bluuebunny/crossref_metadata_2025 huggingface dataset:
249 Is Our Diabetic Control Too Tight? An Audit of Management of Type II Diabetes in a Long Term Care Setting
Authors: MacMahon Clare , O'Gorman Millie , Martin John , Doyle Marie , O'Donoghue Alice , O'Donnell Desmond , O'Mahoney Anne , Henin Maged , John Cooke , Pope George , Mulcahy Riona
Published: September 2019

Background

Recent guidelines on diabetes management recommend individualisation of management particularly in those with frailty or significant co-morbidities.

The aim of our audit was to assess diabetic control of residents in a long term care setting. Studies have shown that intensive control in an older population increases the risk of hypoglycaemia and does not necessarily improve clinical outcomes. There is also evidence that increased pill burden and hypoglycaemic events negatively affect quality of life among older people.

Methods

176 nursing home residents were assessed. Detailed chart review was carried out on the 47 residents with a diagnosis of type 2 diabetes. Information collated included age, sex, diabetes type, frequency of blood sugar monitoring, weight, BMI, Clinical Frailty Scale, allocation of diabetic diet and treatments including insulin and oral hypoglycaemic agents. Diabetic control was assessed by HbA1c. Evidence of hypoglycaemia in the preceding four weeks was documented.

Results

Of 47 patients (33 female), average age was 79.8 years and median BMI was 25. 41/47 residents had a Clinical Frailty Score of 6 or greater. The median HbA1c overall was 44mmol/l (range was 29-116mmol/l). All patients were on a diabetic diet. 23/47 residents on oral hypoglycaemic agents and the median HbA1c of this group was 51mmol/l. 6/47 were on insulin. Sugars were checked weekly (daily in those on insulin) and HbA1c was checked in the previous 6 months in 36/47.There was 1 recorded hypoglycaemic episode.

Conclusion

Our data showed that long stay residents continue to have tight diabetic control despite low BMI, evidence of frailty, significant co morbidities and dependency. HbA1c can also decrease due to renal disease, weight loss and poor oral intake. In line with recent guidelines our data shows there is scope to rationalise diabetic treatment regimens with reduction in polypharmacy and improvement in quality of life.
258 FLEXIT: Geriatric Muscle on the Orthopedic Ward
Authors: Reddin Catriona , Murphy Robert , Dempsey Aoife , Kissane Bláithín , Waters Ruairi , Murphy Colin , Egan Ciara , O'Keeffe Shaun , Mulkerrin Eamon , O'Donnell Martin , Walsh Thomas , Byrne Fergus , Robinson Stephanie , Canavan Michelle
Published: September 2019

Background

Older patients post hip fracture benefit from specialist orthogeriatric care. Best practice tariffs incentivising compliance with the Irish Hip Fracture Standards (IHFS) have been introduced in Ireland(1). We compared levels of compliance to IHFS before and after introduction of a dedicated orthogeriatric service in a tertiary referral hospital. We also hypothesized that improved continuity of care by regular orthogeriatric review would result in less general medical consults to medical teams. We looked at the number of inpatient consults sent for each time period and compared the number of general medical consults sought by orthopaedic teams for similar time periods.

Methods

Data was prospectively collected on all hip fracture patients seen by the orthogeriatric service from Aug 2018-Feb 2019 and was retrospectively compared with patients admitted with hip fractures from Aug 2017-Feb2018.

Results

Similar numbers of patients were seen in each time period (n=146 v n=139) with similar age profiles (81.8 vs 79.6 years). Improvements were seen in all of the six IHFS. The most significant improvements were an increase from 31.2% to 96.5% in the proportion of patients seen by a Geriatrician, and an increase from 7.4% to 98.5% in those who had a formal falls assessment.

Fewer patients required medical team consults after the service began (32.2% vs 46.8%, p=0.016). The resultant total number of consults sent fell from 120 consults to 59 consults.

Conclusion

Introduction of an orthogeriatric service has substantially improved compliance with IHFS. The reduction in the number of medical consults requested by orthopaedic teams reflects the improved quality and continuity of care for these patients.
266 Patient and Carers Experience of an Acute Care at Home Team: A Service Evaluation
Authors: Toal Deborah , McCaffrey DrPatricia
Published: September 2019

Background

The Aim of the Acute Care at Home Team is to provide acute care to over 65's in the patient's own home, providing assessment and treatment of acute conditions such as pneumonia, urinary sepsis and heart failure. It is a multidisciplinary team that works together to streamline services to enable a patient to stay safely in their own home. A full comprehensive geriatric assessment is carried out in all patients to help improve patient outcomes. The patients have full access to in patient services such as scans, and x-rays. All blood tests are treated as urgent to ensure the patient is in no way disadvantaged by being treated by acute care at home compared with hospital care.

The aims and objectives are to explore patient and family experiences and identify any areas for improvement.

Methods

A service users and carers experience Questionnaire (N=31) was used to gain insight into how satisfied the patient or family were with the service and what the experience was like having the team come into their home.

Results

Patient satisfaction with this Acute Care at Home Team was reported at 100%. Patients were happy with the care they received, 100% of patients were happy with staff's knowledge of their condition and treatment plan. All of the respondents stated they would both recommend the service and use it again. The qualitative responses were in keeping with 100% satisfaction in that they were positive in nature.

Conclusion

This service evaluation has shown that patient and carer experience of this Acute Care at Home Team is a positive one, with 100% satisfaction levels. There are some small areas to be improved upon, however the results show this service is providing the over 65 population with a good experience of being treated at home as an alternative to hospital care when acutely unwell.
279 Quality Improvement Audit on Bone Health Assessment and Secondary Prevention of Patients Discharged from an In-patient Rehabilitation Unit Post Fracture
Authors: Synnott Pádraig , Brennan Michelle , O'Keeffe Shaun , Canavan Michelle
Published: September 2019

Background

Osteoporosis accounts for more disability-adjusted life years than many non-communicable diseases. Identification and treatment is important to reduce morbidity and mortality associated with further fracture.(1)

National Osteoporosis Guideline Group recommends all patients with a fragility fracture should undergo a bone health assessment and commence pharmacological therapy if indicated.(2)

Methods

Electronic discharge summaries of all patients with a diagnosis of fracture discharged from an off-site rehabilitation unit from 1st January 2018 to 31st December 2018 were reviewed.

Patient details, location and mechanism of fracture, bone health assessment and discharge prescription were assessed.

Following data collection, an education session directed at NCHDs was performed and a discharge checklist prompting bone health review and consideration of pharmacological therapy was introduced. A re-audit was performed at 4 months to assess change following this intervention.

Results

74 patients had a diagnosis of fracture. 4 were excluded as fracture resulted from high impact trauma.

100% had corrected calcium measured.

93%(n=65) had Vitamin D(OH) measured.

91%(n=64) had PTH measured.

55%(n=39) were discharged on calcium/vitamin D(OH) supplementation. 33%(n=23) were discharged on Vitamin D(OH) alone.

66%(n=46) were discharged on antiresorptive therapy: 28%(n=13) bisphosphonate, 67% (n=31) denosumab, 4% others.

33%(n=23) were not prescribed any bone protection on discharge. 4 had advanced chronic kidney disease.

6%(n=4) were discharged without calcium/Vitamin D or antiresorptive therapy.

A re-audit from January to April 2019 of 15 patients post NCHD education has shown an increase in antiresorptive therapy prescription 86%(n=13)

Conclusion

Bone health assessment and prescribing practices of antiresorptive therapy in patients undergoing rehabilitation post fracture is sub-optimal. Education of non-consultant hospital doctors can substantially improve rates of antiresorptive therapy prescription.
295 Characteristics of Older Hip Fracture Adults Admitted to a Dublin Hospital
Authors: Maher Niamh , Steen Georgina , Fallon Nessa , Carroll Claire O , Rafferty Máire , Walsh J B , McCarroll Kevin , Lannon Rosaleen
Published: September 2019

Background

Hip fractures are common in older adults and are associated with increased mortality and morbidity resulting in medical and socioeconomic burden for healthcare system and patient alike.

Methods

A retrospective study was conducted on patients admitted to a Dublin hospital for hip fracture repair between October 2018 and February 2019. Data on sociodemographic characteristics such as; gender; age; pre-admission residence; fracture history; bone protection medication use; pre-fracture mobility; discharge mobility and destination; length of stay and mortality rate was collected.

Results

50 patients admitted between 01/10/19 and 31/01/2019. 2:1 female to male. Average age 78 ranging from 48-93. 88% admitted from home. 44% had previous fractures. Vertebral (36%), wrist (23%) and pelvic (23%) most common fractures. 27% of these were on bone protection medication on admission. 41% were taking Calcium and Vit D or Vitamin D only. 70% of participants were independently mobile pre-fracture. 94% required some form of mobility aid on discharge. The average length of stay was 32 days ranging from 2 to 160 days. 38% went home whilst 36% were discharged to rehabilitation. 88% were discharged on bone protection medication - 70% received IV Zoledronic acid as inpatients, 14% commenced Prolia 6 monthly injections and 4% on oral bisphosphonates. Mortality rate was 6%

Conclusion

Hip fractures have a negative effect on a person’s mobility. Whilst many guidelines for the assessment and treatment of osteoporosis recommend intervention be considered in men and women who have sustained a fragility fracture, it is clear from this study that an osteoporosis care gap exists and further work is required to better identify, assess and treat patients following their first fracture in the hope of reducing further fractures, particularly hip and vertebral fractures.
301 Older Farmers' Experiences of Musculoskeletal Disorders
Authors: Cunningham John , Kerin Austin , Galvin Rose , Robinson Katie
Published: September 2019

Background

Almost a third (n=41,000) of all Irish farm holders are aged 65 years or older. Older farmers are vulnerable to Musculoskeletal Disorders (MSD’s) both by virtue of the nature of their work and their age. MSD’s are a known risk factor for workplace accidents and farming is the highest risk occupation in Ireland.

This study aimed to explore older farmers’ experiences of living with and accessing healthcare for MSD’s.

Methods

A qualitative study design employing semi-structured interviews was employed. Nine Irish farmers aged 65 years and over with current or previous experience of MSD's were recruited. All participants continued to farm on either a full-time or part-time basis. Data were analysed using thematic analysis.

Results

Four themes describing older farmers' experiences of MSD’s and healthcare were identified; (1) acceptance of MSD’s as inevitable (2) biomechanical and biological beliefs about MSD’s (3) resilience and a commitment to continuing work in response to MSD’s (4) scepticism and avoidance of healthcare.

Conclusion

To the best of our knowledge this is the first qualitative study of older Irish farmers’ experiences of MSD’s. Findings reveal that older farmer’s experiences differ significantly from those reported by other occupational groups. Commitment to continue working permeated the findings of this study and shaped older farmers' experiences and responses to MSD's. Older farmers accept MSD’s and pain as inevitable consequences of farming, and they respond to MSD’s with stoicism. Lack of healthcare provider knowledge about farming culture and practices contributes to older farmers' negative healthcare experiences and avoidance of healthcare. Given the prevalence of MSD’s in this population future research should focus on developing and evaluating appropriate health promoting and patient-centered interventions to support continued safe farming for older Irish farmers.
319 Appropriate Duration of Extended Cardiac Monitoring for Atrial Fibrillation in Cryptogenic Stroke
Authors: Donlon Kate , Murphy Robert , Mannion Edel , Waters Ruairi
Published: September 2019

Background

Strokes due to cardio embolism are generally more severe and prone to early and long term recurrence. All forms of anticoagulant therapy are associated with a two thirds risk reduction in acute ischaemic stroke associated with atrial fibrillation.

Establishing a diagnosis of paroxysmal atrial fibrillation can be a challenging one.

Our study will attempt to answer the question as to what duration of extended cardiac monitoring is required when screening for atrial fibrillation in cryptogenic stroke.

Methods

We examined the time of atrial fibrillation initial diagnosis in 50 patients with an original working diagnosis of cryptogenic stroke but later have atrial fibrillation confirmed on extended monitoring.

All patients wore the external loop recorder from 1 day to 3 weeks’ duration. On return of the device, data from the external loop recorder was downloaded, and reviewed by a consultant cardiologist.

The total duration of monitoring using the external loop recorder was recorded. The time to first episode of algorithm detected atrial fibrillation was recorded.

Results

The mean duration of extended cardiac monitoring using the external loop recorder was 120.1days

By seven days, atrial fibrillation had been detected in 94% of patients. By 72 hours, atrial fibrillation had been detected in 78% of patients.

The mean age of participants was 58.3 years. 54.4% were female. The mean time to detection of atrial fibrillation was 52.9 hours. The median time to detection of atrial fibrillation was 34.2 hours.

Conclusion

External loop recorders present an opportunity for detection of paroxysmal atrial fibrillation in high risk individuals. Our study shows the feasibility and accuracy of a screening duration of seven days in the high risk post ischaemic stroke population.

A one week screening timeframe allows us to screen twice as many patients for paroxysmal atrial fibrillation. Successful screening for atrial fibrillation in this high risk group allows the commencement of acceptable and safe anticoagulant therapy.
337 Falls Pathway and Assessment, an Audit
Authors: McCarthy Kate , Hannon Evelyn , Carroll Jennifer
Published: September 2019

Background

Falls remain a common presentation to emergency departments and medical assessment units. They can result in serious injuries requiring surgical intervention and prolonged hospital admission. Conversely a fall may have minimal injury yet still result in prolonged hospital admission. The frailty intervention therapy team (FITT) aims to complete a comprehensive assessment physical and social needs in a time efficient manner.

Methods

We reviewed the medical notes of a cross-section of patients, aged over 65 years, on medical wards admitted with a fall. The service, under which, the patient was admitted was noted. We looked at the length of time between admission and physiotherapy review, undertaking bedside tests for postural hypotension and assessment of bone health, with commencement of appropriate therapy pre discharge. We also reviewed medications and if anti hypertensives were stopped or adjusted.

Results

Of the 30 patients included, the average length of time from admission to physiotherapy review was 2.6 days. 7 of the patients were seen on the same day, however 3 were awaiting review.

Postural blood pressures were requested in one third of the group, predominately in those patients admitted under a geriatric service.

A similar pattern was seen in assessment of bone health, although of the patients included, half of them were on at least a single agent for osteoporosis.

Conclusion

Development of FITT is of benefit to the health service as a whole and improves early mobilisation, extension for weekend cover should be considered.

Interventions such as adjustments to anti hypertensives and opportunistic assessment of bone health should be highlighted to all medical teams.

A concise falls pathway encompassing these interventions and FITT assessment does not seem obscure in this age of over-crowding and crisis.
351 Integration of Auditory and Visual Information is Associated with Ageing, Sex and Cognitive Performance
Authors: Setti Annalisa , Hernández Belinda , Anne Kenny Rose , Newell Fiona N
Published: September 2019

Background

In ageing, multisensory integration, i.e. the ability to combine efficiently information from different sensory modalities, is emerging as a stand-alone contributor to explaining cognitive and functional deficits. Experimental evidence shows that inefficient multisensory integration is associated with cognitive impairment, falls and balance maintenance; however these findings need to be supported by large population representative studies. We utilised the Sound-induced flash illusion (SIFI) as test of multisensory efficiency; the test was conducted on a population representative sample from the Irish Longitudinal Study on Ageing (TILDA). We hypothesized that Susceptibility to the SIFI would increase with ageing and would be associated with poorer Montreal Cognitive Assessment (MoCA) scores.

Methods

Participants: 3,955 adults aged 50 years and over. Participants provided informed consent. Data were drawn from the third wave of the TILDA study, in which participants took part in a Computer Assisted Interview and a Health Assessment.

The SIFI test was part of the Health Assessment; SIFI is a computer-based test in which participants see a series of white dots appearing quickly on the screen, which participants are required to count; the dots (flashes) can be paired with 0, 1 or 2 beeps; when one dot is paired with two beeps, there is the illusory perception that two dots are presented.

A hierarchical Bayesian, ordinal-regression model was used to determine which variables predicted audio-visual integration (SIFI proportion of correct responses, i.e. no illusions). We controlled for a range of covariates.

Results

As predicted, higher susceptibility to the SIFI, indicating higher integration of audio-visual information, was associated with older age, and poorer scores at MoCA. Female sex was also associated with higher susceptibility, which represents a novel result in the literature.

Conclusion

The present study presents the first findings on multisensory integration in a large population representative study. They confirm that inefficient integration is associated with ageing, poorer cognition and, unexpectedly, being female.
43 Addressing Polypharmacy in the Frail Older Person - the WIDE (Wholistic, Integrated, Deprescribing, Evaluation) Review
Authors: Kinahan Clare , Soomro Nazir , Daniels Florrie , Hussain Wafaa , Heery Helen
Published: September 2019

Background

People are living longer, with more chronic conditions and are prescribed more medications according to disease specific guidelines. The WIDE Review is an innovative model of comprehensive medication review devised to treat the whole patient. Frail patients are twice as likely to be prescribed inappropriate medications and are more vulnerable to their harmful effects. Use of the STOPP/START criteria and the Medication Appropriateness Index (MAI) have been shown to improve patient outcomes. This study examined the impact and cost effectiveness of pharmacist led WIDE Reviews.

Methods

This quantitative prospective cohort study was conducted over 8 weeks in a Model 3 hospital. Inclusion criteria: inpatients age > 65 years; prescribed > 6 regular medications and screened positive for frailty (PRISMA 7 score >3). Critically ill patients were excluded. Eligible patients were randomly allocated to intervention or control group. The intervention group received a pharmacist led WIDE Review: Wholistic (establishing patients' priorities), Integrated (collaborating with primary care providers), Deprescribing Evaluation of medication harms versus benefits. Medications were screened using the STOPP/START criteria and the MAI was calculated. In conjunction with the patients and their consultants, deprescribing plans were devised and communicated to their GPs and community pharmacists

Results

A total of 20 intervention and 20 control group patients were enrolled. Patient characteristics (age, sex and length of stay) were similar for both groups. 65% of STOPP and 62% of START criteria were addressed in the intervention group versus 12% and 5% respectively in the control group. In the intervention group 83 medications were stopped, 23 dose reduced and the total MAI score was reduced by 64%. Cost savings to the annual drug budget alone represented a 9:1 return on investment of hospital pharmacist time.

Conclusion

Pharmacists performing WIDE Reviews significantly improved medication appropriateness and realised compelling cost savings. A larger scale study of this innovative approach to medication review is planned.
50 My Healthcare Information Folders
Authors: Deasy James , Griffin Josephine , Hayes Mary , Cotter Suzanne
Published: September 2019

Background

For many people an admission to an acute hospital can be a stressful and overwhelming experience. During admission it can be difficult to process and understand the information provided by members of the multi-disciplinary team (MDT). Patient information leaflets (PILS) are important in educating and empowering patients in the management of their own health and wellbeing. PILs are frequently provided to patients by MDT members during their admission. These valuable resources are not always consulted by patients or their families and in many cases are not brought home from hospital.

Methods

Using Plan Do Study Act (PDSA) methodology patient information folders named “My healthcare information” were provided to in-patients by MDT members. Patients were encouraged to put all PILs provided by the MDT in these folders and bring them home for future reference. Questionnaires were administered to patients to ascertain if they found the folders useful and would be likely to use them going forward. Two PDSA cycles have been completed to date.

Results

​The results were largely positive. A significant amount of those questioned found it difficult to understand and remember what was said to them by hospital staff (5 of 15 respondents or 33%) and felt they did not receive enough written information about their condition (6 of 15 respondents or 40%). A high proportion of those asked stated they found the folder useful and would be likely to use it at home going forward (22 of 23 respondents or 96%).

Conclusion

My healthcare information folders are a potentially useful tool in empowering patients and educating them about their own health and wellbeing. Further PDSA cycles and staff education is required to continue the project. The next PDSA cycle will focus on the MDT member’s experience of using the folders.
57 The Workload Distribution and Response Times of FAST Scans in a Level 3 Hospital in Ireland
Authors: McGarvey Caoimhe , O'Brien Paul
Published: September 2019

Background

With the advent of time sensitive treatments like thrombolysis and thrombectomy for acute ischaemic stroke, it would be expected that stroke CT would place an increased demand on CT services out of hours. Our aim is to demonstrate the change in the workload distribution in the investigation and management of acute stroke over the last year.

Methods

Data was collected from the radiology systems used in our hospital (NIMIS/PACS). Firstly, CT multiphase angiograms done between 17/10/2017 and 17/10/2018 were examined, followed by all FAST-positive CT brains in the same period. Arrival times for FAST positive patients were collected from the ED Symphony system. These details were used to calculate time to CT and time to report in hours and minutes. Scans were categorised into 5-time windows, in and out of hours. The process was repeated for CT brain and all other CT scans for comparison.

Results

58.14% of all FAST-positive CT scans were performed out of hours. FAST positive scans accounted for 9.49% of all out of hour CT scans, this rose to 20% when examining the out of hour scans from Monday to Friday. The most common indication for non-FAST positive CT was trauma. There was a higher likelihood of receiving a CTA during hours as opposed to out of hours, (73.33% vs 66.94%). Median time to CT in FAST positive patients: window 1 – 30mins, window 2 – 49mins, window 3 – 49mins, window 4 – 34mins, window 5 – 39mins.

Conclusion

Stroke CT will continue to increase the out of hours work load for CT departments across the country especially with our ageing population. It is vital that services, particularly in level 3 stroke centres, are adequately equipped in terms of staffing to meet the highest standard of care in the management of acute stroke.
81 A Review of the Referrals to a Daily TIA Service and Subsequent Specialist Diagnosis
Authors: Magee Michael , Vahidassr Djamil
Published: September 2019

Background

Current guidelines highlight the need for all patients experiencing transient ischaemic attacks (TIA) within the previous 7 days to be seen by a specialist service within 24 hours. (RCP National Clinical Guideline for Stroke 2016) Risk stratification tools are no longer recommended.(Lavallee 2007;Wardlaw, 2014) We reviewed the referrals to such a service to assess the proportion of patients who received a diagnosis of TIA and the time taken for assessment.

Methods

We used a retrospective review of 131 patients coded under the daily TIA clinic in 2018 and analysed the clinic letter from the attendance. We assessed the time taken from referral to clinic review and the percentage of patients diagnosed with TIA by the specialist service.

Results

Of 131 patients seen only 33.6% were diagnosed TIA by the stroke specialist team. Other frequently seen diagnoses were migraine (22.9%), presyncope (12.2%), transient global amnesia (4.6%). ‘Other’ diagnoses such as peripheral nerve palsy, cervical root impingement and delirium made up the remainder. Referrals from the emergency department only received TIA diagnosis in 25.3%, GP referrals (34.9%) and eye casualty (83.3%).

The time from referral to review was a mean of 2.45 days. The patients diagnosed with TIA were seen with average of 2.14 days, non TIAs were 2.6 days.

Conclusion

Evidence shows that patients suffering TIA should be seen urgently within 24hrs. The degree of non TIA symptoms being reviewed risks these services being overrun. A review of our service has shown that the average time of referral to review is longer than desired, however only a third of patients seen were felt to have a TIA. Unless there is a change in the standard of referral it will continue to be difficult to see all true TIAs within 24hrs. This will require further education for our colleagues and a more robust triaging system.
86 Haemorrhagic Stroke: What's in a Bleed?
Authors: Noone Imelda , Kate Meagher Mary , Davey Naomi , O'Shea Diarmuid , Cassidy Tim
Published: September 2019

Background

Intracerebral haemorrhage (ICH) accounts for approximately 20% of all strokes and is a leading cause of disability and mortality. The distribution of the ICH(Lobar v Deep) may be explained by the two major aetiologies of ICH, Cerebral Amyloid Angiopathy (CAA) versus hypertensive (HBP) respectively. The aim of our study was to look at outcomes of lobar versus deep ICH stroke patients.

Methods

We analyzed data of all ICH’s admitted in 2018 using SPSS. Demography, classification of haemorrhage, hypertension, atrial fibrillation (AF) and anticoagulation history, pre and post stroke Rankin and subsequent outcome were analyzed.

Results

373 acute strokes were admitted of which 66(18%) were ICH. Mean age was 73yrs (52-93) and 50% were male. On neuroradiology imaging, 40(60%) were lobar and 26(39%) were deep. Lobar haemorrhages were significantly more likely to be older (p = 0.0001) however, there was no significant difference in pre-stroke Rankin. Post stroke the lobar haemorrhages had both a worse outcome from disability (p = 0.005) and mortality (p = 0.0001). 17(26%) patients with a ICH also had AF with 94% were on an oral anticoagulant(OAC).17.5% of the lobar bleeds were on an OAC versus 36% of the deep ICH. Of the lobar bleeds on OAC none died versus 4 of the deep ICH (p = .001). In total, 48(72%) of patients had a history of hypertension, but only 34(51%) were on HBP medication on admission.

Conclusion

There were a greater proportion of patients with lobar versus deep bleeds in our cohort which may be due to the older population in our area. Mortality and disability was far greater in the lobar cohort. None of the lobar bleeds with AF who were on OAC died in contrast to the deep ICH patients. This may suggest that more aggressive hypertensive treatment is required in this subpopulation.
96 Service Priorities for People with Dementia in Ireland: A Mixed Methods Study of Health Care Professionals
Authors: Keogh Fiona , Pierse Tom , O'Shea Eamon
Published: September 2019

Background

Public services for people with dementia living in the community face significant resource constraints. The aims of this study are to identify an optimum mix of services for six dementia case types and to gain a greater understanding of the resource allocation decision making process.

Methods

Irish datasets were used to identify dementia cases types representing 46% of cases in the datasets. Vignettes were prepared for six case types ranging from low to high dependency and needs. Carers, people with dementia and health and social care professionals (HSCPs) took part in mixed methods workshops. Initial findings for the HSCPs are reported here (N=23). HSCP participants firstly quantitatively identified an optimum care package for a set of six vignettes, then qualitatively discussed the needs and individual case factors that were driving service recommendations. The quantitative exercise was repeated with a budget constraint. The sessions finished with a discussion on service and case prioritisation.

Results

When no budget constraint is imposed, participants recommended the use of a wide range of services. Home help, in-home respite and day care services comprised 62% of spending in this scenario. When a budget constraint was imposed, participants focused on essential care and reduced services aimed at prevention, quality of life and carer support. Resources were not redistributed between cases (e.g. from low need to higher need cases) as a similar proportion of the budget was allocated to each of the cases in both scenarios.

Conclusion

People with dementia living in the community and their families have a wide range of health and social care needs. Optimum dementia care packages included a wide range of services to meet these needs. However, a budget constraint resulted in a much narrower range of services with consequent implications in terms of unmet need and a reactive rather than preventive approach to care.
134 Does a Purely Occipital Lobe Stroke Lead to Significant Long Term Disability and Handicap?
Authors: Davey Naomi , McNally Sarah , Donnelly Kerri , Kate Meagher Mary , Noone Imelda , Cassidy Tim
Published: September 2019

Background

Occipital lobe strokes are characterised by a visual field deficit (VFD) and the absence of a motor deficit. A persistent VFD may have significant long-term implications for a patient and their lifestyle. Our aim was to assess the overall impact of these events particularly patients’ ability to return to driving.

Methods

All patients admitted with an acute occipital lobe stroke to a Dublin teaching hospital in 2017 were identified. Case notes were retrospectively reviewed to identify patients’ pre-stroke function, stroke pathology, neurological losses and further vascular events. A follow up phone call was made 18 months after the event to assess if previous drivers had returned to driving and required the installation of formalised home supports after discharge.

Results

In 2017, 37 of 311 stroke patients admitted had a confirmed occipital lobe stroke. 33 of these patients (89.1%) had ischemic events. The median age was 76 (50-93) years old. Twenty-nine patients were able to undergo formal cognitive testing; the median Montreal Cognitive Assessment (MOCA) was 18 (2-29).

15 patients (40.5%) had underlying Atrial Fibrillation with one (6.7%) of this cohort being identified post discharge; 14 (85.7%) of those patients with ischemic strokes were anticoagulated for atrial fibrillation.

The median length of stay was 33.9 days, with a range of 2-391 days.

Further vascular events occurred in 2 (5.8%) of the patients.

A follow up phone call was made to the 15 patients who drove prior to their event. 12 patients (80%) could not resume driving due to persistent VFD. One (7%) of the previous drivers had a home care package installed since discharge.

Conclusion

A persistent VFD results in long term problems including an increased risk of further vascular events, a reduction in overall independence and quality of life following an occipital lobe stroke. This study has led to a business plan for a dedicated hemianopia clinic.
161 Cross Sectional Study of Pharmacological Management of Rheumatoid Arthritis in Patients over the age of 70
Authors: Reddin Catriona , Costello Maria , Lynch Bernadette
Published: September 2019

Background

Rheumatoid arthritis (RA) is a common inflammatory joint disease. It can lead to joint destruction resulting in joint deformity, functional impairment and reduced mobility. With a growing older population, prevalence of RA is increasing and due to the associated morbidity it is essential to prioritise disease control.

Conventional treatment of RA has comprised of disease modifying anti rheumatic drugs (DMARDs) along with analgesia and corticosteroids. Recently, the development of biologics has revolutionised management of inflammatory arthritis. We now strive for tighter control to prevent joint damage and preserve function. However, studies have shown that uptake of biologic medications in the older population has been slower than their younger counterparts. (1)

Methods

Our departmental electronic record system, Cellma, was interrogated for patients aged 70 and over with a diagnosis of RA. Deceased patients were excluded. The current medication list was reviewed using the online rheumatology outpatient system.

Results

A total of 514 patients over the age of 70 were identified with a diagnosis of RA [(67% (n=343) female, 33% (n=171) male)], 24.5% (n=126) were on biologic therapy, 13% (n=68) patients were on a single DMARD in combination with a biologic, 42% (n=217) of patients were on a single conventional DMARD alone and 9.7% (n=50) were on analgesia alone.

Conclusion

The management of RA in the older population poses its own challenges but this should not prohibit the thoughtful use of newer agents. Awareness of the therapeutic potential and associated adverse events is necessary for maximizing therapeutic benefits while minimizing adverse effects from conventional DMARDs and biologic therapies.
162 An Audit of Comprehensive Geriatric Assessment in the Southern Trust Acute Care at Home Service
Authors: McCann Ann , McCaffrey Patricia , Toal Deborah
Published: September 2019

Background

The population is ageing. Acute Care at Home (AC@H) is a consultant led multidisciplinary team, providing acute non-critical care to our older population, preventing hospital admissions and promoting a better quality of life and supporting them to live independently for longer. A recent Cochrane review shows that older people who receive Comprehensive Geriatric Assessment rather than routine medical care after admission to hospital are more likely to be living at home and are less likely to be admitted to a nursing home at up to a year after hospital admission.

Methods

One-hundred patient charts were selected at random who had been under the AC@H team between 2016 and 2018. The nursing and medical assessments were reviewed to assess how well Comprehensive Geriatric Assessment was being carried out. The domains selected for audit are shown in the results table

Results

The domains were assessed appropriately as follows in percentages - Dementia 93%, Delerium 85%, Depression 6%, Falls, 99%, Fractures/Osteoporosis: 27%, Medication/Polypharmacy: 100%, Pain: 91%, Nutrition: 98%, Skin: 93%, Incontinence: 94%, Advanced Care Planning: 39%, Visual Acuity: 7%, Social Support: 99%

Conclusion

Whilst some areas of Comprehensive Geriatric Assessment are achieved adequately, others are not. Our electronic assessment did not include a Geriatric Depression Score. Although pain was frequently assessed, again a score was not always used. Other areas for improvement include visual acuity, fractures and osteoporosis and advanced care planning

The results of this audit have been presented to the team, adjustments have been made to our electronic assessments so that we can record and capture this data better. There will be a reaudit in 6 month’s to evaluate improvement.
Common bacterial infections and their treatment in hospitalized pediatric patients
Authors: Fusco Nicholas M , Nichols Kristen
Published: September 2019

Purpose

Common bacterial infections in pediatric patients that the hospital pharmacist may encounter are reviewed, and guidance on the safe and effective use of antibiotics to treat those infections is provided.

Pharmacists play a key role in evaluating and creating antibiotic treatment plans for patients with infections. Bacterial infections are a common reason for hospital admission in pediatric patients, and pharmacists working in hospitals may be consulted to provide treatment and monitoring recommendations. It is important for pharmacists to be aware of similarities and differences in adult and pediatric populations with regard to presenting signs and symptoms of bacterial infections, common causative pathogens, and antibiotic selection, dosing, and monitoring. This article reviews current approaches to treatment of common bacterial infections in pediatric patients and also provides general suggestions for antibiotic use.

Conclusion

Pharmacists have an opportunity to positively impact the care of pediatric patients with bacterial infections. Especially at facilities where pediatric patients are not regularly treated, pharmacists can potentially improve care through provision of recommendations for optimal antibiotic selection, dosing, and monitoring.
Select topics in the management of critically ill children
Authors: Hughes Kaitlin , Buenger Lauren
Published: September 2019

Purpose

The purpose of this review article is to discuss considerations for the critically ill child presenting to an emergency department (ED) with pharmacists who have minimal to no pediatric training.

In 2015, 17% of all children visited an ED, constituting 30 million visits. The majority of these children were treated at community hospitals where pediatric care resources, including a pediatric-trained pharmacist, may be limited. Because of the complex array of ages and disease states, the care of critically ill children in the ED creates many concerns for adult and community hospitals. This article will focus on several common disease states seen in the pediatric ED, including septic shock, trauma, status epilepticus, and diabetic ketoacidosis.

Conclusion

Critically ill children admitted to a community or adult ED provide therapeutic dilemmas and medication safety concerns. A pharmacist with training or experience in pediatrics can have a major impact in patient outcomes in many of the disease states seen in these pediatric patients. This article highlights several key differences between critically ill pediatric and adult patients to better prepare all pharmacists to care for these vulnerable patients.
Behavioral and morphological evidence of an Allen’s × Rufous hummingbird (Selasphorus sasin × S. rufus) hybrid zone in southern Oregon and northern California
Authors: Myers Brian M , Rankin David T , Burns Kevin J , Clark Christopher J
Published: September 2019

Allen’s (Selasphorus sasin) and Rufous (S. rufus) hummingbird have long been suspected to hybridize, and potentially form a hybrid zone where their ranges overlap in southern Oregon. Migratory Allen’s Hummingbird (S. s. sasin) breeds along a narrow strip of the California coast up to the Oregon border, while Rufous Hummingbird breeds from southern Oregon to Alaska. Analysis of behavioral and morphological data for 183 males and morphological data from 138 females showed that Allen’s and Rufous hummingbird form a hybrid zone in southern Oregon and northern California. Linear discriminant function analysis and cline analysis of 20 phenotypic characters for males and 9 phenotypic characters for females suggested the center of the coastal transect of this north–south hybrid zone spanned from Bandon, Oregon (Coos County), to Port Orford, Oregon (Curry County). The contact zone extended north into the breeding range of Rufous (into Florence, Lane County, Oregon) and south into the range of Allen’s (into Arcata, Humboldt County, California). Sporadic inland sampling suggested the hybrid zone extended at least 94 km inland from the coast. Behavioral data included courtship displays, which were composed of discrete, modular, behavioral elements. Sexual selection acted on these courtship displays, as behavioral clines related to courtship behaviors were more narrow than morphological clines. Some of the courtship behaviors analyzed included previously undescribed diagnostic behavioral characters for Allen’s and Rufous hummingbird.
Reference intervals for blood-based biochemical analytes of southern Beaufort Sea polar bears
Authors: Fry Tricia L , Friedrichs Kristen R , Atwood Todd C , Duncan Colleen , Simac Kristin , Goldberg Tony
Published: September 2019

Accurate reference intervals (RIs) for commonly measured blood-based analytes are essential for health monitoring programmes. Baseline values for a panel of analytes can be used to monitor physiologic and pathophysiologic processes such as organ function, electrolyte balance and protein catabolism. Our reference population includes 651 serum samples from polar bears (Ursus maritimus) from the southern Beaufort Sea (SB) subpopulation sampled in Alaska, USA, between 1983 and 2016. To establish RI for 13 biochemical analytes, we defined specific criteria for characterizing the reference population and relevant subgroups. To account for differences in seasonal life history characteristics, we determined separate RI for the spring and fall seasons, when prey availability and energetic requirements of bears differ. We established RI for five subgroups in spring based on sex, age class and denning status, and three subgroups in fall based on sex and age class in females only. Alkaline phosphatase activities were twice as high in subadult as in adult polar bears in spring (zmales = 4.08, Pmales < 0.001, zfemales = 3.90, Pfemales < 0.001) and did not differ between seasons. Denning females had significantly higher glucose concentrations than non-denning females (z = 4.94, P < 0.001), possibly reflecting differences in energy expenditure during lactation. A total of 10 of the 13 analytes differed significantly between seasons in either males or females; however, the physiologic importance of these differences may be minimal. Establishing these RIs allows for temporal monitoring of polar bear health in the SB and may prove useful for assessing and monitoring additional polar bear subpopulations in a changing Arctic environment.
A rare case of stiff left atrial syndrome caused by both coconut left atrium and vertebral compression: a case report
Authors: Ooka Junichi , Matsumoto Kensuke , Kondo Morihiko , Otomo Toshiyuki
Published: September 2019

Background

Calcification of the left atrium (LA) is a rare condition and can be the result of long-standing rheumatic mitral stenosis or an unusual complication after mitral valve replacement. Cases of massive LA calcification have sometimes been referred to as those with ‘coconut LA’ or ‘porcelain LA’.

Case summary

A 75-year-old woman was referred to our hospital because of chest discomfort and exertional dyspnoea. Doppler echocardiography revealed the presence of elevated filling pressure with significant LA dysfunction. A cardiac catheter examination revealed a quite impressive pulmonary capillary wedge pressure waveform with a steep up-slope and prominent v wave of 43 mmHg (mean: 15 mmHg). Multidetector row computed tomography revealed that LA was sandwiched by dense calcifications along the roof and bottom of the LA, and the posterior wall was compressed by a vertebral body. Integration of these functional and anatomical findings ultimately led to the diagnosis of ‘stiff LA syndrome’.

Discussion

She had a history of tuberculosis but no history of rheumatic fever or cardiac surgery. Thus, it appeared that the tuberculous pericarditis might have led to the calcified LA by long lasting inflammation. In this case, the LA was encased by a dense calcification and compressed by vertebral body from the posterior direction. Therefore, we speculated that the LA pressure could easily elevate even with a slight haemodynamic load in this special case, and thus eventually resulting in decompensated heart failure.
Experimental study on deformation and failure characteristics of discontinuous prefabricated fractured tuff
Authors: Song Yang , Wang Heping , Ren Meng
Published: September 2019

To study more fully the characteristic law of deformation and failure of tuff jointed rock mass of prefabricated parallel discontinuous joint test specimens, the uniaxial compression test was used. The stress–strain curve, peak intensity, deformation parameters, energy characteristics, etc., of the rock test specimens were systematically studied under different combinations of joint dip angle and joint spacing. The research found that: (1) during the failure process of tuff, the peak intensity and elastic modulus followed a U-shaped change pattern and the minimum value was reached when α = 60°; (2) the fracture modes of test specimens with different joint dip angles were different. When α = 30° and 45°, failure characteristics were mixed modes of tensile or tensile shear failure. When α = 60°, failure characteristics were shear. At α = 75°, the failure characteristic was tensile shear failure. (3) The absorbed and dissipated energy of the rock increased nonlinearly at each stage of deformation. (4) We quantified rock energy damage through a correlation between dissipated energy and absorbed energy of the rock in the process of energy evolution, and obtained an evolution of the relationship between the dissipated energy ratio, crack dip angle and crack spacing. Based on different fracture distribution methods and according to the strain equivalence principle, the constitutive equation of the pre-peak rock damage was obtained.