JMSG Volume 5, 2019

CHAMPIONING STUDENT RESEARCH

Volume No. 4 | SPRING 2018

MEDICAL INNOVATION Foreword by Ms. Carmel Malone Further insight by Professor Tim O’Brien

UNIVERSAL TRUTHS AND THE FUTURE OF MEDICINE Observations by forensic physician and writer Dr. Roger Derham

STUDENT ENCOUNTERS Clinical experiences in Germany and Japan A rare case of pneumoperitoneum

JMSG

Cover image: Immunocytochemical Staining of rat ventral mesencephalic (VM) cells in an in vitro neuro-inflammatory model of glial scarring (Astrocytes - green, Neurons - red, Nuclei - blue). Alex Trotier.

Copyright Š 2019 Journal of Medical Students, Galway School of Medicine, Clinical Sciences Institute, National University of Ireland, Galway, Ireland ISSN (Print): 2019-728X ISSN (Online): 2019-7298 Printed and bound in Co. Galway, Ireland by MediaLinn The content published in this journal is entirely the responsibility of a student organisation, supervised by the Faculty of Medicine at the Clinical Sciences Institute, and operates independently from the National University of Ireland, Galway (NUI Galway). The opinions expressed do not necessarily reflect those of the University or University Hospital Galway. NUI Galway shall not be held liable for any damages resulting directly or indirectly from the use or misuse of the published content.

JMSG | CONTENTS 4 Foreword by Dr. Róisín Dwyer 6 Messages from the Director and Editor-in-Chief 7 JMSG Committee

Abstracts 8 Bridging the gap: an evaluation of palliative day care services 9 Survey of nurses’ readiness to the use of ASQ-3 questionnaire for core developmental surveillance checks 10 The predictive value of referral letters to the emergency department in a paediatric population 11 Otoendoscopy – a new eye on the ear 12 After the transition: an investigation into attendance at adult mental health services by patients referred by child and adolescent mental health services 13 Paediatric emergency medicine resource utilisation – can we plan in advance?

14 Determining patients’ preference for treatment of localised low-risk prostate cancer: designing a discrete choice experiment 15 Sleep in A&E: a pilot study examining an older patient cohort 16 Understanding the natural history of common bile duct stones: a meta-analysis and systematic review 17 Mechanisms underlying the increased fracture risk associated with type 2 diabetes mellitus 18 Blood pressure amongst hospitalised paediatric patients: are we in line with the most recent American association of paediatrics recommendations?

19 Impact of middle cerebral artery occlusion and reperfusion on microglia, MMP9 expression, and micro-vessels in a Sprague Dawley rat model 20 Investigation of the immune modulating effects of low dose chemotherapy in colon cancer and its role in mediating macrophage function 21 Travel medicine research in the new millennium: a bibliometric analysis of articles published in travel medicine and infectious disease, 2003-2018 22 Psychological distress and mental health service access: trends and prevalence among a population-based sample of students from Ontario, Canada 23 Depression, anxiety and quality of life in a palliative population: a comparative study across different settings – community and hospital 24 Potential of extracellular vesicles in patient serum as circulating biomarkers of breast cancer 25 A survey on patient’s attitudes and perceptions of biobanking for breast cancer research in Ireland 26 ‘How should she be managed?’ representations of patients and doctors in the discourse of case vignettes 27 Tackling sepsis: improving performance of peripheral blood cultures in non-consultant hospital doctors using a simulation-based intervention incorporating precision teaching 28 Seawaters and risk of human exposure to antibiotic resistant bacteria 29 Parental attitudes to influenza infection: willingness for annual paediatric vaccination

Case Reports 30 Depression with Psychotic Features in a Young Male With Developmental Coordination Disorder

Editorials 33 The Academic Track for Interns

Student Perspective 35 Reflection: The MB PhD 38 The Academic Clinician 39 Orthopaedics and Traumatology at CES Universidad, Medellin, Colombia 41 My Chinese Elective Experience

JMSG | WELCOME Foreword — The Academic Clinician Dr. Róisín Dwyer Academic clinicians combine specialised clinical activities with

Clinicians

teaching and research responsibilities, and play a key role in

researchers and share research findings with colleagues, patients

translating scientific discoveries to transform medical care.

and the lay person, so the verbal and written communication

Recruitment into academic clinical medicine remains challenging.

skills gained during UR are invaluable. Currently UR is

In response to the shortage of clinical scientists there has been

extracurricular, performed voluntarily by a subset of students

an international campaign to identify the barriers, and implement

during the summer months. Although not without challenges,

1,2

need

sustainability of the programme and provide the opportunity for

funding, lack of priority, infrastructure, and an insufficient number

all students to be involved.

engage medical students in academic aspects of medicine as early as possible and to sustain engagement throughout their time as an undergraduate3.

the

curriculum

multidisciplinary

include time constraints due to demanding clinical commitments,

challenges, there is widespread agreement that it is imperative to

into

with

integration

consensus exists as to the optimal approach to address these

UR

communicate

feasible approaches to reverse this decline . Major barriers

of mentors to support junior clinicians on this path. While no

of

to

would

support

Introduced in 2017, the Academic Track for Internship enables a number of medical interns to undertake clinical research, gain experience in medical education, or develop leadership and healthcare management skills. Through these undergraduate opportunities, students begin to develop a professional identity, and cultivate attitudes and behaviours specific to their chosen

“The undergraduate research programme in the School of Medicine at NUI Galway provides an ideal first exposure to research. Along with special study modules, it ensures student awareness of the link between research and healthcare. ”

area of study. Giving individuals the opportunity to take initiative and network fosters intrinsic motivation and provides an environment in which students can thrive4. As we develop an understanding of student’s attitudes towards, and experience of research, we are presented with opportunities to improve research practices among the clinicians of the future5. Student led initiatives play an important role here too, with JMSG providing an outstanding example of this. Following UR, students have the opportunity to publish an abstract of their research, gaining further experience in academic writing and building their CV.

To this end, the undergraduate research (UR) programme in the

Students involved in production of the volume also gain broad

School of Medicine at NUI Galway provides an ideal first

experience as editors and reviewers.

exposure to research.

Along with special study modules, it

ensures student awareness of the link between research and healthcare. Novel therapeutic strategies for disease management and treatment begin with scientific research. Even if practicing clinicians do not wish to pursue research, they must at least understand the process involved and have the ability to interpret research findings. Aside from the more tangible benefits of UR such as skill acquisition and potential to publish, it is also a recognised means of supporting student integration into academic communities, promoting intellectual “Declare the past, diagnose theindependence present, and personal development. The importance of critical thinking,

foretell the future” - Hippocrates

communication, collaboration and troubleshooting is highlighted, and students gain important transferable skills in this area.

“Although not without challenges, integration of UR into the curriculum would support sustainability of the programme and provide the opportunity for all students to be involved.

Good mentorship is a vital component of the academic clinician pathway and a major determinant of success. The UR programme is entirely dependent upon dedicated supervisors who assist in preparation of grant applications and provide a stimulating and supportive research environment. The clinical teaching environment is an important factor in promoting

JMSG | WELCOME student motivation. Thus it is important to enhance opportunities to interact with mentors who can serve as role models. It is also important that clinicians feel valued and are retained in academia to serve as role models for medical trainees. The NUI Galway Academic Clinician Advancement Programme (ACAP) provides formal acknowledgement of clinician contributions to academic activities,

acknowledging

that

many

make

a

significant

contribution despite having no protected academic time.

“Giving individuals the opportunity to take initiative and network fosters intrinsic motivation and provides an environment in which students can thrive.”

clinical training, including during the post-PhD phase.

The initiatives outlined are aimed at promoting early and sustained engagement of clinicians in research. Junior clinicians will only be attracted to careers in academic medicine that are appropriately funded and have clear pathways for progression.

There has never been a better time to be involved in academic medicine, with

wide-ranging

multidisciplinary

opportunities

available. Bridging the gap between research and patient care has a transformative impact, and supports development of clinicianscientists that will contribute to the future of medical science and education.

Restructuring of funding has been identified as a key enabler of clinician involvement in research at all career stages. Funding agencies such as the Health Research Board (HRB) and the Wellcome Trust, offer research awards for health professionals including clinical primer schemes, academic fellowships and emerging investigator awards which provide protected time for research. Recognising the importance of early engagement, these agencies also offer summer scholarships for UR students. These

Dr Róisín Dwyer is a Lecturer in Translational Science at

opportunities allow integration of development of academic skills

NUI Galway and has coordinated the undergraduate

with specialist clinical training. A major recent endeavour in this

research programme in the School of Medicine for the past

area has been the Wellcome – HRB Irish Clinical Academic

six years. Róisín's current research, in collaboration with

Training (ICAT) programme, which supports postgraduate

national and international research groups, focuses on novel

trainees by providing fully integrated clinical and research training

approaches to breast cancer detection and therapy. Her

up to consultant level. Launched in 2016 with the first intake in

work investigates the potential to engineer adult stem cells

2017, this was the largest ever investment in academic medicine

and secreted extracellular vesicles as vehicles for targeted

through an all-Ireland collaborative partnership. The partner

delivery of therapeutic agents to breast tumours, with a

universities involved in the programme include TCD, UCD, NUI

specific interest in imaging modalities to track migration In

Galway, UCC, the RCSI and Queen’s University Belfast. Each

Vivo. Other areas of interest include cellular interactions in

academic partner is affiliated to hospitals and hospital groups in

the

their region. Again highlighting the importance of mentorship, a

extracellular vesicles and microRNAs, and the potential to

primary goal of the ICAT Programme is to provide continuous

harness secreted factors as biomarkers of disease.

breast

tumour

microenvironment

mediated

by

mentoring to ICAT Fellows throughout their academic and References

1. Milewicz DM, Lorenz RG, Dermody TS, Brass LF, National Association of MDPPEC. Rescuing the physician-scientist workforce: the time for action is now. The Journal of Clinical Investigation. 2015 Oct 1;125(10):3742-7. PMID: 26426074.

2. Lawson McLean A, Saunders C, Velu PP, Iredale J, Hor K, Russell CD. Twelve tips for teachers to encourage student engagement in academic medicine. Medical teacher. 2013 Jul;35(7):549-54.

3. Ommering BWC, van Blankenstein FM, Waaijer CJF, Dekker FW. Future

physician-scientists: could we catch them young? Factors influencing intrinsic and extrinsic motivation for research among first-year medical students.

Perspectives on medical education. 2018 Aug;7(4):248-55. PMID: 30006870.

4. Orsini C, Evans P, Binnie V, Ledezma P, Fuentes F. Encouraging intrinsic motivation in the clinical setting: teachers' perspectives from the selfdetermination theory. European journal of dental education. 2015 Apr 10.

5. Alghamdi KM, Moussa NA, Alessa DS, Alothimeen N, Al-Saud AS. Perceptions, attitudes and practices toward research among senior medical students. Saudi pharmaceutical journal : SPJ. 2014 Apr;22(2):113-7.

JMSG | WELCOME Message from the Director I would like to offer a warm welcome to the fifth edition of JMSG, themed this year around the concept of “The Academic Clinician”. As increasing emphasis is placed on conducting scholarly activities throughout one’s medical career, it is vital that students remain informed about the academic opportunities available to them.

In our foreword, Dr. Roisín Dwyer explores the role of the academic clinician and the many ways in which students and doctors can engage in academic activity, while Prof. Dara Byrne has contributed an editorial further detailing the academic track for internship. I am also excited to include a diverse range of student pieces encompassing reflections on the MB PhD programme, an essay on the nature of academia, and elective experiences in Colombia and China.

I would like to thank my fellow student committee members and our staff reviewers for their diligent work in producing this

Niamh Lang Director JMSG 2018-2019

journal. Finally, I would also like to express my sincere thanks to the School of Medicine for their support in the continued publication of the journal.

Message from the Editor-in-Chief I am happy to present to our readers the 5th volume of the Journal of Medical Students, Galway. We have come a long way since our first publication and it is wonderful to see the continued participation of NUI Galway students in academic research. The theme of this edition was the academic clinician and we are proud to feature perspectives on this topic from undergraduate students, PhD students, and researchers.

As always we have published the abstracts of research conducted by undergraduate students; this volume features a diverse array of abstracts ranging from mental health service attendance to immune modulating effects of chemotherapy in colon cancer.

Thank you to everyone who has contributed to this edition of our journal, this wouldn’t be possible without the authors who

Margaret Frere

have submitted their abstracts and other works. Thank you to

Editor-in-Chief

our invaluable staff reviewers. And the biggest thank you to every committee member, we appreciate all your hard work!

JMSG 2018-2019

JMSG | WELCOME JMSG Committee

Alan Keane

John Pereira

Kieran Joyce

Lauren Muldowney

Editorial Board

Editorial Board

Editorial Board

Editorial Board

Mohammed Al-ghamdi

Daniel Coyle

Hasan Ashkanani

Victor Omiwole

Editorial Board

Copy Editor

Copy Editor

Copy Editor

Missing from photos: Nadine Rady Merna Youssef Díana Alrumhí

Idy Udoeyop

Rachael Power

Copy Editor

Copy Editor

Director Niamh Lang Editor-in-Chief Margaret Frere Editorial Board Alan Keane John Pereira Kieran Joyce Lauren Muldowney Merna Youssef Mohammed Al-ghamdi Nadine Rady Copy Editors Daniel Coyle Hasan Ashkanani Idy Udoeyop Rachael Power Victor Omiwole Please

Salar Daud Photographer & Public Relations

Public Relations Díana Alrumhí Salar Daud Staff Reviewers Prof. Francis Finucane Prof. Geraldine McCarthy Dr. Martin O’Halloran Dr. Brian Hallahan Dr. Dara Cannon Dr. Helen Dodson Photographer Salar Daud

JMSG | ABSTRACT Bridging the Gap: an Evaluation of Palliative Day Care Services Abdul-Fattah, S.1 , Field, C.A.2, & McDarby, G.3 1 School of Medicine, NUI Galway 2 Discipline of Health Promotion, NUI Galway 3 Department of Public Health, HSE West 3 Department of Psychiatry, McMaster University, Canada

Introduction: Palliative Day Care (PDC) aims to deliver holistic, multidisciplinary, and individual care to achieve maximum quality of life within the limitations of life-limiting illnesses. 1Due to patient vulnerability and difficulty in evaluating outcomes, there is a paucity of structured research in the field.

Aim: To assess a PDC service from the viewpoint of patients and healthcare providers, using their experiences to develop an evaluative framework, and to apply a discrete choice experiment (DCE) to determine which service qualities are valued most by both patients and providers.

Methods: A mixed methods pilot study comprising of an initial qualitative phase, informing the subsequent quantitative phase, was conducted at the Galway Hospice. Consent forms were signed prior to participation. Semi-structured interviews with patients and providers (n=38), as well as a DCE

(n=23) with 12 choice cards outlining six chosen attributes of the day care services were conducted. Data was analysed using STATA. Results: Of the six attributes that were analysed through a conditional logit model, four yielded statistical significance (p<0.01): transport, therapies, treatments, and specialist palliative care. The most highly ranked attribute was transport with a coefficient of 0.922(0.136), followed closely by therapies [0.918(0.136)]. Specialist palliative care was ranked highly at 0.71(0.128) while treatments showed a moderate coefficient 0.41 (0.135).

Conclusion: The qualitative phase identified the importance of a social atmosphere, while the quantitative phase identified that of therapies and intensive medical input; the mixed methods approach supports a holistic model of PDC. The study must be conducted with a larger population in order to inform a nationwide model of care for PDC.

References 1. Children, Department of Health and. Report of the National Advisory Council on Palliative Care. s.l. : DOHC, 2001

JMSG | ABSTRACT Survey of Nurses’ readiness to the use of ASQ-3 Questionnaire for Core Developmental Surveillance Checks Edward, S. L., Canny, M. Department of Public Health, HSE West

Introduction: The Ages and Stages Questionnaire (ASQ-3) is a developmental screening tool for children aged 18-24 months which includes 30 items per questionnaire covering 5 domains of development. It is a useful surveillance and screening tool in the identification of developmental delays in children for timely intervention and improved long-term health outcomes1.

Aim: To evaluate Public Health Nurses’ (PHNs) readiness and attitudes towards the implementation of ASQ-3 Questionnaire for core developmental surveillance checks in County Galway.

Methods: An adapted questionnaire survey was designed to ask PHNs regarding scheduling of visits, clinical setting, content, duration, and communication aspects developmental surveillance. PHNs were also asked about

barriers to the implementation of the ASQ-3 in their service, and any suggested strategies to overcome them. Questionnaire results were then inputted and analysed using Microsoft Excel.

Results: A total of 35 responses from the 89 PHNs was recorded, giving a response rate of 39%. 27 PHNs are currently using screening tools as part of their developmental checks, this includes 15 (56%) out of the 27 participants who are utilising the Mayo Early Language tool. The vast majority of the PHNs believe that with education and training, and staff support will help enable the successful implementation of the ASQ-3 roll out.

However, most of the PHNs believe that time and money required will be a major barrier to the implementation of the ASQ-3 rollout.

Conclusion: Overall, PHNs provided positive feedback and appear to be open to the implementation of the ASQ-3 rollout in County, Galway.

References 1. Velikonja T. et al. The psychometric properties of the Ages and Stages Questionnaires for ages 2 – 2.5: a systematic review. Child: care health and development 43, 1, 1 – 17.

JMSG | ABSTRACT The Predictive Value of Referral Methods to the Emergency Department in a Paediatric Population Edwards Murphy D.1, McMorrow M.1, Morgan J.1, MacGiobuin S.2, Moylett E.3 1 School of Medicine, NUI Galway 2 Emergency Department, University Hospital Galway.

3 Academic Department of Paediatrics, NUI Galway.

Introduction: The HSE promotes referral letters to endorse appropriate use of GP and hospital services. A charge of 100 has been in place since January 2009 for patients attending the Emergency Department (ED) without a referral letter1.

Aim: This study aimed to investigate the type and frequency of referrals to the ED and their influence on triage score, admission and representation rates. We aimed to investigate differences in the age groups, under and over 6 year olds, particularly due to the GP visit card.

Table 1: Frequency of Referral by Type

Methods: A retrospective review was conducted of ED notes using the Thereforeâ&#x201E;˘ Navigator system available in the ED at University Hospital Galway (UHG). 327 patients were included; all aged <16 years and triaged in the UHG ED between 5/2/2018 and 11/2/2018 inclusive. Results were analysed using IBM SPSS. Results: Average age was 6.85 years, >6 years 172 (52.6%), male 176 (54%); re-presentation rate 6.72% (22 patients). The overall admission rate was 24% (73 patients), excluding missing 24 patients. Admission rate per age group: <6 years (23.9%) and >6 years (24.2%). GP referral rates per age group; <6 years 41.3% (64), >6 years 39% (67).

Fig. 1: Referral Number by Type and Age Group

Conclusion: GP referral rates were similar in both under and over 6s, 41.3% and 39% respectively, suggesting that a GP visit card does not influence referral number. GP referrals were admitted less frequently than self-referrals questioning whether the referral to ED system relieves the burden it aspires to: sending only the patients needing hospital care to hospital.

References 1.Hospital charges - HSE.ie [Internet]. HSE.ie. 2018 [cited 20 August 2018]. Available from: https://www.hse.ie/eng/ services/list/3/acutehospitals/hospitals/hospitalcharges.html

JMSG | ABSTRACT Otoendoscopy â&#x20AC;&#x201C; A new eye on the ear Fahy R.1 , Corbett M.2, Keogh I. 2 1 School of Medicine, NUI Galway 2 Ear, Nose and Throat Department, University Hospital, Galway

Introduction: Traditionally otologic surgeries are carried out under the microscope. Incisions, overnight stays and post op complications need to be considered. Otoendoscopy, (totally trans-canal endoscopic ear surgery â&#x20AC;&#x201C; TEES) is the use of a rigid endoscope to aid visualization during middle ear surgery. TEES is technically challenging, procedures are minimally invasive, endoscopes provide a wide field of view and superior access to complex anatomy. A small but increasing number of otologists are adapting this novel technique worldwide.

Fig 1: Image of tympanic membrane (TM) using endoscopy.

Results: Location

Microscope

Otoendoscopy

Major operating theatre

1087

198

Day ward

470

0

Total

1557

198

Table 1: Microscope Vs Otoendoscopy 2007-2018 Microscope was used exclusively from 2007 to 2013. Since 2013 an endoscope has been used in 198 otologic surgeries, procedures included vtube insertion, tympanoplasty, cholesteatoma surgery and ossicular chain reconstruction. All TEES procedures were carried out as day case surgeries. Procedures were photo documented.

TEES is limited by ear canal diameter but is suitable for all ages. Recovery is quicker and less complicated, no external incisions are made.

Overall the microscope was used in 1,557 procedures. Otoendoscopy has increased each year for the past 6 years, 68 procedures in 2017 compared to 3 in 2013.

Fig 2: Image of speculum and TM using microscope.

Aim:

Fig 3: Number of Otoendocopy cases over time

Our aim is to share our experience of TESS.

Conclusion:

Methods:

The use of endoscopes in ear surgeries is increasing. While challenging, otoendoscopy allows improved surgical exposure, better visualization and tackles ear disease efficiently.

Recovery is quicker and less complicated.

Following ethical approval. A retrospective review of 1,755 ear surgeries from the year 2007 to September 2018 was undertaken. Patient information was compiled from surgical registers and clinical notes. Senior author performed the first TEES in 2013 at UCHG.

References 1. Tarabichi M. Endoscopic Middle Ear Surgery. Annals of Otology, Rhinology & Laryngology. 1999;108(1):39-46.

2. Magliulo G, Iannella G. Endoscopic versus microscopic approach in attic cholesteatoma surgery. American Journal of Otolaryngology. 2018;39(1):25-30.

JMSG | ABSTRACT After the Transition: An investigation into attendance at Adult Mental Health Services by patients referred by Child and Adolescent Mental Health Services Ganter N.1, Cohen D.2, McDonald C. 1,3 1 School of Medicine, NUI Galway 2 Galway/Roscommon CAMHS, HSE West 3 Department of Psychiatry, NUI Galway

Introduction: It is currently recommended that Child and Adolescent Mental Health Service (CAMHS) patients have a “transition plan” in place if it is planned for them to move to Adult Mental Health Services (AMHS).1 The UK TRACK study found that while many patients transferred from child to adult services, few transfers were good.2 The corresponding study in the Republic of Ireland found that, of the patients who were referred to adult services, there was written documented preparation for transition in just over half of cases3. While this is a useful study it failed to quantify exact numbers transferred to AMHS. Aim: Our aim was to investigate the number of patients under the care of CAMHS who were referred to AMHS and their subsequence attendance or nonattendance.

Methods: This was a retrospective, chart review study.

Patients under the care of CAMHS who turned eighteen in the years 2015 – 2017 were identified, in the South Galway CAMHS catchment area. We ascertained the number who were referred to AMHS. For all patients we identified their diagnosis at CAMHS, agencies involved in their care, correspondence with general practitioner and the process involved in their referral or discharge. We then investigated their subsequent attendance or non-attendance at adult services.

We calculated basic statistics on demographic and clinical variables.

Results: Of the 208 patients, 43 (21.6%) CAMHS patients who turned eighteen while being seen by CAMHS were transferred to AMHS. Patients were referred back to their GP in 136 (68.3%) cases, eight (4.0%) were transferred to private services and seven (3.5%) were discharged. Of the 43 referred to AMHS, four were not offered an appointment. Generally, these were cases with ADHD as their primary diagnosis. Of the remaining 39 patients, eight did not attend their first appointment. A meeting between AMHS, CAMHS, and the patient and their family occurred in three cases. Correspondence from CAMHS to the GP was documented in 145 cases. The mean number of agencies involved was 2.05 per patient.

Conclusion: Only one fifth of patients attending CAMHS when they turn eighteen are referred to AMHS. For patients who were transferred to adult services, a formal transition plan six months in advance, with a meeting between members of both services and the patient and their family is recommended. Such a meeting occurred in only three cases, despite this being best practice.

Correspondence to the GP was seen in the vast majority of cases. This is appropriate in patients for whom AMHS referral is not deemed necessary.

References 1.Health Service Executive, 2015. Child and Adolescent Mental Health Services standard operating procedure. Dublin: Health Service Executive.

2. Paul M, Ford T, Kramer T, Islam Z, Harley K, Singh S. Transfers and transitions between child and adult mental health services. British Journal of Psychiatry. 2013;202(s54):s36-s40.

3. McNicholas F, Adamson M, McNamara N, Gavin B, Paul M, Ford T et al. Who is in the transition gap? Transition from CAMHS to AMHS in the Republic of Ireland. Irish Journal of Psychological Medicine. 2015;32(01):61-69.

JMSG | ABSTRACT Paediatric Emergency Medicine (PEM) Resource Utilisation – can we plan in advance?

Gillespie C.1, O’Gorman S.2 1 School of Medicine, NUI Galway 2 Emergency Department, Letterkenny General Hospital

Introduction: Best practice protocol suggests that complete ‘audio-visual separation’ of paediatric and adult patients is optimal for a child’s care in the Emergency Department (ED)1. This essentially requires two individual EDs within a hospital and so establishing when demand is highest would enable more accurate advance resource allocation.

Aim: This study aims to look at paediatric presentations to ED and the resources required for these patients in order to optimise resource allocation.

Method: Data was collected from the hospital database and patient clinical records, for all paediatric presentations to the ED of a General Hospital (Letterkenny) over 4 weeks. Data regarding the day and time of presentation, length of time in the ED (Patient Experience Time or PET), investigations performed, treatment provided and disposition were collected, anonymised and entered in SPSS for statistical analysis.

Comparisons were drawn between school term and school holidays/weekends.

Results:

and 251 during holidays/weekends (14 days).

Attendance peaked between 1pm and 5pm during school term and 3pm to 9pm during school holidays/weekends. Over this period, Wednesdays were the busiest (103 presentations) and Fridays were quietest (71 presentations). The effects of the academic calendar on the nature of presentations (illness, injury or other) were analysed using a Pearson Chi Square test but there was no significance (x2 (2) = 2.737, p = 0.255). Mean PET was 3.6 hours. 42.1% of children had radiological imaging, 27.7% had blood tests, 22.9% were admitted, 0.9% were transferred to another hospital, 23.3% received advice only, 6.8% received a cast, 21.4% received another form of bandage, and 5.1% received wound care. 50% of children were seen and discharged and didn’t require any follow up care.

Resource demand was greatest during school term but the nature of care required didn’t change significantly based on the academic calendar.

Conclusion: Demand for PEM services is greatest during school term and peak presentation time for paediatric patients to ED varies with the academic calendar. The data from this study may assist with planning for paediatric services within this ED and hospital.

570 paediatric patients attended the ED over the 28 day period, 319 during school term (14 days) References 1.Martin C. A National Model of Care for Paediatric Healthcare Services in Ireland Chapter 24: Paediatric Emergency Medicine. HSE (Health Service Executive) – Clinical Strategy and Programmes Division, RCPI. 2014.

JMSG | ABSTRACT Determining patients’ preference for treatment of localised low-risk prostate cancer: Designing a Discrete Choice Experiment Jayasamraj, O.1, Corcoran, R.2, Sullivan, F.3,, O’Donovan, D.1,2 1 School of Medicine, NUI Galway 2 Department of Public Health, Health Service Executive, West 3 Prostate Cancer Institute, NUI Galway, Galway Clinic

Introduction: Prostate cancer is one of the more treatable cancers, especially if diagnosed at an early stage and is localised to the prostate. There are several treatment options available for patients with lowrisk localised prostate cancer, including: active surveillance, surgery (prostatectomy), External Beam Radiation Therapy (EBRT) and brachytherapy.1 Care outcomes are optimised and regret is minimised if patients have the opportunity to choose their own treatment, and this can be done using a Discrete Choice Experiment, a methodology that elicits a user/ patient’s preference for a service/treatment based on its attributes and attribute levels.

analysis was carried out using SPSS v24. We used cross-tabulation to determine the percentage of people in the D’Amico low-risk category, brachytherapy, and combined radiotherapy treatment groups who still had problems with symptoms three years post treatment.

Results: The following table details the attributes and attribute levels which we identified and which will be included in our final DCE.

Aim: To design a Discrete patient preferences cancer treatments: Brachytherapy and Therapy (EBRT).

Choice Experiment to elicit for alternative prostate Surgery (Prostatectomy), External Beam Radiation

Methods: Published literature(2, 3), patient and clinician consultation revealed five main attributes. To justify inclusion of these attributes into the final DCE, we analysed Patient Reported Outcome Measures (PROMS), namely the Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP) collected from patients 3 years post treatment. (n=89). We analysed the total symptom scores for urinary incontinence, urinary obstruction/irritation and rectal problems from the EPIC-CP form against D’Amico risk category, brachytherapy and combined radiotherapy (EBRT + Brachytherapy). Statistical

Table 1: Attributes and attribute levels Our statistical analysis showed that patients still had problems with the identified attributes/side effects three-years after treatment.

Conclusion: The presence of urinary and bowel symptoms 3 years post-treatment justified the identified attributes. Such justification was not possible for prostatectomy (similar data unavailable). Further statistical analysis needs to be done in order to further confirm our results for brachytherapy due to some overlap with other treatment data and to make sure there is no other overlap between data.

References 1. Weiner AB, Kundu SD. Prostate Cancer: A Contemporary Approach to Treatment and Outcomes. Med Clin North Am. 2018;102(2):215-29.

2. Bekker-Grob EWD, Rose JM, Donkers B, Essink-Bot ML, Bangma CH, Steyerberg EW. Men’s preferences for prostate cancer screening: a discrete choice experiment. British Journal of Cancer. 2013;108(3):533.

3. Bekker-Grob E, Bliemer M, Donkers B, Essink-Bot M-L, Korfage I, Roobol-Bouts M, et al. Patients' and urologists' preferences for prostate cancer treatment: A discrete choice experiment. British Journal of Cancer. 2013;109(3):633-40.

JMSG | ABSTRACT Sleep in A&E: A Pilot Study Examining An Older Patient Cohort Mannion H.1, Ó’Caoímh R.2 1 School of Medicine, NUI Galway 2 Frailty Service, Department of Geriatric & Stroke Medicine, University Hospital Galway

Introduction:

Results:

Impaired sleep is common in hospital, potentially resulting in poor clinical outcomes and increased total cost of healthcare1. Little is known about sleep disturbance among older adults attending Emergency Departments (ED).

The median age of patients was 80 years (IQR=74-84); 61% were male (n=92). Most, 68%, were ED boarders (n=103). The median duration spent in ED was 23 hours (IQR=1831); median duration slept in ED was 1 hour (IQR=0-3). Most, 70%, reported impaired sleep quality at baseline and 15% reported clinical insomnia. Overnight sleep quality was significantly poorer for ED boarders compared with non-boarders: median RCSQ scores of 22 (IQR=10-55) vs 71(IQR=46-80), respectively, (p<0.001). Median length of stay (LOS) was 6 days (IQR=4-10) and there was no significant difference between boarders and non-boarders, (p=0.84).

Aim: Assess the prevalence, predictors and impact of sleep disturbance in a large university hospital ED and investigate differential effects on overnight-boarders.

Methods: Following ethics approval,152 patients consented to this single-centre cross-sectional pilot study. Data were collected from consecutive patients ≥70 admitted medically.

Patients completed a study-specific questionnaire comprising validated measures assessing overnight sleep quality (Richards Campbell Sleep Questionnaire/RCSQ), baseline sleep (Pittsburgh Sleep Quality Index/PSQI) and insomnia (Insomnia Severity Index/ISI).

Additional variables included medications, trolley location, hours spent in ED and nighttime noise levels. Patients were reassessed 48 hours later. Statistical analysis included PearsonChi Square and Mann-Whitney U-test.

Conclusion: Sleep disturbance is prevalent among older adults admitted through ED. After adjusting for confounders, ED boarders experienced significantly poorer sleep. While no impact on LOS was evident, further analysis is planned to examine 30 and 90-day readmission rates.

References 1. Ensrud KE, Blackwell TL, Redline S, Ancoli‐Israel S, Paudel ML, Cawthon PM, Dam TT, Barrett‐Connor E, Leung PC, Stone KL, Osteoporotic Fractures in Men Study Group. Sleep disturbances and frailty status in older community‐ dwelling men. Journal of the American Geriatrics Society. 2009 Nov;57(11):2085-93.

JMSG | ABSTRACT Understanding the natural history of common bile duct stones: A meta-analysis & systematic review Mathew C.1,2, Donnellan E.1,2, McIntyre C.1,3, Johnston A.1, Bucholc M.5, Flanagan L.4, Sugrue M.1,4,5 1 Donegal Clinical and Research Academy, Department of Surgery, Letterkenny University Hospital 2 School of Medicine, NUI Galway 3 School of Medicine, UCD 4 EU INTERREG, Emergency Surgery Outcome Advancement Project 5 EU INTERREG Centre for Precision Medicine Project, Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University

Introduction:

Results:

Biliary disease is a leading cause for surgical emergency admissions globally and despite the association of common bile duct (CBD) stones with increased mortality, the natural history of CBD stones is not well documented.

This study identified 11215 articles. 42 were found to meet the inclusion criteria and 29 of these were included for analysis after applying the MINORS criteria. A total of 46588 cholecystectomies were reported, with CBD stones identified in 4955 patients (10.6%) (Range: 1.3%-20.9%). Post cholecystectomy, CBD stones passed spontaneously in 49.6%(mean) of patients (Range: 12.5% - 73%) . Only four papers reported the clinical sequelae of CBD stones: the rate of pancreatitis, jaundice, cholangitis, and abdominal pain in cholecystectomy patients were 11.8%, 45.3%, 8.2% and 43.8% respectively.

Aim: This study undertook a meta- analysis of the significance of CBD stones in cholecystectomy patients.

Methods: An ethically approved, PROSPERO-registered (CRD42018102167) meta-analysis following the PRISMA guidelines was undertaken. The databases PubMed and Scopus were searched for relevant literature from the last thirty years.

Articles were assessed using the Methodological Index for Non-Randomised Studies (MINORS).

MINORS scores for included articles were > 10/16 (non-comparative studies) and > 15/24 (comparative studies). The primary outcome was the natural history of CBD stones.

Conclusion: Remarkably, few papers report known outcomes of CBD stones in patients undergoing cholecystectomy. Complications are significant in 8-45% of patients. With decreasing cholangiography rates, this may result in increased long term biliary related mortality. Multinational risk registries are urgently required to identify the sequelae in CBD stones.

References 1. Collins, C., Maguire, D., Ireland, A., Fitzgerald, E., & Oâ&#x20AC;&#x2122;Sullivan, G. C. (2004). A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Annals of surgery, 239(1), 28.

2. MĂśller, M., Gustafsson, U., Rasmussen, F., Persson, G., & Thorell, A. (2014). Natural course vs interventions to clear common bile duct stones: data from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks). JAMA surgery, 149(10), 1008-1013.

3. Cox, M. R., Budge, J. P., & Eslick, G. D. (2015). Timing and nature of presentation of unsuspected retained common bile duct stones after laparoscopic cholecystectomy: a retrospective study. Surgical endoscopy, 29(7), 2033-2038.

JMSG | ABSTRACT Mechanisms underlying the increased fracture risk associated with Type 2 Diabetes Mellitus McDonnell, T.¹, Parle, E.², Gardner, S.³, Carey, J.⁴, Murphy, C.⁴, Coleman, C.⁵, Vaughan, T.², McNamara, L.M.² ¹School of Medicine, NUI Galway ²Biomedical Engineering Department, NUI Galway ³Leigh University, Pennsylvania, USA ⁴Merlin Park University Hospital and University College Hospital, Galway, Ireland

Introduction:

Results:

Type 2 Diabetes Mellitus (T2DM) is a growing epidemic, resulting in 2 million deaths each year and is a leading cause of disability¹. Despite elevated bone mineral density during T2DM, there is a greater risk of fractures, the reason for which is unknown².

To investigate the mechanisms underpinning the increased risk of hip fractures in T2DM patients (n=4), compared to osteoarthritic (OA)( n=7) and osteoporotic (OP) (n=7) patients

The Kruskal Wallis test showed a difference in Kic mean ranks (Median (mean rank): OA= 0.596 (14), OP=0.345(5.1), T2DM= 0.375(9.3)), with the osteoarthritic group being higher in comparison to the other 2 groups (p=0.008). BV/ TV (Median (mean rank): OA= 0.319(14.3), OP= 0.240(6.3), T2DM= 0.212(6.8)) and mean mineralisation (Median (mean rank): OA= 856.439(4.9), OP= 896.676(10.6), T2DM= 939.144(15.8)), was also found to be significantly different across the 3 disease states (p=0.010 and 0.004 respectively).

Methods:

Conclusion:

Human femoral heads (HFHs) were donated by consenting patients who underwent total hip arthroplasty in 2 Galway hospitals. Ethical approval was granted by the Galway Clinical Research Ethics Committee. HFH trabecular bone was cut and scanned with a Micro CT to evaluate bone volume fraction (BV/TV) and mean mineralisation. A Zwick was used to determine the fracture toughness (Kic), using single edge notched bend beam specimens.

The lower Kic value in T2DM, compared to OA controls, suggests that decreased bone toughness may contribute to the increased fracture risk associated with diabetes. The lower BV/TV and higher mineralisation are likely to cause this reduction in toughness.

Aims:

References 1. Zhou B., Lu Y et al. NCD Risk Factor Collaboration. Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4·4 million participants. The Lancet. 9 April 2016. Volume 387, Issue 10027, P15131530.

2. Oei L., Zillikens M.C. et al. High Bone Mineral Density and Fracture Risk in Type 2 Diabetes as Skeletal Complications of Inadequate Glucose Control-The Rotterdam Study. Diabetes Care 2013 Jun; 36(6): 1619-1628.

JMSG | ABSTRACT BP amongst hospitalised paediatric patients: Are we in line with the most recent AAP recommendations 1 2

School of Medicine, NUI Galway, Academic Department of Paediatrics

Introduction:

Results:

In 2017, the American Association of Paediatrics released new clinical guidelines for Paediatric Hypertension:

139 patients were included, 93 over 3 years and 46 under 3 years of age with 97% of total patients’ BP documented.

·BP should be measured annually in children and

Twice daily was the most frequent measurement 91 (65.47%) were surgical patients were more likely to have BP measurement twice daily (54/72) than medical or elective admissions. Over 3s were more likely to have twice daily BP measurement than under 3s.

adolescents ≥3 years of age ·BP should be checked in all children and adolescents ≥3 years of age at every health care encounter if increased risk of paediatric hypertension 1.

Aim: We aimed to review the frequency of BP measurement during hospital admission and to compare results with the new guidelines.

Methods: R e tr os pec t iv e d ocu men ta t i on of B P documentation was obtained from the Paediatric Early Warning Score (PEWS) for all patients admitted to the paediatric ward of University Hospital Galway over a two-week period in June 2018.

Age (>3/<3 yrs), gender, and type of admission (medical/surgical/elective) and frequency of BP measurement were documented. Results were analysed using SPSS.

Frequency of documentation was followed by Daily 16 (11.51%), 2-3 weekly: 13 (9.35%), Once during their inpatient stay: 13 (9.35%) and Once weekly: 2 (1.44%).

Not measured was 4 (2.88 %) with Surgical (3) and Elective (1) patients were more likely to have no BP measurement. These patients were all male though gender was found not to influence documentation.

Conclusion: 3% of patients did not receive BP measurement during their inpatient stay. This warrants further promotion of the guidelines’ suggestions that BP should be used as a screening tool as well as a vital sign.

References 1. Flynn, Joseph T., David C. Kaelber, Carissa M. Baker-Smith, Douglas Blowey, Aaron E. Carroll, Stephen R. Daniels, Sarah D. de Ferranti, et al. “Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents.” Pediatrics, August 21, 2017, e20171904. https://doi.org/10.1542/peds.2017-1904.

JMSG | ABSTRACT Impact of Middle Cerebral Artery Occlusion (MCAO) and Reperfusion on Microglia, MMP9 expression, and micro-vessels in a Sprague Dawley rat model Neo W.1, Tamberrino D.2, Prendergast J.2, Douglas A.2, Doyle K.2 1 School of Medicine, NUI Galway 2 Discipline of Anatomy, School of Medicine, NUI Galway

Introduction: Ischemic stroke is a major cause of death and disability worldwide, affecting an estimated 10million people worldwide and 23000 people in Ireland (Institute of Public Health Ireland, 2012) and vastly reducing the quality of life in its survivors. However, current acute treatments for managing stroke, such as recombinant tissue plasminogen activator (rtPA) and thrombectomy, only benefit approximately 5% of patients (Fang et al, 2010), partly because its exact pathophysiological mechanism remains to be fully elucidated.

microglia count (p<0.05) and microglial volume (p<0.05) in the ipsilateral vs contralateral hemispheres. Additionally, increased MMP9 expression was observed following 2hour ischaemia, and 2hour with reperfusion in comparison to sham controls (p<0.05), with increased MMP9 expression in microvessels (p<0.05) following ischaemia.

Aim: We investigated the impact of Middle Cerebral Artery Occlusion (MCAO) and reperfusion injury on microglia count, the area and volume of the lesion, and Matrix Metalloproteases 9 (MMP9) expression in microvessels in a Sprague Dawley rat model of focal cerebral ischaemia.

Methods: Ischemic Stroke was induced for 2hours in male Sprague Dawley rats (n=36), and 30 micrometer brain slices were subsequently imaged and analysed using Olyvia software and using stereology via ImageJ to characterize differences.

Results: Our results show a significant increase in

Fig 1. Microglial count Conclusion: The data from the study improves our understanding of the pathophysiological mechanisms following stroke. More research in this area should be conducted in order to gain a complete appreciation of ischemic stroke & reperfusion pathology, which could facilitate the development of novel treatments and may improve responses to currently available therapies.

References 1. IPH Stroke Briefing [Internet]. Publichealth.ie. 2012 [cited 18 October 2018]. Available from: https:// www.publichealth.ie/sites/default/files/documents/files/Stroke%20Briefing%2024%20Sept.pdf 2. Fang M, Cutler D, Rosen A. Trends in thrombolytic use for ischemic stroke in the United States. Journal of Hospital Medicine. 2010;5(7):406-409.

JMSG | ABSTRACT Investigation of the immune modulating effects of low dose chemotherapy in colon cancer and its role in mediating macrophage function O’Mahony A.1, Leonard N.2, Egan H.2, Lynch K.2, Ryan A.E.2,3 1 School of Medicine, NUI Galway 2 Immunology Group, Regenerative Medicine Institute (REMEDI), CMNHS, NUI Galway 3 Discipline of Pharmacology and Therapeutics, CMNHS, NUI Galway

Introduction: Colorectal cancer is a leading cause of cancerrelated death worldwide. Treatment limitations include resistance to conventional chemotherapy.

Although traditionally believed to be immunosuppressive, emerging evidence demonstrates that many chemotherapeutics stimulate immune cells in a dose-dependent manner. When bound to antibodies attached to pathogens, Fc receptors on macrophages stimulate tumour cell phagocytosis. This is antibody-dependent cellular phagocytosis (ADCP).

Aim: To establish the existence of this immunestimulatory phenomenon in colon cancer in the context of drugs likely to be used in combination with monoclonal antibody-based immunotherapies for colon cancer treatment.

Methods: HT29 colon cancer cell media was placed on THP -1 macrophages for 24 and 48 hours. Using flow cytometry, it was observed that Fc receptor

CD64 expression decreased after 48 hours, suggesting the tumour microenvironment decreases the potential of macrophages to mediate ADCP. In an attempt to reverse this, HT29 cells were treated with low dose cyclophosphamide for 24 hours. After washing with PBS, subsequent media was collected at 24 and 48 hours and placed onto macrophages.

Results: It was observed that at 48-hour time we had a restoration of CD64. This potentially indicates that low dose cyclophosphamide overcomes the tumour microenvironment mediated decrease in CD64, potentially increasing macrophage ADCP ability.

Conclusion: AMR-E of clinical significance were detected in all 3 sampling locations across the bathing water period, confirming that bathing waters are a reservoir for AMR-E. Thus, it is an important transmission route to humans and routine monitoring of bathing waters for AMR-E should be considered.

References 1.Morris, D. et al. Enterococcus faecium of the vanA genotype in rural drinking water, effluent, and the aqueous environment. Appl. Environ. Microbiol. 78, 596–598 (2012).

2. Galvin, S. et al. Enumeration and characterization of antimicrobial-resistant escherichia coli bacteria in effluent from municipal, hospital, and secondary treatment facility sources. Appl. Environ. Microbiol. 76, 4772–4779 (2010) 3. Morris, D. et al., 2016. CapE (capture, amplify, extract): A rapid method for detection of low level contamination of water with Verocytotoxigenic Escherichia coli (VTEC). Sci Total Environ. 2016 Sep 1;563-564:267-72

JMSG | ABSTRACT Travel medicine research in the new millennium: a bibliometric analysis of articles published in Travel Medicine and Infectious Disease, 2003-2018 Oh, K.E.1, Flaherty, G.2 1 2

School of Medicine, NUI Galway School of Medicine, International Medical University, Kuala Lumpur, Malaysia

Introduction:

Results:

Evidence-based travel medicine requires that research priorities reflect the wide knowledge base of this relatively new discipline. This bibliometric analysis aimed to map the research output of a leading travel medicine journal against a recognised syllabus.

Categorical mapping of 1,047 eligible articles belonging to 9 article categories yielded the following number of articles per domain: Epidemiology (7.9%, n=83); Immunology/ Vaccinology (8.5%, n=89); Pre-travel assessment/ consultation (39.1%, n=409); Diseases contracted during travel (45.5%, n=476); Other clinical conditions associated with travel (5.5%, n=58); Post-travel assessment (9.6%, n=100); and Administrative and general travel medicine issues (7.3%, n=76). A mapping exercise was performed at the sub-domain level. Three articles relating to global health and travel medicine research were uncategorisable.

Aim: To identify research trends and gaps in the Body of Knowledge by mapping articles to the syllabus domains and sub-domains, thus informing the setting of research priorities in this expanding area of clinical activity.

Methods: All eligible articles published in Travel Medicine and Infectious Disease (2017 impact factor 4.45) between 2003 and 2018 were mapped against the Body of Knowledge curriculum of the International Society of Travel Medicine, comprising 7 domains and 178 sub-domains.

Where an individual article reflected more than one sub-domain, it was categorised to each subdomain. A temporal analysis of publication trends was also performed.

Conclusion: This bibliometric analysis of travel medicine research publications provides useful information about research output, demonstrating a significantly higher level of activity in pre-travel assessment and diseases contracted during travel.

Sub-domain analysis provided further insights.

Our study also highlights deficiencies in the travel medicine curriculum which should be addressed in future revisions of the Body of Knowledge.

References 1. Kozarsky PE, Keystones JS. ISTM Committee to Establish the Body of Knowledge for the practice of travel medicine. J Travel Med 2002; 9:112-5 2. Flaherty GT, Lim Yap K. Bibliometric analysis and curriculum mapping of travel medicine research. J. Travel Med. 2017 1;24(5)

JMSG | ABSTRACT Psychological Distress and Mental Health Service Access:Trends Among a PopulationBased Sample of Students from Ontario, Canada Ostoich, K. C.1, Cheung, A.2,3,4, Cook, S.5, Williams, A.2,4, Mason, G.6 1

School of Medicine, NUI Galway Department of Psychiatry, Sunnybrook Health Sciences Centre, Canada 3 Department of Psychiatry, University of Toronto, Canada 4 Hurvitz Brain Sciences Research Program, Sunnybrook Health Sciences Centre, Canada 5 Cardiff University, United Kingdom 6 Department of Psychology, Queenâ&#x20AC;&#x2122;s University, Canada 2

Introduction There is evidence suggesting that the prevalence of mental health concerns among children and adolescents has increased globally over time.1 Much of clinical practice remains based on the adult literature and traditional models of care.

Childhood and adolescence is a pivotal developmental stage; mental health issues may lead to difficulties and functional impairment in many aspects of life. It has been shown that a large proportion of adolescents have high psychological distress with wholly unmet mental health needs.2 Aim To examine the prevalence of psychological distress and the patterns of mental health service access among a population-based sample of students from Ontario, Canada.

Methods Data was extracted from the Ontario Student Drug Use and Health Survey (OSDUHS). The 2013, 2015 and 2017 waves were merged, including 32,213 students; analyses were conducted using design-based survey commands in Stata14. Psychological distress was measured based on the Kessler 6-item Psychological Distress Scale3 with two cut-off scores used(out of 24); moderate(>8) and severe(>13). Mental health service access was evaluated through questions concerning self-reported need for

service access, actual services accessed, unmet service need, mental health medication use and helpline use.

Results There was a significant increase in psychological distress between 2013 and 2017; for moderate (>8) and severe(>13), and for males and females.

Females had higher levels of distress in 2013 and continued to have higher levels. The 2017 wave showed increased mental health service access and helpline use. There was an increase in selfreported need for mental health services and unmet service need over the three waves.

Females were 1.8 times more likely to report unmet service need. The relationship between severe distress and unmet service need did not significantly change over the waves.

Conclusion The results exemplify supporting evidence of the increasing prevalence of adolescent mental health concerns; higher levels of psychological distress reported by females warrants further investigation to assist in preventive efforts. The increase in mental health service access over time was small in comparison to increases in psychological distress; these findings, in addition to the increased reported unmet need for services, suggests further research to help better identify and understand barriers to service access.

References 1. Mojitabai, R., Olfson, M., & Han, B. (2016). National Trends in the Prevalence and Treatment of Depression in Adolescents and Young Adults. Pediatrics, doi:10.1542/peds.2016-1878.

2. Sheppard, R., Deane, F.P., Ciarrochi, J. (2017). Unmet need for professional mental health care among adolescents with high psychological distress. Australian & New Zealand Journal of Psychiatry. doi:10.1177/0004867417707818.

3. Kessler R.C., Barker P.R., Colpe L.J., Epstein, J.F., Gfroerer J.C., Hiripi, E., â&#x20AC;Ś Zaslavasky, A.M. Screening for serious mental illness in the general population. Arch Gen Psychiatry. 2003 Feb;60(2):184-9.

4. Boak, A., Hamilton, H.A., Adlaf, E.M, & Mann, R.E. (2013). Drug use among Ontario students, 1977-2013: Detailed OSDUHS findings (CAMH Research Document series No. 36). Toronto, ON: Centre for Addiction and Mental Health.

5. Boak, A., Hamilton, H.A., Adlaf, E.M., Henderson, J.L., & Mann, R.E. (2016). The mental health and well-being of Ontario students, 19912015: Detailed OSDUHS findings (CAMH Research Document Series No. 43). Toronto, ON: Centre for Addiction and Mental Health.

6. Boak, A., Hamilton, H.A., Adlaf, E.M., & Mann, R.E. (2017). Drug use among Ontario students, 1977-2017: detailed findings from the Ontario Student Drug Use and Health Suvey (OSDUHS) (CAMH Research Document Series No.46). Toronto, ON: Centre for Addition and Mental Health.

JMSG | ABSTRACT Depression, anxiety and quality of life in a palliative population: a comparative study across different settings – community and hospital Salmon, C.1, Reilly, L.2, McMahon, E.3, Waldron, D.2, Doherty, A.3 1School of Medicine, NUI Galway 2 Palliative Medicine, Galway University Hospital 3 Psychiatry, Galway University Hospital

Introduction Palliative care patients commonly experience fluctuating moods due to the nature of their diagnosis. Management plans focus on keeping physical pain at bay, resulting in the patient’s mental health being overlooked. Understanding adjustment and depressive disorders in this population better may be an important target for improved quality of life.

Methods Patients in the West of Ireland were approached in this ethically approved cross-sectional study. The scales used were Hospital Anxiety and Depression Scale (HADS), the short form of the Adjustment Disorder-New Module scale (ADMN6) and the EQ-5D to measure quality of life. The HADS focuses on the patient’s recent emotional responses experienced whereas the EQ-5D is a 5item validated scale which explores functioning in activities of daily living and related quality of life.

Results Of all patients approached 30 agreed to

participate in the study. Adjustment disorderNew module 6 (ADNM-6) highlighted 63.13% of patients whose situation was a burden to them, only 36.84% reported any change to their sleeping habits. 52.63% of patients admit to ‘supressing’ their feelings with others while but only 15.79% of participants say they have withdrawn from their friends and family. The Quality of Life questionnaire reported 42.11% of patients to be moderately depressed. Finally, when asked to rate their current health on a scale, a mean of 56 was obtained.

Conclusion Working with a sensitive and acutely ill cohort has its challenges. This pilot study will deepen our understanding of the psychological and overall care requirements of palliative care patients. The data collected suggests that end-of-life patients require mental health care to complement their physical management. This will result in an improvement of the overall wellbeing of HSE palliative patients, in both community and inpatient based settings.

References 1. Grotmol KS, Lie HC, Hjermstad MJ, Aass N, Currow D, Kaasa S, Moum TÅ, Pigni A, Loge JH; European Palliative Care Research Collaborative (EPCRC). Depression - a major contributor to poor quality of life in patients with advanced cancer. J Pain Symptom Manage.

2017; 9: S0885-3924(17)30334-2.

2. Price A, McCormack R, Wiseman T, Hotopf M. Concepts of mental capacity for patients requesting assisted suicide: a qualitative analysis of expert evidence presented to the Commission on Assisted Dying. BMC Med Ethics. 2014: 22;15-32.

3. Rayner L, Higginson IJ, Price A, Hotopf M. The Management of Depression in Palliative Care: European Clinical Guidelines. London: Department of Palliative Care, Policy & Rehabilitation (www.kcl.ac.uk/schools/medicine/depts/palliative)/ European Palliative Care Research Collaborative (www.epcrc.org); 2010.

JMSG | ABSTRACT Potential of Extracellular Vesicles (EVs) in Patient Serum as Circulating Biomarkers of Breast Cancer Shafik L., Khozi B., Challapalli R., Oâ&#x20AC;&#x2122;Neill C., Oâ&#x20AC;&#x2122;Connell E., Giligan K., Dwyer R.M Discipline of Surgery, Lambe Institute for Translational Research, School of Medicine, NUI Galway

Introduction:

Results:

There is an urgent need for a biomarker to support early detection of breast cancer to improve patient survival. Breast cancer cells actively secrete extracellular vesicles (EVs) containing microRNAs (miRs), which may be reflective of cell characteristics. EVmiRs may represent an ideal biomarker of disease.

EVs were successfully isolated from all serum samples (n=40). NTA revealed singly dispersed vesicles, with the majority of a size similar to exosomes(30-150nm). The range of EV concentrations was 5.11 x 109/ml to 8.9 x 1010/ ml with a significantly higher concentration detected in breast cancer patient sera compared to healthy controls (p<0.05). There was no relationship between protein yield and EV concentration (rho=0.124, p=0.293). miR-181b was detectable in 6 of 20 breast cancer sera and 15 of 20 healthy control samples.

Aim: To isolate EVs from sera of breast cancer patients and healthy controls and investigate the presence of miRs of interest.

Methods: Following ethical approval and informed consent, EVs were isolated from sera of breast cancer patients (n=20) and healthy controls (n=20) using differential centrifugation, microfiltration and ultracentrifugation. Nanoparticle tracking Analysis (NTA) was used to determine the number and size of EVs. RNA was extracted from EVs using the MagnaPure system, reverse transcribed and amplified using PCR targeting miR-181b. Protein Estimation was conducted using a BCA assay.

Table 1: Details of BC cohort Conclusion:

Fig 1: Example of analysis of extracellular vesicles (isolated from human sera: Nanoparticle Tracking Analysis (NTA) demonstrating size distribution, with majority of expected size of 30-120nm

Protein yield is not a suitable indicator of EV concentration and direct measurement using NTA is required. miR-181b is more strongly detected in EVs of healthy individuals than breast cancer patients, however a larger sample size is required to validate these findings.

References 1. Joyce, D.P., Kerin, M.J., Dwyer, R.M. Exosome-encapsulated microRNAs as circulating biomarkers for breast cancer.

Int J Cancer. 2016; 10:1002.

JMSG | ABSTRACT A survey on patient’s attitudes and perceptions of biobanking for Breast Cancer Research in Ireland Tan J. J. C1, Balasubramanian I.2, Barry K.2, McLoughlin R.2, Malone C.2, Sweeney K.2, Kerin M.J.2, Lowery A.J.2 1 School of Medicine, NUI Galway 2

Discipline of Surgery, NUI Galway

Introduction: Significant advances in cancer research have been made possible by molecular investigation using well-preserved biospecimens at structured and supported biobanks. Understanding patients’ attitudes towards contributing biological samples and other information to biobanks is thus important.

Biobanks are seen as a powerful tool/resource to foster large scale molecular and genetic research which will improve our professional’s understanding of the molecular basis of disease.

Research shows that the rate limiting step for genomic discoveries will not be technological but rather the limited availability of high quality biospecimens to sustain such research 1.

Aim: This study aimed to assess patient attitudes towards the same and examine how demographic, social, and health-related factors correlate with willingness to contribute.

Methods: All patients who attended the Symptomatic Breast Unit (SBU) in University Hospital Galway from 24th May to 28th June 2018 were invited to complete a questionnaire. Only patients who could provide verbal and written consent were included in this study . Data was stored in an anonymized password protected database.

Statistical analysis was completed using SPSS version 25.

589 patients participated. Most participants were females (97.8%), aged between 41 and 60 years (48.4%) and with an education level equivalent to secondary school or less (47.2%). Of these patients, 22.1% (130/589) and 22.4% (132/589) attended the SBU for family history and personal history of breast cancer respectively. Although only 17.3% of patients (102/589) had prior knowledge on biobanks, 76.2% (449/589) said they were willing to donate to one. Willingness to contribute was statistically associable to an education level of university or higher (p=0.043).

No association was identified for age (p=0.407), gender (p=0.930), race (p=0.869), family history of breast cancer (p=0.937) or personal history of breast cancer (p=0.967).

Conclusion: Limited understanding of the role of biobanks and their importance in advancing medical research persists. Although positive attitudes towards donation was observed, further education on biobanking is required to ensure/ encourage participation. This research could lead to further research based on the fact that a minority of patients who filled in the questionnaire were aware of biobanking. Patient education/information strategies could be devised to assess if this would further increase patient willingness to contribute to biobank.

Results: References 1. Forsti A, Hemminki K. Breast cancer genomics based on biobanks. Methods Mol Biol. 2011;675:375–385

JMSG | ABSTRACT ‘How should she be managed?’ Representations of patients and doctors in the discourse of case vignettes.

Teh, R.M.N.1, O’Malley-Keighran, M.2 1 2

School of Medicine, NUI Galway School of Speech and Language Therapy, NUI Galway

Introduction: To date, few qualitative studies have explored the quality of the language in medical texts in representing the patient and doctors. This paper aims to explore this under-researched area in medical education. The research question addressed in this study: “How are patients and doctors represented in the language of medical texts/textbooks?”

presents with, examine) followed by Being verbs (E.g. is, have). The Appraisal Analysis indicates negative appreciation as the predominant form of patient evaluation. The four main representations of the patient and doctor were: 1.

The Patient is represented by his/her complaint/problem.

2.

The Patient is represented as unable and susceptible to/controlled by his/her disease.

3.

The Doctor is rarely mentioned, if ever represented.

4.

The Patient and represented (rare).

Aim: To explore how patients and doctors are represented in the language of medical textbooks.

Methods: The data set was derived via purposive sampling from the recommended list of textbooks from NUIG, generating 3 books – Neuroanatomy and Neuroscience at a glance, Oxford Clinical Cases and Neurology Crash Course. From each book, 20 cases were randomly generated, producing 60 cases to analyse. This is a qualitative study where Critical Discourse Analysis, Transitivity Analysis and Appraisal Analysis drawing on Systemic Functional Linguistics were used1. Observation of linguistic features used allowed interpretation of any underlying ideologies or social agendas2.

Ethical approval was not applicable as the data set was obtained from readily available resources in the form of case vignettes.

Results: The transitivity analysis shows that the most commonly occurring verbs used were Doing (E.g.

Doctor

are

both

Overall, the representation of patients and doctors explored in this study revealed a general lack of patient-centeredness and presence of the doctor, and an inclination to cases as a disease to be managed medically.

Conclusion: This paper reveals insight to the area of representations of patients and doctors which has been under-explored. It seeks to unveil underlying ideologies towards representations of the patient and doctor, with hopes of stimulating discussion for improvement for a more patientcentred medical care. A possible further direction could be to analyse case writings written in the hospital as an interface of communication for doctors and nurses to handover and explore how that may change in the representation of patients and doctors.

References 1. DePoy E., Gitlin L. Introduction to research. 5th ed. St. Louis: Mosby; 2016.

2. O’Malley-Keighran M., Lohan G. Encourages and guides, or diagnoses and monitors: Woman centred-ness in the discourse of professional midwifery bodies. Midwifery. 2016;43:48-58.

JMSG | ABSTRACT Tackling Sepsis: Improving Performance of Peripheral Blood Cultures (PBCs) in NonConsultant Hospital Doctors (NCHDs) using a simulation-based intervention incorporating precision teaching.

M Walsh1, B Reid McDermott2, A de Bhulbh2, E O’Dowd2, C Madden2, C Walsh2, S Lydon1,2 ,D Byrne1,2 1 School of Medicine, NUI Galway 2 Irish Centre for Applied Patient Safety & Simulation

Introduction: Research demonstrating ill-preparedness for clinical practice among NCHDs has led to the realisation that traditional approaches to skills training are insufficient.1 Simulation-based interventions incorporating precision teaching offer a novel approach. Behavioural fluency (accurate and rapid performance) can be achieved following a relatively small amount of training, with performance that does not deteriorate over time.2 The project utilises this method to teach PBCs (a component of the ‘Sepsis Six’ bundle), among a sample of NCHDs. The management of sepsis is a time critical emergency, it is therefore crucial that PBCs are taken accurately. Incorrect technique can result in contaminated samples and necessitate multiple attempts, directly impacting upon patient safety and outcomes.

Aim: To evaluate the efficacy of a simulation-based intervention incorporating precision teaching in producing behavioural fluency in PBCs among NCHDs. Methods: A task analysis was developed through reviewing best practice documents, combined with expert input. The fluency criterion (i.e., the expert benchmark) was then established, through expert

testing, for the performance of PBC. Following ethical approval, 59 NCHDs were recruited and consented to participate. Baseline testing was performed followed by randomization into three groups; control, intervention and those who received a task analysis following baseline testing.

Intervention group members engaged with the simulation-based intervention for PBC training.

Descriptive statistics were run in SPSS to summarise the demographics of the study group along with other variables of interest.

Results: The mean age of participants was 25 years + 3.

39% (n=23) of the participants were male. The mean number of PBCs performed in clinical practice prior to the study was 1.44 + 4.64, confidence on a scale of 0 to 100 on ability to perform PBC (0 not confident) was 42.71 + 24.76. At this point in time, 13 of the intervention group (n=20) have reached fluency, in an average of 7.07 trials. 12 participants have completed stability trials, results indicate that the skill is stable under distracting conditions.

Conclusion: The achievement of behavioural fluency within a relatively short number of trials and stability to date is a positive result in predicting the outcome of the other intervention group participants.

References 1. Kerin M.J., Byrne D., Lydon S., O'Connor P. Preparing new doctors for clinical practice: an evaluation of preinternship training. Irish medical journal. 2012.

2. Lydon S., Burns N., Healy O., O'Connor P., McDermott B.R., Byrne D. Preliminary evaluation of the efficacy of an intervention incorporating precision teaching to train procedural skills among final cycle medical students. BMJ Simulation and Technology Enhanced Learning. 2017 Feb 13:bmjstel-2016.

JMSG | ABSTRACT Seawaters and Risk of Human Exposure to Antibiotic Resistant Bacteria Wong Ngie Xiong, B.¹, Hooban, B.², Mahon, B.², Cahill, N.², Morris, D ².

1 School of Medicine, NUI Galway 2 Antimicrobial Resistance and Microbial Ecology (ARME) Group, Discipline of Bacteriology, School of Medicine, NUI Galway

Introduction: The aquatic environment represents an important potential transmission route for antimicrobial resistance to humans. A previous EPA-funded project (EPA STRIVE Report 89) conducted by members of the Antimicrobial Resistance and Microbial Ecology (ARME) group highlights the extent of contamination of Ireland’s aquatic environment with antimicrobial resistant organisms 1,2. Some Enterobacteriaceae are resistant to last resort antibiotics, e.g. the carbapenemase producing Enterobacteriaceae (CPE). Unfortunately reports of resistance to last resort agents are emerging which makes it imperative that a “One-Health” approach is adopted to tackle the problem of AMR. Aim: To examine bathing waters for the presence of antimicrobial resistant Enterobacteriaceae (AMR-E).

Methods: A total of 7 samples (30 litres each) of seawater were collected from 3 different locations (2 from location A, 4 from location B, 1 from location C) on separate dates across the month of June. Samples were processed using the CapE [3] method and enrichment broths were then screened for antimicrobial resistant bacteria by culture on selective agars (mSuperCARBA and CHROMID ESBL chromogenic agars, and also using MacConkey agar stamped with a ciprofloxacin disc). Isolates were subsequently

identified via Matrix-Assisted Laser Desorption/ Ionization Time-of-Flight (MALDI-TOF) Mass Spectrometry. Susceptibility to 13 antimicrobial agents were examined in accordance with EUCAST criteria. Confirmed ESBL producers were screened for the presence of blaCTX-M gene via Real Time PCR. Results: In total, 23 isolates of Enterobacteriaceae were isolated from the seawater samples (20 = E. coli, 1 = Enterobacter cloacae and 2 = Klebsiella pneumoniae). Antimicrobial susceptibility testing results showed that in 23 isolates, 12 (52%) were ESBL producers. 21 isolates (91%) were resistant to ampicillin. 13 isolates were resistant to cefotaxime (57%) and 12 isolates were resistant to ceftazidime (52%). Of the 12 isolates positive with ESBL-producing Enterobacteriaceae detected from the 3 locations, 10 (85%) harboured a blaCTX-M-1 gene and 1 isolate was positive for the blaCTX-M-9 gene.

Conclusion: OP vs OA and OP vs DB are statistically significant. DB vs OA, only significant increase in FWHM, indicating more heterogeneity in DB which might be contributing factor to bone brittleness compared to OA.

References 1. Morris, D. et al. Enterococcus faecium of the vanA genotype in rural drinking water, effluent, and the aqueous environment. Appl. Environ. Microbiol. 78, 596–598 (2012).

2. Galvin, S. et al. Enumeration and characterization of antimicrobial-resistant escherichia coli bacteria in effluent from municipal, hospital, and secondary treatment facility sources. Appl. Environ. Microbiol. 76, 4772–4779 (2010) 3. Morris, D et al., 2016. CapE (capture, amplify, extract): A rapid method for detection of low level contamination of water with Verocytotoxigenic Escherichia coli (VTEC). Sci Total Environ. 2016 Sep 1;563-564:267-72

JMSG | ABSTRACT Parental Attitudes To Influenza Infection: Willingness For Annual Paediatric Vaccination Woon, Y1, Moylett, E.1,2 1 School of Medicine, NUI Galway 2 Department of Paediatrics, NUI Galway

Introduction: Influenza is a highly infectious, acute viral respiratory tract infection which can cause severe or even fatal complications in young children.1 As Ireland anticipates possible recommendations for universal annual paediatric influenza vaccine, it is important to identify factors that may affect its uptake.2 Aim: To explore parental knowledge and attitudes towards influenza infection and the factors affecting willingness to routinely vaccinate their child(ren).

Methods: This descriptive study involved interviewing parents (n=300) attending the paediatric Outpatient Department at University Hospital Galway. A pilot study assisted with standardizing the questionnaire and in optimizing the clinical catchment area. Galway Clinical Research Ethics Committee granted the ethical approval and data was analyzed using SPSS. Results: Majority of respondents were Irish (n=251, 83.7%), 236 (78.7%) had private health insurance. The most frequent age range was 31-

40 (n=163, 54.3%). Less than 40% had Bachelor’s degree (n=113, 37.7%) as their highest education level. Most participants (n=226, 75.3%) agreed with annual influenza vaccine for their child if recommended.

The factors below were shown to positively affect potential annual influenza vaccine uptake (p<0.05) and the respective percentage which supported routine influenza vaccine: Positive general perception towards childhood immunization. (n=217, 96.1%) Parents who received influenza vaccine. (n=127, 56.2%) Mothers who received the influenza vaccine antenatally. (n= 81, 42.4%) Positive childhood immunization experiences. (n= 223, 98.7%) Amongst community supporting influenza vaccination. (n= 167, 73.9%) No concerns about influenza vaccine. (n= 200, 88.5%) High test score for parental knowledge on influenza vaccine. (33.6%, n= 76, achieved full marks, mean score= 4.57 ± 1.28).

Conclusion: The overall feedback for routine paediatric influenza vaccination was positive. Parental knowledge, attitudes, prior history of vaccination and social norms each had an independent influence on parents’ willingness to vaccinate their child.

References 1. World Health Organization. Influenza [Internet]; 2003 March. Available from: http://www.who.int/mediacentre/ factsheets/2003/fs211/en/ 2. Ryan G., Cleary A., Keady D., Allen N.M., Moylett E. 2015-2016 Influenza Season in an Irish Regional Paediatric Unit: Importance of Influenza Vaccination Highlighted [Internet]. Ir Med J. 2017 Aug 8;110(7):609.

JMSG | CASE REPORT Depression with Psychotic Features in a Young Male With Developmental Coordination Disorder Kinsella, Emma1 1 School of Medicine, NUI Galway

Summary H, an 18-year-old male, was admitted to hospital as an inpatient after urgent GP referral for worsening depressive symptoms and new onset of psychotic features with expressed risk to others.

H has a 4-month history of depressive disorder, 5 -day history of auditory hallucinations, and persecutory delusions and an 11-year history of developmental coordination disorder (DCD). His symptoms have had a drastic impact on him with a notable stressor for his current presentation was the recent passing of his grandmother. H denies a past psychiatric history, substance or alcohol abuse. Family history is significant for schizophrenia and bipolar affective disorder. H was unkempt, and expressed psychomotor retardation, H’s speech was spontaneous and coherent. H denied thought possession, suicidal ideation or intent to harm others, with partial insight to his condition. H was admitted to hospital for investigations, and later discharged with plan for follow up.

Introduction This case is important as it emphasizes the significance of early developmental delays and their life long impact on an individual’s physical and mental well-being. Specifically, I was moved to write this case as it addresses the precipitating factors for mental illness, by writing this report it is my hope that patients like H who present with DCD may be better off in the future and that the impact of their illness may be lessened than otherwise would be the case.

Case History of Presenting Complaint H began to feel low following the passing of his grandmother 5-months prior. Leading to admission H became socially withdrawn, apathetic with a depressed mood for most of the day, everyday. The month prior to admission, H’s symptoms progressed poorly, H began to experience sleep disturbances, and worsening concentration, his appetite had completely diminished, causing the patient to lose 1 stone.

Five days prior to admission, H reported hearing ten male & female voices, located outside of his head saying, “You are worthless”. Three days before admission, the voices became more persistent and intense. “I couldn’t go minutes without hearing from the voices.” And, began to have a debilitating desire to run away from home and find safety. These symptoms took a great toll on his life, he was unable to attend school nor could he socialize with his friends or family. He denies any thoughts of self-harm, suicidal ideation or harm to others. H states that he was admitted to the inpatient ward after attending the outpatient clinic, due to consultants concerns for worsening depressive symptoms, and grasp of reality.

Past Psychiatric History H has no past psychiatric history.

Past Medical/ Surgical H has no past medical/surgical history.

Medication H was prescribed, Olanzapine 7.5mg PO, OD, and Citalopram 20mg, PO, OD. H is compliant with his medication; denies any allergies.

Drugs / Alcohol History Patient H denies any illicit substances including cannabis, alcohol or cigarette use.

Family History H’s father was diagnosed with bipolar disorder, and uncle schizophrenia. There is no other significant family history of psychiatric or medical conditions.

Social History H lives with his siblings and parents, they have a close relationship, he notably was the closet with his grandmother who passed.

JMSG | CASE REPORT Personal History

Outcome

H was born 10 days over-due, 5kg birth weight, via uncomplicated vaginal delivery. His mother had a smooth pregnancy with no complications during the pre-natal period. The baby fed well, and was a good baby/toddler. Due in part to DCD H experienced developmental delays, such as bum shuffled and walking at 17 months, talking at 20 months and sentences at 3 ½ years. He had separation issues, when being dropped off for the first five years of school. H remembers a happy childhood, with no traumatic experiences. H is an introvert, and reclusive, believed himself to be shy, but enjoyed the company his close friends and family. In 2007, at hospital was diagnosed with DCD. H expressed difficulty with fine motor co-ordination, slowness in learning and incoherent speech. The patient saw an occupational therapist, as well a speech therapist and progressed well since his diagnosis, however he still struggles with a poor self-image, and significant insecurities regarding his academic performance. Up until admission he was a student entering his final year of secondary school. H performed average academically and socialized poorly, with a limited friend group.

Patient H has progressed well since his admission to hospital, and activation of his treatment plan. He has noticed improvements in his sleep, mood and appetite. H only hears one male voice now and they are reassuring thoughts. H has better insight, and is content complying with medication, and group therapy outside hospital. After careful observation on the ward and discussion with his family, H was discharged, with planned follow up for the next week. H’s long-term plan is to continue his treatment plan, including psychological and social supports, and visits with a community health nurse weekly to check in.

Differential Diagnosis and Investigations.

H’s provisional diagnosis was attainted from clinical presentation, and review of DSM-V & ICD-10 criteria. DSM-V criteria indicate the primary complaint of psychotic depression must be affective disorder, with psychosis that is mood congruent. (1) As H predominately struggled with depression, only after poor progression of his primary illness did he begin to experience mood congruent psychotic features, it is reasonable to conclude this as a likely diagnosis. Schizophrenia was included in the differentials due to H experiencing, auditory hallucinations and negative symptoms, However, the criteria notes six months of continuous signs of disturbances, and one month of active-phase symptoms. As well, DSM-V dictates if the mood symptoms were experienced they must be for a minority of the total active-phase.

(1) Schizoaffective disorder was also listed in the differentials, however, as DSM-V requires over two weeks with solely psychotic symptoms, and H was never without mood features, this diagnosis is less likely (1). Finally, substance abuse, however, it is unlikely in this case given the patient’s demographics, and denial of substance use.

Investigations FBC, Glucose, U&E, TFT, Urine toxicology Treatment and/or management Patient H was admitted as an inpatient, a full history, exam and risk assessment was carried out to ensure safety of patient and others. H’s biological management plan is to start H on Citalopram 10 mg, and Olanzapine 7.5mg, and monitor his progress and side effects. The patient was put on 30-minute observations, and allowed accompanied 20-minute leaves.

Psychological treatment includes CBT, and family therapy, and his social support plan is social skills training.

Reflection Patient H was diagnosed with DCD a neurodevelopmental condition, defined by poor motor skills and coordination. (2) With a prevalence of 2-6% in school-aged children across the world, it is a great health concern. (3) However, little was known about the impacts that DCD had on a child’s life besides motor proficiency, until recent years. Physicians and researchers have identified a significant correlation between DCD and mental health difficulties, predominantly anxiety and depressive disorder. (4) There is now significant evidence that mental health problems are more likely in DCD children relative to their peers. (5) It is not completely understood how children with DCD subsequently develop mental health problems (6, 7). However, it may be useful to explore this correlation further to assist clinicians and families to better identify precisely what treatment measures should be taken for these children and discover protective factors to help prevent the onset of mental health difficulties. A 2017 cohort study conducted

by Harrowell, showed that late adolescents with DCD had a greater risk of mental health, than their peers (3). This study was also able to identify self-confidence as a protective factor for these patients. Interestingly, a 2011 cohort study investigated by Lingham, looked further into potential protective factors. This study also found children with DCD had greater self-reported depression; however, when accounting for strong IQ, social relationships, and self-esteem the results drastically changed. (5) This robust evidence shows the significance of protective factors in a patient’s well-being, and suggests reassessing children with probable & diagnosed DCD, to now direct support to enhance mediating factors, improve functioning, and aid in prevention of anxiety and depression. (5) Most of H’s DCD therapy, was geared to remediate his motor difficulties, and failed to assist with his social, and psychological needs, which from this evidence could have contributed to how he presents today in hospital. Therefore, it is important when treating these children that healthcare workers, and families also address key protective areas, and understand the significant impact failing to do so has on their quality of life, and health of DCD population. (3) In conclusion, prevention and treatment resilience of this population should address both physical and mental risks, with equal importance, as they are key elements in the quality of life for these patients now and in the future. (7)

JMSG | CASE REPORT Personal Reflection This case was an incredibly rewarding, and an eye-opening experience for me. I was able to learn closely from many members of the MDT, including social workers, occupational therapists, and community nurses, which was a very humbling experience. I felt that I was fully immersed in this patient’s case and part of his care team. I learned a tremendous amount from each individual, gaining a greater insight into depression and psychosis, as well as the everlasting impact that neurodevelopmental conditions have on patients.

References 1.

Diagnostic and statistical manual of mental disorders. 5th ed.

Washington: American Psychiatric Publishing; 2014.

2.

Einfeld S, Emerson E: Intellectual disability, in Rutter’s Child and Adolescent Psychiatry, 5th Edition. Edited by Rutter M. London, Blackwell Publishing, 2008, pp 820–840 3.

Harrowell I, Hollen L, Lingam R, Emond A. Mental Health outcomes of Developmental Coordination Disorder in late adolescence. Developmental Medicine and Child Neurology [Internet]. 2017 [cited 15 September 2018]. 59(9): 973–979.

4.

Cunningham A, Delport S, Cumines W, Busse M, Linden D, Hall J et al. Developmental coordination disorder, psychopathology and IQ in 22q11.2 Deletion Syndrome. Br J Psychiatry. 2018;212(1):2733.

5. Lingam, R., Jongams, M., Ellis, M. and Hunt, L. (2012). Mental Health Difficulties in Children with Developmental Coordination Disorder.

PEDIATRICS, 129(4).

6. Hill, E. and Brown, D. (2013). Mood impairments in adults previously diagnosed with developmental coordination disorder. Journal of Mental Health, 22(4), pp.334-340.

7. Cairney, J., Rigoli, D. and Piek, J. (2013). Developmental coordination disorder and internalizing problems in children: The environmental stress hypothesis elaborated. Developmental Review, [online] 33(3), pp.224-238.

Available at: https://www.researchgate.net/ publication/259123689_Developmental_coordination_disorder_and_intern alizing_problems_in_children_The_environmental_stress_hypothesis_elab orated [Accessed 14 Sep. 2018]

JMSG | EDITORIAL The Academic Track for Interns Professor Dara Byrne The academic track for interns was launched in July 2017 and is an initiative for internship in Ireland. It is a national programme between the 6 Irish Medical Schools and their partner Intern Training Networks. At its core is a 1-year academic internship programme providing supported and mentored academic and clinical training targeted at the inception of graduate practice and within the context of acquiring full registration. The broad aims of the programme are:

· To provide an opportunity for doctors at the beginning of their clinical careers to develop or continue to develop research, teaching and leadership skills

· To promote scientific discovery and sustained academic development

The application process is different to that for a standard intern position. It requires completion of an online application form and an interview.

There are currently 24 academic track intern positions in Ireland, and each of the 6 networks has 4 positions. The application process and interview are highly competitive. Applications are scored in the following areas: performance

Interns on the academic track have protected time within the working week to pursue a project of their choosing with the support of an academic supervisor. Their protected time takes place during one three-month rotation and is 2.5 to 3 days per week, no more than 36 days in total. The remainder of the week is spent in clinical work and there will also be an on call commitment.

Interns on the academic track are required to achieve the same clinical competencies as all other interns, and are required to complete the same mandatory elements of intern training. In addition, they have academic goals and outputs to achieve.

Interns on the academic track can chose to participate in a project in one of the following areas:

· To retain medical talent

· Academic

supervisor early.

(a

transcript

is

required)

· Publications and presentations · Research experience (especially in the area of your proposed project)

· Project proposal · Feasibility of the project · Expected outputs (Where this fits with the applicants career plans) The applications are scored and usually 50 applicants are called to interview. If successful at interview, you will be ranked and offered a position in March, in one of the 24 academic track posts. If you decline, then you go back into the normal application process for intern posts. If you accept then you are advised to contact your

· Clinical research · Medical education · Healthcare leadership and management Outcomes for the academic rotation are agreed upon with the supervisor at the beginning of the placement. Conditional places on the academic track will be offered in March of each year (conditional because the final med exams/IEET must still be passed), and from that point onwards, successful candidates are encouraged to contact their allocated supervisor and begin planning for the project. The project must be something which is practical and achievable within the short time frame available to interns and bearing in mind they will have training and clinical commitments as well. The work of the academic interns is showcased at an annual national event.

An intern on the academic track may achieve some or all of the suggested competencies below for their project and other additional competencies might be agreed upon depending on the nature of the project.

JMSG | EDITORIAL Suggestions include:

· As presentations and publications and experience are

Clinical Research:

important, aim to do Summer projects and get some experience under your belt

· Identify a research question

· Present and publish your work at local, national and

· Draft a research proposal

international meetings

· Apply for ethical approval

· Think outside of the box and explore the possibilities beyond

· Conduct or participate in a study/experiment (a lab-based study, a study that uses patient/human volunteers or a population based study)

· Write up a study/experiment for publication

clinical research. Think about quality improvement projects, leadership development and new technologies and innovations.

You can engage with industry, other Colleges in the University (e.g. Engineering) and with the HSE

· Speak to an academic track intern about their project,

· Present findings at a local/national/international meeting

application, interview and job.

Medical Education:

· Develop a new course or module in the undergraduate or postgraduate medical curriculum

· Develop and use an assessment programme to test knowledge, skills and attitudes

· Complete a piece of medical education research · Deliver bedside tutorials and lectures to undergraduate medical students

· Participate in Problem Based Learning tutorials Healthcare Leadership and Management:

· Identify an area for quality or safety improvement in the hospital environment

· Produce a plan for improving quality or safety and engage with key stakeholders including representatives if appropriate

staff

members

and

patient

· Evaluate the effectiveness of the project and develop recommendations for the future to further improve patient care

· Present and disseminate learning from the improvement project Top tips for medical students hoping to apply for an academic track internship in final med:

· If you are interested in being an academic track intern, it is worth looking at what is required on the application form and working towards those goals.

· Grades are important · You should think about an area that you would like to work in as an academic intern and make links with senior academic staff in that area

Professor Dara Byrne is the Intern Coordinator for the NUI Galway/West Northwest Intern Training Network.

She is Personal Professor of Simulation Education in Healthcare at the School of Medicine and the Director of Simulation for the Saolta Group and at the Irish Centre for Applied Patient Safety and Simulation (ICAPSS). She is the Programme Director for the MSc. in Healthcare Simulation and Patient Safety and Simulation.

JMSG | STUDENT PERSPECTIVE Reflection: The MB PhD Kieran Joyce1 1

School of Medicine, NUI Galway

The integrated MB/PhD program may be undertaken by students following the third clinical medical year, after which the final two years of undergraduate medicine are completed to graduate with both degrees. To be eligible for this program, students must undertake and undergraduate summer research project at the end of second and third medical year.

These projects must be written up as a thesis for submission to the School of Medicine to be awarded a Bachelor of Medical Sciences.

At the end of the third medical year, the students will enter a period of 3 years of research through a structured PhD program under the supervision of a nominated principal investigator at NUI, Galway. The 3 research years will be fully funded including college fees, research consumable costs and a monthly student stipend. In addition to research activity, students will continue clinical training through integrated, structured clinical modules. At this time, there is no dedicated scholarship for applicants so students with an interest must apply for an Irish Research Council Scholarship, NUI Galway Hardiman Scholarship or other sources to secure funding well in advance of beginning the program.

Research activity in pursuit of PhD will be undertaken in one of the areas of strategic interest for NUI, Galway: • Regenerative Medicine • Cancer Biology • Medical Devices Biomedical Engineering Science • Neuroscience • Population Health and Health Services Research Upon completion of 3 years of intensive research, students will write up and defend their research findings as a PhD thesis and through viva voce examination. Thereafter, they will return to clinical training through the fourth- and fifth-year medical program. Upon successful completion of their final year medical examinations, students who have undertaken this course, and successfully written up and defended their PhD thesis within the specified

timeframe, will graduate with an MB, BAO, BCh and PhD in Medicine.

But what does this really entail and what can one expect from the program?

Image 1: Podium presentation from EORS (European Orthopaedic research society) conference in Galway

Getting started: I approached my supervisor to-be, Prof. Abhay Pandit, about doing a project in orthopaedics (my field of interest). He provided great insight and guidance in the field and about potential projects I could take on. I’d highly recommend doing two lab-based summer research projects during clinical years to get a head start on learning techniques but also to figure out very quickly whether lab work is for you or not.

Although I think it doing a summer project where you’re told what to do is very different to driving your own project and investigations to answer a pressing research question, so it’s not a fair comparison (If you really detest the thought of working in a lab then it’s probably not for you).

A synopsis of my project My project is based in the Centre for Research in Medical Devices (CURAM) and focuses on the pathophysiology of intervertebral disc disease and the design of new biomaterials for disc regeneration.

JMSG | STUDENT PERSPECTIVE The Abstract Discogenic low back pain affects 42% of patients suffering low back pain1. Degenerative disc disease is described as failure in cellular response to external stresses leading to physiologic dysfunction. Glycosylation patterns of tissues give insights into the spatially and temporally regulated inflammatory and degenerative processes. These glycoconjugates participate in many key biological processes including molecular trafficking and clearance, receptor activation, signal transduction, and immunomodulation.

We hypothesise that glycoprofile of the intervertebral disc (IVD) is temporally and spatially distinct in health and degeneration.

The glycoprofile of the IVD has been studied in murine, bovine and ovine models for injury2,3 and aging4. In this study, healthy (n=2) and degenerated (n=2) human IVD samples received from (UU, ND) with ethical approval (NUIG), were compared using lectin histochemistry. The N-glycan profile of human degenerated IVD samples was characterised by high resolution quantitative UPLC-MS. Healthy and degenerated human discs present distinct glycosylation trends intracellularly/extracellularly in annulus fibrosus (AF) and nucleus pulposus (NP) tissue. There are quantitative and spatial differences in glycosylation in healthy and degenerated tissue. These findings are consistent with previous studies of IVD in murine2, bovine3 and ovine4 models. The human N-glycan profile of degenerated surgical tissues is distinct from other cited tissue profiles such as human plasma5. These studies offer validation of previous animal models of IVD injury and degeneration, demonstrating similar changes in the glycoprofile in both animals and humans. Glycoprofiling may offer insight into disease progression, offering new realms of disease classification in patient specific manner while also elucidating potentials therapeutic targets, inhibiting disease progression.

Image 2: hiking trip organised during the eCM conference in Davos during the summer Self-Motivation A supervisor will always push you in the right direction and there will always be a post doc (someone who has completed their PhD) in the lab to assist you if you need it but nobody is going to make sure the work gets done, only yourself. This is a four-year course that must be done in three years which means often working late and most weekends (not all that different to medicine). Every day is a challenge. Experiments fail a lot. Things break, cells get contaminated. I’ve lost hours and hours of work spanning over weeks because of contamination and rejected hypotheses. It happens to everyone and it’s important to recognize that it’s all part of the process and not a personal failing. There is always something valuable to take away from it to avoid future mistakes.

The first six months: I began by reading as many articles and reviews as I could for the first month to get a grasp on the state-of-the-art, identifying potential research questions that would fundamental to my project. It safe to say I felt way out of my depth, especially when listening to colleagues present the intricacies of their work during the lab group meetings, only for me to not understand 90% of it.

It took several months to feel competent in the field in which I’m supposed to be an expert.

During this time, I also tried to learn as many lab techniques as possible that I would later use in my own work. While it’s good to read about techniques such as qPCR and western blotting, nothing compares to watching it being done and then doing it yourself. One conversation with a colleague, or a lab technician or a stranger at a conference can offer more insight than reading a hundred articles so it’s important to put yourself out there.

Image 3: With another medical student from Cambridge also at EORS

JMSG | STUDENT PERSPECTIVE Creativity You must ask the questions. While many projects are well defined in the beginning, things will always change, and hypotheses will be adapted or completely changed. Protocols may have to be modified. New therapeutic approaches must be identified. This all requires creativity and problem-solving skills.

Your research must tell a story and you are the story teller (nonfiction only).

Communication Skills You will become an expert communicator and proficient in Word and PowerPoint as that line on your CV indicates. Every week, each student is required to present their work for the week under the friendly scrutiny of the rest of the lab. You must defend your work with confidence, giving rationale for every experiment to answer a distinct research question. You will be expected to engage with other researchers, students, teachers, children and members of the community, pitching your work at entirely different levels, careful to avoid jargon with 10-year old’s.

Ultimately, the strength and impact of your work relies on how it’s communicated.

Image 5: Hiking trip organised during the eCM conference in Davos during the summer

The take home: Disadvantages: Endless monotonous work, long hours, constant failure, isolation, stress, uncertainty, three more years at university.

Advantages: Rewarding work, positive personal development, career prospects and diversity, opportunity to travel/work abroad, three more years of student discounts.

It’s tough but it’s worth doing.

Image 4: Everyone in attendance at eCM in Davos, Switzerland.

Collaboration There are lots of opportunities to travel depending on the project. Usually at least a few months will be spent in a foreign lab specializing in an aspect of your project. Every year, you can be expected to attend one international conference, meeting the leaders in the field, the abstract names on the papers you’ve been reading for months. These are invaluable experiences in the guiding your work.

JMSG | STUDENT PERSPECTIVE The Academic Clinician Réiltín Tynan 1 1

School of Medicine, NUI Galway

I never truly believed that the exams would just end- just like that- once I qualified. That being said, I never truly understood what it meant to be a doctor either. That I would find myself side-byside daily with doctors of all stages in the academy library came as a bit of a shock if I’m honest. It was no longer phone ringtones or people eating that would irk you as you studied but the sound of bleeps of varying urgencies ringing out at all hours.

Once answered, the doctors would return to their still warm seats and continue with their studies.

If I am completely honest, though, I was never genuinely irritated by the sound of the bleeping and disruption of those constantly entering and exiting the library. I was impressed by the dedication, the patience and the evident desire to progress that I saw in these individuals that spent their lunch break gathering scientific data. I was impressed, but part of me was overwhelmed, daunted by the prospect of a similar future and part of me was more than a little fearful of that sinking feeling that the academic part of my life was far from over.

One SHO told me that the only way one could dream of progressing was to maintain an interesting CV, have concurrent research projects and be seen often presenting at prestigious conferences. His words had some merit- are we not always encouraged to maintain scholarship?

Expected to remain up to date on the latest treatments and medical advancements? Although I personally have always been excited by research, the expectation that one must constantly complete research is unappealing. The notion that research should be completed for research’s sake, and not to improve the quality of life of another in the future, never resonated with me either. I have colleagues who would consider leaving medicine if they were told they must complete research throughout their career.

And yet academia cannot be limited to or simply labelled research. It is defined in the Oxford

Dictionary as ‘The environment or community concerned with the pursuit of research, education, and scholarship’. If a person truly wants to be what is considered ‘a good doctor’, they must ultimately be academic- they must learn from their environment, their mistakes, their colleagues and make sense of new information and advancements they face. As one of the Eight Domains of Good Professional Practice1, scholarship is a key aspect of one’s medical life. The importance of learning is sometimes forgotten but in the context of patientcentred care, education is one of the best ways to prevent adverse outcomes2. Experience is only a great teacher if one is willing to learn from it, grow and prevent it from occurring again.

So why did I fear a future of literary papers, randomised control trials, peer reviewed articles and hours yet to come in the library? Perhaps I am alone in my fears. Perhaps not. But more than once so far in my studies I have questioned the vast amount of knowledge available to us. I have struggled to obtain the latest information, unbiased and true facts. I have been overwhelmed by the rapid advancements in certain areas in medicine, and disappointed in the lack of progress in others. I have felt like my whole life was in danger of being consumed by my decision to follow a medical pathway- hobbies, friends, family, social opportunities often secondary to the academic pull of a medical degree.

Despite these fears I have never lost that child-like curiosity for life. I enjoy understanding new concepts, applying new knowledge, experiencing new situations. I want to know more, be better. I crave it, like a thirst unsated- perhaps one that could never be sated, should never be sated. The academic clinician, I have come to realise, in not just someone with numerous degrees, publications and concurrent research projects. The academic clinician is any doctor who ensures they are a better doctor tomorrow then they were the day previously. As goals go, perhaps this is a reasonable one.

1. Irish Medical Council (2010). Eight Domains of Good Professional Practice. Accessed 2019, available at: https://www.medicalcouncil.ie/ Existing-Registrants-/Good-Professional-Practice/Eight-Domains-of-Good-Professional-Practice-as-devised-by-Medical-Council.pdf 2. Forsetlund L, Bjørndal A, Rashidian A, Jamtvedt G, O'Brien MA, Wolf FM, Davis D, Odgaard‐Jensen J, Oxman AD. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2009, Issue 2.

Art. No.: CD003030. DOI: 10.1002/14651858.CD003030.pub2.

JMSG | STUDENT PERSPECTIVE Orthopaedics and Traumatology at CES Universidad, Medellin, Colombia Jack Dunne1 1

School of Medicine, NUI Galway

Why Medellin, Colombia?

I read positive reports on Colombian hospital electives. They detailed a hands-on, intensive environment, but one that had been very rewarding.

The application procedure I applied to CES Universidad, Medellin, through the GEMx portal, rather than through the university portal, saving me the cost of fees.

Winning straight off the bat! Overall, the application procedure was very straightforward, I just needed the usual documents (letter of recommendation, grade transcripts etc). I was very happy with CES Universidad. The programme was professionally run; I had a preelective orientation, and I was brought on a ‘welcoming’ guided graffiti tour with other exchange students. I spent my four weeks placed in a private hospital called Clinica Del Norte, in Bello, a suburb of Medellin. The hospital had arrangements made for me when I arrived, was used to taking foreign students and had preassigned me to a doctor.

Image 1: View of Medellin Accommodation It’s hard to judge an area you’ve never been to halfway across the world, so I decided to figure out accommodation once I arrived and could ‘feel out’ the place. My advice would be to find accommodation for the first few days through Airbnb and then revaluate.

Orthopaedics and Traumatology Traumatology in this elective was an orthopaedic doctor based in the Emergency department. The

vast majority of patients I saw were involved in low speed, minor trauma, motorcycle accidents.

There were some polytrauma/major trauma cases, such as pelvic fractures and cranial fractures which I got to view/assist in. In the Emergency Department, I got to view/assist in many other cases, for example resuscitations, ventricular tachycardias etc. If you want to see gun shots and stab wounds trauma, take a rotation in a public hospital. There is something to be said though for the less hectic, private hospital rotation, especially when you don’t speak fluent Spanish. I got a lot of practical experience from my time in CDN, and I was actively encouraged to try my hand wherever an opportunity presented itself, with the staff were happy to teach and patiently guide me through a procedure. I tried my hand at: various types of casts, splints, suturing for various cuts/wounds, intramuscular injections, digit ring blocks, venous catheters, urinary catheters, resuscitation procedures, pelvic fracture stabilisation and shoulder relocation. Know how to put on sterile gloves, wash your hands, and scrub in (your sterile techniques). 7am starts and finishing at 6pm most days, Monday to Friday. At 7am, the patient cases were reviewed with teaching. 9am: Go see the patients and do any of the tasks e.g. casts. 10am: Teaching on a specific topic.

Afternoons were based in the emergency department, seeing patients that came in. I expressed my interest to see orthopaedic surgery, and one of the consultants then happily brought me along to theatre with him, making me feel very welcome. I got to scrub in, assist and close during the operations. The consultant would then struggle with his English to teach me the intricacies of the surgery, which I really appreciated. I got to see rotator cuff repairs, internal fixation of the tibia and LCA repairs.

Spanish Requirement CES Universidad doesn’t require a Spanish competency certificate, however this may change after my stint there. It would take an intermediate level of Spanish to work at least somewhat competently and independently in the hospital,

JMSG | STUDENT PERSPECTIVE as you’d be expected to do. Orthopaedics, however, is an ideal rotation for those with less Spanish ability. You need far less medical Spanish, and the nuances of a medical history aren’t as relevant.

There were no hospital/university costs for the elective, and I got a free lunch every day, so technically I was making money! My accommodation was 165 for a month. Food per day was maybe 15, including breakfast, the free lunch at the hospital and a nice meal in a restaurant that night.

Overall I would highly recommend doing a traumatology rotation at CES Universidad. The practical experience amongst such warm and friendly people has been so memorable. I thoroughly enjoyed my time both at the hospital and around Medellin.

Image 2: Colourful houses in Colombia

Tourist Activities There’s an incredible range of things to do and see in Colombia and Medellin itself. I’d recommend allowing time to travel before or after the elective. You’ll be pretty wrecked by the time Saturday rolls around.

Safety of the city It’s highly recommended to read up on the do’s/don’ts, the common pitfalls and dangers, and to have backup plans if an unfortunate situation arises. Medellin is a city that can be dangerous in every zone, and there’s places non-locals should never go. The etiquette in Medellin differs vastly from that in a European city. You shouldn’t take out your phone in public, regardless of the time of day. No zones are safe to walk late at night, so take Ubers. Be extra cautious on nights out, especially of your drinks. All in all, I never experienced any problems or frightening experiences, and I would have no hesitations about returning or encouraging my friends to visit.

Image 3: The author in Colombia

Costs

JMSG | STUDENT PERSPECTIVE My Chinese Elective Experience Alice Meagher1 1

School of Medicine, NUI Galway

The Chinese elective experience was fascinating and enjoyable from a cultural perspective. The opportunity to travel to a distant country and learn about their society, culture and history from locals has been a privilege. The first weekend in China, we travelled as a group on the fast train to Beijing, to see the Forbidden City, Summer Palace, Buddhist temples, Tiananmen square, and finished by climbing the steep steps of the Great Wall, this served as an introduction to Chinese history from their Emperors and dynasties to modern day communism. We were immersed in the Chinese culture from the beginning, due to the hospitality of our hosts and also the fact we appeared to be the only non-Chinese people in the city of 10 million. A group of 16 students were fortunate to be afforded this opportunity to visit Shijiazhuang in the summer after fourth med, as NUIG have ties with the University of Hebei which is based there - this allowed us to travel to China with the safety net of a big group, local guides and also the accommodation was provided for us in the university halls.

Image 1: Students from NUI Galway at the Univeristy of Heibei I began my attachment in the second hospital of Hebei; this hospital specializes in cardiology - their system is different to that in Ireland where many specialties occupy the same building. It was informative to see the alternative health care systems to compare and contrast with both Ireland and Switzerland where I completed my Erasmus placement. The single specialty model allowed the hospital to tailor their infrastructure to facilitate cardiology procedures - in this hospital serving a population 80 million approximately 12,000 PCIs are performed annually. One of the disadvantages of this system

was that although the doctors were specialised in the treatment of cardiac disorders - they had very little exposure to other conditions which became a problem especially when there is no facility to request consults from another specialty. This led to patients attending one hospital for their heart condition and being discharged and readmitted to another hospital for management of their comorbid conditions. Another divergence of healthcare systems between the two countries is the lack of primary care infrastructure in China.

With the exception of few community hospitals who serve as the first point of contact for the minority - most care is based in tertiary centres.

This requires patients to travel vast distances to manage, for example, hypertension. This precludes many of the poorer patients from receiving any healthcare and may partially account for the popularity of Chinese herbal medicine - which is much more accessible for those living rurally. In terms of medical knowledge - the language barrier made it difficult to learn a great amount. We were given several lectures in English by the professor of cardiology however it was still challenging to understand the content. I was attached to a team of doctors and followed their ward rounds everyday, however I was at the mercy of a junior doctor to translate the discussion which was not always possible, this lead to many mornings of awkwardly following the team while patients and their families took pictures of me on their phones - many had never seen a white person in real life, I was told. We were housed on the university campus in the international student building - this was a eight storey concrete block with a turnstile entrance (fortunately it was broken when we stayed so could come and go as we pleased). I was grateful to be provided with accommodation as I would have been dissuaded from participating had I needed to figure out the Chinese rental market.

It was a clean, safe campus right across from a mall that had a supermarket and several Chinese restaurants. There were no cooking facilities for us to use - however the onsite canteen had cheap meals ( 1.50 for dinner). There is a running track and basketball court about three minutes away from the student accommodation, as well as a fruit market. We were housed in groups of two or three but all our rooms were on the same

JMSG | STUDENT PERSPECTIVE floor which allowed us to socialise. In terms of socialising outside the building we were quite restricted as there was a curfew of 10pm - at this time the ‘aunty’ chained and padlocked the main door closed. This was a common theme in China, the students described their university experience in a way similar to an Irish boarding school. There were eight people in a dorm room of four bunk beds, their curfew was 10:30pm and their electricity was switched off at 11pm, luckily this was not the case for us.

I thoroughly enjoyed my experience in China and would definitely recommend it for future groups - I think it suits and adventurous and easy going student who is not a picky eater! Overall, I it was fascinating to be afforded the opportunity to learn about another country’s culture, healthcare system and people - however, for those looking for an academically fruitful elective - China is not the right option.

Image 2: Meeting students from the University of Heibei

JMSG | SPONSORS

Special thanks to the School of Medicine, NUI Galway for sponsoring this publication of the Journal of Medical Students, Galway and for championing student research at NUI Galway.

ISSN: 2019-728X

Journal of Medical Students, Galway National University of Ireland, Galway

Accessible online at http://jmsgalway.com