibility by two reviewers, and two studies met the inclusion criteria for the review. Results: The two included studies implemented and evaluated multimorbidity workshops, and highlight the need for further research addressing the learning needs of doctors tasked with managing patients with multimorbidity in their daily practice. Conclusion: While much has been published about the challenges presented to medical staff by patients with multimorbidity, published research regarding education of doctors to manage these problems is lacking. Further research is required to determine whether there is a need for, or benefit from, specific training for doctors to manage patients with multimorbidity. PROSPERO registration number: CRD42013004010.

International journal of stroke : official journal of the International Stroke Society, Jan 3, 2016

Few studies have directly compared stroke recurrence rates after stroke and transient ischemic at... more Few studies have directly compared stroke recurrence rates after stroke and transient ischemic attack, and the risk factors underlying early recurrence are poorly understood. We aimed to investigate risk factors for recurrent stroke after first stroke and transient ischemic attack in a population-based study. The North Dublin Population Stroke Study applied multiple overlapping hot and cold pursuit methods, to ascertain hospital- and community-treated stroke and transient ischemic attack patients over a 12-month period. Inclusion criteria were: (1) Stroke-physician confirmed transient ischemic attack/ischemic stroke; (2) first-stroke/transient ischemic attack event within the ascertainment period. Patients were prospectively followed at 72 h, 7, 28 and 90 days. A total of 584 patients met eligibility criteria (172 transient ischemic attack, 412 stroke). More transient ischemic attack than stroke patients presented to medical attention with recurrent stroke (8.24% vs. 0.24%, p = 0.00...

The Clinical Teacher, 2012

Many advantages to community-oriented medical education have already been described. Responding t... more Many advantages to community-oriented medical education have already been described. Responding to reforms in undergraduate medical education policy, our medical school reconfigured its clinical curriculum to include a module with a broad community focus, based in primary and secondary care. We describe our initial experience developing, implementing and evaluating this module. The aim of the module was to provide students with an understanding of medicine as practised, and health care as delivered, in the community. The 6-week module is delivered four times annually in the final stage of the medical degree programme, with 40-50 students attending each time. Learning experiences encompass clinical attachments, lectures, workshops, seminars and group presentations, with multifaceted assessment and formal student feedback at the end of the module (Ramsden's Module/Course Experience Questionnaire, and student self-assessment of specified learning objectives, using a five-point Likert scale). RESULTS OF STUDENT FEEDBACK: A total of 104 out of 181 (57.5%) students completed the evaluation. Of these, 69.3 per cent were satisfied with the course (with a mean Likert score of 3.7). More than 75 per cent of the students agreed or strongly agreed that they had attained 12 of 13 specified learning objectives, and 64.6 per cent (95% CI 55.0-74.2%) agreed that they could use common diagnostic/therapeutic equipment. The mean Likert scores for Ramsden questionnaire subscales were: good teaching, 3.5; clarity of goals, 3.1; appropriate assessment, 3.6; appropriate workload, 3.7; and generic skills development, 3.4. The most positive scores were attained for teachers' ability to explain (3.95; 77.5% agreed or strongly agreed) and effort at making subjects interesting (3.83; 73.5% agreed or strongly agreed). Our experience shows a community-based module with a strong combined primary care and elderly care focus is feasible, and enables the achievement of valuable learning objectives.

Stroke, 2009

Background and Purpose— Transient ischemic attack (TIA) diagnosis is frequently difficult in clin... more Background and Purpose— Transient ischemic attack (TIA) diagnosis is frequently difficult in clinical practice. Noncerebrovascular symptoms are often misclassified as TIA by nonspecialist physicians. Clinical prediction rules such as ABCD 2 improve the identification of patients with TIA at high risk of early stroke. We hypothesized that the ABCD 2 score may partly improve risk stratification due to improved discrimination of true TIA and minor ischemic stroke (MIS) from noncerebrovascular events. Methods— Consecutive patients with TIA were identified within a prospective population-based cohort study of stroke and TIA. The cohort was expanded by inclusion of patients with MIS and noncerebrovascular events referred to a daily TIA clinic serving the population. Diagnosis was assigned by a trained stroke physician independent of ABCD 2 score. Results— Five hundred ninety-four patients were included (292 [49.2%] TIA, 45 [7.6%] MIS, and 257 [43.3%] noncerebrovascular). The mean ABCD 2 s...

Stroke, 2011

Background and Purpose— Statins improve infarct volume and neurological outcome in animal stroke ... more Background and Purpose— Statins improve infarct volume and neurological outcome in animal stroke models. We investigated the relationship between statin therapy and ischemic stroke outcome in the North Dublin Population Stroke Study. Methods— A population-based prospective cohort study was performed using rigorous ascertainment methods. Prestroke and acute (≤72 hours) poststroke medications were recorded. Modified Rankin score and fatality were assessed at 7, 28, and 90 days and 1 year. Results— Of 448 ischemic stroke patients, statins were prescribed before stroke onset in 30.1% (134/445) and were begun acutely (≤72 hours) in an additional 42.5% (189/445). On logistic regression analysis, adjusting for age, prestroke disability (modified Rankin scale), NIHSS score, hypertension, and aspirin, new poststroke statin therapy was independently associated with improved early and late survival (compared with statin untreated patients: OR for death, 0.12; CI, 0.03–0.54 at 7 days; OR, 0.19;...

Journal of Vascular Surgery, 2012

At this point, vascular surgeons are not likely to be involved with the selection of patients for... more At this point, vascular surgeons are not likely to be involved with the selection of patients for TAVI. However, TAVI will become more widely performed in the U.S. during the next few years as approved devices are gradually disseminated to selected hospitals. Because the devices can require large introducer sheaths (up to 24F) and the transapical approach appears to be associated with higher mortality, vascular surgeons may be involved with selection of access for placement of these devices and treatment of the complications of transfemoral or trans-subclavian access. At this point, major vascular complications in patients undergoing TAVI via the transfemoral approach appear to occur in about 5.5% of the cases. It also appears that in Europe, patients are increasingly opting for TAVI rather than open aortic valve replacement, and there are suggestions of a high rate of off-label use of the device (Zahn R et al, Eur Heart J 2011;32:198-204). Vascular surgeons should be aware of the complexity of these patients, access options, and the complications and outcomes of TAVI.

Journal of the Neurological Sciences, 2013

cognitive decline, cerebral haemorrhages and TIA like episodes. Early diagnosis is important to a... more cognitive decline, cerebral haemorrhages and TIA like episodes. Early diagnosis is important to avoid catastrophic bleeding with antiplatelet or anticoagulant medication. Objective: To demonstrate practical difficulties in diagnosis and management of CAA in patients with vascular risk factors. Patients and methods: We present a case of pathologically proved CAA. Clinical presentation and investigation results are discussed. Results: This gentleman initially presented to psychiatric services with memory problems at the age of 76. Brain MRI showed evidence of small vessel disease. Other vascular risk factors included hypertension, previous smoking and IHD. His medication included aspirin, clopidogrel, citalopram and ramipril. At the age of 79 he had a brief episode of language difficulties lasting for a few hours. One month later he developed a similar but longer episode. CT of the brain showed a right frontal subarachnoid haemorrhage. MRI of the brain 2 days later showed a further left superficial parietotemporal bleeding. Antiplatelets were stopped and the patient made a good recovery. Further fatal intracranial bleeding occurred 2 months later. Pathological examination confirmed CAA. Conclusion: CAA is common in older patients who may have other vascular risk factors. Cognitive impairment and changes on CT or MRI are often attributed to ischemic small vessel disease. This case demonstrates the importance of obtaining specialised MRI sequences in older patients before decisions are made on the use of several antiplatelet agents or oral anticoagulation.

Journal of Medical Microbiology, 2011

Clostridium difficile is the most common cause of nosocomial bacterial diarrhoea in the Western w... more Clostridium difficile is the most common cause of nosocomial bacterial diarrhoea in the Western world. Diarrhoea and colitis are caused by the actions of toxins A and B released by pathogenic strains of C. difficile. Adaptive immune responses to these toxins influence the outcomes of C. difficile infection (CDI). Symptomless carriers of toxinogenic C. difficile and those with a single episode of CDI without recurrence show more robust antitoxin immune responses than those with symptomatic and recurrent disease. Immune-based approaches to CDI therapy and prevention have been developed using active vaccination or passive immunotherapy targeting C. difficile toxins. Innate immune responses to C. difficile and its toxins are also central to the pathophysiology of CDI. An acute intestinal inflammatory response with prominent neutrophil infiltration and associated tissue injury is characteristic of CDI. Furthermore, inhibiting this acute inflammatory response can protect against the intestinal injury that results from exposure to C. difficile toxins in animal models. Studies examining host risk factors for CDI have led to validated clinical prediction tools for risk of primary and of recurrent disease. Risk factors associated with severe CDI with poor clinical outcomes have also been identified and include marked elevation of the peripheral white blood cell count and elevated creatinine. However, further work is needed in this area to guide the clinical application of new approaches to disease prevention and treatment including new antimicrobials as well as passive and active immunization.

Clinical Gastroenterology and Hepatology, 2008

Background & Aims: Recent studies of Clostridium difficile infection (CDI) have indicated a drama... more Background & Aims: Recent studies of Clostridium difficile infection (CDI) have indicated a dramatic increase in metronidazole failure. The aims of this study were to compare current and historical rates of metronidazole failure and to identify risk factors for metronidazole failure. Methods: Eighty-nine patients with CDI in 2004 to 2006 were followed for 60 days and were compared with a historical cohort of 63 CDI patients studied prospectively in 1998. Metronidazole failure was defined as persistent diarrhea after 10 days of therapy or a change of therapy to vancomycin. Stool samples were analyzed for the presence of the North American pulsed-field gel electrophoresis type-1 (NAP-1) strain. Results: Metronidazole failure rates were 35% in both cohorts. There was no difference in the median time to resolution of diarrhea (8 vs 5 d; P ‫؍‬ .52) or the proportion with >10 days of diarrhea (35% vs 29%; P ‫؍‬ .51). Risk factors for metronidazole failure included recent cephalosporin use (odds ratio [OR], 32; 95% confidence interval [CI], 5-219), CDI on admission (OR, 23; 95% CI, 3-156), and transfer from another hospital (OR, 11; 95% CI, 2-72). The frequency of NAP-1 infection in patients with and without metronidazole failure was similar (26% vs 21%; P ‫؍‬ .67). Conclusions: We found no difference in metronidazole failure rates in 1998 and 2004 to 2006. Patients with recent cephalosporin use, CDI on admission, and transfer from another hospital were more likely to metronidazole failure. Infection with the epidemic NAP-1 strain was not associated with metronidazole failure in endemic CDI.

BioDrugs, 1998

Clostridium difficile diarrhoea and colitis is a new disease that is attributable to broad spectr... more Clostridium difficile diarrhoea and colitis is a new disease that is attributable to broad spectrum antibiotic therapy. During the past 2 decades C. difficile has become one of the most common nosocomial pathogens in the developed world. As changing demographics create an increasingly elderly population and the use of broad spectrum antimicrobials continues to expand, C. difficile is likely to become increasingly problematic. Disease caused by this organism is caused by the inflammatory actions of its 2 toxins, A and B, on the intestinal mucosa. Human antibody responses to these toxins are common in the general population and in patients with C. difficileassociated disease. There is substantial, albeit inconclusive, evidence to indicate that antitoxin antibodies provide protection against severe, prolonged or recurrent C. difficile diarrhoea. Immunity induced by oral or parenteral passive administration of antibody is protective in animal models of C. difficile infection. In humans, intravenous passive immunisation with pooled human immunoglobulin has been successful in the treatment of recurrent and severe C. difficile colitis. Human trials of oral passive immunotherapy with bovine immunoglobulin therapy are in progress. Formalin-inactivated culture filtrate from toxigenic C. difficile, as well as purified and inactivated toxins, have been used to successfully immunise animals. Similar preparations are under investigation as possible human vaccines. Antibiotic therapy is effective in treating most individual patients with C. difficile diarrhoea, but has proven ineffective in reducing the overall incidence of nosocomial infection. Active immunisation is probably the most promising approach to long term control of this difficult iatrogenic disease.