College of Medicine and Health - Masters by Research Theses
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Item An exploration of how the wheelchair procurement system in Ireland compares to the needs and wants of the wheelchair users and clinicians, and how it influences everyday life(University College Cork, 2023) Murphy, Jack D.; Pennisi, Yvone; Boyle, Bryan; University College CorkIntroduction: For many people, wheelchairs are an essential part of daily life to enable participation and engagement in occupations. Despite being a vital personal mobility aid, the literature points to inefficient systems which procure and provide wheelchairs to the users. This places undue stress and pressure on both clinicians and service users alike. In Ireland, publicly funded wheelchair procurement occurs through the Health Service Executive [HSE] via use of a standardised national wheelchair contract. Prior to the introduction of the wheelchair contract, ownness for procuring wheelchairs fell to individual clinicians, and/or locally held contracts in some areas in Ireland. The aim of the new national wheelchair contract was to standardise the quality of wheelchairs provided by the HSE, reduce monetary waste, and reduce the workload on individual clinicians to procure wheelchairs. The experiences of those who use the wheelchair procurement system in Ireland everyday are yet to be investigated. This leads to questions regarding how the wheelchair procurement system is working from the perspectives of both the occupational therapists and service users. This project aims to review how the introduction of a national standardised wheelchair contract impacts time-savings, monetary savings, administration load and quality of life of the wheelchair users. Background: The background requires understanding two perspectives: how disability has been viewed historically and how this may have influenced daily life and policy engagement; and how the wheelchair procurement works here in Ireland, specifically using a wheelchair contract system to streamline the procurement process. Literature: The literature indicates that wheelchair provision is studied frequently, however wheelchair procurement is rarely studied. The procurement of wheelchairs is an integral aspect of provision and has the potential to impact its effectiveness. The literature indicates the importance of the meaning of the wheelchair to the user, and its impact on identity. This presents an opportunity for investigation to explore if this meaning is reflected in the wheelchair contract in Ireland. Additionally, the literature looks more broadly at how the wheelchair systems impact the user in terms of the status, regulatory frameworks and funding of these devices. Methodology: This project utilises a descriptive phenomenology methodology to explore the lived experiences of those whom the wheelchair contract directly impacts. Ethical approval was gained prior to commencement of data collection. This research was conducted in the midst of the COVID-19 global pandemic, which impacted the timeframes of the project. Five Occupational Therapists and four Manual Wheelchair Users were recruited for in-depth, semi-structured qualitative interviews, from gatekeepers including the Irish Wheelchair Association and the Association of Occupational Therapists Ireland. Findings: The project has three main findings. These included Personal Factors, which describe all of the factors identified by participants which impacted decisions with regards to wheelchair procurement. Next, the Impact of the System refers to the structures in place which must be navigated by participants to obtain their wheelchairs. Additionally, the final theme is a description of the ‘Business’ of Wheelchair Provision. This section describes the realities of working with Businesses and this is reflected in how the HSE is run like a Business. Discussion: The contract intended to streamline and standardise wheelchair provision and procurement for occupational therapists in Ireland. With wheelchair procurement being an important step in the overall process of wheelchair provision, the project uncovered interesting findings with regards to how it is used and its practical implementation. The wheelchair contract is used in different ways. The occupational therapist group use this directly, while the manual wheelchair user group use it indirectly. Conclusion: The wheelchair contract was noted to be dichotomous in nature. Participants were frustrated with the system inefficiencies which impact procurement and provision. However, participants felt the wheelchair contract was a step in the right direction despite some of its shortcomings.Item Induction of transdermal buprenorphine (Butrans®) to extended-release buprenorphine subcutaneous injection (Sublocade®) for opioid use disorder: a case series & a qualitative study on the experiences, barriers, and understanding of opioid agonist treatment among youth with opioid use disorder in Vancouver, British Columbia(University College Cork, 2023) Schneiderman, Hannah; Ó Tuathaigh, Colm; Coakley, Niamh; Azar, Pouya; Ignaszewski, Martha; Budd, George; University College CorkThe opioid crisis is a profound public health crisis, with devastating impacts on individuals, families, and communities in North America. Vancouver is one of the most affected regions in Canada. To combat the rising opioid overdose epidemic, opioid agonist treatment and harm reduction services have become more readily accessible, and patient centered. The most effective approach to decreasing the morbidity and mortality of people with opioid use disorder is opioid agonist treatment. Initiation of opioid agonist treatment, including buprenorphine and methadone, is a complex and crucial step in care for those beginning pharmacological treatment, as well as those transitioning between medications, as poor treatment retention is largely attributed to discomfort during the induction period due to precipitated withdrawal symptoms. A variety of techniques and protocols have been developed to combat treatment barriers, including rapid micro-induction using sublingual buprenorphine-naloxone; this method eliminates the need for an abstinence period prior to administration of the first dose of buprenorphine/naloxone, and lowers the risk of precipitated withdrawal symptoms. We conducted a case series, involving two patients, that demonstrates the efficacy and safety of a novel induction technique using transdermal buprenorphine (Butrans)®, to extended-release buprenorphine subcutaneous injection (Sublocade®) for the treatment of opioid use disorder, done over a 48-hour period. Both patients experienced minimal withdrawal symptoms throughout induction and no adverse effects. This technique, also called the IPPAS method, has similar advantages to that of rapid micro-induction, in addition to reduced nurse workload, steadier blood level concentrations of buprenorphine, and increased accuracy of dose administration. In addition, this technique is more outpatient friendly with less reliance on patients to time their own doses. There is a need for further research among larger patient populations to assess the safety and efficacy of this induction method using transdermal buprenorphine in different settings and patient demographics, including youth with OUD. A population at increased risk of overdose, with lower rates of accessing pharmacological treatment, are youth (15-24 years old). Since 2018, over 1000 people between the age of 0 to 29 have died from illicit drug toxicity in Canada. Despite the effectiveness of opioid agonist treatment for opioid use disorder, only 2.4% of youth who use opioids receive pharmacological treatment compared to 26.3% of adults who use opioids. Another study found that less than 2% of youth who have suffered from a nonfatal opioid-related overdose received the recommended evidence-based pharmacotherapy. Understanding perceptions of OAT among this highly vulnerable young population is essential in combating barriers and harmful perceptions of treatment that lead to reduced treatment access. Few studies have investigated these perceptions among youth. We conducted a qualitative study involving semi-structured interviews among twelve young people with opioid use disorder at Foundry Vancouver-Granville clinic in Vancouver, British Columbia. The findings of this study highlight the complexities involving individual experiences of initiation and retention of opioid agonist treatment, as well as the unique barriers of treatment that young people with opioid use disorder experience. The four major themes identified during thematic analysis include: preparedness to begin opioid agonist treatment, effects of opioid agonist treatment on personal relationships and social life, navigating the pharmacological treatment options, and the role of the healthcare worker. The data from this qualitative research study on the experiences of pharmacological treatment among youth with opioid use disorder can be used to inform future research efforts, clinical practice, and policy change to improve the treatment and social supports available for young people struggling with opioid misuse. Future research is essential to further develop our understanding of young people, and their experiences seeking and retaining opioid agonist treatment for opioid use disorder.Item Microbial regulation of barrier function in the gut-brain axis(University College Cork, 2023) Sánchez Díaz, Paula; Clarke, Gerard; Cryan, John; Leigh, Sarah-Jane; Advancement in Neurosciences (Geneva, Switzerland)The gut microbiome plays a critical role in host health through modulation of gut and blood-brain barrier integrity, responding to factors such as diet, stress, and medication. A key pathway by which the gut microbiota affects gut and bloodbrain barrier integrity is through the production of bioactive metabolites. This thesis explores the role of barriers in the microbiota-gut-brain axis, which are essential for the proper functioning of body systems and homeostasis. Chapter 2 investigates how fermenting infant nutrient formulations with different bifidobacteria strains isolated from infant gut microbiome can influence the integrity of gut and blood-brain barriers in vitro. The study found that the presence of bifidobacteria strains, in some cases, had protective effects on the barriers, and these effects sometimes differed depending on the barrier studied. Chapter 3 explores the effects of indole and two of its derivates, indole-3-acetate and indole- 3-propionate, on gut barrier function in vitro. The results indicate that indole has a protective effect on barrier function, particularly at higher concentrations, and indole-3-acetate has a protective effect at the lowest concentrations tested. Surprisingly, indole-3-propionate was not protective and at higher concentrations exacerbated the effects of LPS-induced disruption. Finally, Chapter 4 focuses on the effect of cancer therapy, specifically cisplatin, on gut and blood-brain barrier structure in mice, to further explore the role of gut microbiome in cancer-related cognitive impairment. The study used mice treated with cisplatin to investigate the expression of genes involved in the structural function of barriers and inflammation, as well as gene expression of receptors activated by microbial ligands in the ileum, colon, and hippocampus. The results showed that cisplatin affected gene expression in a region- and dose-dependent manner, leading to changes in anxiety-like and fatigue behaviours in mice. Overall, this research highlights the critical role of the gut microbiome in gut barrier and blood-brain barrier function. Microbial metabolite supplementation may present a useful therapeutic option for disease processes involving disruption of the gut and/or blood-brain barriers.Item Major trauma in older Irish adults(University College Cork, 2023) Junker, Kate; Ó Tuathaigh, Colm; Deasy, ConorIntroduction: The world’s population is rapidly ageing. In Ireland, the population over sixty five years is expected to increase from 629,800 to 1.6 million by 2051. Such changes in demographics pose a challenge for healthcare and all areas of our service must adapt to meet the needs of this cohort. Major trauma is a leading cause of death and disability worldwide. Recent literature has shown that low falls are the biggest contributor to major trauma. Major trauma in older Irish adults is an area about which little research has been done. The primary aim of this study was to determine the prevalence of major trauma in older Irish adults and describe injuries sustained and their management. This study also explores outcomes for older adults who experience major trauma and makes comparison with younger counterparts. Methods: This is a retrospective secondary analysis of data from the Major Trauma Audit (MTA). The MTA prospectively gathers data on patient care and outcomes following trauma from twenty six participating hospitals in Ireland. This study included all patients who presented to a single centre in Ireland with an injury severity score (ISS) indicative of major trauma over five years. Data was divided into the following age groups; 0-24 years, 25-49 years, 50-64 years, 65-74 years, 75-84 years, and 85 years or older. Data was analysed using SPSS version 28. Descriptive statistics were used to define demographics and injury characteristics and chi-square test was used to make comparisons between groups. Univariate and multivariate logistic regression analysis was used to consider factors associated with specific outcomes. A p-value of <0.05 was considered statistically significant. Results: In the five year period studied, 1,123 cases of major trauma were identified in Cork University Hospital. Of these, 659 were aged less than sixty five years and 464 were aged greater than sixty five years meaning that 41.3% were older adults. The majority of older adults presenting with major trauma were male (56%) but the proportion of females presenting increased with age. Low falls were the most common mechanism of injury (74.1%). 80.6% of older adults were alive thirty days post injury and 47.2% had a good recovery. Conclusion: Major trauma in older Irish adults is becoming an important public health issue. Specialist education and training is required to ensure the needs of this cohort are appropriately met. This study highlights the burden of major trauma in older Irish adults.Item Defining the patient safety trajectory of breast cancer at a National Cancer Centre(University College Cork, 2023) Forrest, Clara; Ó Tuathaigh, Colm; Health Service Executive; University College CorkIntroduction: One in seven Irish women will develop breast cancer in their lifetime. A well-researched management pathway commences thereafter, involving multiple treatment modalities and specialities. In contrast, there is sparse research examining the patient safety trajectory that mirrors this clinical journey. Learnings from previous events can illuminate this otherwise unknown patient safety trajectory of those with breast cancer. Furthermore, there is little known of patients’ and doctors’ views and experiences of this patient safety trajectory. Aims: This study aimed to characterise patient safety incidents that have occurred during breast cancer care, their contributory and preventative factors, outcome and impact. Using this data, patient safety trajectories were created. In addition, this paper aimed to explore the patient safety views and concerns of patients receiving and doctors providing breast cancer care. Methods: Anonymous, quantitative patient and doctor questionnaires were used. In addition, data related to medical negligence claims involving breast cancer and handled by the State Claims Agency was analysed. Pearson chi-squared test and Fisher’s exact test were utilised for categorical data. The median degrees of harm were used to construct trajectories. Results: 83 patient safety incidents were included (61 medical errors and 22 medical negligence claims). Failure or delay to correctly diagnose was the most commonly implicated adverse event type overall (n=32/83, 38.6%) and was involved in a higher proportion of medical negligence claims than medical errors (p=0.01). Forty percent of events occurred in the outpatient department (n=33/83) and 31% of events took place before a patient’s formal breast cancer diagnosis (n=26/83). Inadequate communication was the most common contributory factor. Events during neoadjuvant chemotherapy and after discharge from follow-up had the highest median degree of harm of 4 (Q1-Q3:3.5-4.5 and Q1-Q3:4.0-4.5). More doctors felt patient safety has worsened in the past five years compared to patients (41.4% vs 13.0%) (p<0.001). Twice as many doctors reported that there were inadequate measures in place to prevent medical error compared to patients (54.3% vs 27.2%) (p<0.001). Conclusion: Patient safety incidents during breast cancer care occur in a variety of settings and during all clinical stages but often occur before diagnosis and involve inadequate communication. Doctors who provide breast cancer care have a more pessimistic outlook on patient safety compared to patients and are more concerned about medical error in breast cancer care. Addressing and acting on the experiences and concerns of those involved in breast cancer care is vital to improve patient safety trajectories for breast cancer patients.