Odds of gambling among adolescents: a secondary analysis of the cross-sectional European School Survey Project on Alcohol and Other Drugs.

BACKGROUND: Gambling among adolescents is associated with gambling disorder in adulthood. This study investigated factors associated with gambling and excessive gambling in adolescents. METHODS: This secondary analysis of the cross-sectional European School Survey Project on Alcohol and Other Drugs (ESPAD) used nationally representative data from the Irish cohort of the 2019 ESPAD wave. Data were collected between March and May 2019. We included 1949 students aged 15-16 years (946 [48·5%] male, 1003 [51·5%] female), with a response rate of 85%. We calculated past year gambling prevalence as the rate of those who had gambled for money on at least one of four games of chance (slot machines, cards or dice, the lottery, betting on sports or animals) in the past 12 months. An adapted version of the three-item Consumption Screen for Problem Gambling was used to identify excessive gambling (score ≥4). We carried out descriptive and logistic regression analyses using binary covariates with Stata v16.1. We included 19 variables in the multivariable analysis. Ethics approval was granted by Dublin Institute of Technology's Ethics Committee. Non-consent forms were issued to all parents to opt out. FINDINGS: Overall, 447 (23%) of 1949 students gambled in the past year, of whom 45 (10%) engaged in excessive gambling. Using a mutually adjusted multivariable logistic regression analysis, past year gambling was associated with alcohol use (adjusted odds ratio [aOR] 1·6, 95% CI 1·1-2·2), experiencing serious arguments (aOR 1·4, 1·1-1·9), and trouble with the police (aOR 1·9, 1·2-2·8). Female gender was a protective factor (aOR 0·6, 0·4-0·9). In the univariable analysis, excessive gambling was associated with gaming (OR 2·3, 1·0-5·1), tobacco use (2·1, 1·1-4·2), e-cigarette use (2·1, 1·1-4·1), heavy episodic drinking (2·7, 1·4-5·1), trouble with the police (2·8, 1·5-5·4, p<0·01), and deliberately hurting themselves (2·8, 1·4-5·6). Female gender (OR 0·3, 0·1-0·6) and social media use (0·4, 0·2-0·8) were protective factors. Excessive gambling was also associated with betting on sports and animals (OR 3·6, 1·6-8·4), slot machines (2·9, 1·5-5·8), card or dice (2·4, 1·2-4·6), and online gambling (4·2, 2·0-8·0). INTERPRETATION: A large proportion of 15-16 year olds in Ireland have gambled for money in the past year, with one in ten of those having engaged in excessive gambling. This number is likely to be underestimated due to recall and social desirability bias. Reducing the availability, access, and appeal of gambling products in Ireland should be addressed through ongoing gambling reform. FUNDING: Institute of Public Health.

Impact of malnutrition management e-learning module on GPs' knowledge: a pilot study.

BACKGROUND: Malnutrition is underdiagnosed in primary care. GPs are key healthcare contacts for older adults at risk of protein-energy malnutrition; however, lack of knowledge and confidence in its diagnosis and treatment is often reported. AIM: To evaluate the impact of a bespoke online education module on GP malnutrition knowledge and management. DESIGN & SETTING: A prospective pre-post pilot study with 23 GPs and eight GP trainees in the Republic of Ireland. METHOD: The module included units on the following: 'malnutrition definition, prevalence, and latest evidence'; 'identifying malnutrition in clinical practice'; 'food-first advice'; 'reviewing malnutrition'; and 'oral nutritional supplements'. Participant knowledge was measured using a multiple choice questionnaire (MCQ) before and after the module (n = 31), and 6 weeks following completion (n = 11). Case studies assessing identification and management of malnutrition were evaluated by a clinical specialist dietitian with expertise in managing malnutrition. Changes in assessment performance were calculated using paired t-tests. Acceptability was evaluated using a questionnaire. RESULTS: Post-training, 97% of GPs increased MCQ scores from baseline (+25%, P<0.001), with the greatest improvement in 'identifying malnutrition in clinical practice' (mean increase 47%, P<0.001). Eleven GPs completed the 6-week MCQ with scores remaining significantly higher than baseline (mean increase 15%, P = 0.005); 'identifying malnutrition in clinical practice' remained the most highly scored (mean increase 40%, P<0.001). Seventeen GPs completed the case studies; 76% at baseline and 88% post-module correctly calculated malnutrition risk scores. Appropriate malnutrition management improved for 47% of GPs after module completion. CONCLUSION: This e-learning module improved malnutrition knowledge, with good short-term retention in a small cohort. Development of online evidence-based nutrition education may improve GP nutrition care.

Shift in the seasonality of ixodid ticks after a warm winter in an urban habitat with notes on morphotypes of Ixodes ricinus and data in support of cryptic species within Ixodes frontalis.

This study was initiated to assess the seasonality and to investigate the morphology of questing ixodid ticks in an urban habitat in Central Europe, Hungary. A neglected part of a large cemetery, with sparse tree covering and dense lower vegetation, was sampled monthly from February 2019 to May 2021. All ticks were analyzed morphologically, and selected specimens by amplifying and sequencing two genetic markers. During the study 3818 ticks were collected, including Ixodes ricinus (n = 2772), Ixodes frontalis (n = 350) and Haemaphysalis concinna (n = 696). Ixodes ricinus adults and nymphs showed year-round activity, whereas H. concinna was not active during winter months and early spring. Most I. frontalis nymphs were collected in late winter and early spring, whereas the peak activity of larvae was during late autumn. Interestingly, during the spring, the peak activity of I. ricinus adults and nymphs was later (in May) when preceded by a warm winter in 2020. In contrast, the 2019 and 2021 spring activity peaks occurred in March and April after sharply rising temperatures in February. This shift in the peak activity of I. ricinus coincided with the initiation of questing activity of H. concinna. Three notably different morphotypes and four malformed specimens of I. ricinus were found. However, these were not significantly different in their mitochondrial haplotypes and phylogenetic clustering from typical specimens of this species. On the other hand, I. frontalis was represented by two remarkably different haplogroups, between which in the nymph stage there were no recognizable morphological differences, suggesting the status of these as cryptic species.

Reflections on recruiting healthcare professionals as research participants: Learning from the ONSPres Study.

The involvement of healthcare professionals (HCPs) as research participants is essential to generate high quality evidence for enhancing health services and practice.  Research teams face many challenges in recruiting HCPs for research, and barriers and enablers for interdisciplinary research are not well described in the literature.  The Oral Nutritional Supplement Prescribing Malnutrition Research Study (ONSPres Study) examined malnutrition identification, management, and appropriate oral nutritional supplement prescribing in primary care in Ireland.  The ONSPres Study offers a unique view of recruiting HCPs for research because a range of disciplines were sought for participation in a mixed methods study.  The purpose of this open letter is to describe the experiences of recruitment and participation.  Sixteen general practitioners (GPs) were recruited to participate in one-to-one interviews, eighty health and social care professionals working in community care (including nurses, pharmacists, dietitians, physiotherapists, speech and language therapists, and occupational therapists) were recruited to take part in 12 focus groups, and 31 GPs and trainee GPs were recruited to participate in an education programme developed by the study team.   Strategies required to gain access and reach HCPs differed between disciplines.   Professional networks enhanced access to HCPs working in practice and recruitment was slower and more tailored when those networks were less available to the team.  An interest in malnutrition, to assist in research, to advance patient care, and the opportunity for learning were incentives for the participating HCPs.  Limitations in the diversity of the sample arose, with a bias towards female participants and GPs motivated by an interest in the topic.  It is recommended that study teams collaborate early with relevant HCP disciplines so they can contribute to recruitment planning at project concept and design stages.  To enhance and incentivise HCP participation in research, dedicated time and acknowledgement of participation as continuous professional development is proposed.

Disparities in Oral Nutritional Supplement Usage and Dispensing Patterns across Primary Care in Ireland: ONSPres Project.

When treating malnutrition, oral nutritional supplements (ONSs) are advised when optimising the diet is insufficient; however, ONS usage and user characteristics have not been previously analysed. A retrospective secondary analysis was performed on dispensed pharmacy claim data for 14,282 anonymised adult patients in primary care in Ireland in 2018. Patient sex, age, residential status, ONS volume (units) and ONS cost (EUR) were analysed. The categories of 'Moderate' (<75th centile), 'High' (75th-89th centile) and 'Very High' ONS users (≥90th centile) were created. The analyses among groups utilised t-tests, Mann-Whitney U tests and chi-squared tests. This cohort was 58.2% female, median age was 76 years, with 18.7% in residential care. The most frequently dispensed ONS type was very-high-energy sip feeds (45% of cohort). Younger males were dispensed more ONSs than females (<65 years: median units, 136 vs. 90; p < 0.01). Patients living independently were dispensed half the volume of those in residential care (112 vs. 240 units; p < 0.01). 'Moderate' ONS users were dispensed a yearly median of 84 ONS units (median cost, EUR 153), 'High' users were dispensed 420 units (EUR 806) and 'Very High' users 892 yearly units (EUR 2402; p < 0.01). Further analyses should focus on elucidating the reasons for high ONS usage in residential care patients and younger males.

Comparison of ultrasound with biomarkers to identify large-for-gestational age in women screened for gestational diabetes mellitus.

OBJECTIVE: Large-for-gestational-age (LGA) is associated with both fetal and maternal complications. One of the few modifiable risk factors for LGA is Gestational Diabetes Mellitus (GDM); for this reason, fetal growth is usually monitored by ultrasound in the third trimester. This prospective study compared a panel of ten established biomarkers measured at the time of selective screening for GDM at 26-28 weeks gestation with the ultrasound prediction of LGA. METHOD: Women were recruited using convenience sampling and consented at the first antenatal visit. Women with maternal risk factors for GDM attended for the one-step 75 g oral glucose tolerance test. An additional blood sample was taken for biomarker measurement. GDM was diagnosed according to the 2013 World Health Organization (WHO) criteria. Fetal biometry, including the abdominal circumference (AC) and the fetal abdominal subcutaneous tissue (FAST) thickness, were measured at 37 weeks gestation. RESULTS: Of the 195 women included, 105 (53.8%) had GDM. Of the 195 babies, 36 (18.5%) were LGA. Whether the woman had GDM or not, fetal biometry was strongly predictive of LGA but none of the following biomarkers measured at 26-28 weeks gestation alone or in combination were predictive: c-peptide, ghrelin, gastric inhibitory polypeptide, glucagon-like peptide-1 (GLP-1), glucagon, insulin, leptin, plasminogen activator inhibitor-1, resistin and visfatin. CONCLUSIONS: In women diagnosed with GDM, surveillance of fetal growth to identify LGA by ultrasound should continue in the third trimester. None of the ten established maternal biomarkers measured at the time of the OGTT was as strongly predictive of LGA as ultrasound.

Maternal obesity and depression reported at the first antenatal visit.

BACKGROUND: Maternal obesity and depression are common and both have been associated with adverse pregnancy outcomes. AIMS: The aim of this observational study was to examine the relationship between maternal body mass index (BMI) category and self-reported depression at the first antenatal visit. METHODS: Women who delivered a baby weighing ≥ 500 g over nine years 2009-2017 were included. Self-reported sociodemographic and clinical details were computerised at the first antenatal visit by a trained midwife, and maternal BMI was calculated after standardised measurement of weight and height. RESULTS: Of 73,266 women, 12,304 (16.7%) had obesity, 1.6% (n = 1126) reported current depression and 7.5% (n = 3277) multiparas reported a history of postnatal depression. The prevalence of self-reported maternal depression was higher in women who had obesity, > 35 years old, were socially disadvantaged, smokers, had an unplanned pregnancy and used illicit drugs. After adjustment for confounding variables, obesity was associated with an increased odds ratio (aOR) for current depression in both nulliparas (aOR 1.7, 95% CI 1.3-2.3, p < 0.001) and multiparas (aOR 1.8, 95% CI 1.5-2.1, p < 0.001) and postnatal depression in multiparas (aOR 1.4, 95% CI 1.3-1.5, p < 0.001). The prevalence of current depression was higher in women with moderate/severe obesity than in women with mild obesity (both p < 0.001). CONCLUSIONS: We found that self-reported maternal depression in early pregnancy was independently associated with obesity. The prevalence of depression increased with the severity of obesity. Our findings highlight the need for implementation of strategies and provision of services for the prevention and treatment of both obesity and depression.

Malnutrition: A Misunderstood Diagnosis by Primary Care Health Care Professionals and Community-Dwelling Older Adults in Ireland.

BACKGROUND: Language and communication have an impact on how a clinical condition is treated and experienced, from both the health care professional (HCP) and patient perspective. Malnutrition is prevalent among community-dwelling older adults, yet perceptions of patient understanding of the term malnutrition to date remain underexplored. OBJECTIVE: This qualitative study explored the use and perceptions of the term malnutrition among HCPs and older adults at risk of malnutrition. DESIGN: Semi-structured interviews and focus groups were conducted with HCPs and older adults with a prescription for oral nutritional supplements (ONS) in the community, to explore perspectives. PARTICIPANTS AND SETTING: HCPs with experience of working with older adults were recruited in primary care centers, general practitioner practices, community health organizations, and community pharmacies in County Dublin, Ireland, between 2018 and 2019. Older adults, aged ≥60 years, with a current or previous prescription for ONS were recruited from daycare centers. One-to-one interviews were conducted with general practitioners (n = 16) and patients (n = 13), and focus groups were conducted with other HCPs, including dietitians (n = 22), nurses (n = 22), pharmacists (n = 9), physiotherapists (n = 12), occupational therapists (n = 6), and speech and language therapists (n = 4). DATA ANALYSIS: Data from interviews and focus groups were transcribed verbatim and analyzed using thematic analysis. RESULTS: There was mutual agreement between HCPs and patients on the main theme, "malnutrition is a term to be avoided." There were three subthemes with varying input from the different HCP groups and patients: "Malnutrition is a term a patient doesn't want to hear"-malnutrition has negative connotations that imply neglect and stigma; "malnutrition is a clinical term which patients don't understand"-with perceptions that it is better to substitute the term with simpler motivating messages; and "lack of confidence identifying malnutrition"-expressed by non-dietetics HCPs who believed they had insufficient expertise on malnutrition to communicate effectively with patients. CONCLUSIONS: HCPs and patients perceived negative connotations with the term malnutrition, and HCPs used alternatives in practice. Additional consultation with HCPs and patients is recommended to explore appropriate language for conveying health risks associated with malnutrition. Future research should also address how current communication challenges can be addressed as part of strategic management programs or interventions to prevent and treat malnutrition.

'It takes a village': a qualitative study on malnutrition and oral nutritional supplements with older adults in Ireland.

BACKGROUND: Malnutrition affects approximately 20% of older adult populations in Europe, yet their views on the condition are rarely explored. This qualitative study aimed to explore the experiences of older adults living with malnutrition and prescribed oral nutritional supplements in the community setting. METHODS: Semi-structured individual interviews were used to collect data from 13 community-dwelling individuals aged ≥60 years with a current or previous prescription for oral nutritional supplements. Self-perceived health status was measured using the EuroQol EQ-5D-5L, a short questionnaire and visual analogue scale. Interviews were audio-recorded and transcribed verbatim. Interview data were organized using NVivo 12 and analyzed using inductive thematic analysis. RESULTS: Median age was 80.0 (interquartile range 19.5) years, seven were male and six were female. Median health score was 60.0 (interquartile range 35.0) out of 100. Almost one-third reported severe or extreme problems with usual activities, and pain or discomfort. One main theme was identified from the interviews: 'It takes a village', with four subthemes (i) 'I get by with a little help from my friends', (ii) 'The obvious diagnosis', (iii) 'The missing T in MDT' and (iv) 'Confusion'. Participants with malnutrition reported relying on friends, family and carers with poor multidisciplinary team communication and lack of dietetic support. CONCLUSIONS: Participants in this study experienced poor management of malnutrition with missing links between the hospital and community healthcare settings, and lack of dietetic services. Patient views should be used to inform public health guidelines and guide future interventions in the community to improve the health status of older adults with malnutrition.

Healthcare professionals' perceptions of malnutrition management and oral nutritional supplement prescribing in the community: A qualitative study.

BACKGROUND & AIM: Protein-energy malnutrition is under-recognised in the community despite being common in older adults due to physiological and social changes which are often compounded by chronic disease. This qualitative study aimed to explore the opinions of healthcare professionals (HCPs) working in the primary care and community settings about the management of malnutrition and the prescription of oral nutritional supplements (ONS), often included in the treatment of malnutrition. METHODS: Twelve healthcare professional (HCP) focus groups with 75 participants were conducted: community dietitians (n = 17), registered dietitians working in industry (n = 5), community and residential care nurses (n = 22), physiotherapists (n = 12), pharmacists (n = 9), occupational therapists (n = 6) and speech and language therapists (n = 4). Focus group discussions were audio-recorded and transcribed verbatim. The data were coded and analysed using thematic analysis and key themes with illustrative quotes extracted are presented. RESULTS: Similar views on malnutrition management existed across professions. 'Gaps in Primary Care Management' was the first key theme wherein HCPs identified limitations in malnutrition management in the community. Barriers included limited or no dietetic services available in primary care and poor communication between general practitioners and wider primary care team members which resulted in inappropriate or delayed treatment. The second key theme, 'Challenges with ONS use in the Community', encapsulated several issues HCPs experienced with ONS usage including inappropriate prescribing and lack of monitoring of treatment goals. Conflicts of interest regarding dietitians working in industry assessing and treating older adults in residential care settings was highlighted by participants. CONCLUSIONS: This study highlights that more emphasis is needed to identify patients when they are at risk of malnutrition to avoid advanced or severe malnutrition presentations currently seen. Community dietitians for older people are required to address many of the issues raised including the need for awareness, education and training, resources, and malnutrition care pathway structures.

Factors associated with changes in consumption among smokers and alcohol drinkers during the COVID-19 'lockdown' period.

BACKGROUND: The impact of the COVID-19 public health social measures (PHSM) on health behaviours is poorly understood. We aimed to identify factors associated with changes in alcohol and tobacco consumption during the strictest period of PHSM 'lockdown'. METHODS: Logistic regression analysis was conducted using secondary data from the Central Statistics Office Social Impact Survey collected during the first lockdown in Ireland (23 April- 1 May 2020). RESULTS: Of the 1362 (33.8%) individuals that responded to the survey, 80.6% were current drinkers and 26.0% were smokers. The majority of smokers (60.9%) and drinkers (60.6%) reported no change in consumption. However, 30.5% of smokers and 22.2% of drinkers reported increased consumption. Being concerned about household stress from confinement [adjusted odds ratio (aOR) 1.9, 95% confidence interval (CI) 1.3-2.9, P = 0.002], working from home (aOR 2.1, 95 CI 1.4-3.3, P < 0.001) and urban living (aOR 2.0, 95 CI 1.5-2.9, P < 0.001) were associated with increases in alcohol consumption. Feeling very nervous (aOR 2.2, 95% CI 1.2-4.0, P = 0.009), feeling downhearted/depressed (aOR 2.4, 95% CI 1.3-4.4, P = 0.004), being concerned about someone else's health (aOR 2.0, 95% CI 1.1-3.9, P = 0.031), working from home (aOR 2.3, 95% CI 1.0-5.3, P = 0.046) and increases in alcohol consumption (aOR 3.6, 95% CI 1.7-7.7, P = 0.023) were associated with increases in tobacco consumption. CONCLUSION: A mixed picture was evident in terms of changes in consumption among current smokers and drinkers. Increased consumption was more commonly reported than reductions. Increased consumption was associated with psychological distress and socio-economic factors. Policies and services should consider a response to widening inequalities in harmful consumption.

Characteristics and determinants of high volume dispensing in long-term oral nutritional supplement users in primary care: a secondary analysis.

BACKGROUND: Oral nutritional supplements (ONS) are recommended for patients who are malnourished or at risk of malnutrition. Appropriate ONS prescribing requires regular monitoring to assess its continued requirement. Previous research identified long-term ONS prescriptions (>6 months) without review, with 70% of these influenced by social factors. AIM: To investigate the characteristics of long-term ONS users in Ireland and the determinants of larger volumes of ONS dispensing. DESIGN & SETTING: Secondary analysis of anonymous dispensed pharmacy claims data of patients dispensed standard ONS for 12 consecutive months in 2018 (n = 912). METHOD: Factors showing significant (P<0.05) univariate associations with above the median consumption of ONS units were entered into a multivariable model. RESULTS: Median age was 76 (range 18 to 101) years, with 66.9% of the sample being ≥65 years. Almost 70% of the samples were on polypharmacy (45.6%; ≥5 medications) or excessive polypharmacy (21.5%; ≥10 medications). Younger age and being on polypharmacy for drugs having an effect on the central nervous system (CNS) were significantly associated with being dispensed more ONS units in univariate and multivariate analysis. Those patients in the age range 18 to 44 were 2.5 fold more likely to be prescribed more ONS units (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.5 to 4.3; P<0.001). Patients using CNS drugs or on CNS polypharmacy were more likely to be prescribed more ONS units (ORs 1.2 and 2.4; 95% CI 0.9 to 1.4 and 1.3 to 4.4 respectively; P = 0.029). CONCLUSION: Older age and polypharmacy characterise long-term ONS users in this study. Younger age and CNS medication polypharmacy are predictors of more ONS units prescribed over a year.

An investigation of community-dwelling older adults' opinions about their nutritional needs and risk of malnutrition; a scoping review.

BACKGROUND & AIMS: Understanding how older adults perceive their nutritional needs and malnutrition risk is important to inform strategies to improve prevention and management of the condition. This scoping review aimed to identify, characterize and summarize the findings from studies analysing community-dwelling older adults' opinions and perceptions towards their nutritional needs and malnutrition risk. METHODS: An electronic literature search was carried out using three databases, Pubmed, Embase, and CINAHL up to January 2020. Articles were reviewed following PRISMA guidelines. RESULTS: A total of 16,190 records were identified and reviewed with 15 studies being included, all of which were conducted in high income countries. Common conceptual categories that were identified included; older community-dwelling adults consider that a healthy diet for them is the same as that recommended for the general population, consisting of fruits, vegetables, reduced fat and reduced sugar. Weight loss was seen as a positive outcome and a normal component of the ageing process. Lack of appetite was identified by participants in the majority of studies as a barrier to food intake. CONCLUSIONS: This review shows how older community-dwelling adults, with a high risk of malnutrition, follow dietary public health recommendations for the general population and have a greater awareness of the risks of overweight. The implementation of nutritional guidelines that consider the nutritional needs of all older adults and education of non-dietetic community healthcare professionals on providing appropriate nutritional advice to this population are warranted.

Trends in private maternity care in Ireland's capital during and after the Great Economic Recession 2009-2017.

BACKGROUND: Maternity care in hospitals in the Republic of Ireland is funded by a hybrid of public finance and private health insurance. AIMS: The aim of this longitudinal observational study was to investigate the annual trends in maternity care from 2009 to 2017 during and after the Great Economic Recession. METHODS: All women who delivered a singleton baby weighing ≥ 500 g during the 9 years (2009-2017) were included. Detailed clinical and sociodemographic details were computerised at the first antenatal visit by a trained midwife. Women who delivered their first baby during the study were analysed longitudinally if they delivered again during the 9 years. RESULTS: The mean age of the 73,266 women was 31.3 ± 5.6 years, 40.1% were nulliparas, and 70.3% were Irish-born. Overall, 75.2% opted for the public, 10.8% for the semi-private, and 14.0% for the private package of maternity care. Over the 9 years, the number of women choosing private and semi-private care decreased by 21.6% and 35.3%, respectively, whereas the number of women using public care increased by 12.3%. Most women opted for the same package of care in subsequent pregnancies. CONCLUSIONS: Ireland's recent economic recession was accompanied by an overall decrease in the number of women choosing private maternity care after 2009. Furthermore, economic recovery with increasing female employment after 2012 was not associated with a recovery in demand for private care. These findings have important implications for healthcare policies and for the future organisation and funding of our maternity services.

Caesarean section rates in women in the Republic of Ireland who chose to attend their obstetrician privately: a retrospective observational study.

BACKGROUND: Caesarean section (CS) rates are increasing and there are wide variations in rates internationally and nationally. There is evidence that women who attend their obstetrician privately have a higher incidence of CS than those who attend publicly. The purpose of this observational study was to further investigate why CS rates may be higher in women who chose to attend their obstetrician privately. METHODS: This study analysed data collected as part of the clinical records by midwives at the woman's first antenatal appointment in a large European maternity hospital. All women who delivered between the years 2009 and 2017 were included. Data were analysed both cross-sectionally and longitudinally. RESULTS: Overall, 73,266 women had a singleton pregnancy and 1830 had a multiple pregnancy. Of the packages of maternity care, 75.2% chose public, 10.8% chose semiprivate and 14.0% chose private. During the study, 11,991 women attended the hospital for their first and second pregnancies. Overall, women who attended privately were older and had higher proportions of infertility treatment and history of miscarriage (all p < 0.001) compared to those publicly-funded. Private patients were more likely to have a history of infertility, a history of miscarriage, a multiple pregnancy and to be ≥35 yrs. They had lower rates of obesity, smoking and illicit drug use in pregnancy (all p < 0.001). In women who chose private care, the overall rate of CS was higher compared to women choosing publicly-funded (42.7% vs 25.3%, p < 0.001) The increase was due to an increase in elective rather than emergency CS. The increase in elective CS fell after adjustment for clinical risks. In the longitudinal analysis, 89.7% chose the same package second time around. Women who changed from public to private care for the second pregnancy were more likely to have had a previous emergency CS or admission to the Neonatal Unit. CONCLUSIONS: This study suggests that the increased CS rate in women privately insured may be attributed, in part, to the fact that women who can afford health insurance choose continuity of care from a senior obstetrician because they are risk adverse and wish to have the option of an elective CS.

The impact of revised diagnostic criteria on hospital trends in gestational diabetes mellitus rates in a high income country.

OBJECTIVE: In 2010, national guidelines were published in Ireland recommending more sensitive criteria for the diagnosis of Gestational Diabetes Mellitus (GDM). The criteria were based on the 2008 Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) Study and were endorsed subsequently by the World Health Organization (WHO). Screening nationally is selective based on risk factors. We examined the impact of the new criteria on hospital trends nationally for GDM over the 10 years 2008-17. RESEARCH DESIGN AND METHODS: Data from three national databases, the Hospital Inpatient Enquiry System (HIPE), National Perinatal Reporting System (NPRS) and the Irish Maternity Indicator System (IMIS), were analyzed using descriptive statistics, analysis of variance, and Poisson loglinear modelling. RESULTS: The overall incidence of GDM nationally increased almost five-fold from 3.1% in 2008 to 14.8% in 2017 (p ≤ 0.001). The incidence varied widely across maternity units. In 2008, the incidence varied from 0.4 to 5.9% and in 2017 it varied from 1.9 to 29.4%. There were increased obstetric interventions among women with GDM over the decade, specifically women with GDM having increased cesarean sections (CS) and induction of labor (IOL) (p ≤ 0.001). These trends were significant in large and mid-sized maternity hospitals (p ≤ 0.001). The increase in GDM diagnosis could not be explained by an increase in maternal age nationally over the decade. The data did not include information on other risk factors such as obesity. The increased incidence in GDM diagnosis was accompanied by a decrease in high birthweight ≥ 4.5 kg nationally. CONCLUSIONS: We found adoption of the new criteria for diagnosis of GDM resulted in a major increase in the incidence of GDM rates. Inter-hospital variations increased over the decade, which may be explained by variations in the implementation of the new national guidelines in different maternity units. It is likely to escalate further as compliance with national guidelines improves at all maternity hospitals, with implications for provision and configuration of maternity services. We observed trends that may indicate improvements for women and their offspring, but more research is required to understand patterns of guideline implementation across hospitals and to demonstrate how increased GDM diagnosis will improve clinical outcomes.

Acute ingestion of beetroot juice does not improve short-duration repeated sprint running performance in male team sport athletes.

The effects of acute ingestion of nitrate on short-duration repeated sprint performance (RSP) are unclear. This study investigated the effect of acute ingestion of beetroot juice on a test of RSP in team sport athletes. Sixteen male team sport athletes undertook four trials using a 40 m maximum shuttle run test (MST), which incorporates 10 × 40 m shuttle sprints with 30 s between the start of each sprint. Two familiarisation trials, followed by nitrate-rich beetroot juice (BR; ~6 mmol nitrate) and nitrate-depleted beetroot juice (PLA; ~0.0034 mmol nitrate) trials were completed in a randomised, double-blind manner. Ingestion of beetroot juice 3 h prior to exercise elevated plasma nitrate concentrations ~6-fold in BR (BR, 413 ± 56 µM; PLA, 69 ± 30 µM; P < 0.001). RSP, assessed by sprint performance decrement (Sdec; %), did not differ (P = 0.337) between BR (5.31 ± 2.49%) and PLA (5.71 ± 2.61%). There was no difference between trials for total sprint time (P = 0.806), fastest sprint (P = 0.341), slowest sprint (P = 0.787), or post-exercise blood lactate concentration (BR, 11.8 ± 2.5 mM; PLA, 12.2 ± 2.3 mM; P = 0.109). Therefore, acute ingestion of beetroot juice did not improve a test of short-duration RSP in team sport athletes.

Maternal employment and pregnancy outcomes in a large European maternity hospital.

OBJECTIVE: Epidemiological studies have previously reported that maternal socioeconomic disadvantage is associated with adverse feto-maternal outcomes. However, little attention has been paid to the question of the woman's employment status. The aim of this observational study was to examine the relationship between maternal employment status at the first antenatal visit and pregnancy outcomes. STUDY DESIGN: The study was confined to women with a singleton pregnancy who attended for maternity care between the years 2010 and 2017 and delivered a baby weighing ≥500 g. Self-reported sociodemographic and clinical details were recorded at the first antenatal visit by a trained midwife and updated before hospital discharge. The hospital is one of the largest in Europe and accepts women from all socioeconomic groups, including women in the public system and those with private health insurance, across the rural-urban spectrum. RESULTS: Of the 62,395 women, the mean age was 31.5 years (SD 5.4), 39.3% were nulliparas and 70.7% were Irish born. Compared with the 45,028 (72.2%) women who reported as being in paid employment, the 4984 (8.0%) women who were unemployed had a higher rate of stillbirth (8/4984 vs. 27/45,028, p = 0.005) and homemakers had a higher incidence of neonatal death (31/12,383 vs. 73/45,028, p = 0.02). On multivariable analysis, women who were unemployed or homemakers had increased adjusted odds ratios for neonatal unit (NNU) admissions, preterm birth, low birth weight, and small-for-gestational-age. Compared to women in paid employment, women who were unemployed or homemakers were associated with younger age (<30 years) in pregnancy, multiparity, unplanned pregnancy, no or postconceptional only folic acid supplementation, anxiolytic/antidepressant use, as well as persistent smoking and illicit drug use during pregnancy. CONCLUSIONS: In a high-income European country, women who reported as unemployed or homemakers were associated with higher rates of adverse pregnancy outcomes. Furthermore, these women were associated with suboptimal lifestyle behaviours such as smoking and illicit drug use in early pregnancy. This highlights the need for long term public policies on female unemployment and retaining women with children in employment.

The use of biomarkers at the end of the second trimester to predict Gestational Diabetes Mellitus.

OBJECTIVE: Previous studies that investigated the relationship between biomarkers and gestational diabetes mellitus (GDM) generally focused on individual biomarkers with significant heterogeneity in terms of the screening methodologies, diagnostic criteria for GDM and sample handling of glucose within these studies. This prospective study used an established panel of ten biomarkers to determine if they could predict the diagnosis of GDM. STUDY DESIGN: Women with risk factors for GDM were recruited at their first antenatal visit. They attended for an oral glucose tolerance test at 26-28 weeks' gestation with strict preanalytical handling of glucose samples to minimise glycolysis. A fasting plasma sample taken simultaneously was stored at -80 °C and analysed in bulk for 10 biomarkers (insulin, c-peptide, glucagon, ghrelin, gastric inhibitory polypeptide (GIP), glucagon like peptide-1 (GLP-1), leptin, visfatin, resistin and plasminogen activator inhibitor-1 (PAI-1)) using the Bio-plex-pro Human Diabetes Assay. RESULTS: Insulin and C-peptide levels in the third tertile were associated with the development of GDM (adjusted odds ratio (aOR) 2.6, 95 % CI 1.3-5.0, p = 0.005 and aOR 3.7, 95 % CI 1.8-7.4, p < 0.001 respectively, adjusted for maternal obesity). Elevated levels of ghrelin were associated with a lower odds of developing GDM, after adjustment for maternal obesity. However, approximately half of the women with GDM who were in the obesity category did not have insulin or c-peptide levels in the third tertile. CONCLUSIONS: While three of the ten biomarkers were statistically associated with an increased risk of GDM, the large overlap in values between those with normal and abnormal glucose tolerance meant that the biomarkers (alone or in combination) were not useful clinically.

General practitioners' views on malnutrition management and oral nutritional supplementation prescription in the community: A qualitative study.

BACKGROUND & AIMS: Malnutrition or undernutrition, arising from a deficiency of energy and protein intake, occurs commonly among community-dwelling individuals in developed countries. Once identified, malnutrition can be effectively treated in the majority of cases with dietary advice and the prescription of oral nutritional supplements (ONS) for patients who can eat and drink orally. However, previous research has reported inadequate screening and treatment of malnutrition in the community. The aim of this qualitative study was to explore general practitioners' (GPs) experiences and opinions on the management of malnutrition and the prescription of ONS in the primary care/community setting in Ireland. METHODS: Sixteen semi-structured interviews including chart stimulated recalls (CSR) were conducted with GPs. The interviews and CSRs explored, among others, the following domains; barriers and facilitators in the management of malnutrition, ONS prescribing in the primary care/community setting, and future directions in the management of malnutrition and ONS prescribing. Recorded interviews were transcribed and analysed following a generic qualitative approach with inductive thematic analysis using NVIVO 12 to facilitate data management. RESULTS: Three main themes were identified. Theme 1: 'Malnutrition is a secondary concern', encapsulating the idea that the identification of malnutrition is usually secondary to other clinical issues or disease rather than an independent clinical outcome. This theme also includes the idea that obesity is viewed as a dominant nutritional issue for GPs. Theme 2: 'Responsibility for malnutrition and ONS management in the community', highlighting that GPs feel they do not know who is responsible for the management of malnutrition in the community setting and expressed their need for more support from other healthcare professionals (HCPs) to effectively monitor and treat malnutrition. Theme 3: 'Reluctance to prescribe ONS', emerging from the GPs reported lack of knowledge to prescribe the appropriate ONS, their concern that ONS will replace the patient's meals and the costs associated with the prescription of ONS. CONCLUSIONS: GPs in Ireland do not routinely screen for malnutrition in their clinics as they feel unsupported in treating and managing malnutrition in the community due to limited or no dietetic service availability and time constraints. GPs also view malnutrition as a secondary concern to disease management and prioritise referral to dietetic services for patients with overweight and obesity. GPs reported that they have insufficient knowledge to change or discontinue ONS prescriptions. This study demonstrates that there is a clear need for primary care training in malnutrition identification, treatment and management and more community dietetic services are needed in order to support GPs and deliver high quality care to patients.