The changing face of Capacity legislation in Ireland: algorithms for clinicians.

Capacity legislation in Ireland is evolving. The Assisted Decision-Making (Capacity) Act 2015 has been passed into law, but its main provisions are yet to be commenced. This paper compares the law and its practical implications currently and under the new legislation. Quick reference algorithms for frontline clinicians are proposed.

Metal coordinating inhibitors of Rift Valley fever virus replication.

Rift Valley fever virus (RVFV) is a veterinary and human pathogen and is an agent of bioterrorism concern. Currently, RVFV treatment is limited to supportive care, so new drugs to control RVFV infection are urgently needed. RVFV is a member of the order Bunyavirales, whose replication depends on the enzymatic activity of the viral L protein. Screening for RVFV inhibitors among compounds with divalent cation-coordinating motifs similar to known viral nuclease inhibitors identified 47 novel RVFV inhibitors with selective indexes from 1.1-103 and 50% effective concentrations of 1.2-56 µM in Vero cells, primarily α-Hydroxytropolones and N-Hydroxypyridinediones. Inhibitor activity and selective index was validated in the human cell line A549. To evaluate specificity, select compounds were tested against a second Bunyavirus, La Crosse Virus (LACV), and the flavivirus Zika (ZIKV). These data indicate that the α-Hydroxytropolone and N-Hydroxypyridinedione chemotypes should be investigated in the future to determine their mechanism(s) of action allowing further development as therapeutics for RVFV and LACV, and these chemotypes should be evaluated for activity against related pathogens, including Hantaan virus, severe fever with thrombocytopenia syndrome virus, Crimean-Congo hemorrhagic fever virus.

The collaborative development through multidisciplinary and advocate consensus of an accessible notice of rights for people with intellectual disabilities in police custody.

Background People with intellectual disabilities are over-represented in the criminal justice system. The United Nations' Convention on the Rights of Persons with Disabilities (UNCRPD) enshrines a right to equal access to justice for persons with disabilities (Article 13, UNCRPD). Accessible information is a key aspect of exercising this right. Yet, many jurisdictions, including Ireland, are yet to develop accessible information for disabled people who may be arrested. Aims This paper describes the collaborative development through multidisciplinary and advocate consensus of an accessible (Easy -to- Read) Notice of Rights (ERNR) for people with intellectual disabilities in police custody in Ireland. Methods Guidelines developed by Ireland's representative organisation for people with intellectual disabilities and examples of international practice were used to develop a draft ERNR by the primary researcher in partnership with an expert from a representative organisation for people with intellectual disabilities. The ERNR was developed thereafter through two focus groups with a view to achieving consensus with a focus on accessibility, accuracy and layout. This included a multidisciplinary focus group with participants from a representative organisation for people with intellectual disabilities, psychology, speech and language therapy, the police force, public health, forensic psychiatry, mental health, law and, subsequently, a focus group of people with lived experience of intellectual disability. Results Progressive development of the ERNR resulted in incremental improvements in textual accuracy as well as the inclusion of more accessible language and imagery. Originality/value This is the first attempt at developing an easy-to-read document relating to the legal rights of suspects in police custody in Ireland and, accordingly, this procedural innovation promises to assist, not just persons with intellectual disabilities, but also those with limited literacy at the point of arrest. The methodology used in the preparation of the document, employing a focus group to achieve consensus with participation from both multiple disciplines and persons with an intellectual disability, is in harmony with the ethos of the UNCPRD. This methodology may usefully be employed by other member states that have ratified the Convention but have yet to develop accessible version of the legal rights and entitlements that extend to arrested persons under their domestic law.

The evaluation of a training course to enhance intellectual disability awareness amongst law enforcement officers: a pilot study.

OBJECTIVES: Disability awareness training is mandated by the United Nations Convention on People with Disabilities (UNCRPD), but there is a paucity of evidence regarding the systematic evaluation of the effectiveness of such training. This study describes the evaluation of a pilot intellectual disability awareness programme for law enforcement officers (LEOs) in Ireland. METHODS: Pre-and post-training Likert scales and a semi-structured survey were used to evaluate the effectiveness of an intellectual disabilities awareness programme delivered to LEOs. Quantitative differences in Likert scores and thematic analyses of practice-based responses were used in evaluation. RESULTS: Twenty-two LEOs participated in the training and 11 completed the evaluation cycle. Statistically significant improvements were found in participants' self-rated knowledge of intellectual disability, their understanding of the challenges faced by people with intellectual disabilities in law enforcement interactions, their communication skills and their knowledge of how to approach a person with a disability in crisis. Thematic analysis excavated potential practical application of learning around pre-arrest considerations, recognition of disability, communication skills and need for procedural safeguards. CONCLUSIONS: An approach grounded in the views of people with intellectual disabilities and with emphasis on recognition of disability, communication, accessibility of information and providing appropriate support in custody, appears to promote improvement in self-reported knowledge and prospective application in LEOs. The findings of this study are potentially applicable to countries that have ratified the UNCRPD.

The neurology-psychiatry interface in epilepsy.

Epilepsy and mental illness have a bidirectional association. Psychiatrists are likely to encounter epilepsy as comorbidity. Seizures may present as mental illness. Equally, the management of psychiatric conditions has the potential to destabilise epilepsy. There is a need for structured epilepsy awareness and training amongst psychiatrists. This paper outlines key considerations around diagnosis, treatment and risk while suggesting practical recommendations.

Challenges for people with intellectual disabilities in law enforcement interactions in Ireland; thematic analysis informed by 1537 person-years' experience.

BACKGROUND: People with intellectual disabilities (PWID) are over-represented in criminal justice systems globally. This over-representation reveals itself at once in the demographic make-up of prison populations, as well as those detained in police settings as suspects of crime. While it is well-established in international literature that individuals who find themselves in the latter scenario face particular challenges in negotiating the forensic formalities routinely followed by the police at the pre-trial stage of criminal proceedings on account of their impairments, the specific difficulties experienced by PWID as suspects within Ireland's criminal justice system has yet to be explained, or indeed, understood. In seeking to address this research lacuna, this paper yields an account of a qualitative study which was aimed at identifying the unique challenges which PWID face in their interactions with Law Enforcement Officials (LEOs) in Ireland. AIMS: This study aimed to elicit perspectives across a range of disciplines with regard to barriers for PWID interacting with LEOs in Ireland, and sought viewpoints on the content of a proposed awareness programme. METHODS: A survey using purposive sampling was used to elicit viewpoints from people from representative organisations for PWID, people working with voluntary organisations for PWID, healthcare professionals working with PWID and professionals from the criminal justice system (including members of An Garda Siochana, lawyers, members of the Irish judiciary and officials within the Airport Police). Data were anonymised at the point of collection. Qualitative thematic analysis was conducted to extract themes based on the data retrieved through the survey. RESULTS: Ninety-five (n = 95) responses were received from individuals reporting a cumulative experience of 1537 person-years. Respondents identified themselves as members of one of three groups; people working in a voluntary or representative organisation for PWID (n = 42, 44.2%); people working in healthcare (n = 31, 32.6%); and people working in law enforcement (n = 22, 23.1%). Three themes were identified from the qualitative thematic analysis. The first theme, "Barriers to Communication", identified challenges which PWID and LEO experience in their mutual interactions and communications with one another. The second theme, "Building Awareness and Skills", identified elements of an ID awareness programme for LEOs. The third theme, "Institutional and System Change", identified possible lines of innovation with respect to contemporary police practice and the availability of supports for both PWID and the LEOs who work with them. ORIGINALITY/VALUE: This study represents the first dedicated qualitative inquiry conducted on a multidisciplinary level into the barriers which healthcare professionals, legal professionals and disability advocacy groups perceive to be faced by PWID in their interactions with LEOs in Ireland. Consequently, the findings from this study will act as a valuable template in the direction of informing the development of an ID awareness programme for LEOs in Ireland. In addition, these research findings are expected to usefully inform the development of national policy and protocols in areas related to health, disability and justice. In offering a rich evidence-base for future policy initiatives, the timing of this study is particularly significant. The recent ratification by Ireland of the UN Convention for the Rights of People with Disabilities (UNCRPD), together with the synchronous emergence of an evolving emphasis on human rights-based policing at a national level in Ireland, has meant that Irish policymakers have a unique opportunity to re-imagine the pre-trial formalities of Ireland's criminal process in order to demonstrate an increased sensitivity to the needs of PWID. Securing equal access to justice for such individuals, it is important to emphasise, is a legal requirement pursuant to Article 13 of the UNCRPD. To the extent therefore that this study yields unique insights into the barriers faced by PWID in their interactions with LEOs, the results of this study are potentially generalisable to other jurisdictions that have ratified the UNCRPD and are developing policy to accord with Article 13.

Prescribing Patterns and Patient Outcomes for Bone and Joint Infections Treated with Cefazolin and Probenecid: A Retrospective Observational Study.

BACKGROUND: Previous studies have described the use of cefazolin with probenecid to treat uncomplicated skin and soft-tissue infections. Some prescribers are extrapolating from this evidence to treat more invasive infections, which have a greater potential for poor outcomes, including treatment failure that could lead to increased morbidity and mortality. Information supporting cefazolin with probenecid as effective treatment in this context is needed. OBJECTIVES: To describe prescribing patterns and outcomes for patients who received cefazolin with probenecid for the treatment of bone and joint infections. METHODS: This single-centre retrospective study involved adult outpatients for whom cefazolin and probenecid were prescribed for bone and joint infections between April 1, 2012, and March 31, 2017. Patient charts were reviewed, and data were collected for clinical and microbiological variables using a standardized data collection form. RESULTS: In a total of 80 cases, the patient received cefazolin and probenecid for treatment of a bone or joint infection, of which 69 cases met the inclusion criteria. In most cases (n = 67), the patients were treated with cefazolin 2 g IV plus probenecid 1 g PO, both given twice daily. Completion of prescribed treatment occurred in 56 patient cases (81%), resolution of signs and symptoms in 53 (77%), readmission to hospital in 11 (16%), recurrence of infection in 6 (9%), and treatment failure requiring a change in therapy in 7 (10%). CONCLUSIONS: The effectiveness of cefazolin and probenecid for the treatment of bone and joint infections appears to be similar to that of standard treatment, as reported in the literature. Antibiotic effectiveness is difficult to determine conclusively in a retrospective analysis, so these results should be interpreted with caution, but they may stimulate further research.

CONTEXTE: Des études précédentes ont décrit l'utilisation de la céfazoline et du probénécide pour traiter les infections cutanées et les infections de tissus mous. Quelques prescripteurs extrapolent ces éléments probants pour traiter des infections plus invasives, dont les résultats risquent d'être défavorables, comme un échec du traitement pouvant entraîner une morbidité et une mortalité accrues. De l'information supplémentaire étayant l'efficacité du traitement à l'aide de la céfazoline et du probénécide dans ce contexte est nécessaire. OBJECTIFS: Décrire les modes de prescription et les résultats obtenus par des patients ayant reçu de la céfazoline et du probénécide pour traiter des infections osseuses et articulaires. MÉTHODES: Cette étude rétrospective unicentrique porte sur des patients ambulatoires adultes à qui on a prescrit de la céfazoline et du probénécide pour traiter des infections osseuses et articulaires entre le 1er avril 2012 et le 31 mars 2017. L'examen des dossiers médicaux des patients a permis la récolte de données sur les variables cliniques et microbiologiques à l'aide d'un formulaire de recueil de données standard. RÉSULTATS: Les patients, soit 80 cas en tout, ont reçu de la céfazoline et du probénécide pour traiter une infection osseuse ou articulaire et 69 de ces cas répondaient aux critères d'inclusion. Dans la plupart des cas (n = 67), les patients étaient traités avec de la céfazoline IV dosée à 2 g et du probénécide dosé à 1 g PO, les deux produits étant administrés deux fois par jour. Le traitement a été appliqué au complet dans 56 cas (81 %), la résolution des signes et des symptômes a eu lieu dans 53 cas (77 %), la réadmission à l'hôpital s'est produite dans 11 cas (16 %), les infections ont récidivé dans 6 cas (9 %) et le traitement s'est soldé par un échec et a nécessité un changement de thérapie dans 7 cas (10 %). CONCLUSIONS: L'efficacité de la céfazoline et du probénécide dans le traitement des infections osseuses et articulaires semble être similaire à celle des traitements standard, comme le rapporte la littérature scientifique. L'efficacité des antibiotiques est difficile à déterminer de façon concluante dans une analyse rétrospective, ces résultats doivent donc être interprétés avec prudence, mais ils pourraient stimuler des recherches supplémentaires.

The inherent jurisdiction of the Irish High Court: Interface with psychiatry.

The term "inherent jurisdiction" refers to a set of default powers, usually not set out in statute, which enables a court to fulfil its roles. We discuss recently reported cases where such power has been exercised by the Irish High Court and what this means for psychiatrists in practice. These cases demonstrate that (a) the Irish High Court can be involved in decision-making where there is a lacuna in mental health legislation and a lack of mental capacity; (b) when a minor has been placed by the Court in a specialist facility in the UK and then attains the age of 18 years, decisions can be based on mental capacity but not on preventative detention on the basis of risk; (c) complexities arise when definitions of mental disorder vary between jurisdictions, especially when the Court orders involuntary detention in a case where statute would not ordinarily allow this; and (d) the appropriate route to seek decision-making for adults with mental incapacity is through Ireland's "Ward of Court" process, although, on the face of it, this seems to be contrary to the approach taken in other cases in which inherent jurisdiction was used. Overall, while it is reassuring for state health services that they can seek to approach higher courts in respect of decision-making in complex cases, some of these decisions raise important ethical questions for psychiatrists who may be asked to treat patients detained under their care who may not have a treatable mental illness as their condition falls outside of mental disorder within Irish legislation. We recommend that clear guidance is made available to psychiatrists in light of these judgments, particularly as there is likely to be a reconsideration of cases where Irish patients are placed in the UK given the UK's planned departure from the EU.

A novel care pathway for prisoners with intellectual disability designed through a Delphi process.

PURPOSE: Individuals with an intellectual disability (ID) form a significant minority in the Irish prison population and worldwide prison populations. There is growing recognition that specialist services for such individuals are in need of development. The purpose of this paper is to propose a care pathway for the management of individuals with an ID who present in prison, based on expert elicitation and consensus. DESIGN/METHODOLOGY/APPROACH: A convenience sample of professionals with a special interest in forensic intellectual disabilities was invited to participate in a Delphi exercise. In total, 12 agreed to participation and 10 subsequently completed the study (83.3 per cent). Expert views were elicited using a semi-structured questionnaire. Content analysis was completed using NVivo 11 software. A care pathway was subsequently proposed, based on the outcomes of the analysis, and circulated to participants for debate and consensus. A consensus was reached on management considerations. FINDINGS: Ten experts across a range of disciplines with a combined experience of 187 years participated in the study. Current provision of care was seen as limited and geographically variable. The vulnerability of prisoners with ID was highlighted. The need for equivalence of care with the community through multidisciplinary input and development of specialist secure and residential placements to facilitate diversion was identified. Consensus was achieved on a proposed care pathway. ORIGINALITY/VALUE: This study proposes a care pathway for the assessment and management of prisoners with an ID and is, therefore, potentially relevant to those interested in this topic internationally who may similarly struggle with the current lack of decision-making tools for this setting. Although written from an Irish perspective, it outlines key considerations for psychiatrists in keeping with international guidance and, therefore, may be generalisable to other jurisdictions.

Intellectual disability in Irish prisoners: systematic review of prevalence.

Purpose While individuals with an intellectual disability form a significant minority in the worldwide prison population, their healthcare needs require specialist attention. In Ireland, services for prisoners with intellectual disabilities need development. However, there is little substantive data estimating the prevalence of intellectual disabilities within the Irish prison system. The paper aims to discuss these issues. Design/methodology/approach The authors systematically review published data relating to the prevalence of intellectual disabilities in prisons in the Republic of Ireland. The authors searched four databases, governmental websites and corresponded with experts. Findings Little published data were elicited from searches except for one nationwide cross-sectional survey which reflected a higher prevalence than reported in international studies. Studies from forensic mental health populations are narrated to contextualise findings. Originality/value This study found that there is little data to accurately estimate the prevalence of intellectual disabilities in the Irish prison system and the limited data available suggests that this is likely to be higher than international estimates. The authors highlight the need for further research to accurately estimate prevalence in this jurisdiction, alongside the need to develop screening and care pathways for prisoners with an intellectual disability.

Challenging behaviour in a patient with schizophrenia and a 1q21.1 duplication.

We report the case of a 42-year-old man with a 22-year history of schizophrenia, necessitating frequent detentions under the Mental Health Act for relapses in his mental state and challenging behaviour which has also brought him into contact with the law. His illness has proven resistant to treatment with conventional strategies and he developed serious priapism with clozapine. His challenging behaviour, some of which is not felt to be associated with schizophrenia, complicates any discharge planning from his current detention. Based on a history of childhood cardiac disease, and mildly atypical facies, a genetic screen was requested which showed a 1q21.1 duplication, likely causal in his schizophrenic illness. A review of proteins coded by the locus of the duplication did not reveal any specific targets for pharmacotherapy.

Exome sequencing can detect pathogenic mosaic mutations present at low allele frequencies.

The development of next generation sequencing (NGS) has radically transformed the scientific landscape, making it possible to sequence the exome of any given individual in a cost-effective way. The power of this approach has been demonstrated by a number of groups who have identified pathogenic mutations in small pedigrees that have been resistant to traditional genetic mapping. Recently it has become clear that exome sequencing has great potential with respect to sporadic disease and the identification of de novo mutations. This is highlighted by studies reporting whole-exome sequencing of patient-parental trios affected by learning disability, autism and schizophrenia. It is widely anticipated that the introduction of this technique into a clinical setting will revolutionise genetic diagnosis. However, the sensitivity of NGS exome sequencing is currently unclear. Here, we describe the exome sequencing of DNA samples from a patient with double cortex syndrome and her parents, resulting in the detection of a mosaic splicing mutation in LIS1. This variant was found at an allele frequency of just 18%, demonstrating that NGS methods have the capacity to identify pathogenic mosaic mutations present at a low level.

The connection between strong social support and joint replacement outcomes.

A myriad of emotional, informational, and tangible needs can easily overwhelm patients as they seek to navigate a complicated surgical procedure. This article demonstrates that a dedicated family member or friend supporting their loved one before, during, and after joint replacement surgery measurably impacts quality and outcomes. The multidisciplinary, multihospital study team developed the following Opportunity Statement: "To define, measure, and implement a progressive family/friend support system across the continuum of care promoting optimal patient recovery after total joint arthroplasty." The team used the modified Groningen Orthopedic Social Support Scale to measure levels of social support and associated these levels with other patient outcomes.Analysis of 1722 observations across 4 hospitals found that patients with strong social support have shorter hospital stays, are more likely to be discharged home, to meet ambulation and transfer-out-of-bed targets, and to score hospital quality of care higher, and are more confident and ready to go home on discharge. Three presence intervals were also found to be significant predictors of key outcome measures: family/friend presence during the preoperative classes, in the preoperative holding area, and during the last physical therapy session. These intervals may serve as reasonable social support proxies for organizations desiring to measure social support to ultimately affect quality and outcomes.

COX-2/EGFR expression and survival among women with adenocarcinoma of the lung.

Previous studies suggest that cyclooxygenase-2 (COX-2) expression may predict survival among patients with non-small cell lung cancer. COX-2 may interact with epidermal growth factor receptor (EGFR), suggesting that combined COX-2/EGFR expression may provide predictive value. The extent to which their independent or combined expression is associated with prognosis in women with adenocarcinoma of the lung is unknown. In the present study, we examined relationships between COX-2 expression (n = 238), EGFR expression (n = 158) and dual COX-2/EGFR expression (n = 157) and survival among women with adenocarcinoma of the lung. Overall survival was estimated by constructing Cox proportional hazards models adjusting for other significant variables and stratifying by stage at diagnosis and race. Clinical or demographic parameters were not associated with either COX-2 or EGFR expression. Patients with COX-2-positive tumors tended to have poorer prognosis than did patients with COX-2-negative tumors [hazard ratio (HR) 1.67, 95% confidence interval (CI) 1.01-2.78]. African-Americans with COX-2-positive tumors had a statistically non-significant higher risk of death than African-Americans with COX-2-negative tumors (HR 5.58, 95% CI 0.64-48.37). No association between COX-2 expression and survival was observed among Caucasians (HR 1.29, 95% CI 0.72-2.30). EGFR expression was associated with a 44% reduction in the risk of death (HR 0.56, 95% CI 0.32-0.98). COX-2-/EGFR+ tumor expression, but not COX-2+/EGFR+ tumor expression, was associated with survival when compared with other combined expression results. In conclusion, COX-2 and EGFR expression, but not combined COX-2+/EGFR+ expression, independently predict survival of women with adenocarcinoma of the lung.

Reproductive factors, hormone use, estrogen receptor expression and risk of non small-cell lung cancer in women.

PURPOSE: Estrogen receptor (ER) expression in lung tumors suggests that estrogens may play a role in the development of lung cancer. We evaluated the role of hormone-related factors in determining risk of non-small-cell lung cancer (NSCLC) in women. We also evaluated whether risk factors were differentially associated with cytoplasmic ER-alpha and/or nuclear ER-beta expression-defined NSCLC in postmenopausal women. PATIENTS AND METHODS: Population-based participants included women aged 18 to 74 years diagnosed with NSCLC in metropolitan Detroit between November 1, 2001 and October 31, 2005. Population-based controls were identified through random digit dialing, matched to patient cases on race and 5-year age group. Interview data were analyzed for 488 patient cases (241 with tumor ER results) and 498 controls. RESULTS: Increased duration of hormone replacement therapy (HRT) use in quartiles was associated with decreased risk of NSCLC in postmenopausal women (odds ratio = 0.88; 95% CI, 0.78 to 1.00; P = .04), adjusting for age, race, pack-years, education, family history of lung cancer, current body mass index, years exposed to second-hand smoke in the workplace, and obstructive lung disease history. Among postmenopausal women, ever using HRT, increasing HRT duration of use in quartiles, and increasing quartiles of estrogen use were significant predictors of reduced risk of NSCLC characterized as ER-alpha and/or ER-beta positive. None of the hormone-related variables were associated with nuclear ER-alpha- or ER-beta-negative NSCLC. CONCLUSION: These findings suggest that postmenopausal hormone exposures are associated with reduced risk of ER-alpha- and ER-beta-expressing NSCLC. Understanding tumor characteristics may direct development of targeted treatment for this disease.

Nuclear estrogen receptor beta in lung cancer: expression and survival differences by sex.

PURPOSE: A role for estrogens in determining lung cancer risk and prognosis is suggested by reported sex differences in susceptibility and survival. Archival lung tissue was evaluated for the presence of nuclear estrogen receptor (ER)-alpha and ER-beta and the relationship between ER status, subject characteristics, and survival. EXPERIMENTAL DESIGN: Paraffin-embedded lung tumor samples were obtained from 214 women and 64 men from two population-based, case-control studies as were 10 normal lung autopsy samples from patients without cancer. Nuclear ER-alpha and ER-beta expression was determined by immunohistochemistry. Logistic regression was used to identify factors associated with ER positivity and Cox proportional hazards models were used to measure survival differences by ER status. RESULTS: Neither tumor (0 of 94) nor normal (0 of 10) lung tissue stained positive for ER-alpha. Nuclear ER-beta positivity was present in 61% of tumor tissue samples (170 of 278; 70.3% in men and 58.3% in women) and 20% of normal tissue samples (2 of 10; P = 0.01). In multivariate analyses, females were 46% less likely to have ER-beta-positive tumors than males (odds ratio, 0.54; 95% confidence interval, 0.27-1.08). This relationship was stronger and statistically significant in adenocarcinomas (odds ratio, 0.40; 95% confidence interval, 0.18-0.89). Women with ER-beta-positive tumors had a nonsignificant 73% (P = 0.1) increase in mortality, whereas men with ER-beta-positive tumors had a significant 55% (P = 0.04) reduction in mortality compared with those with ER-beta-negative tumors. CONCLUSIONS: This study suggests differential expression by sex and influence on survival in men of nuclear ER-beta in lung cancer, particularly in adenocarcinomas.