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1.  Parents’ perspectives on the value of assistance dogs for children with autism spectrum disorder: a cross-sectional study 
BMJ Open  2014;4(6):e004786.
While there is an emerging literature on the usefulness of assistance dogs for children with autism spectrum disorder (ASD), there is a dearth of quantitative data on the value of assistance dog interventions for the family unit and family functioning. Using previously validated scales and scales developed specifically for this study, we measured parents’/guardians’ perceptions of how having an assistance dog affects: (1) child safety from environmental dangers, (2) public reception of ASD and (3) levels of caregiver strain and sense of competence. We also obtained open-ended response data from parents/guardians on benefits and constraints of having an assistance dog.
This study was based in the primary care setting, within the context of a specific accredited assistance dog centre in Ireland.
A total of 134 parents/guardians with an assistance dog, and 87 parents of children on the waiting list were surveyed.
Primary and secondary outcome measures
The primary outcome measures were scores on environmental hazards and public reception scales. The secondary outcome measures were scores on caregiver strain and competence scales.
Parents/guardians of children who have ASD and an assistance dog rate their child as significantly safer from environmental dangers (p<0.001), perceive that the public act more respectfully and responsibly towards their child (p<0.001) and feel more competent about managing their child (p=0.023) compared with parents on the waiting list. There was a concentration of positive feeling towards assistance dog interventions with particular focus on safety and comfort for children, and a sense of freedom from family restrictions associated with ASD. The amount of dedication and commitment required to care for a dog were viewed as the primary constraints.
Our findings indicate that parents perceive that assistance dog interventions can be a valuable intervention for families with children who have ASD.
PMCID: PMC4067897  PMID: 24928583
Epidemiology; Public Health; Primary Care
2.  Chronic disease burden associated with overweight and obesity in Ireland: the effects of a small BMI reduction at population level 
BMC Public Health  2014;14:143.
Overweight and obesity prevalence has risen dramatically in recent decades. While it is known that overweight and obesity is associated with a wide range of chronic diseases, the cumulative burden of chronic disease in the population associated with overweight and obesity is not well quantified. The aims of this paper were to examine the associations between BMI and chronic disease prevalence; to calculate Population Attributable Fractions (PAFs) associated with overweight and obesity; and to estimate the impact of a one unit reduction in BMI on the population prevalence of chronic disease.
A cross-sectional analysis of 10,364 adults aged ≥18 years from the Republic of Ireland National Survey of Lifestyle, Attitudes and Nutrition (SLÁN 2007) was performed. Using binary regression, we examined the relationship between BMI and the selected chronic diseases. In further analyses, we calculated PAFs of selected chronic diseases attributable to overweight and obesity and we assessed the impact of a one unit reduction in BMI on the overall burden of chronic disease.
Overweight and obesity prevalence was higher in men (43.0% and 16.1%) compared to women (29.2% and 13.4%), respectively. The most prevalent chronic conditions were lower back pain, hypertension, and raised cholesterol. Prevalence of chronic disease generally increased with increasing BMI. Compared to normal weight persons, the strongest associations were found in obese women for diabetes (RR 3.9, 95% CI 2.5-6.3), followed by hypertension (RR 2.9, 95% CI 2.3-3.6); and in obese men for hypertension (RR 2.1, 95% CI 1.6-2.7), followed by osteoarthritis (RR 2.0, 95% CI 1.2-3.2). Calculated PAFs indicated that a large proportion of chronic disease is attributable to increased BMI, most noticeably for diabetes in women (42%) and for hypertension in men (30%). Overall, a one unit decrease in BMI results in 26 and 28 fewer cases of chronic disease per 1,000 men and women, respectively.
Overweight and obesity are major contributors to the burden of chronic disease in the population. The achievement of a relatively modest reduction in average BMI in the population has the potential to make a significant impact on the burden of chronic disease.
PMCID: PMC3929131  PMID: 24512151
Overweight; Obesity; BMI; Burden; Chronic disease; Prevalence; Population attributable fraction
3.  Unhealthy Days and Quality of Life in Irish Patients with Diabetes 
PLoS ONE  2013;8(12):e81102.
To study the determinants of health-related quality of life (HRQoL) in Irish patients with diabetes using the Centres for Disease Controls' (CDC's) ‘Unhealthy Days’ summary measure and to assesses the agreement between this generic HRQoL measure and the disease-specific Audit of Diabetes Dependant Quality of Life (ADDQoL) measure.
Research Design and Methods
Data were analysed from the Diabetes Quality of Life Study, a cross-sectional study of 1,456 people with diabetes in Ireland (71% response rate). Unhealthy days were assessed using the CDC's ‘Unhealthy days’ summary measure. Quality of life (QoL) was also assessed using the ADDQoL measure. Analyses were conducted primarily using logistic regression. The agreement between the two QoL instruments was measured using the kappa co-efficient.
Participants reported a median of 2 unhealthy days per month. In multivariate analyses, female gender (P = 0.001), insulin use (P = 0.030), diabetes complications (P = <0.001) were significantly associated with more unhealthy days. Older patients had fewer unhealthy days per month (P = 0.003). Agreement between the two measures of QoL (unhealthy days measure and ADDQoL) was poor, Kappa = 0.234
The findings highlight the determinants of HRQoL in patients with diabetes using a generic HRQoL summary measure. The ‘Unhealthy Days’ and the ADDQoL have poor agreement, therefore the ‘Unhealthy Days’ summary measure may be assessing a different construct. Nonetheless, this study demonstrates that the generic ‘Unhealthy Days’ summary measure can be used to detect determinants of HRQoL in patients with diabetes.
PMCID: PMC3862478  PMID: 24349036
4.  Comparison of Diabetes Risk Score Estimates and Cardiometabolic Risk Profiles in a Middle-Aged Irish Population 
PLoS ONE  2013;8(11):e78950.
To compare diabetes risk assessment tools in estimating risk of developing type 2 diabetes (T2DM) and to evaluate cardiometabolic risk profiles in a middle-aged Irish population.
Future risk of developing T2DM was estimated using 7 risk scores, including clinical measures with or without anthropometric, biological and lifestyle data, in the cross-sectional Mitchelstown cohort of 2,047 middle-aged men and women. Cardiometabolic phenotypes including markers of glucose metabolism, inflammatory and lipid profiles were determined.
Estimates of subjects at risk for developing T2DM varied considerably according to the risk assessment tool used (0.3% to 20%), with higher proportions of males at risk (0–29.2% vs. 0.1–13.4%, for men and women, respectively). Extrapolated to the Irish population of similar age, the overall number of adults at high risk of developing T2DM ranges from 3,378 to 236,632. Numbers of non-optimal metabolic features were generally greater among those at high risk of developing T2DM. However, cardiometabolic profile characterisation revealed that only those classified at high risk by the Griffin (UK Cambridge) score displayed a more pro-inflammatory, obese, hypertensive, dysglycaemic and insulin resistant metabolic phenotype.
Most diabetes risk scores examined offer limited ability to identify subjects with metabolic abnormalities and at risk of developing T2DM. Our results highlight the need to validate diabetes risk scoring tools for each population studied and the potential for developing an Irish diabetes risk score, which may help to promote self awareness and identify high risk individuals and diabetes hot spots for targeted public health interventions.
PMCID: PMC3827294  PMID: 24236074
5.  Haematinic Deficiency and Macrocytosis in Middle-Aged and Older Adults 
PLoS ONE  2013;8(11):e77743.
To assess the prevalence and determinants of haematinic deficiency (lack of B12 folate or iron) and macrocytosis in blood from a national population-based study of middle-aged and older adults.
A cross-sectional study involving 1,207 adults aged ≥45 years, recruited from a sub-study of the Irish National Survey of Lifestyle Attitudes and Nutrition (SLÁN 2007). Participants completed a health and lifestyle questionnaire and a standard food frequency questionnaire. Non-fasting blood samples were obtained for measurement of full blood count and expert morphological assessment, serum ferritin, soluble transferrin receptor assay (sTfR), B12, folate and coeliac antibodies. Blood samples were also assayed for thyroid function (T4, TSH), liver function, aminotransferase (AST) and gamma-glutamyl transferase (GGT).
The overall prevalence (95% C.I.) of anaemia (Hb <13.5g/dl men and 11.3 g/dl women) was 4.6% (2.9%–6.4%) in men and 1.0% (0.2%–1.9%) in women. Iron deficiency (ferritin <17ng/ml men and <11ng/ml in women) was detected in 6.3% of participants (3.7% in males and 8.7% in females, p<0.001). Based on both low ferritin and raised sTfR (>21nmol/ml) only 2.3% were iron-deficient. 3.0% and 2.7% were found to have low levels of serum folate (<2.3ng/ml) and serum B12 (<120ng/l) respectively. Clinically significant macrocytosis (MCV>99fl) was detected in 8.4% of subjects. Strong, significant and independent associations with macrocytosis were observed for lower social status, current smoking status, moderate to heavy alcohol intake, elevated GGT levels, deficiency of folate and vitamin B12, hypothyroidism and coeliac disease. The population attributable fraction (PAF) for macrocytosis associated with elevated GGT (25.0%) and smoking (24.6%) was higher than for excess alcohol intake (6.3%), folate deficiency (10.5%) or vitamin B12 (3.4%).
Haematinic deficiency and macrocytosis are common in middle-aged/older adults in Ireland. Macrocytosis is more likely to be attributable to an elevated GGT and smoking than vitamin B12 or folate deficiency.
PMCID: PMC3820699  PMID: 24244281
6.  Defining Metabolically Healthy Obesity: Role of Dietary and Lifestyle Factors 
PLoS ONE  2013;8(10):e76188.
There is a current lack of consensus on defining metabolically healthy obesity (MHO). Limited data on dietary and lifestyle factors and MHO exist. The aim of this study is to compare the prevalence, dietary factors and lifestyle behaviours of metabolically healthy and unhealthy obese and non-obese subjects according to different metabolic health criteria.
Cross-sectional sample of 1,008 men and 1,039 women aged 45-74 years participated in the study. Participants were classified as obese (BMI ≥30kg/m2) and non-obese (BMI <30kg/m2). Metabolic health status was defined using five existing MH definitions based on a range of cardiometabolic abnormalities. Dietary composition and quality, food pyramid servings, physical activity, alcohol and smoking behaviours were examined.
The prevalence of MHO varied considerably between definitions (2.2% to 11.9%), was higher among females and generally increased with age. Agreement between MHO classifications was poor. Among the obese, prevalence of MH was 6.8% to 36.6%. Among the non-obese, prevalence of metabolically unhealthy subjects was 21.8% to 87%. Calorie intake, dietary macronutrient composition, physical activity, alcohol and smoking behaviours were similar between the metabolically healthy and unhealthy regardless of BMI. Greater compliance with food pyramid recommendations and higher dietary quality were positively associated with metabolic health in obese (OR 1.45-1.53 unadjusted model) and non-obese subjects (OR 1.37-1.39 unadjusted model), respectively. Physical activity was associated with MHO defined by insulin resistance (OR 1.87, 95% CI 1.19-2.92, p = 0.006).
A standard MHO definition is required. Moderate and high levels of physical activity and compliance with food pyramid recommendations increase the likelihood of MHO. Stratification of obese individuals based on their metabolic health phenotype may be important in ascertaining the appropriate therapeutic or intervention strategy.
PMCID: PMC3798285  PMID: 24146838
7.  Prevalence of diminished kidney function in a representative sample of middle and older age adults in the Irish population 
BMC Nephrology  2012;13:144.
The prevalence of chronic kidney disease (CKD) using available estimating equations with the Republic of Ireland is unknown.
A randomly selected population based cross-sectional study of 1,098 adults aged 45 years and older was conducted using data from the 2007 Survey of Lifestyle, Attitudes and Nutrition (SLÁN). Estimated Glomerular Filtration Rate (eGFR) was calculated from a single IDMS aligned serum creatinine using the CKD-EPI and the MDRD equations, and albumin to creatinine ratio was based on a single random urine sample.
The sample clinical characteristics and demography was similar to middle and older age adults in the general Irish population, though with an underrepresentation of subjects >75 years and of males. All results are based on subjects with available blood and urine samples. Applying weighting to obtain survey based population estimates, using Irish population census data, the estimated weighted prevalence of CKD-EPI eGFR<60 mL/min/1.73m2 was 11.6%, (95% confidence interval; 9.0, 14.2%), 12.0% ( 9.0, 14.2%) of men and 11.2% (7.3, 15.2%) of women. Unweighted prevalence estimates were similar at 11.8% (9.9, 13.8%). Albuminuria increased with lower CKD-EPI eGFR category. 10.1% of all subjects had albuminuria and an eGFR≥60 mL/min/1.73 m2 giving an overall weighted estimated prevalence of National Kidney Foundation (NKF) defined CKD 21.3% (18.0, 24.6%), with the unadjusted estimate of 21.9% (19.5, 24.4%). MDRD related estimates for eGFR <60 mL/min/1.73 m2, and NFK defined CKD were higher than CKD-EPI and differences were greater in younger and female subjects.
CKD is highly prevalent in middle and older aged adults within the Republic of Ireland. In this population, there is poor agreement between CKD-EPI and MDRD equations especially at higher GFRs. CKD is associated with lower educational status and poor self rated health.
PMCID: PMC3537756  PMID: 23121733
Chronic kidney disease; Glomerular filtration rate; Albuminuria; Population survey
8.  The Incidence and Repetition of Hospital-Treated Deliberate Self Harm: Findings from the World's First National Registry 
PLoS ONE  2012;7(2):e31663.
Suicide is a significant public health issue with almost one million people dying by suicide each year worldwide. Deliberate self harm (DSH) is the single most important risk factor for suicide yet few countries have reliable data on DSH. We developed a national DSH registry in the Republic of Ireland to establish the incidence of hospital-treated DSH at national level and the spectrum and pattern of presentations with DSH and repetition.
Methods and Findings
Between 2003 and 2009, the Irish National Registry of Deliberate Self Harm collected data on DSH presentations to all 40 hospital emergency departments in the country. Data were collected by trained data registration officers using standard methods of case ascertainment and definition. The Registry recorded 75,119 DSH presentations involving 48,206 individuals. The total incidence rate fell from 209 (95% CI: 205–213) per 100,000 in 2003 to 184 (95% CI: 180–189) per 100,000 in 2006 and increased again to 209 (95% CI: 204–213) per 100,000 in 2009. The most notable annual changes were successive 10% increases in the male rate in 2008 and 2009. There was significant variation by age with peak rates in women in the 15–19 year age group (620 (95% CI: 605–636) per 100,000), and in men in the 20–24 age group (427 (95% CI: 416–439) per 100,000). Repetition rates varied significantly by age, method of self harm and number of previous episodes.
Population-based data on hospital-treated DSH represent an important index of the burden of mental illness and suicide risk in the community. The increased DSH rate in Irish men in 2008 and 2009 coincided with the advent of the economic recession in Ireland. The findings underline the need for developing effective interventions to reduce DSH repetition rates as a key priority for health systems.
PMCID: PMC3282760  PMID: 22363700
9.  Efficient Hybrid EM for Linear and Nonlinear Mixed Effects Models with Censored Response 
Medical laboratory data are often censored, due to limitations of the measuring technology. For pharmacokinetics measurements and dilution-based assays, for example, there is a lower quantification limit, which depends on the type of assay used. The concentration of HIV particles in the plasma is subject to both lower and upper quantification limit. Linear and nonlinear mixed effects models, which are often used in these types of medical applications, need to be able to deal with such data issues. In this paper we discuss a hybrid Monte Carlo and numerical integration EM algorithm for computing the maximum likelihood estimates for linear and non-linear mixed models with censored data. Our implementation uses an efficient block-sampling scheme, automated monitoring of convergence, and dimension reduction based on the QR decomposition. For clusters with up to two censored observations numerical integration is used instead of Monte Carlo simulation. These improvements lead to a several-fold reduction in computation time. We illustrate the algorithm using data from an HIV/AIDS trial. The Monte Carlo EM is evaluated and compared with existing methods via a simulation study.
PMCID: PMC2705201  PMID: 19578533
Monte Carlo EM; HIV-1 viral dynamics; quantification limit; LME; NLME; likelihood estimation
10.  Elevated white cell count in acute coronary syndromes: relationship to variants in inflammatory and thrombotic genes 
BMC Medical Genetics  2004;5:13.
Elevated white blood cell counts (WBC) in acute coronary syndromes (ACS) increase the risk of recurrent events, but it is not known if this is exacerbated by pro-inflammatory factors. We sought to identify whether pro-inflammatory genetic variants contributed to alterations in WBC and C-reactive protein (CRP) in an ACS population.
WBC and genotype of interleukin 6 (IL-6 G-174C) and of interleukin-1 receptor antagonist (IL1RN intronic repeat polymorphism) were investigated in 732 Caucasian patients with ACS in the OPUS-TIMI-16 trial. Samples for measurement of WBC and inflammatory factors were taken at baseline, i.e. Within 72 hours of an acute myocardial infarction or an unstable angina event.
An increased white blood cell count (WBC) was associated with an increased C-reactive protein (r = 0.23, p < 0.001) and there was also a positive correlation between levels of β-fibrinogen and C-reactive protein (r = 0.42, p < 0.0001). IL1RN and IL6 genotypes had no significant impact upon WBC. The difference in median WBC between the two homozygote IL6 genotypes was 0.21/mm3 (95% CI = -0.41, 0.77), and -0.03/mm3 (95% CI = -0.55, 0.86) for IL1RN. Moreover, the composite endpoint was not significantly affected by an interaction between WBC and the IL1 (p = 0.61) or IL6 (p = 0.48) genotype.
Cytokine pro-inflammatory genetic variants do not influence the increased inflammatory profile of ACS patients.
PMCID: PMC425582  PMID: 15171792
Inflammation; acute coronary syndromes; White cell count; interleukin 1 receptor antagonist; interleukin 6

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