bluuebunny/crossref_metadata_2025 huggingface dataset:
122 Are We Effective Prescribers? A Retrospective Audit of DOAC Prescribing Post Embolic Stroke for Non Valvular Atrial Fibrillation
Authors: Dennehy Karen , Morris Joseph , Hughes Diarmaid , Donlon Kate , Walsh Thomas
Published: September 2019

Background

Direct oral anticoagulants (DOAC) are indicated for stroke prophylaxis in non-valvular atrial fibrillation, which is responsible for up to 20% of all ischaemic strokes(1). We performed a retrospective audit of all consecutive stroke patients in an Irish teaching hospital over a 1-year period to investigate the rate of incorrect dosing and any risk factors for this occurring.

Methods

We assessed our hospital stroke database from January to December 2017. Our research focused on DOAC prescribing in non valvular atrial fibrillation post embolic stroke. We collected data on baseline characteristics, choice of anticoagulation, dosing, and assessment of renal function, with follow up renal function if available. We reviewed electronic discharge summaries, online laboratory systems and completed a chart review.

Results

There was a total of 116 people with atrial fibrillation who developed an embolic stroke in our centre, of which 68 were eligible for anticoagulation using a DOAC (59). The main reasons for omission were CKD and haemorrhagic transformation. Patients were discharged on either Apixaban (32 patients), Rivaroxoban (32 patients), or Dabigatran (4 patients).

Following our review, we established that 54/68 (79%) of patients were correctly anticoagulated. Over 20% of patients were incorrectly dosed and there was a clear tendency to under-dose 13/14 (93%). There were significant differences between the correct and incorrect dosing groups, with the latter group of patients being older and more at risk of polypharmacy. Renal function did not differ significantly between the groups at discharge or follow up and none of the incorrectly dosed patients were on a concurrent anti platelet.

Conclusion

A significant number of patients prescribed DOAC in hospital were not appropriately anticoagulated (21%), a majority of which were under-dosed. The patients who were under-dosed were older and more likely to be on 5 or more medications.
123 Empowering Patients after Stroke: Development of a Stroke Information Booklet
Authors: Dennehy Karen , Synnott Padraig , Murphy Robert , Galvin Patricia , Canavan Michelle , Walsh Thomas , O' Donnell Martin
Published: September 2019

Background

Patient involvement in healthcare is key to the provision of patient centred care. The national patient experience survey 2018 found that up to 40% of patients did not get adequate information about their condition after discharge.(1) As the planning phase in introducing a stroke information booklet, we sought to examine what patients, families and healthcare professionals feel are important components in such an information booklet.

Methods

We performed a cross sectional cohort study. A questionnaire was developed after a panel discussion among physicians, allied health professionals, and clinical nurse specialists about what would be important facets to include. Thirteen items were shortlisted and assessed using a Likert scale.

Results

There were 76 respondents to the questionnaire including nurses (17), allied health professionals (13), doctors (28), stroke patients (10) and relatives (8). Items viewed as most important to include were: an introduction to stroke, future stroke risk, and effects of stroke on daily life. Items viewed as least important to include were - an overview of medical treatments for stroke and information on equipment needs post stroke. A Mann Whitney U test found that patients/families rated information about future stroke risk as more important to include than healthcare professionals (p=0.021). Free text found that psychological effects of stroke, and sexual health post stroke were commonly suggested.

Conclusion

Patients/Families are keen to receive information regarding stroke, particularly about future risk of stroke. Empowering patients with information about stroke that is relevant to them and their care providers is a fundamental part of secondary stroke prevention. We also need to focus more on the psychological impact of stroke. Our booklet will incorporate information we have gathered in this study to make it a truly patient centred resource.
126 Urinary Incontinence: Prevalence, Clinical Characteristics and Impact on Quality of Life of Older People in Ireland
Authors: Claffey Paul , Sullivan Rachel , Anne Kenny Rose , McNicholas Triona , Briggs Robert
Published: September 2019

Background

Urinary incontinence (UI) is one of the ‘giants’ of gerontological care, associated with early mortality, depression and falls in later life. It is often amenable to treatment, yet clinical experience suggests that older people with urinary incontinence often go undiagnosed and therefore untreated.

The aim of this study therefore was to ascertain the prevalence of UI in a large population representative sample of Irish adults ≥50 years; to examine how often participants report UI to healthcare professionals; to profile factors associated with UI and its impact on quality of life (QOL).

Methods

This study was embedded within the Irish Longitudinal Study on Ageing.

Participants were a population-representative sample of almost 7,000 Irish adults aged ≥50 years.

UI was defined as any involuntary loss of urine from the bladder within the last 12 months, based on the International Continence Society Definition.

QOL was measured using the Control, Autonomy, Self-realisation and Pleasure-19 Scale (CASP-19).

Results

Fifteen % (1,061/6,996) of participants had UI within the last 12 months; 9% (269/3,162) of males and 21% (792/3,834) of females.

Almost half (486/1,061) of participants with UI had not reported it to a healthcare professional, with one fifth (240/1,061) reporting UI limited everyday activities.

Logistic regression modelling demonstrated UI was associated with advancing age, female sex, alcohol excess, polypharmacy, chronic disease and depression.

Linear regression models showed that UI was associated with significantly lower self-rated QOL, as measured by CASP-19 (β =-1.13 (95% CI: -1.69 - -0.57), p <0.001).

Conclusion

UI affects 1 in 7 people aged ≥50 years.

It is closely associated with other geriatric syndromes such as polypharmacy, depression and multimorbidity and impacts significantly on QOL.

Despite this, almost half of those with UI do not report symptoms to a healthcare professional, highlighting the need for structured assessment of UI as part of comprehensive age-attuned care.
131 Meta-analysis of Primary Care Interventions to Address Frailty Among Adults Aged 65+
Authors: Macdonald Steve , Travers John , Shé Éidín Ní , Bailey Jade , Romero-Ortuno Roman , Keyes Michael , O'Shea Diarmuid , Cooney Marie Therese
Published: September 2019

Background

Frailty can contribute to poor clinical outcomes including disability, illness, and death. Intervention against frailty may help older adults maintain overall health and independence, and a growing body of recent literature describes interventions specifically targeting frailty. The diversity of measurement constructs and intervention types raises a challenge for those seeking to identify best-practice strategies to manage frailty in the primary care setting, therefore this study aimed to quantify the relative effectiveness of reported interventions.

Methods

PubMed, CINAHL, Cochrane Register of Controlled Trials, and PEDr databases were interrogated, and reference lists of retrieved studies were also examined. For comparisons, articles were grouped by intervention and meta-analysis using the random effects model was performed wherever two or more studies examined the same outcome measure using similar interventions.

Results

29 studies with a total of 4430 participants were included in this series of meta-analyses. Interventions included exercise (alone or plus nutrition supplementation or education), nutrition supplementation alone, comprehensive geriatric assessment (CGA), and hormone supplementation. Outcome measures included frailty (Fried criteria), physical performance, leg strength, and grip strength, among others. Interventions varied in relative effectiveness. When comparing studies that assessed frailty status using Fried’s criteria, exercise alone (n=3, RR=0.63 (CI 0.47–0.85), I2=0%) appeared effective versus control in improving status, as did exercise plus nutritional supplementation (n=2, RR=0.62 (CI 0.48–0.79), I2=0%), and exercise plus nutritional education (n=3, RR=0.69 (CI 0.58–0.82), I2=0%). CGA also appeared effective in improving frailty status (n=3, RR=0.77 (CI 0.64–0.93), I2=0%).

Conclusion

This series of meta-analyses indicates that several intervention types are associated with positive improvements in frailty status, and frailty-associated indicators. These results agree with previous findings, and represent an up-to-date quantitative synthesis of available literature on primary care interventions addressing frailty among older adults.
133 Prospective Audit of Adherence to Current Guidelines for Urinary Catheterisation on a Dedicated Geriatric ward in a Tertiary Hospital
Authors: Comber Ruth
Published: September 2019

Background

A review of current practice in urinary catheterisation of geriatric patients on admission to hospital in respect of current HSE guidelines; looking at adherence to prescribed indications.

Methods

A consecutive sample of inpatients (age >65 years) were included from a geriatric ward in a tertiary hospital. Medical notes and admission pro-forma were reviewed. Relevant demographic and clinical information was extrapolated and analysed descriptively using the Statistical Package for the Social Sciences software.

Results

Data from thirty-one patients was included. Mean age of the cohort was 81.58 years (SD=6.67) and 51.6% (n=16) were female (SD=6.67). The primary reasons for admission were increased care needs (n=6, 19.4%), and collapse/weakness (n=6, 19.4%), thereafter stroke (n=4, 12.9%). Urinary catheters were inserted in 45.2% (n=14); for output monitoring (n=4, 28.57%), diuresis (n=4, 28.57%) and management of acute urinary retention (n=3, 21.42%). The insertion was warranted as per guidelines in only 42.85% (n=6); for urinary retention (n=3, 21.42%), sepsis/ICU (n=2, 14.28%) and at patient's request for comfort (n=1,7.14%). Urinary incontinence was present in 25.8% (n=8). This was found to be poorly documented in medical admission notes (n=2, 6.5%). Mean hospital admissions in the previous twelve months was 1.61 (SD=2.20) and mean urinary tract infection in the same timeframe was 1.00 (SD=1.57). Trial without catheter was unsuccessful in 3.2% (n=1). Healthcare associated infection was recorded in 6.5% of cases (n=2).

Conclusion

Although this audit represents a small cohort, the results demonstrate a high rate of urinary catheter insertion without adequate indication. This audit should be repeated using a larger sample size. Appropriate education at ward level and with admitting NCHDs about: appropriate catheterisation practice should be performed with a view to re-auditing subsequently. Update of current guidelines is warranted.
136 Early Ambulatory Blood Pressure Monitoring Post Stroke
Authors: D'Alton Maeve , Donaghy Lisa , Farrell Sarah , Hartigan Denise , Leguis Flordelie , Long Shirley , McAteer Claire , Morrison Laura , O'Connor Marie , Dolan Eamon
Published: September 2019

Background

While hypertension is the leading cause of stroke, early blood pressure (BP) management post event can be a challenge. Adjustment of antihypertensive medications is largely based on daytime ward readings. Abnormal nocturnal BP patterns may go undetected with increased risk to the patients from either extreme of BP. 24-hour ABPM has been shown to provide additional prognostic information over routine clinic measurements. We evaluated stroke patients for abnormal circadian BP profiles early after their event.

Methods

Patients admitted with a stroke, whose BP had normalised for at least 48 hours, were invited to participate. ABPM was fitted for 24 hours and readings compared with routine ward BP measurements. Daytime BP was calculated between 9am-9pm; nighttime midnight-6am. Additional information was gathered on medical history, cardiovascular risks and neuroimaging.

Results

Twenty-nine patients were recruited (median 6 days post event) with mean age 70.5, 62% male. The majority (86.2%) had ischaemic stroke or TIA. Seventeen had diagnosed hypertension and were taking median of 2 medications. Mean baseline ward systolic BP was 129mmHg (range 104-148 mmHg). Mean systolic BP on ABPM was 126mmHg (range 92-154 mmHg) and 123mmHg (range 93-181 mmHg) for daytime and nighttime respectively. Patients with a history of atrial fibrillation (N=13) had a higher prevalence of a non-dipping pattern, with an average 10.4 mmHg rise in their nighttime systolic BP compared with a 3mmHg fall in those without atrial fibrillation (p = 0.011). They also exhibited greater BP variability.

Conclusion

In this pilot study, through the use of early ABPM we found high rates of non-dipping nocturnal BP in patients following stroke, particularly in those with underlying atrial fibrillation. The availability of 24-hour BP might allow for more individualised antihypertensive management particularly at this high-risk acute stage. Furthermore the presence of abnormal circadian patterns might be a marker for conditions such as atrial fibrillation and obstructive sleep apnoea that compound stroke risk.
139 Prevalence of Hypernatraemia in the West of Ireland during 2018 Heatwave: A Retrospective Cross-sectional Study
Authors: Brennan Michelle , Murray Orla , Shea Paula O , Mulkerrin Eamon
Published: September 2019

Background

Hypernatraemia is a surrogate marker of morbidity and mortality, particularly in the older person.(1) Met Eireann defines a heatwave as 5 consecutive days >25°C. HSE guidelines outline preventative strategies for community-dwelling adults and inpatients during heatwaves.(2) Our objective was to compare the prevalence of hypernatraemia (Na>145mmol/l), in biochemical samples during the heatwave of 2018 to the same period in 2017

Methods

A retrospective cross-sectional study using patient demographics, biochemical data from Laboratory Information System and meteorological data from Met Éireann was performed. A ten-day period from 24thJune to 3rdJuly was assessed in 2017 and 2018. Patients aged >65 with at least one biochemical sample were included. Only the first sample from each patient was included. Predictor variables of age, gender and source of sample were measured.

Results

Maximum air temperatures were higher in 2018 than 2017 (mean 27 v 16.8°C, p<0.0001). Hypernatraemia had 3.6% prevalence (66/1840 samples) during the heatwave of 2018 in comparison to 1.4% prevalence (23/1593 samples) in 2017. This corresponds to a prevalence ratio of 2.5 in heatwave 2018 compared with 2017. In 2018 hypernatraemic samples: 56%(n=37) were male, mean age was 75 with 71(n=47) General Practitioner(GP) samples,12%(n=8) inpatients and 17%(n=11) from outpatient department(OPD). In 2017 hypernatraemic samples: 30%(n=7) were male, mean age was 75 and 74%(n=17) were GP samples,17%(n=4) were inpatients, 9%(n=2) from OPD. The sources of total samples (regardless of Na level) were 63% GP, 7% inpatients and 30% outpatients.

Conclusion

Hypernatraemia was 2.5 times more prevalent during the heatwave in 2018 than the previous year in patients aged over 65. Hypernatraemia is more prevalent in GP and inpatients taking into account the usual distribution of samples by source. Current guidelines are either not being adhered to or ineffective, a matter which merits further evaluation.
140 The Use of the Variable Indicative of Placement risk (VIP) as a Frailty Identification Tool
Authors: Sayers Karen , Pender Ciara , Maher Jennifer , Ryan Siobhan , Cooney Eamonn , O'Reilly Aine , Donnellan Christina , Pillay Isweri
Published: September 2019

Background

The Variable Indicative of Placement risk (VIP) was developed in order to identify, at the time of hospital admission, those who need liaison geriatrics and those who do not (Vandewoude et al, 2008). It was derived from physical and cognitive measures of known risk factors for frailty. This supports its face and content validity as an indicator of frailty. The Clinical Frailty Score (CFS) is a validated measure of frailty (Rockwood et al, 2005), recommended as part of a patient’s Comprehensive Geriatric Assessment (CGA). Construct validity and inter-rater reliability of the VIP, as a frailty identification tool, have not been evaluated.

Methods

A prospective analysis was undertaken of 232 consecutive people, 70 years and older, presenting to an acute hospital. The VIP is administered by a triage nurse in the Emergency Department. A VIP-positive patient (2 or more “Yes” answers) triggers a CGA by a member of the Integrated Inter-Disciplinary team. The VIP screen is undertaken again by the team member, prior to commencing CGA. The VIP and CFS of each patient was entered onto an Excel spreadsheet. Inter-rater agreement was evaluated by looking at percentage agreement between raters. Validity was explored by looking at the relationship between VIP and CFS.

Results

Inter-rater agreement of the VIP was 90%; 78% of VIP positive people were mild, moderate or severely pre-frail, as measured by the CFS. A further 18% of people were categorised as vulnerable.

Conclusion

The VIP is a quick, easy to use tool that doesn’t require training. It shows agreement between raters. It predominantly identifies people who are mildly to severely frail. It may not be valid in identifying those who are pre-frail. Further evaluation of the validity and reliability of the VIP, as a frailty identification tool, is required.
152 Implementation of Older Persons Rapid Assessment Hub (OPRAH) in the Emergency Department (ED)
Authors: Adedokun Comfort , McNamara Rosa , O’Herlihy Nessa
Published: September 2019

Background

The Emergency Department (ED) is where most people, including older adults in crises, seek care. OPRAH was introduced in order to meet the needs of our changing population. The unit was developed out of existing resources within the ED and cohorts both older patients and staff to an area more suitable to carry out assessments.

Methods

We used a quality improvement framework to develop our service. OPRAH is led by an ED GEM (Geriatric Emergency Medicine) consultant, staffed using the existing ED team, housed within footprint of the ED as part of the Clinical Decision Unit (CDU) with the addition of an HCA (healthcare assistant) as required. To determine the impact of the service on admissions of older adults, we collated patient records prospectively. These were reviewed and coded by senior ED professionals blinded to outcomes, to determine medical-referral rate for admission in these cohort.

Results

In the first 3 weeks of implementation, 76 patients were assessed. Four were admitted and 2 transferred to other hospitals. Mean age was 83 years ranging 66-103 years with an average of 262 minutes in the ED prior to OPRAH admission.

Blinded coders review determined 53 (76%) of these patients would have been referred for admission. The majority of the remainder would have completed their care in the ED, as they were not eligible for admission to CDU.

Conclusion

Introduction of OPRAH to the ED has improved access for older people to short-stay ED led care and reduced admission rates. We have identified a trend towards fewer episodes where care by in-house teams is completed within the ED.

We are in an early phase of this project. Nonetheless, it is evident that by redesigning how we assess older people in the ED and using available outpatient resources, we could impact on admission rate and length of stay in the ED without compromising patient care. Implementation has increased the use of the integrated care team, hospital and community MDT (multidisciplinary team).
156 Review of Outcomes of a Dedicated Geriatric Surgical Liaison Service
Authors: Coary Roisin , McCarthy Kathryn , Sumrien Haytham , Shipway David
Published: September 2019

Background

In the United Kingdom, the 2010 National Confidential Enquiry into Patient Outcome and Death report ‘An Age Old Problem’ outlined significant shortcomings in the perioperative care of older people. Other than hip fractures, the care of older patients under surgical specialities is largely devoid of routine geriatrician input. In August 2018, we introduced daily geriatric reviews (GR) on the gastrointestinal surgical wards, aiming to improve length of stay (LOS) and mortality.

Methods

All acute general surgery admissions for patients ≥70 years were reviewed between September and October 2017 (pre-introduction) and 2018 (post-introduction), and outcomes compared. For 2018, comparisons were also made between those who had GR and those who didn’t.

Results

There were 173 admissions in 2017, vs 190 in 2018. In both 2017 and 2018, median age was 80, median LOS was 4 days, and clinical frailty scale (CFS) 4. Twenty-two percent (38/173) of patients had a surgical procedure in 2017, vs 33% (63/190) in 2018. Inpatient mortality was 8% (13/173) in 2017 (median CFS 6), vs 6% (11/190) in 2018 (median CFS 6).

In 2018, 21% (40/190) of patients had GR: median time to review 3 days. 54% (n=22) of the patients with GR underwent a surgical procedure, 37% (n=15) were admitted to ICU, and inpatient mortality was 5% (n=2), vs 28% (n=42), 4% (n=6) and 6% (n=9) respectively for those without GR. 30 day readmission for those with GR was 12.5% (n=5), vs 18.4% (n=28) for those not seen.

Conclusion

While more surgical procedures were performed in 2018 (post-introduction), overall LOS remained unchanged and improved mortality was observed compared to 2017. Geriatricians are seeing more post-operative and ICU patients, and despite presumed increased complexity, both mortality and readmission rates remain low. Screening for frailty and specific inclusion criteria may improve rates of GR.
163 Rehabilitation to Nursing Home - The Waiting Period
Authors: Salawu Adefunke , Palatty Jaimon , Glynn Marian
Published: September 2019

Background

The average application processing time for the National Nursing Home Support Scheme (NHSS) has seen drastic improvement from 15 weeks in 2014 to 4 weeks in 20161. There is no available data of the duration of stay in rehabilitation beds after approval of NHSS application and reasons for delay in transition to nursing home.

Aims

(1) To examine average length of stay in rehabilitation before multidisciplinary team (MDT) decision is made for nursing home care.

(2) To examine average length of stay in rehabilitation bed from the time of NHSS approval to discharge into nursing home.

(3) To examine reasons for delay in discharge to nursing home after NHSS approval.

Methods

A retrospective chart review of patients discharged into nursing homes between January to June, 2018 from geriatric rehabilitation units.

Data collected include age, length of stay in rehabilitation unit before multidisciplinary decision was made in conjunction with patients/family to seek nursing home care (LOS1), Length of stay in rehabilitation bed following decision for nursing home care (LOS 2). Reasons for the delay in the transition from rehabilitation bed to nursing home bed were also documented.

Results

Seventeen patients were discharged into nursing homes, LOS1 of 43.12 days and LOS2 of 50 days. Complexity of application in terms of financial evaluation especially for patients who were deemed cognitively incapable of managing their finances, lack of suitable nursing homes for patients with complex needs/challenging behaviours, family dynamics with regards to choice of nursing homes and medical stability to facilitate such transfers were reasons for delay in transition to nursing home beds.

Conclusion

Transitional care beds, which are generally acknowledged to be more appropriate to these patients' care needs and are less expensive than rehabilitation beds, need to be utilized more.

Education of healthy adults over 65 years to proactively plan for future care needs and promote awareness of legislatures regarding capacity and decision making.
164 Dementia, a Familial Affair
Authors: Qureshi Aqueel , Gabr Ahmed , Zulkifli Daniel , Chaila Elijah , O'Connor Margaret
Published: September 2019

Background

In Ireland, there are approximately 55,000 cases of dementia. One of the rare causes of dementia is Creutzfeldt-Jakob disease (CJD), affecting one person per million each year worldwide. It is a rapidly progressive degenerative fatal disorder with an estimated mortality of 70% within one year. In this case report we present a rare case of possible familial-CJD which presented initially as a stroke mimic.

Methods

A 64-year old female referred via GP with abnormal left arm athetoid movements and in-coordination. MRI brain demonstrated a small sub-acute hyper-intense lesion in the right basal ganglia on diffusion weighted imaging. Her symptoms were atypical for acute stroke, however an alternative cause was not evident. She was monitored closely with early supported discharge. However the left sided athetoid movements worsened and were associated with intermittent myoclonic jerks and dystonic posturing. She was reassessed with a wider differential including focal impaired seizures, Rasmussen’s encephalitis, and CJD. EEG showed periodic lateralizing epileptic discharges, however patient failed to show any response to anti-epileptic treatment and her clinical course was one of rapid deterioration. Clinical findings and subsequent MRI findings showed new areas of hyperintensity supporting CJD.

Results

Ultimately our patient deteriorated rapidly resulting in an akinetic and abulic state, resulting in death. A final diagnosis of sporadic-CJD was made based on rapid progressive deterioration and findings on MRI as well as confirmation on post-mortem brain pathology. A deeper review of family history revealed a sister who had passed away years prior with rapid progressive neurological illness. Her work-up showed clinical signs and EEG findings supporting CJD, however there was no post mortem to confirm her diagnosis.

Conclusion

This case highlights the importance of genetics shaping phenotypes and that consideration should always be given to a full relevant family history. It also shows a rare case of rapidly progressive dementia confirmed due to CJD with a likely underlying familial predisposition.
167 An Alternative to the Emergency Department for Frail Older People
Authors: Shanahan Elaine , Antonenko Alisa , Kennelly Siobhan , Fan Chie Wei , McCarthy Frances
Published: September 2019

Background

53% of hospital inpatient beds are occupied by patients >/= 65 years. These patients often experience functional decline. In those transferred to our post-acute rehabilitation unit the average length of stay prior to transfer is 16 days and 38 days post transfer. Our hospital has a Community Response Unit (CRU) which provides an alternative to this care pathway, offering direct admission to a 15 bed unit with 24-hour medical cover and full multidisciplinary input. This study reviews the use of this unit over a one year period.

Methods

We retrospectively reviewed the discharge letter or medical notes of patients admitted to the CRU during 2018. The referral source, indication for admission, length of stay and discharge destination were recorded.

Results

One-hundred and fourteen patients were admitted over the one year period. Source of referral was identified for 81 patients and included day hospitals (53.1%), acute hospitals (14.8%), respite/ transitional care wards (12.3%), nursing homes (8.7%), home visits (6.2%), community sources (3.7%) and other speciality clinics (1.2%).

The most common indications for admission were-mobility/functional decline (26.3%), falls (17.5%), requirement for medical investigations (14.9%), cognitive decline with behavioural issues (11.4%), blood transfusion (10.5%), pain management (7%), general deterioration (7%), requirement for increased home supports (7%), treatment of infection (6.1%), rehab post fracture (5.3%), wound management (4.4%), alcohol detoxification (1.8%) and self-neglect (1.8%). Multifactorial reasons for admission frequently occurred.

The median length of stay was 24 days (1-176 days), 67% of patients were discharged to their original residence, 17.4% were newly admitted to residential care, 9.2% required transfer to an acute hospital and 6.4% died during their admission.

Conclusion

The CRU provides comprehensive Geriatrician led care for a wide variety of indications. This model of care offers a valid alternative to Emergency Department presentation and acute hospital admission.
Pharmacokinetic considerations in pediatric pharmacotherapy
Authors: Lim Sin Yin , Pettit Rebecca S
Published: September 2019

Purpose

The changes in physiological functions as children grow and organ systems mature result in pharmacokinetic alterations throughout childhood. These alterations in children result in absorption, distribution, metabolism, and excretion of drugs that are different from those seen in the typical adult diseased population.

Changes in gastrointestinal motility and gastric pH in neonates and infants affect the absorption rate and bioavailability of drugs. Skin absorption rate and extent can be altered by different skin structures and perfusion in young children. Intramuscular and rectal absorption become less predictable in children due to erratic absorption site perfusion and other factors. Children’s body compositions also differ greatly from that in adults. Water-soluble drugs distribute more extensively in newborns due to larger water content than in older children and adults. Drug elimination and excretion are also affected in pediatric population due to differences in liver and renal function. Immature enzyme development and renal function result in reduced clearance of drugs in young children. There are limited pharmacokinetic data available for many drugs used in children.

Conclusion

Considering the changes in pharmacokinetics in children can help pharmacists optimize the dosing and monitoring of drugs and do the best they can to help this vulnerable population.
Pediatric medication safety considerations for pharmacists in an adult hospital setting
Authors: Kennedy Audrey R , Massey Lindsay R
Published: September 2019

Purpose

Risks and vulnerabilities of the medication-use process in nonpediatric institutions that also serve pediatric patients are reviewed, and guidance on risk mitigation strategies is provided.

There are many risks and vulnerabilities in the medication-use process as it relates to pharmacotherapy for pediatric patients admitted to adult institutions. Mitigation of these risks is critical and should encompass various available resources and strategies. Special emphasis should be placed on use of technology to improve overall safety. Available literature recommends optimization of technology and resource use, institutional support for pediatric pharmacists’ involvement in managing pediatric medication use, and provision of early exposure to pediatric patients in pharmacist training programs as additional methods of mitigating risks associated with pediatric medication use in adult institutions. Adult hospitals that provide care for pediatric patients should assess their processes in order to identify hospital-specific interventions to promote pediatric medication safety.

Conclusion

Pediatric medication safety frameworks in U.S. adult institutions vary widely. Treating pediatric patients involves risks in all areas of the medication-use process. Optimizing technology, utilizing external resources, supporting a pediatric pharmacist, and providing early-career exposure to pediatric patients are methods to mitigate risks in institutions that primarily serve adult patients.
The Real Facts Supporting Jeanne Calment as the Oldest Ever Human
Authors: Robine Jean-Marie , Allard Michel , Herrmann François R , Jeune Bernard
Published: September 2019

Background

The 122 years and 164 days age claim of Jeanne Calment, the world oldest person who died in 1997, is the most thoroughly validated age claim. Recently the claim that families Calment and Billot organized a conspiracy concerning tax fraud based on identity fraud between mother and daughter gained international media attention.

Methods

Here, we reference the original components of the validation as well as additional documentation to address various claims of the conspiracy theory and provide evidence for why these claims are based on inaccurate facts or unrelated to the death of Yvonne Billot-Calment, the daughter of Jeanne Calment, in 1934.

Results

Also, countering the contention that the occurrence of a 122 year old person is statistically impossible, mathematical models are presented which also supports the hypothesis that though extremely rare, as would be expected for the oldest person ever, Jeanne Calment’s age claim is plausible.

Conclusions

In total, the quality of the investigation supporting the claim of conspiracy as well as the mathematical analysis aiming to back it do not reach the level expected for a scientific publication.
Differential responses by urban brown rats (Rattus norvegicus) toward male or female-produced scents in sheltered and high-risk presentations
Authors: Parsons Michael H , Deutsch Michael A , Dumitriu Dani , Munshi-South Jason
Published: September 2019

Wild rats (Rattus norvegicus) are among the most ubiquitous and consequential organisms in the urban environment. However, collecting data from city rats is difficult, and there has been little research to determine the influence, or valence, of rat scents on urban conspecifics. Using a mark-release-monitor protocol, we previously learned rats can be attracted to remote-sensing points when baited with mixed-bedding from male and female laboratory rats. It was thus essential that we disambiguate which scents were eliciting attraction (+ valence), inspection, a conditioned response whereby attraction may be followed by avoidance (–valence), or null-response (0 valence). We used radio-frequency identification tagging and scent-baited antennas to assess extended (>40 days) responses to either male or female scents against two risk presentations (near-shelter and exposed to predators). In response to male scents, rats (n = 8) visited both treatments (shelter, exposed) more than controls (0.2 visits/day treatment vs. 0.1/day; P < 0.05) indicating scents accounted for response more so than risk. Dwell-times, however, did not differ (1.2 s/visit treatment vs. 0.9 s/visit; P > 0.5). These outcomes are consistent with inspection (–valence). In response to female scents, rats (n = 7) increased visitation (5.02 visits/day vs. 0.1/day controls; P < 0.05), while dwell-times also increased 6.8 s/visit vs. 0.2 s/visit in both risk-settings. The latter is consistent with persistent attraction (+valence), but was also influenced by shelter, as runway visits (1.1 visits/day) were a magnitude more common than predator-exposed (0.1 visits/day). Further understanding and exploiting the mobility of city rats is necessary for improvements in basic and applied research, including city pathogen-surveillance and urban wildlife management.
Right Orbitozygomatic Craniotomy for Clip Wrapping of an A2 Fusiform Aneurysm: 2-Dimensional Operative Video
Authors: Hendricks Benjamin K , Spetzler Robert F
Published: September 2019

Distal anterior cerebral artery aneurysms often rupture at a small size and are associated with overall higher operative morbidity relative to other anterior circulation aneurysms. This patient had an incidentally identified anterior cerebral artery proximal A2 segment fusiform aneurysm that did not respond to endovascular treatment and required open surgical management. The fusiform dilation was mobilized and isolated circumferentially within the interhemispheric fissure, and a Gore-Tex clip-wrapping was planned. A permanent clip was applied along the aneurysmal dilation parallel to the vessel directly prior to completing the wrapping to attempt to establish native flow dynamics through the aneurysmal segment. The clip-wrapping was then completed, and intraoperative indocyanine green fluoroscopy demonstrated good distal flow through the aneurysmal segment. The patient gave informed consent for surgery and video recording. The institutional review board approval was deemed unnecessary. Used with permission from the Barrow Neurological Institute, Phoenix, Arizona.
Giant Cervical Cavernous Malformation: 2-Dimensional Operative Video
Authors: Hendricks Benjamin K , Spetzler Robert F
Published: September 2019

Cervical spinal cord cavernous malformations are rare but can be neurologically devastating lesions and, when symptomatic, are best treated with gross total resection to prevent progressive neurologic decline related to recurrent hemorrhage. This patient had a large high cervical cord cavernous malformation with evidence of recent hemorrhage. A midline myelotomy was utilized to enter the cavernous malformation. The cavernous malformation was then circumferentially separated from the spinal parenchyma and removed in a piecemeal manner. Postoperative imaging confirmed gross total resection of the lesion with preservation of the surrounding spinal cord. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.
Women and Their Mothers-in-Law: Triangles, Ambiguity, and Relationship Quality
Authors: Greif Geoffrey L , Woolley Michael E
Published: September 2019

Each marriage is the beginning of multiple intergenerational in-law relationships. Drawing on a survey of 351 women about their relationships with their mothers-in-law (MILs), this article reports on the impact of family triangles and boundary ambiguity on the quality of the relationship. In a three-block regression analysis, predicting a seven-item relationship quality scale, the first block included six demographic variables. The second and third blocks included three survey items each of reported relationship triangles and boundary ambiguity in a woman’s interactions with her MIL. Results revealed that although the couple having children predicted worse relationship quality in the demographic block, that result was no longer significant once family triangle measures were entered. All three measures of boundary ambiguity were also significant. The three measures of boundary ambiguity eclipsed two of the three family triangles when entered in the third block, leaving only the daughter-in-law feeling comfortable going directly to the MIL about important issues still significant.
Outcomes Following Transcanal Endoscopic Lateral Graft Tympanoplasty
Authors: Creighton Francis X. , Kozin Elliot , Rong Anni , Cohen Michael , Lee Daniel
Published: September 2019

Outcome Objectives:

Demonstrate feasibility of performing endoscopic transcanal lateral graft tympanoplasty.

Compare audiometric and clinical outcomes of transcanal endoscopic lateral graft with previously reported outcomes of microscopic post-auricular lateral graft tympanoplasty.

Methods:

A retrospective review of sequential pediatric and adult endoscopic transcanal lateral graft tympanoplasties (type I) performed between May 2014 and August 2015 at a single institution by two experienced otologists. Rate of perforation closure and audiometric outcomes (pure-tone average [PTA] and word recognition scores [WRS]) were obtained and compared with previous published outcomes of post-auricular microscopic lateral grafts.

Results:

Twenty patients, five right and 15 left ears, met criteria. Ninety percent of patients had successful closure of their perforation. One patient had a residual central perforation; active acute otitis media was noted intraoperatively in this case. One patient had graft lateralization. Mean follow up was 10.5 months (standard deviation [SD] = 141 d). Mean operative time was 160 (SD = 26.1) minutes. Mean improvement in PTA was 18 dB (SD = 10.3). Two patients had worsening of audiometric outcomes with <15 dB decreases in PTA and unchanged WRS; all other patients showed improvement or no change in audiometric outcomes. These results are similar to previously published outcomes for post-auricular microscopic approaches.

Conclusion:

Transcanal endoscopic lateral graft tympanoplasty is a novel technique for closure of anterior and subtotal perforations that avoids a postauricular incision. Outcomes in this cohort were similar to historical results for post-auricular microscopic approaches. Prospective studies with larger cohorts will be crucial to understanding the advantages and limitations of this new surgical approach.
Genome-wide association and multi-omic analyses reveal new mechanisms for Heart Failure
Authors: Arvanitis Marios , Zhang Yanxiao , Wang Wei , Auton Adam ,   23andMe Research Team, Keramati Ali , Chi Neil C. , Ren Bing , Post Wendy S. , Battle Alexis
Published: September 2019

Heart failure is a major medical and economic burden in the healthcare system affecting over 23 million people worldwide. Although recent pedigree studies estimate heart failure heritability around 26%, genome-wide association studies (GWAS) have had limited success in explaining disease pathogenesis. We conducted the largest meta-analysis of heart failure GWAS to-date and replicated our findings in a comparable sized cohort to identify one known and two novel variants associated with heart failure. Leveraging heart failure sub-phenotyping and fine-mapping, we reveal a putative causal variant found in a cardiac muscle specific regulatory region that binds to the ACTN2 cardiac sarcolemmal gene and affects left ventricular adverse remodeling and clinical heart failure in response to different initial cardiac muscle insults. Via genetic correlation, we show evidence of broadly shared heritability between heart failure and multiple musculoskeletal traits. Our findings extend our understanding of biological mechanisms underlying heart failure.
Bi-directional effects between loneliness and substance use: Evidence from a Mendelian randomisation study
Authors: Greenstone Harriet S R , Wootton Robyn E , Abdellaoui Abdel , Denys Damiaan , Verweij Karin J H , Munafò Marcus R , Treur Jorien L
Published: September 2019

Aims

Loneliness and social isolation are associated with cigarette smoking and problematic alcohol use. Observational evidence suggests these associations arise because loneliness increases substance use, however there is potential for reverse causation (problematic drinking causing damage to social networks, leading to loneliness). With conventional epidemiological methods, controlling for (residual) confounding and reverse causality is difficult. In this study, we apply Mendelian randomisation (MR) to assess bi-directional causal effects between loneliness on the one hand and smoking behaviour and alcohol (ab)use on the other.

Design

We applied bi-directional MR using summary-level data of the largest available genome-wide association studies of loneliness (n=511,280), smoking (initiation (n=249,171), cigarettes-per-day (n=249,171) and cessation (n=143,852)), alcoholic drinks-per-week (n=226,223) and alcohol dependence (n=46,568), using independent samples. For each relationship, we selected genetic variants predictive of the exposure variable as instruments and tested their association with the outcome variable. Effect estimates for individual variants were combined with inverse-variance weighted regression (gene-outcome/gene-exposure association) and the robustness of these findings was assessed with five different sensitivity methods.

Findings

There was weak evidence of increased loneliness leading to higher likelihood of initiating smoking and smoking more cigarettes, and a lower likelihood of quitting smoking. Additionally, there was evidence that initiating smoking increases loneliness. We found no evidence of a causal effect between loneliness and alcohol (ab)use.

Conclusions

We report tentative evidence for causal, bidirectional, increasing effects between loneliness and cigarette smoking. These findings improve our understanding of the interrelatedness of smoking and loneliness, however, replication with better powered genetic instruments is recommended.
Plasminogenuria is associated with podocyte injury, edema, and kidney dysfunction in incident glomerular disease
Authors: Egerman Marc A. , Wong Jenny S. , Runxia Tian , Mosoyan Gohar , Chauhan Kinsuk , El Salem Fadi , Meliambro Kristin , Li Hong , Azeloglu Evren , Coca Steven , Campbell Kirk N. , Raij Leopoldo
Published: September 2019

Urinary plasminogen/plasmin, or plasmin(ogen)uria, has been demonstrated in proteinuric patients and exposure of cultured podocytes to plasminogen results in injury via oxidative stress pathways. A causative role for plasmin(ogen) as a “second hit” in kidney disease progression has yet to be demonstratedin vivo, and the association between plasmin(ogen)uria and kidney function in glomerular diseases remains unclear. We performed comparative studies in a puromycin aminonucleoside (PAN) nephropathy rat model treated with amiloride, an inhibitor of plasminogen activation, and measured changes in plasmin(ogen)uria and urinary endothelin-1 (ET1). In a glomerular disease biorepository cohort (n=128), we measured time-of-biopsy albuminuria, proteinuria, and plasmin(ogen)uria for correlations with renal outcomes. Increased glomerular plasmin(ogen) was found in PAN rats and FSGS patients. PAN nephropathy was associated with increases in plasmin(ogen)uria, proteinuria, and urinary ET1. Amiloride was protective against PAN-induced glomerular injury, reducing urinary ET1 and oxidative stress. In patients, we found associations between plasmin(ogen)uria and edema status as well as eGFR. Our study demonstrates a role for plasmin(ogen)-induced podocyte injury in the PAN nephropathy model, with amiloride having podocyte-protective properties. In one of largest glomerular disease cohorts to study plasminogen, we validated previous findings while suggesting a potentially novel relationship between plasmin(ogen)uria and eGFR. Together, these findings suggest a role for plasmin(ogen) in mediating glomerular injury and as a viable targetable biomarker for podocyte-sparing treatments.

TRANSLATIONAL STATEMENT

Proteinuria is associated with CKD progression, and increased cardiovascular morbidity and mortality. The underlying mechanisms of podocyte injury, the hallmark of proteinuric kidney disease, are poorly understood with limited, non-specific therapeutic options. This study adds to the evidence that plasmin(ogen) in the urine of proteinuric patients is associated with podocyte injury, edema, and impaired renal function. Previously published results from us and others, taken together with our current rodent model and human data, suggest that urinary plasmin(ogen) is a potential targetable biomarker. Efforts to decrease plasmin(ogen)-mediated podocyte injury could be part of a novel therapeutic strategy for glomerular disease.