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On-call and crisis psychiatry is a very challenging aspect of psychiatric training. This study aimed to describe the experiences of psychiatric trainees on-call in hospitals, emergency departments and psychiatric units in Ireland.
In total, 193 psychiatric trainees in Ireland were emailed a survey in 2017. The survey included questions regarding the duties expected of the trainee, frequency of on-call obligations, un-rostered hours worked, level of senior support, assessment facilities available and doctors’ satisfaction with the on-call experience.
Overall, 68 trainees responded to the survey. In total, 35% of respondents reported dissatisfaction with their experience of on-call and crisis psychiatry, 46% reported that they were not provided with training in risk assessment and 21% of respondents stated that there was not a suitable room available to perform their assessments.
This survey has raised important issues facing those on the frontline of psychiatric services in Ireland. Of particular concern are resource issues faced by trainees and the need for further training and support related to risk assessment when on-call. Remedying these issues may lead to a decreased rate of dropout as well as a safer and better environment for patients and doctors alike.
Kefir consumption has been demonstrated to improve lipid and cholesterol metabolism; however, our previous study identified that benefits vary between different commercial and traditional kefir. Here, we investigate the ability of pitched culture kefir, that is, kefir produced by a small number of specific strains, to recapitulate health benefits of a traditional kefir, in a diet-induced obesity mouse model, and examine how microbial composition of kefir impacts these benefits. Eight-week-old female C57BL/6 mice were fed a high-fat diet (40 % energy from fat) supplemented with one of five kefir varieties (traditional, pitched, pitched with no Lactobacillus, pitched with no yeast and commercial control) at 2 ml in 20 g of food for 8 weeks prior to analysis of plasma and liver lipid profiles, and liver gene expression profiles related to lipid metabolism. Both traditional and pitched kefir lowered plasma cholesterol by about 35 % (P = 0·0005) and liver TAG by about 55 % (P = 0·0001) when compared with commercial kefir despite no difference in body weight. Furthermore, pitched kefir produced without either yeast or Lactobacillus did not lower cholesterol. The traditional and pitched kefir with the full complement of microbes were able to impart corresponding decreases in the expression of the cholesterol and lipid metabolism genes encoding 3-hydroxy-3-methylglutaryl-coenzyme A reductase, PPARγ and CD36 in the liver. These results demonstrate that traditional kefir organisms can successfully be utilised in a commercial process, while highlighting the importance of microbial interactions during fermentation in the ability of fermented foods to benefit host health.
This chapter addresses a special category of cases in which an asserted patent is, or has been declared to be, essential to the implementation of a collaboratively developed voluntary consensus standard, and the holder of that patent has agreed to license it to implementers of the standard on terms that are fair, reasonable, and nondiscriminatory (FRAND).This chapter explores how the existence of such a FRAND commitment may affect a patent holder’s entitlement to monetary damages and injunctive relief. In addition to issues of patent law, remedies law, and contracts law, we consider the effect of competition law on this issue.
This chapter describes the current state of, and normative basis for, the law of reasonable royalties among the leading jurisdictions for patent infringement litigation, as well as the principal arguments for and against various practices relating to the calculation of reasonable royalties; and for each of the major issues discussed, the chapter provides one or more recommendations. The chapter’s principal recommendation is that, when applying a “bottom-up” approach to estimating reasonable royalties, courts should replace the Georgia-Pacific factors (and analogous factors used outside the United States) with a smaller list of considerations, specifically (1) calculating the incremental value of the invention and dividing it appropriately between the parties; (2) assessing market evidence, such as comparable licenses; and (3) where feasible and cost justified, using each of these first two considerations as a “check” on the accuracy of the other
This chapter discusses the law and policy of monetary awards — including exemplary damages and litigation cost recoveries — that go beyond the compensatory damages to which prevailing parties in patent litigation are normally entitled. Up to treble damages are authorized in the United States for knowing infringement, but attorney fees are awarded only in exceptional cases. The rest of the world tends toward the opposite: Attorney fees are awarded as a matter of course, but punitive damages are generally prohibited as against public policy.This chapter discusses the theory, law, and policy of enhanced damages and attorney fee awards in the United States, Europe, and Asia. While the availability of enhanced damages and fees can bring accused infringers that might otherwise “hold out” to the table, care must also be taken to ensure that it does not discourage productive learning from patents or challenges to overbroad and vague patents. Rather than endorse any single set of doctrinal rules, there is a recommendation for further research into a number of unanswered questions about current and potential future configurations, in order to inform future policymaking.
This chapter addresses two types of monetary remedies for patent infringement: (1) recovery of the patentee’s lost profits and (2) disgorgement of the infringer’s profits. Both remedies make a comparison between what actually happened and a hypothetical “but for” world in which no infringement occurred. But the two remedies have substantially different objectives: Lost profits are intended to compensate the patentee by restoring it to the position it would have occupied absent infringement, while disgorgement may serve other purposes, including deterrence, recapturing wrongful gains, and encouraging ex ante licensing of patented technology. Section 1 addresses several key issues regarding lost profits awards, including the availability and standard of proof, the role of noninfringing alternatives, potential recovery for the sale of related but unpatented goods, whether and how to apportion lost profits awards for complex products, and potential recovery for other infringement-related harms. Section 2 describes the justifications for, and availability of, the disgorgement (accounting) remedy in major patent systems and, additionally, analyzes a number of questions related to calculating such awards. In both sections, recommendations are made and areas for further research are identified.
Patent systems commonly empower courts to order accused or adjudged infringers to refrain from continuing infringing conduct in the future. Some patentees file suit for the primary purpose of obtaining and enforcing an injunction against infringement by a competitor, and even in cases in which the patentee is willing to license an invention to an accused infringer for an agreed price, the indirect monetary value of an injunction against future infringement can dwarf the amount a finder of fact is likely to award as compensation for past infringement. In some of these cases, an injunction, if granted, would impose costs on accused infringers or third parties that go well beyond the more intrinsic value of the patented technology. This chapter explores the theory behind injunctive relief in patent cases, surveys the availability of this remedy in major patent systems, and suggests a general framework for courts to use when deciding whether injunctive relief is appropriate in individual cases.
Embedding psychosis research within community mental services is highly desirable from several perspectives but can be difficult to establish and sustain, especially when the clinical service has a rural location at a distance from academic settings with established research expertise. In this article, we share the experience of a successful partnership in psychosis research between a rural Irish mental health service and the academic department of a Dublin medical school that has lasted over 30 years. We describe the origins and evolution of this relationship, the benefits that accrued and the challenges encountered, from the overlapping perspectives of the academic department, the mental health service and psychiatric training. We discuss the potential learning that arose from the initiative, particularly for national programme planning for early intervention in psychosis, and we explore the opportunities for enhanced training, career development and professional reward that can emerge from this type of partnership.
Recovery rates in schizophrenia remain suboptimal with up to one-third resistant to standard treatments, a population prevalence of 0.2%. Clozapine is the only evidenced-based treatment for treatment resistant schizophrenia (TRS), yet there are significant delays in its use or it may not be trialled, potentially impacting the chance of recovery. Better outcomes with earlier use of clozapine may be possible. There is emerging evidence that early treatment resistance is not uncommon from the earliest stages of psychosis. In this review, we provide an update on TRS, its epidemiology and its management, with a specific focus on the optimal use and timing of clozapine and augmentation strategies for the one-third of patients who do not respond to clozapine.
We evaluated and compared the completeness, timeliness, simplicity, usefulness and flexibility between the former National Tuberculosis (TB) Surveillance System (NTBSS) and the newer Computerised Infectious Disease Reporting System (CIDR). Completeness was assessed by examining the field completion of key variables and median time from diagnosis to notification was calculated to evaluate timeliness. Differences between the two systems on completeness and timeliness were statistically assessed using χ2 and Wilcoxon rank-sum test, respectively. An online questionnaire on simplicity, flexibility and usefulness was sent to key stakeholders. Time and diagnosis-related variables were more complete in NTBSS, while variables on drug susceptibility, HIV and laboratory tests were more complete in CIDR (P < 0.05). The median time notification interval increased significantly in CIDR (P < 0.05). Stakeholders thought that CIDR is simpler (37.5%), more useful (41.7%) and more flexible (29.2%) than NTBSS. This study demonstrated that CIDR did not improve data completeness and decreased timeliness of notification. Simplicity, usefulness and flexibility were improved but qualitative methods should be applied to further explore these results.
Research into the gut microbiota of human infants is necessary in order to better understand how inter-species interactions and ecological succession shape the diversity of the gut microbiota, and in turn, how the specific composition of the gut microbiota impacts on host health both during infancy and in later years. Blastocystis is a ubiquitous intestinal protist that has been linked to a number of intestinal and extra-intestinal diseases. However, emerging data show that asymptomatic carriage is common and that Blastocystis is prevalent in the healthy adult gut microbiota. Nonetheless, little is known about the prevalence and diversity of this microorganism in the healthy infant gut, including when and how individuals become colonized by Blastocystis. Here, we surveyed the prevalence and diversity of Blastocystis in an infant population (n = 59) from an industrialized country (Ireland) using Blastocystis-specific primers at three or more time-points up to 24 months old. Only three infants were positive for Blastocystis (prevalence = 5%) and this was only noted for samples collected at month 24. This rate is comparatively low relative to previously reported prevalence rates in the contemporaneous adult population. These data suggest that infants in Westernized countries that are successfully colonized by Blastocystis most likely acquire this microorganism via horizontal transfer.
Exposure to traumatic experiences in childhood is a risk (and potentially causal) factor for the development of a range of adverse physical and mental health conditions. In addition to the onset of clinical disorders, there is emerging evidence that childhood trauma may also be associated with other long-term outcomes, such as the persistence and severity of an individual’s symptoms, as well as their long-term social and occupational functioning. However, the reasons for this remain poorly understood. A greater understanding both of the mediators that drive these associations, and those variables that enhance resilience against such damaging experiences may help to inform effective therapeutic interventions. In addition to biological and cognitive measures, there is a need to consider social and environmental factors, such as parental bonding and attachment, when investigating these complex relationships.
In Ireland, National Clinical Programmes are being established to improve and standardise patient care throughout the Health Service Executive. In line with internationally recognised guidelines on the treatment of first episode psychosis the Early Intervention in Psychosis (EIP) programme is being drafted with a view to implementation by mental health services across the country. We undertook a review of patients presenting with a first episode of psychosis to the Dublin Southwest Mental Health Service before the implementation of the EIP. This baseline information will be used to measure the efficacy of our EIP programme.
Patients who presented with a first episode psychosis were retrospectively identified through case note reviews and consultation with treating teams. We gathered demographic and clinical information from patients as well as data on treatment provision over a 2-year period from the time of first presentation. Data included age at first presentation, duration of untreated psychosis, diagnosis, referral source, antipsychotic prescribing rates and dosing, rates of provision of psychological interventions and standards of physical healthcare monitoring. Outcome measures with regards to rates of admission over a 2-year period following initial presentation were also recorded.
In total, 66 cases were identified. The majority were male, single, unemployed and living with their family or spouse. The mean age at first presentation was 31 years with a mean duration of untreated psychosis of 17 months. Just under one-third were diagnosed with schizophrenia. Approximately half of the patients had no contact with a health service before presentation. The majority of patients presented through the emergency department. Two-thirds of all patients had a hospital admission within 2 years of presentation and almost one quarter of patients had an involuntary admission. The majority of patients were prescribed antipsychotic doses within recommended British National Formulary guidelines. Most patients received individual support through their keyworker and family intervention was provided in the majority of cases. Only a small number received formal Cognitive-Behavioural Therapy. Physical healthcare monitoring was insufficiently recorded in the majority of patients.
There is a shortage of information on the profile and treatment of patients presenting with a first episode of psychosis in Ireland. This baseline information is important in evaluating the efficacy of any new programme for this patient group. Many aspects of good practice were identified within the service in particular with regards to the appropriate prescribing of antipsychotic medication and the rates of family intervention. Deficiencies remain however in the monitoring of physical health and the provision of formal psychological interventions to patients. With the implementation of an EIP programme it is hoped that service provision would improve nationwide and to internationally recognised standards.
The 7 and 13-valent pneumococcal conjugate vaccines (PCVs) have reduced the incidence of invasive pneumococcal disease (IPD) in children in many countries. The objective of this work was to assess the impact of PCVs and potential herd-protection in older adults in Ireland. IPD notification and typing data from adults ⩾65 years of age from July 2007 to June 2016 was assessed using national surveillance data. There was a 94% reduction in PCV7 serotypes from 2007–2008 to 2015–2016, incidence rate ratio (IRR 0·05, P < 0·0001). However, there was no decline in the additional PCV13 (PCV13-7) serotypes over the same period (IRR 0·90) nor in comparison with the pre-PCV13 period 2009–2010 (IRR 0·92). The incidence of serotypes in the 23-valent pneumococcal polysaccharide vaccine only (PPV23-PCV13) and non-vaccine types (NVTs) increased significantly (IRR 2·17, P = 0·0002 and IRR 3·43, P = 0·0001 respectively). Consequently, the overall IPD incidence rate in adults has remained relatively unchanged (from 28·66/100 000 to 28·88/100 000, IRR 1·01, P = 0·9477). Serotype 19A and NVTs were mainly responsible for penicillin resistance in recent years. The decline of PCV7 serotypes indicate that the introduction of PCV7 resulted in herd-protection for adults. However, increases in PPV23-PCV13 and NVTs suggest that changes in vaccination strategy amongst older adults are needed to build on the success of PCVs in children.
A measles outbreak occurred in a school in a small town in the South East of Ireland in September–November 2013. Most (and all early) cases had one dose of the measles-mumps- rubella (MMR) vaccination. All suspected cases were followed up, in order to advise on sampling and provide public health advice to them and their contacts. MMR vaccination control measures were instituted in the town. These included early second MMR in primary schools and childcare facilities, bringing forward the planned school MMR catch-up programme, early first MMR dose for children aged 6–12 months and targeted advice to unvaccinated children. There were 20 cases (17 confirmed) of measles associated with the outbreak. Fifteen cases occurred in the index school, with four in pre-school-age children (<4 years) who had clear epidemiological links with children at the school. This was a well-circumscribed outbreak occurring, unusually, in a well-vaccinated population. The outbreak came late to the attention of Department of Public Health staff but prompt action, once notified, and institution of control measures resulted in quick termination of the outbreak and prevention of cases in a neighbouring city.
Individuals identified as at ultra-high risk (UHR) for psychosis are at risk of poor functional outcome regardless of development of psychotic disorder. Studies examining longitudinal predictors of poor functioning have tended to be small and report only medium-term follow-up data. We sought to examine clinical predictors of functional outcome in a long-term longitudinal study.
Participants were 268 (152 females, 116 males) individuals identified as UHR 2–14 years previously. A range of clinical and sociodemographic variables were assessed at baseline. Functioning at follow-up was assessed using the Social and Occupational Functioning Assessment Scale (SOFAS).
Baseline negative symptoms, impaired emotional functioning, disorders of thought content, low functioning, past substance use disorder and history of childhood maltreatment predicted poor functioning at follow-up in univariate analyses. Only childhood maltreatment remained significant in the multivariate analysis (p < 0.001). Transition to psychosis was also significantly associated with poor functioning at long-term follow-up [mean SOFAS score 59.12 (s.d. = 18.54) in the transitioned group compared to 70.89 (s.d. = 14.00) in the non-transitioned group, p < 0.001]. Childhood maltreatment was a significant predictor of poor functioning in both the transitioned and non-transitioned groups.
Childhood maltreatment and transition to psychotic disorder independently predicted poor long-term functioning. This suggests that it is important to assess history of childhood maltreatment in clinical management of UHR individuals. The finding that transition to psychosis predicts poor long-term functioning strengthens the evidence that the UHR criteria detect a subgroup at risk for schizophrenia.
The typically poor outcomes of schizophrenia could be improved through interventions that reduce cardiometabolic risk, negative symptoms and cognitive deficits; aspects of the illness which often go untreated. The present review and meta-analysis aimed to establish the effectiveness of exercise for improving both physical and mental health outcomes in schizophrenia patients.
We conducted a systematic literature search to identify all studies that examined the physical or mental effects of exercise interventions in non-affective psychotic disorders. Of 1581 references, 20 eligible studies were identified. Data on study design, sample characteristics, outcomes and feasibility were extracted from all studies and systematically reviewed. Meta-analyses were also conducted on the physical and mental health outcomes of randomized controlled trials.
Exercise interventions had no significant effect on body mass index, but can improve physical fitness and other cardiometabolic risk factors. Psychiatric symptoms were significantly reduced by interventions using around 90 min of moderate-to-vigorous exercise per week (standardized mean difference: 0.72, 95% confidence interval −1.14 to −0.29). This amount of exercise was also reported to significantly improve functioning, co-morbid disorders and neurocognition.
Interventions that implement a sufficient dose of exercise, in supervised or group settings, can be feasible and effective interventions for schizophrenia.
We aimed to examine the association between childhood trauma and functional impairment in psychotic disorders, bipolar disorder and borderline personality disorder, to speculate on possible mechanisms that underlie this association and discuss the implications for clinical work.
Narrative review of the peer-reviewed English language literature in the area.
High rates of childhood trauma in psychotic disorders, bipolar disorder and borderline personality disorder were identified. This was associated with impaired social and occupational functioning in both the premorbid and established phases of each of these psychiatric disorders over and above the deficits typically observed in these populations. Possible mechanisms mediating this relationship include neurocognitive deficits, insecure attachment, higher rates of comorbidities and problems with adherence and response to treatment.
Routine clinical inquiry about childhood maltreatment should be adopted within mental health settings. This has potentially important treatment implications for identifying those individuals at elevated risk of functional disability. While there is no clear guidance currently available on how to target childhood trauma in the treatment of psychotic disorders, bipolar disorder or borderline personality disorder, there are several promising lines of enquiry and further research is warranted.