CORA
Cork Open Research Archive (CORA) is UCC’s Open Access institutional repository which enables UCC researchers to make their research outputs freely available and accessible.
UCC Research Communities
Recent Submissions
The impact of the COVID-19 pandemic on prehospital emergency care for stroke/transient ischaemic attacks (TIAs) and implications for future policy and service delivery
(University College Cork, 2024) Burton, Edel; Buckley, Claire; Kearney, Patricia M.; Mc Carthy, Vera; Merwick, Aine; Health Research Board
Background and aims
Time plays a fundamental role in managing acute stroke and transient ischemic attack (TIA), with the minimisation of prehospital delays critical to the stroke chain of survival. The COVID-19 pandemic led to worldwide restrictions, resulting in significant societal changes, including alterations to healthcare access and delivery, which particularly impacted time-sensitive conditions. Thus, the aim of this thesis was to investigate the impact of a “shock”, such as the COVID-19 pandemic on prehospital emergency care for exemplar time-sensitive conditions; stroke and TIA, with the goal of exploring potential implications for future policy and service delivery.
Methods
This PhD thesis employed a mixed-methods approach, using the multilevel model of triangulation design. This approach was informed by the “Resilient Health System as a Conceptual Framework for Strengthening Public Health Disaster Risk Management”. Five studies were conducted. Firstly, a systematic review and meta-analysis synthesised existing evidence on the impact of the COVID-19 pandemic on prehospital care for suspected stroke/TIA and calculated pooled estimates for ambulance time intervals and call volume during the pandemic. Secondly a quasi-experimental study using Republic of Ireland National Ambulance Service data investigated the impact of COVID-19 on ambulance time intervals and emergency call volume for suspected stroke/TIA using linear regression and autoregressive integrated moving averages. Thirdly, a qualitative study using semi-structured interviews explored the experiences of stroke/TIA survivors, caregivers, prehospital and hospital-based practitioners of acute stroke/TIA care during the COVID-19 pandemic in Ireland. Fourthly, a benchmarking study facilitated the comparison of international terminology and definitions for ambulance times and intervals. This enabled the final study; an international comparative analysis using a quasi-experimental before and after design to compare ambulance time intervals and call volume for suspected stroke/TIA before and during COVID-19, using linear regression and times series analysis. Stakeholder involvement was included throughout all studies.
Results
The meta-analysis demonstrated that pre-COVID-19, the mean response interval was shorter by -1.29 minutes (95% CI: -2.19 to -0.38), and the mean total prehospital interval was shorter by -6.42 minutes (95% CI: -10.60 to -2.25), compared to during the pandemic. Additionally, there was a higher incidence rate ratio (IRR) of emergency calls for suspected stroke/TIA per day pre-COVID-19 compared to during COVID-19 (log IRR = 0.17, 95% CI: 0.02 to 0.33). In Ireland, during the pandemic period, the five included ambulance time intervals increased compared to pre-COVID-19 (all p<0.001). Overall, call volume increased during the COVID-19 period compared to the pre-COVID-19 period (p<0.001). However, dips in call volume were observed during the initial wave and wave 4. Qualitative interviews with stroke/TIA survivors, caregivers and healthcare professionals revealed that the integrity of the acute stroke/TIA pathway remained intact during the COVID-19 pandemic. However, overall patient experience and willingness to seek care for suspected stroke/TIA were negatively impacted. Significant heterogeneity in terminology and definitions for ambulance times and intervals were observed in the international benchmarking study. In the international comparative study, on-scene time increased across all seven services between 1.05-3.78 minutes (all <0.001) during the COVID-19 period. Whereas response time interval increased in six of the seven services, ranging from 0.5-9.13 minutes (all p<0.001), and decreased in New Zealand by 1.57 minutes (<0.001). Mean monthly call volume rose across all services during COVID-19, ranging from 1.9-9 minutes, apart from the Netherlands, which saw no change (p=0.4).
Conclusion
This thesis used a multistakeholder mixed methods approach to investigate the resilience of the acute stroke/TIA pathway during a public health crisis, highlighting prehospital delays and potential care avoidance by stroke/TIA survivors. It calls for stakeholder collaboration to optimise the stroke chain of survival and further studies on the pandemic's long-term impacts on stroke/TIA care.
Improving identification and management of the at-risk foot in diabetes
(University College Cork, 2024) Pallin, Jennifer Ann; Buckley, Claire; Kearney, Patricia M.; Dinneen, Sean; Health Research Board
Background: Diabetes-related foot ulcers (DFUs) are one of the most common lower extremity complications of diabetes. The lifetime risk of a person developing a DFU is estimated to be as high as 34%. They are associated with increased risk of limb loss, increased hospitalisations and poorer quality of life. However, they are preventable through timely identification of risk factors, and referral to appropriate prevention services. It is internationally recommended that people with diabetes be offered annual diabetic foot screening to identify risk factors and allow for timely implementation of prevention strategies. However, evidence suggests diabetic foot screening is one of the least complied with elements of diabetes care internationally. This means many people who have risk factors are not being identified, not receiving appropriate care for risk factors and experiencing preventable DFUs and subsequent limb loss.
Aim: To enhance understanding of how recommendations for identifying and managing individuals at-risk for DFUs are being implemented and how best to identify and manage those at risk.
Methods: This thesis followed a convergent mixed methods study design, comprising five studies to answer four interrelated research objectives. Firstly, to achieve consensus on what terms should be used within clinical practice guidelines to describe identification of the at-risk foot, guidelines were assessed and people with lived experience of diabetes were consulted. Secondly, to examine what care people with diabetes are receiving and where and by whom their care is being delivered, using Ireland as a case study, two separate studies examined healthcare professionals’ and people with diabetes’ experiences of preventative diabetic foot care in Ireland. An online cross-sectional survey of podiatrists examined podiatrists experiences of providing integrated diabetic foot care. A qualitative study involving semi-structured interviews with general practitioners, practice nurses and people with diabetes explored their experiences of providing and accessing diabetic foot screening and factors influencing this. This qualitative study also explored perspectives on moving diabetic foot screening into a systematic screening programme. Third, to evaluate potential risks and benefits of a systematic diabetic foot screening programme, a scoping review study conducted in line with Arksey and O’Malley and the Joanna Briggs Institute methodologies, evaluated and mapped the evidence on diabetes-related foot screening using the World Health Organisation screening principles. Fourth, to improve identification of those at-risk for DFUs, a prospective cohort study including people with Type 1 diabetes and Type 2 diabetes assessed the association of cardiac autonomic neuropathy with incident DFUs and amputation. Results from these individual studies were brought together using a narrative approach.
Results: Following a review of seven clinical practice guidelines, and consultation with people with diabetes, consensus on the appropriate terminology to describe identification of the at-risk foot was achieved. Findings from the national survey of podiatrists (n = 50) and qualitative study (n = 26) suggested that national policies outlining referral pathways are insufficient to ensure at-risk individuals are managed appropriately. Adequate staffing, and information technology infrastructure to enable improved information flow between healthcare settings are needed to support the transition of patients between settings. In addition, increased efforts are needed to educate patients on the importance of foot screening. The scoping review of 46 articles found introduction of foot screening into a systematic screening programme could lead to more harm than benefit. Finally, those with cardiac autonomic neuropathy have a threefold (IRR: 2.99; 1.5 – 5.5; p<0.01) increased risk of ulceration.
Conclusion: Findings from this thesis enhance our understanding of factors enabling identification and management of the at-risk foot in diabetes. Collectively, the results indicate that while current national policies and clinical guidelines provide a foundation, they are insufficient on their own to ensure people at risk for DFUs are being identified and managed in line with international recommendations. A more integrated systematic approach involving information technology infrastructure that supports communication between healthcare settings is needed. Health systems also need to ensure adequate staffing and enhanced patient education to ensure at-risk individuals receive timely and appropriate care. Based on current evidence, findings suggest addressing these factors may be more effective than implementing a systematic diabetic foot screening programme. Finally, the identification of cardiac autonomic neuropathy as an independent risk factor for DFUs improves our understanding of risk factors for disease onset. The findings from this thesis have the potential to inform future policy, improve clinical practice, and ultimately reduce the burden of diabetes-related foot complications on both patients and healthcare systems.
Working with schools in disadvantaged communities: a case study of Learning Neighbourhoods in Cork, Ireland
(OpenEdition Journals, 2025-04) O’Sullivan, Siobhán; Kenny, Lorna; Ó Tuama, Séamus; Browne, Norma; Barrett, Denis; Duke, Karen
This article documents the initiatives of Cork Learning Cities and Neighbourhoods with schools in disadvantaged communities in Cork City, Ireland’s second largest city, to tackle the persistence of education stratification and inequality of education opportunities and outcomes. Through a community development approach, Learning Cities and Neighbourhoods works to create collaboration across learning sectors, including primary and secondary schools, community groups, and further and higher education institutions. The article explores the bottom-up, collaborative approach of Learning Neighbourhoods and shows how authentic partnerships between learning organisations and communities can be developed to enhance learning opportunities and pathways to further and higher education.
Establishment of Next Generation Sequencing (NGS) in a clinical diagnostic laboratory for diagnostic and research purposes
(University College Cork, 2025) Werner, Reiltin; Burke, Louise; Hand, Collette; CUH Charity; Karen Fenton Ovarian Cancer Charity
This thesis examines the implementation of Next Generation Sequencing (NGS) technology for cancer molecular profiling within a previously NGS-naïve clinical pathology laboratory at Cork University Hospital (CUH). The project addresses the growing clinical need for multi-gene analysis by moving from single-gene testing to a comprehensive NGS approach, significantly improving diagnostic capabilities and research integration. The thesis had three primary objectives:
1) Implementation of an Irish National Accreditation Board (INAB) accredited NGS diagnostic service to ISO 15189 standards in an NGS-naïve pathology department.
2) Expand NGS panel repertoire from tissue- to liquid-based and incorporate the platform into clinical research protocols.
3) Training and education of cancer centre staff and trainees in NGS.
Implementation of NGS in the Clinical Diagnostic Setting to ISO 15189 Standards: This involved optimising and validating targeted NGS panels for formalin-fixed paraffin-embedded (FFPE) tumour tissue and plasma samples, reducing the turnaround time (TAT) for results from three weeks to less than seven days. It also assessed the potential of novel automated NGS technologies capable of delivering results within 24 hours—an advancement not yet available in Ireland.
Expand NGS Panel Repertoire and Incorporate Research Protocols: This objective focused on expanding protocols for both tissue and liquid biopsies and conducting concordance studies, with an initial emphasis on non-small cell lung cancer (NSCLC). The research project described in Chapter 4 “Temporal Evaluation of Oncogenic Driver Mutations and Co-Variant Changes in NSCLC Patients Using NGS,” demonstrated the success of NGS in both tumour and plasma samples. It contributed significantly to understanding tumour evolution and treatment response. The attainment of accreditation to ISO 15189 standards for liquid biopsy enabled CUH to participate in pan-European studies and expand its NGS research output and collaborations.
Training and Education: A primary focus of the project was developing comprehensive NGS training programmes for medical scientists, doctors in training (DIT), and undergraduate and postgraduate students. These accreditation-compliant programmes have ensured that CUH has highly skilled professionals capable of using NGS technology in diagnostic and research contexts. The educational framework established supports the long-term development of NGS services at CUH and contributes to ongoing professional and academic advancement in pathology.
In conclusion, the project achieved and exceeded its key objectives. By establishing robust pathways for multidisciplinary collaboration and embedding NGS technology in clinical diagnostics, CUH has positioned itself as a molecular research hub. The success of the NSCLC study, highlights the clinical benefits of NGS and sets a solid foundation for future advancements in precision oncology. The project’s achievements in diagnostic accuracy, research output and professional development have put CUH at the forefront of molecular pathology, paving the way for further innovations and collaborations.
Multidimensional household poverty in Ireland: child and maternal psychopathology outcomes
(University College Cork, 2024) O'Driscoll, David; Khashan, Ali; Kiely, Elizabeth; O'Keeffe, Linda
Background and aims: There is evidence that children and mothers exposed to poverty have an increased likelihood of developing mental health problems. Despite this, there is a dearth of literature that informs policy on the timing, and type of poverty experienced during childhood to better understand in turn the subsequent development of psychopathology. Most poverty related studies are cross-sectional in nature and do not take into account a life-course approach. As such, there is a need to consider a broader definition of poverty (i.e., multidimensional household poverty (MHP)) to capture as many households at risk and their subsequent psychopathology outcomes. The aim of this thesis was to evaluate the association between MHP and child and maternal psychopathology using a large contemporary nationally representative prospective longitudinal cohort study in Ireland.
Structure and methods: Chapter 1 contains a description of the thesis rationale, theoretical framework, aims and objectives, and hypothesis. In Chapter 2, the existing published literature relating to MHP and child and maternal psychopathology was critically evaluated and synthesised to identify major research gaps. The Growing Up in Ireland study, a nationally representative, prospective longitudinal study was used in each of the four studies ( i.e., Chapter 4-7). A range of statistical analytic approaches were used including logistic and Poisson regression. Multiple imputation was used to examine missing data. Interaction and stratification analysis was employed. In Study 1 (Chapter 4), group based multi-trajectory cluster modelling was used to classify trajectories of poverty from 9-months(m) to 9-years(y). Confounder-adjusted logistic regression was used to understand the association of poverty trajectories from 9m to 9y with child outcomes (overweight, any longstanding illness and psychopathology) at age 9y and the same poverty trajectories over the same 9y period with mother outcomes (overweight, any longstanding illness and depression) using the Infant cohort. In Study 2 (Chapter 5), MHP was derived from monetary, subjective and material poverty questionnaires completed by mothers before 3y using latent-class-analysis. Confounder-adjusted linear spline multilevel modelling was employed to understand the association between MHP prior to 3y and psychopathology trajectories in child (3-to-13y) and mother (34-to-46y) using the Infant cohort. In Study 3 (Chapter 6), latent-class-analysis was used to derive a MHP variable and confounder-adjusted logistic regression modelling was used to understand the association between transitioning into MHP (9m-to-9y and 9y-to-17/18y) and child and maternal psychopathology (when child was 13y and 20y) using both GUI cohorts. In Study 4 (Chapter 7), household energy poverty (EP) was derived using a composite of two relative measures of energy poverty. Confounder-adjusted linear spline multilevel modelling was used to examine the association between (1) EP (9m or 3y) and trajectories of emotional and behavioural difficulties from 3 to 9y in the Infant cohort and (2) EP at 9 y and the same trajectories from 9 to 18y in the Child cohort. The final chapter (Chapter 8) discusses the main findings of each study, including limitations, strengths, policy and research recommendations.
Results:
Study 1: Of 11,134 participants, four trajectories were identified: never-in-poverty (43.1%), material/subjective>monetary-poverty (16.1%), monetary>material-poverty (25.6%), and persistent-poverty (15.2%). Children in persistent-poverty compared with never in poverty experienced higher odds of being overweight at 9y (adjusted odds ratio aOR 1.70,95% CI 1.34, 2.16), having a longstanding illness (aOR 1.51,95% CI 1.20, 1.91) and psychopathology (aOR 2.06,95% CI 1.42, 2.99). The outcomes for primary parent (99.7% were mothers) had higher odds of being overweight (aOR 1.49,95% CI 1.16, 1.92), having a longstanding illness (aOR 2.13,95% CI 1.63, 2.79), and depression (aOR 3.54,95% CI 2.54, 4.94). Study 2: In adjusted analyses, MHP before 3y was associated with a higher mean difference (MD) (MD:0.67, 95% CI 0.41,0.92) in child psychopathology at 3y and this was broadly similar at age 13y (MD:0.87, 95% CI 0.57,1.17). MHP prior to 3y was associated with a higher mother psychopathology when her child was age 3y (MD:1.07, 95% CI 0.90,1.23) and this persisted albeit with a slight reduction in magnitude at age 13y of the child (MD:0.72, 95% CI 0.53,0.90). Study 3: In the child sample (i.e., Infant cohort) (9m-to-9y), 22.9%(n=1766) households transitioned into MHP, and 6.7%(n=514) lived in persistent MHP. In the adolescent sample (i.e., Child cohort) (9y-to-17/18y), 10.2%(n=791) households transitioned into MHP, and 9.5%(n=734) lived in persistent MHP. In adjusted analyses, transitioning into MHP from 9m-to-9y was associated with higher child (aOR,2.06CI-95%,1.49,2.84) and maternal (aOR,2.59,CI-95%,1.90,3.53) psychopathology when child was 13y. Transitioning into MHP from 9y-to-17/18y was associated with higher adolescent (aOR,1.24,CI-95%,1.00,1.63) and maternal (aOR,1.99,CI-95%,1.34,2.95) psychopathology at 20y. Being in persistent MHP was associated with higher psychopathology than having transitioned into MHP. Study 4: In adjusted analyses, EP at 9m or 3y of age was associated with higher total difficulties score at 3y (0.66, 95% CI 0.41, 0.91) and 5y (0.77, 95% CI 0.48, 1.05) but not at 7y or 9y. EP at 9y was associated with higher total difficulties score at 9y (1.73, 95% CI 1.28, 2.18), with this difference reducing over time leading to 0.68 (95% CI 0.19, 1.17) at 17/18y.
Conclusion: This thesis highlighted that different multidimensional household poverty trajectories, early life multidimensional household poverty prior to 3 years of age in the child and transitioning into multidimensional household poverty during childhood was associated with poorer child and mother psychopathology outcomes. Moreover, household energy poverty showed a potential association with subsequent child psychopathology. All in all, while these findings are specific to Ireland and require replication in other cohorts, they highlight the need for early anti-poverty policy interventions in the hope to alleviate and improve a child’s and mother’s psychopathology over time.