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

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

A pilot study of performance among hospitalised elderly patients on a novel test of visuospatial cognition: the letter and shape drawing (LSD) test.

peer-reviewedObjectives. Conventional bedside tests of visuospatial function such as the clock drawing (CDT) and intersecting pentagons tests (IPT) are subject to considerable inconsistency in their delivery and interpretation. We compared performance on a novel test – the letter and shape drawing (LSD) test –with these conventional tests in hospitalised elderly patients. Methods. The LSD, IPT, CDT and the Montreal Cognitive Assessment (MoCA) were performed in 40 acute elderly medical inpatients at University Hospital Limerick The correlation between these tests was examined as well as the accuracy of the visuospatial tests to identify significant cognitive impairment on the MoCA. Results. The patients (mean age 81.0±7.71; 21 female) had a median MoCA score of 15.5 (range = 1–29). There was a strong, positive correlation between the LSD and both the CDT (r = 0.56) and IPT (r = 0.71). The correlation between the LSD and MoCA (r = 0.91) was greater than for the CDT and IPT (both 0.67). The LSD correlated highly with all MoCA domains (ranging from 0.54 to 0.86) and especially for the domains of orientation (r = 0.86), attention (0.81) and visuospatial function (r = 0.73). Two or more errors on the LSD identified 90% (26/29) of those patients with MoCA scores of ⩽20, which was substantially higher than for the CDT (59%) and IPT (55%). Conclusion. The LSD is a novel test of visuospatial function that is brief, readily administered and easily interpreted. Performance correlates strongly with other tests of visuospatial ability, with favourable ability to identify patients with significant impairment of general cognition.PUBLISHEDpeer-reviewe

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

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

Incidence, management and outcomes of the first cfr-mediated linezolid-resistant Staphylococcus epidermidis outbreak in a tertiary referral centre in the Republic of Ireland.

peer-reviewedAim: To report the first Irish outbreak of cfr-mediated linezolid-resistant Staphylococcus epidermidis. Methods: Linezolid-resistant S. epidermidis isolated at University Hospital Limerick from four blood cultures, one wound and four screening swabs (from nine patients) between April and June 2013 were characterized by pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST) and staphylococcal cassette chromosome (SCCmec) typing. Antibiotic susceptibilities were determined according to the guidelines of the British Society for Antimicrobial Chemotherapy. The outbreak was controlled through prohibiting prescription and use of linezolid, adherence to infection prevention and control practices, enhanced environmental cleaning, isolation of affected patients, and hospital-wide education programmes. Findings: PFGE showed that all nine isolates represented a single clonal strain. MLST showed that they belonged to ST2, and SCCmec typing showed that they encoded a variant of SCCmecIII. All nine isolates were cfr positive, and eight isolates were positive for the G2576T 23S rRNA mutation commonly associated with linezolid resistance. Isolates exhibited multiple antibiotic resistances (i.e. linezolid, gentamicin, methicillin, clindamycin, ciprofloxacin, fusidic acid and rifampicin). The adopted infection prevention intervention was effective, and the outbreak was limited to the affected intensive care unit.PUBLISHEDpeer-reviewe

The impact of a novel tool for comprehensive assessment of palliative care (MPCAT) on assessment outcome at 6- and 12-Month Follow-Up.

peer-reviewedContext Assessment in palliative care settings should be focused, sensitive, specific, and effective to minimize discomfort to vulnerable and often highly morbid patients. This report describes the development of an admission assessment protocol for a Specialist Palliative Care Inpatient Unit and its implementation into clinical practice. Objectives The aim of this study was to develop and investigate the impact of the implementation of a Specialist Palliative Care admission assessment tool on documentation of key patient needs. Methods The outcome of a systematic literature review was used to develop an admission assessment protocol (the intervention) in a Specialist Palliative Care Inpatient Unit. Mixed methods were used to facilitate a comprehensive evaluation pre- and post-intervention to test the effectiveness, feasibility, and acceptability of the intervention. Results The documented evidence of pain assessment improved from a baseline rate of 71% to 100% post-intervention. This improvement was maintained 12 months post-introduction of the tool (P < 0.001). The documented evidence of screening for spiritual distress increased from a baseline rate of 23% to 70% at 6 months and to 82% at 12 months (P < 0.001). The number of referrals made in the first 24 hours after assessment increased post-intervention (physiotherapy, P = 0.001; occupational therapy, P = 0.001; social work, P = 0.005; pastoral care, P = 0.005); this was maintained at 12 months. Significantly, more clinicians (88%) agreed that palliative care domains were comprehensively assessed post-intervention in comparison with 59% pre-intervention (P = 0.01). Conclusion Introducing the Milford Palliative Care Assessment Tool was associated with significant improvement in assessment of multiple important aspects of patient need.ACCEPTEDpeer-reviewe

Editorial hot topic: prebiotics and probiotics: delivering therapeutics as dietary components

The functionality of dietary components, beyond provision of inherent nutritional benefits, has in relatively recent times become the focus of both lay and scientific interest. The imagination of the public has been captured by the concept that diet has a significant impact on health. The belief that one’s quality of life can be enhanced through manipulation of patterns of food intake has resulted in “prebiotic” and, most especially, “probiotic” becoming common or garden household terms, no longer scientific jargo

Casting light on the links between delirium, infection, and dementia risk

The study by Sarah Pendlebury and colleagues1 merits comment. The authors have addressed the challenge of determining whether there might be a direct association between incidence of delirium or infection and dementia risk in the context of white matter disease. Working with a high-quality dataset, the authors have provided credible evidence that, as found in previous studies,2, 3, 4 the presence of preceding delirium or infection increases subsequent risk of dementia. However, this study contributes new insight by showing that that the effects of delirium and infection on dementia risk were independent of one another, as well as showing the modifying role of white matter disease. Another key contribution of the study is demonstrating the differentiation of the impacts of delirium and infection for older patients (≥80 years) and those who are younger. In particular, the increased dementia risk after delirium was driven mainly by older patients, while the increased risk of dementia after infection was driven by younger patients. In light of the data provided, specific to these modifiable contributing factors for dementia, it is reasonable to conclude that mechanisms mediating dementia in older and younger patients might be entirely disparate or at least sufficiently distinct to warrant further investigation. Building on previous work,5 the authors correctly emphasise that prevention of vascular dementia in patients with white matter disease should focus on post-infection care. Of note, in performing the study, Pendlebury and colleagues have made considerable efforts to work within a well-defined scope of small vessel disease, accessing data for more than 1360 patients. This is no small feat, as the authors have, in effect, mitigated potential confounding by variability in white matter hyperintensities.</p

A review of the differences and similarities between generic drugs and their originator counterparts, including economic benefits associated with usage of generic medicines, using Ireland as a case study

Generic medicines are those where patent protection has expired, and which may be produced by manufacturers other than the innovator company. Use of generic medicines has been increasing in recent years, primarily as a cost saving measure in healthcare provision. Generic medicines are typically 20 to 90% cheaper than originator equivalents. Our objective is to provide a high-level description of what generic medicines are and how they differ, at a regulatory and legislative level, from originator medicines. We describe the current and historical regulation of medicines in the world’s two main pharmaceutical markets, in addition to the similarities, as well as the differences, between generics and their originator equivalents including the reasons for the cost differences seen between originator and generic medicines. Ireland is currently poised to introduce generic substitution and reference pricing. This article refers to this situation as an exemplar of a national system on the cusp of significant health policy change, and specifically details Ireland’s history with usage of generic medicines and how the proposed changes could affect healthcare provision