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Reflective practice is increasingly being recognized as an important component of doctors’ professional development. Balint group practice is centered on the doctor–patient relationship: what it means, how it may be used to benefit patients, and why it commonly fails owing to a lack of understanding between doctor and patient. The COVID-19 pandemic led to unprecedented disruption to postgraduate medical training programs, including the mandatory Balint groups for psychiatric trainees. This editorial reports on the experience of online Balint groups in the North West of Ireland during the COVID-19 pandemic, and furthermore provides guidance for online Balint group practice into the future.
The COVID-19 pandemic caused significant disruptions in services and necessitated innovation to continue care provision to the vulnerable population of older adults with psychiatric needs.
The objective of this study was to examine the experiences of staff and patients using a hands-free electronic smart-hub (eSMART hub) intervention to keep patients connected with psychiatry of old age following COVID-19 restrictions.
A risk stratification register was created of all patients known to the Psychiatry of Old Age service in the North-West of Ireland to identify those at highest risk of relapse. These patients were offered a smart-hub with remote communication and personal assistant technology to be installed into their homes. Smart-hubs were also installed in the team base to facilitate direct device to device communication. Semi-structured qualitative interviews were conducted with 10 staff members and 15 patients at 6-12 months following the installation of the smart-hubs.
The smart-hubs were utilized by the POA team to offer remote interventions over video including clinician reviews, regular contact with key workers and day-hospital based therapeutic interventions such as anxiety management groups and OT led physical exercises. Patients also used the personal assistant aspect of the hub to attend to personal hobbies such as accessing music and radio. Positive feedback related to companionship during isolation and connectivity to services. Negative feedback was mainly related to technology, particularly internet access and narrow scope of communication abilities.
Electronic smart-hub devices may offer an acceptable avenue for remote intervention and communication for isolated high-risk older persons.
The smart hub devices used in this study were donated by Amazon. However, the company was not involved in any other aspect of the study and the researchers have no significant financial interest, consultancy or other relationship with products, manufactur
Covid-19 pandemic caused a pivot to online clinical education and assessment across the globe.
To explore the views of psychiatric trainees and examiners on assessment of communication skills during online high stakes postgraduate examination.
This study was designed as interpretive descriptive qualitative research. All candidates and examiners of the online Irish Basic Specialist Training exam in September and November 2020 were included. The respondents were interviewed by Zoom which were transcribed verbatim. Data was coded using NVivo20 pro and Braun and Clarke thematic analysis was used to draw various themes and subthemes.
A total of seven candidates and seven examiners from different training deaneries and specialties were interviewed with average duration of 29m 45s and 24m 20s respectively. The participants were largely satisfied with the online examination but did not consider it equal to face-to-face for picking nonverbal cues. The candidates were very conscious of eye contact while examiners placed more emphasis on overall professional behavior and patient engagement. All candidates preferred to continue online format post pandemic for practical reasons e.g., avoiding travel and overnight stay, while all examiners preferred to go back to in-person Objective Structured Clinical Examination due to some limitations in assessing physical and cognitive examination. However, continuation of online Clinical Formulation and Management Examination was agreed by both groups.
The results of the study have shown different insights of two important stakeholders in a professional postgraduate psychiatry examination which can be useful to improve same exam and design similar assessments in other settings.
Objective structured clinical examinations (OSCEs) play a pivotal role in medical education assessment. The Advanced Clinical Skills (ACS) OSCE examines clinical skills in psychiatry, general practice, obstetrics and gynaecology and paediatrics. This study examined if the 2020 ACS OSCE for fourth year medical students attending the National University of Ireland, Galway, was associated with any significant result differences compared to the equivalent 2019 OSCE. Additionally, we assessed students’ satisfaction and explored any organisational difficulties in conducting a face-to-face OSCE during the COVID-19 pandemic.
Materials and methods:
This study compared anonymised data between the 2019 and 2020 ACS OSCEs and analysed anonymised student feedback pertaining to the modified 2020 OSCE.
The mean total ACS OSCE result achieved in 2020 was statistically higher compared to the 2019 OSCE [62.95% (SD = 6.21) v. 59.35% (SD = 5.54), t = 6.092, p < 0.01], with higher marks noted in psychiatry (p = 0.001), paediatrics (p = 0.001) and general practice (p < 0.001) with more students attaining honours grades (χ2 = 27.257, df = 3, p < 0.001). No difference in failure rates were found. Students reported feeling safe performing the 2020 OSCE (89.2%), but some expressed face-mask wearing impeded their communication skills (47.8%).
This study demonstrates that conducting a face-to-face OSCE during the pandemic is feasible and associated with positive student feedback. Exam validity has been demonstrated as there was no difference in the overall pass rate.
Response to lithium in patients with bipolar disorder is associated with clinical and transdiagnostic genetic factors. The predictive combination of these variables might help clinicians better predict which patients will respond to lithium treatment.
To use a combination of transdiagnostic genetic and clinical factors to predict lithium response in patients with bipolar disorder.
This study utilised genetic and clinical data (n = 1034) collected as part of the International Consortium on Lithium Genetics (ConLi+Gen) project. Polygenic risk scores (PRS) were computed for schizophrenia and major depressive disorder, and then combined with clinical variables using a cross-validated machine-learning regression approach. Unimodal, multimodal and genetically stratified models were trained and validated using ridge, elastic net and random forest regression on 692 patients with bipolar disorder from ten study sites using leave-site-out cross-validation. All models were then tested on an independent test set of 342 patients. The best performing models were then tested in a classification framework.
The best performing linear model explained 5.1% (P = 0.0001) of variance in lithium response and was composed of clinical variables, PRS variables and interaction terms between them. The best performing non-linear model used only clinical variables and explained 8.1% (P = 0.0001) of variance in lithium response. A priori genomic stratification improved non-linear model performance to 13.7% (P = 0.0001) and improved the binary classification of lithium response. This model stratified patients based on their meta-polygenic loadings for major depressive disorder and schizophrenia and was then trained using clinical data.
Using PRS to first stratify patients genetically and then train machine-learning models with clinical predictors led to large improvements in lithium response prediction. When used with other PRS and biological markers in the future this approach may help inform which patients are most likely to respond to lithium treatment.
Lithium has a narrow therapeutic index with a risk of toxicity and potential to increase morbidity and mortality, particularly in the elderly with co-morbid illness and polypharmacy. Lithium therapy and monitoring of lithium levels require precision and several guidelines have been issued including recommendations for strict control of lithium levels in the elderly population.
We evaluated the effect of implementation of a multifaceted management programme on the compliance with international practice standards for lithium monitoring in patients under the care of Psychiatry of Old Age (POA), Sligo Leitrim Mental Health Services in the North West of Ireland.
Results from a prior audit performed in February 2020 involving a cohort of 18 patients prescribed lithium under the care of POA were analysed and compared to accepted standards. The guideline used as the benchmark for compliance was the National Institute for Clinical Excellence (NICE) guidelines on the use and monitoring of lithium therapy, as published in 2014. Several deficits were found and therefore a designated Lithium Management Programme was established. A subsequent audit, performed using a simplified audit tool incorporating the NICE guidelines, delivered results which were directly compared to the initial findings and analysed to evaluate the effect of the implemented management programme.
PRELIMINARY RESULTS OF THE ONGOING STUDY:
In comparison with findings from 2020, there had been a significant improvement in most facets of lithium management and compliance to practice standards. Of particular note was the improvement of biochemical monitoring, side effect screening, polypharmacy surveillance, patient education and interdisciplinary communication.
The launch of a dedicated Lithium Management Programme with specific features aimed at identifying and addressing poor compliance with monitoring guidelines has led to improved adherence to accepted international practice standards. Our model provides a dynamic, multi-layered system which paves the way for better patient outcomes, timely access to care and furthering education for patients and staff members.
Equipping our medical students with as many tools as possible to cope with the challenges that they will inevitably face has never been more important than it is today.
The aim of this study was to examine the effectiveness of a reflective practice (RP) group for medical students, particularly with adaptation to COVID-19 and transition to video.
A pilot programme of RP for 3rd year medical students commencing their clinical placement was run by the Sligo Medical Academy, NUIG in Ireland between January – April 2020. This group for nine students was initially run face-to-face but pivoted to an online group in March 2020 with the COVID-19 pandemic. Data was collected through one-to-one interviews with all student participants and the facilitator (n=10). Interviews were recorded and transcribed. Data were analysed using thematic content analysis.
Our analysis identified four main discussion themes: transition to clinical environment, gender in the workplace, building professional identity and family and support systems. The students who continued the RP group over zoom during the COVID-19 pandemic particularly identified with the theme of support systems and solidarity. The smooth transition to zoom and its effectiveness in a time of social distancing were discussed. Identified challenges related primarily to timing of the RP group, particularly after a full day of placements or time differences for international students overseas.
Reflective practice programmes are not routinely offered to medical students in Ireland currently and this study gives recommendations on implementing and improving experiences of undergraduate training based on RP.
The COVID-19 pandemic has required services to evolve quickly to continue routine care and telemedicine has been rapidly implemented to facilitate this. Older persons are at high risk of serious complications of COVID-19 and it is essential that their exposure to COVID-19 is minimized.
Our aim was to assess staff and patient satisfaction with remote psychiatric assessments using mobile tablets in long-stay facilities.
Remote clinics using Skype video on mobile tablets were conducted with patients in long-stay facilities attending psychiatry in rural North-West Ireland between April and July 2020. At each review, a satisfaction survey was administered to the patient, their keyworker and the clinician. The patient/keyworker survey instrument had four yes/no statements and the clinician survey had four statements with 5-point likert scale responses (1=very low to 5=very high). Open feedback was also obtained for thematic analysis. Descriptive analyses were completed using SPSS software.
23 patients (mean age 80.9yrs) were assessed in 10 long-stay facilities. All patients were agreeable to participating in video consultation although only 13 patients were able to respond to survey due to cognitive impairment. There was a 92.3% positive patient response (12/13) and 95.7% positive keyworker response (N=22/23) for all statements. The mean score on the assessor response ranged from 3.43 to 4.04 with the lowest rate for quality of transmission. The main themes identified were related to the quality of connection and sensory difficulties.
Video consultations using mobile tablets offer an acceptable form of remote psychiatry assessment for older persons in long-stay facilities.
Synchrotron radiation images from runaway electrons (REs) in an ASDEX Upgrade discharge disrupted by argon injection are analysed using the synchrotron diagnostic tool Soft and coupled fluid-kinetic simulations. We show that the evolution of the runaway distribution is well described by an initial hot-tail seed population, which is accelerated to energies between 25–50 MeV during the current quench, together with an avalanche runaway tail which has an exponentially decreasing energy spectrum. We find that, although the avalanche component carries the vast majority of the current, it is the high-energy seed remnant that dominates synchrotron emission. With insights from the fluid-kinetic simulations, an analytic model for the evolution of the runaway seed component is developed and used to reconstruct the radial density profile of the RE beam. The analysis shows that the observed change of the synchrotron pattern from circular to crescent shape is caused by a rapid redistribution of the radial profile of the runaway density.
Delirium, which is associated with adverse health outcomes, is poorly detected in hospital settings. This study aimed to determine delirium occurrence among older medical inpatients and to capture associated risk factors.
This prospective cohort study was performed at an Irish University Hospital. Medical inpatients 70 years and over were included. Baseline assessments within 72 hours of admission included delirium status and severity as determined by the Revised Delirium Rating Scale (DRS-R-98), cognition, physical illness severity and physical functioning. Pre-existing cognitive impairment was determined with Short Informant Questionnaire on Cognitive Decline (IQCODE). Serial assessment of delirium status, cognition and the physical illness severity were undertaken every 3 (±1) days during participants’ hospital admission.
Of 198 study participants, 92 (46.5%) were women and mean age was 80.6 years (s.d. 6.81; range 70–97). Using DRS-R-98, 17.7% (n = 35) had delirium on admission and 11.6% (n = 23) had new-onset delirium during admission. In regression analysis, older age, impaired cognition and lower functional ability at admission were associated with a significant likelihood of delirium.
In this study, almost one-third of older medical inpatients in an acute hospital had delirium during admission. Findings that increasing age, impaired cognition and lower functional ability at admission were associated with increased delirium risk suggest target groups for enhanced delirium detection and prevention strategies. This may improve clinical outcomes.
We present continuous estimates of snow and firn density, layer depth and accumulation from a multi-channel, multi-offset, ground-penetrating radar traverse. Our method uses the electromagnetic velocity, estimated from waveform travel-times measured at common-midpoints between sources and receivers. Previously, common-midpoint radar experiments on ice sheets have been limited to point observations. We completed radar velocity analysis in the upper ~2 m to estimate the surface and average snow density of the Greenland Ice Sheet. We parameterized the Herron and Langway (1980) firn density and age model using the radar-derived snow density, radar-derived surface mass balance (2015–2017) and reanalysis-derived temperature data. We applied structure-oriented filtering to the radar image along constant age horizons and increased the depth at which horizons could be reliably interpreted. We reconstructed the historical instantaneous surface mass balance, which we averaged into annual and multidecadal products along a 78 km traverse for the period 1984–2017. We found good agreement between our physically constrained parameterization and a firn core collected from the dry snow accumulation zone, and gained insights into the spatial correlation of surface snow density.
The Coronavirus Disease 2019 (COVID-19) has accounted for more than 25 000 cases in Ireland with approximately 28% of the clusters in nursing homes as of June 2020. The older population is the most vulnerable to serious complications from this illness and over 90% of deaths due to COVID-19 to date have been in patients over the age of 65. Continuing to provide routine care within nursing homes in these challenging times is an essential part of ensuring that presentations to hospitals for non-essential reasons are minimized. In this article, we describe a project being undertaken by a rural Psychiatry of Old Age Service in the northwest of Ireland. We aim to provide ordinary care in extraordinary times by using mobile tablets within the nursing homes and long-stay facilities in our region for remote video consultations during the COVID-19 crisis.
Twenty-four new optically stimulated luminescence (OSL) and radiocarbon ages from sediment cores in nine lakes associated with the Shipshewana and Sturgis moraines in northern Indiana and southern Michigan estimate when recession of the Saginaw Lobe of the Laurentide Ice Sheet was underway in the southern Great Lakes region, USA. Average OSL ages of 23.4 ± 2.2 ka for the Shipshewana Moraine and 19.7 ± 2.2 ka for the Sturgis Moraine are considered minimum limiting deglacial ages for these recessional moraines. The much younger radiocarbon ages are consistent with other regional radiocarbon ages from lakes, and record climate amelioration around ~16.5 cal ka BP. Early recession of the interlobate Saginaw Lobe was well underway by 23.4 ± 2.2 ka, when the adjacent Lake Michigan and Huron-Erie lobes were a few hundred kilometers farther south and near their maximum southerly limits. The results provide the first time constraints when sediment from the Lake Michigan and Huron-Erie lobes began filling the accommodation space left by the Saginaw Lobe. The difference between the oldest radiocarbon and OSL age is 7400 yr for the Shipshewana Moraine and 3400 yr for the Sturgis Moraine.
The present study explored the moderator role of depression in the relationship of self esteem and the direction of social comparison in the context of marital relationships among married couples. The relationship between the direction of social comparison and depression was also explored. The sample consisted of 100 married individuals (50 Married Couples) having diverse educational and occupational background and form all the three socio economic background. The sample was taken from different cities of Pakistan. The couples were requested to complete Beck Depression Inventory (BDI) and Index of Self Esteem (ISE) along with another scale, Social Comparison in Marital Relationship Measure (SCMRM). SCMRM was developed by the researcher to explore the couples’ inclination of comparing their spouses with others around them on different dimension of marital relationship satisfaction. The standardized method was used for the development of SCMRM. The study provided evidence of significant negative relationship of depression with social comparison in marital relationship and with self esteem. The findings also supported the hypothesis that depression will play a role of moderator in the relationship between direction of social comparison in marital relationship and self esteem. Beck's (1967) cognitive model of depression suggested that depressives’ systematic bias against the self is reflected in their tendency to compare themselves with better off others. Thus our results confirm the cognitive depressive model which proposed that depressives engage in dysfunctional social comparison (upward).
The recent DSM-5 criteria for delirium can lead to different rates of delirium and different case identification.
The aims of this study were to determine how the new DSM-5 criteria might differ from the previous DSM-IV in detecting rates of delirium in elderly medical inpatients and to investigate the agreement between different methods, including the DSM III, DSM III-R, DSM-IV and DSM-5 criteria.
Prospective, observational study of elderly patients aged 70+ admitted under the acute medical teams in a regional general hospital. Each participant was assessed within 3 days using the DSM-5, and DSM-IV criteria plus the DRS-R98, CAM and MoCA scales.
The studied sample included 200 patients. The prevalence rates of delirium for each diagnostic system/scale were respectively for DSM-5 n=26 (13.0%), DSM-IV n=39 (19.5%), DRS-R98 n=27 (13.5%) and for CAM n=34 (17.0%). Using tetrachoric correlation coefficients the agreement between DSM-5 and DSM-IV was statistically significant (rhotetr=0.64, SE= 0.1, p<0.0001). Similar significant agreement was found between the four methods.
DSM-IV identifies more delirium cases compared to any other method and DSM-5 is the more restrictive. These classification systems identify different cases of delirium. This could have clinical, financial and research implications. However, both classification systems (and their antecedents) have significant agreement in the identification of the same concept (delirium). Clarity of diagnosis is required for classification but also has implications for prediction of outcomes, further research looking at outcomes could assist a more in depth evaluation of the DSM-5 criteria.
Delirium is a common neuropsychiatric disorder. The natural course is of an acute, fluctuating and often transient condition; however, accumulating evidence suggests delirium can be associated with incomplete recovery. Despite the growing body of relevant research, a lack of clarity exists regarding definition and outcomes.
To clarify the definition of recovery of delirium used in the literature.
A Medline search was performed using relevant keywords. Studies were included if they were in English, provided any definition of recovery, and were longitudinal. Excluded articles were duplicated studies, case studies, review articles or articles related to alcohol, children, subsyndromal delirium only or those investigating core symptoms such as function.
Fifty-six studies met the inclusion criteria. Only 2 studies used clinical criteria alone for the diagnosis of delirium, most studies used at least one validated scale, either categorical or continuous severity scales. A variety of 16 different terms were used to define the 'recovery of delirium”. The definitions of each term also varied. Studies using severity scales used either cut-off points or percentage reduction between assessments while others using dichotomous scales (yes/ no) defined as recovery one or more days of negative delirium as the end point.
An agreed terminology to define recovery in delirium is required. A distinction should also be made between symptomatic and overall recovery as well as between long and short term outcomes. It is proposed that cognition recovery may be used as outcome to identify recovery of delirium.
Delirium is associated with poor outcomes and high mortality. Current research shows conflicting results regarding mortality rates in patients with delirium.
The aim was to examine the hazard risk associated with delirium in elderly medically ill patients at 1 year follow-up, controlling for baseline risk factors and interaction effects.
This was a prospective, observational, longitudinal study carried out in the medical wards of Sligo Regional Hospital. All acute medical admissions of patients 70 years old and over were approached. Each patient was assessed twice weekly for 2 weeks or until discharge. The following scales were used: CAM, DRS-98R, MoCA, Barthel Index, APACHE II. Primary outcome was time of death during 1 year. Cox proportional hazards were estimated and compared across patients who had delirium during hospitalisation and those who did not.
Two hundred patients agreed to take part in the study. The mean age of the studied sample was 81.13 (SD = 6.45; minimum 70 and maximum 100 years old) with 100 (50%) females. One hundred fifty four (77%) patients never developed delirium during hospitalization. Thirty four (17%) had delirium at admission and 12 (6%) developed prevalence delirium while inpatients. A total of 55 (27.5%) patients died during the one year follow-up. Significant risk factors for 1 year mortality were length of hospital staying, severity of illness (APACHE II), and cognition (MoCA).
Delirium was not found as an independent risk factor for 1 year mortality after controlling for other confounder variables.
Siblings’ relationships have been seen as determinants of emotional and personal development. Although Greece is assumed a country with strong family bonds there is not empirical research in this area. Similarly Ireland is traditionally viewed as a country with strong family values.
In an attempt to conduct a comparative study of siblings’ relations the lack of a Greek valid instrument was obvious. The Sibling Relationship Questionnaire (SRQ) is a widely used scale which is a self reported measurement of this relationship.
Thus, in an attempt to employ an easily administered and valid measure, to assess sibling relationships, but also to be able to compare the results across countries the SRQ was the scale of choice.
a random sample of 185 adolescents aged 13 to 18 years old. SRQ has been translated (forward and backwards) to Greek language. Concurrent validity, internal consistency, test-retest reliability and agreement between children-parents versions of the translated scale were investigated.
The concurrent validity ranged from 0.29 to 0.68, the overall internal consistency (Cronbach's alpha) was equal to 0.86 and the test-retest reliability (Spearman's rho) ranged from 0.58 to 0.78. Agreement between children-parents versions was significant only when mothers do the rating.
Thus it seems that the translated Greek version of SRQ is a valid and reliable instrument to be used in the measurement of sibling relationships in Greek population, and can be used as a measurement for multinational clinical research and comparison with findings from other countries.