bluuebunny/crossref_metadata_2025 huggingface dataset:
254 OPTIMISING COMMUNICATION WITH FAMILIES OF PATIENTS ON ACUTE STROKE AND GERIATRIC MEDICINE WARDS IN A LARGE TERTIARY HOSPITAL
Authors: Killeen E , Doherty R , Higgins M , O'Reilly A , Brewer L
Published: February 2023

Background

Good communication with patients and families is important for older adults admitted to acute stroke or geriatric medicine wards, particularly with COVID19-related restricted visiting. These patients often have communication difficulties including aphasia, delirium, cognitive or hearing impairment, limiting their own communication with relatives. Using the Plan, Do, Study, Act (PDSA) approach we undertook a quality improvement project to optimise communication with families of patients on above wards in a large tertiary hospital.

Methods

PDSA cycle 1: Staff were surveyed to identify satisfaction level with communication and ways to optimise communication. Inpatients on study wards were identified, we recorded demographic and clinical details and prevalence of communication difficulties. We created a designated folder with individual ‘communication sheets’ in conjunction with ward doctors and the nurse manager. PDSA cycle 2: We performed a rapid interval audit of the communication folder use. ‘Outlier’ patients were excluded as their teams did not receive education about folder use.

Results

PDSA cycle 1: A total of 90 inpatients on three wards were included, mean age 78y (SD ±14.4y), 47% were male. Three-quarters (73%) had a communication difficulty noted, reported by nursing staff. Two patients were intubated and six had stroke-related aphasia. Half of surveyed staff reported communication with families was suboptimal. Most (86%) suggested a centrally-located communication logbook would be helpful. PDSA cycle 2: Over two weeks, communication sheets were reviewed for all included patients. Median frequency of calls to families was 4 days (range 0–14). Most (79%) had the name of the primary contact clearly documented. Many (52%) included no contact number. Only 9% had secondary contact information documented.

Conclusion

Communication with families of patients on acute stroke and geriatric medicine wards was suboptimal. Over a short interval this improved with regular phone calls using specific centrally-located communication folders. Further optimisation of their use is needed.
33 ARE CLINICAL TRIALS RANDOMISING HOUSEHOLDS TO LIFESTYLE INTERVENTIONS FOR THE PREVENTION OF COGNITIVE DECLINE FEASIBLE?
Authors: Costello M , McCarthy C , Bosch J , Robinson S , Canavan M , O'Donnell M
Published: February 2023

Background

Dementia is increasing in prevalence worldwide. Several lifestyle factors have been identified as targets for dementia prevention, which may be more effective if targeted at households instead of an individual. To date there have been no clinical trials randomising households to lifestyle interventions of sleep, diet and/or physical activity to prevent cognitive decline. To inform future studies, qualitative approaches can give valuable in-depth insights into the values and beliefs of all household members towards behavioural change.

Methods

Semi structured interviews were carried out among eight households affected by cognitive impairment. Interview content was analysed, and important themes identified.

Results

Eighteen participants were interviewed within household pods. Among those, eight had cognitive impairment and the remainder were spouses or first-degree relatives living in the same home. Several themes of interest emerged including household members without dementia were more likely to report poor sleep habits; sleep was perceived the hardest behaviour to change; although most participants had healthy diets, most were interested in making a change and felt there was a strong link with nutrition and cognition; physical activity is challenging to adapt due to lack of motivation and focus when individuals are cognitively impaired and motivation to pursue physical activity in households centred on relaxation and social interaction.

Conclusion

This study identified beliefs and preferences of households towards lifestyle intervention trials. Barriers to study participation including risk of harm, complexity of intervention and deviation from routine emerged during discussions. Findings from this study should be used to inform future clinical trial protocols and future qualitative studies should explore acceptability and feasibility of digital intervention applications.
46 MEASURING THE IMPACT OF COVID-19 RESTRICTIONS ON MOBILITY IN OLDER ADULTS WITH FRAGILITY FRACTURES USING THE NEW MOBILITY SCORE
Authors: O'Riordan F , Murphy J , Egan G , Ahern E
Published: February 2023

Background

The WHO declared COVID-19 a pandemic in March 2020. Specific public health measures were implemented for older adults who were advised to ‘cocoon’. While this has a positive effect on disease spread, reduced activity increases the risk of falls and fractures as well as all-cause mortality [1]. The New Mobility Score(NMS) stratifies patients according to pre-fracture mobility and predicts 6-month functional level and 1-year mortality [2]. Using the NMS, we evaluated patient mobility pre and post-restrictions. We also obtained basic data, frequency of falls and Clinical Frailty Scale (CFS).

Methods

We prospectively studied 50 patients admitted with a fracture and reviewed by our Orthogeriatric team between August–October 2020.

Results

Mean age was 80 years [range 53–99], 41(82%) were over 70 years and 43 (86%) were female. A hip fracture, 39 (78%) was the most common admission and mean CFS was 4 [Range 1–7] classifying the cohort as mildly frail. Mean NMS was significantly lower post-restrictions compared to pre-restrictions [5 [SD 2.19] vs 6.5 [SD 2.15] [P = 0.0074]]. There was no difference in falls pre and post-restrictions [1.1 [S.D 2.3] vs 1.9 [S.D 1.9] [P = 0.0609].

Conclusion

Our study shows that in a vulnerable cohort, COVID-19 restrictions have significantly impacted mobility over a short time period. As a result, our patients are less likely to regain pre-fracture functional level and are at increased risk of all-cause mortality. As further restrictions are implemented, public health strategies for older adults should be prioritised to maintain mobility and prevent adverse outcomes.

References

1. Cunningham C et al. Consequences of physical inactivity in older adults: a systematic review of reviews and meta-analyses. Scand J Med Sci Sports. 2020;00:1–12. 10.1111/sms.13616.

2. Kristensen MT et al. Prefracture functional level evaluated by the New Mobility Score predicts in-hospital outcome after hip fracture surgery. Acta Orthop. 2010;81(3):296–302. 10.3109/17453674.2010.487240.
49 ASSESSING EFFECTIVENESS OF AN OUTREACH VISIT PATHWAY FROM ED & REQUIRING FURTHER FOLLOW UP IN THEIR OWN ENVIRONMENT
Authors: Loughlin K M , Lyons C , McGettigan L , Maloney P
Published: February 2023

Background

Falls are a leading cause of presentation to the Emergency Department for older adults. They often are at higher risk of admission to hospital which can lead to other complications of frailty such as development of delirium or deconditioning. The risks of admission were further complicated in the past year due to COVID and its adverse outcomes on our older frail population which further highlighted the need to manage their needs at home where possible.

These above changes have led to FITT reviewing the scope of our outreach service with a focus not just on facilitating discharge but preventing further presentation or deconditioning.

Methods

The aim of the project was to identify appropriate FITT patients to provide an Outreach visit from ED within 72 hours of discharge pending needs. This service was in conjunction with the existing Integrated Care Teams/community services but an outreach visit direct from ED may have been indicated due to; staffing levels, response time, catchment area or existing rapport with the individual patient. This was pending staffing levels with reconfiguration of existing staff to support the outreach therapist.

Appropriate patients included.

-Recurrent falls.

-Unresolved delirium/advanced dementia with ongoing therapy needs.—Bridging gap while awaiting community teams.

-Equipment provision.

Results

Over 10 months 34 outreach visits completed.

Average CFS: 6.

Reasons for: 

12 for safety checks.

15 equipment provision/fitting.

6 mobility reviews.

Onward referrals: 

22 (PCCC OT, Physio, PHN & day hospital & ICT).

Represent within 7 days = 0.

Represent within 30 day = 14 (41%).

Conclusion

The provision of an outreach services allowed a swift therapy review in the patient’s own home & onwards referrals as indicated. Often these patients were likely to be admitted however the outreach provided a safety net to facilitate direct discharge from the ED with no representations within the first 7 days.
51 TO EXPLORE EMERGENCY MEDICINE SPRS UNDERSTANDING, IDENTIFICATION AND MANAGEMENT OF FRAILTY WITHIN THE EMERGENCY DEPARTMENT
Authors: Loughlin K M , McNamara R , Timmons S
Published: February 2023

Background

Our frail cohort of older adults represent a large proportion of those presenting to our Emergency Departments. This has led to the introduction of diverse teams in many Emergency Departments to support their complex care needs. However, it is not known if Emergency Clinicians have a clear understanding of frailty identification and management or feel this is part of their own role.

The aim of this study was to engage with Emergency Medicine Senior Trainees on the national training scheme in Ireland to explore their understanding of frailty and what they feel their role is in its identification and management.

Methods

Following a literature review based on defined criteria, a number of focus groups were held with ED PGY4 and above doctors working in various Emergency Departments throughout the country, with thematic analysis of the transcripts of the focus groups.

Results

In total, 13 Emergency Medicine PGY4 and above doctors partook in the focus groups with an overall view that frailty identification was part of their role within the Emergency Department; however there was agreement they have limited insight into the core principles of frailty identification and management. There was also an overall desire for future formal education on frailty to be provided. Three themes in the form of frailty recognition and assessment, education on frailty, and the role of the multidisciplinary team were identified as well as a number of subthemes for further exploration.

Conclusion

The consequences of frailty often lead to presentation to the Emergency Department. There is an increased awareness of its presentation but the core providers of emergency care feel there is a lack of the education required for them to manage the consequences of frailty which they encounter on daily basis and they have a clear desire to increase the knowledge base and skill set.
58 EVALUATION OF DIABETES MELLITUS IN A COHORT OF FRAIL OLDER ADULTS
Authors: McGettigan S , Mohamed A S , Pillay I , Brassill M J
Published: February 2023

Background

The aim of this study was to identify the prevalence of diabetes in a cohort of frail older adults who attended a model 3 hospital and explore the relationship between frailty and diabetes in this cohort. Prognosis and treatment of diabetes can vary greatly in the presence of frailty.

Methods

A multidisciplinary team provide liaison geriatric input to frail older adults in this hospital. Comprehensive geriatric assessments (CGAs) are carried out on patients identified using a VIP tool or via inpatient consults. These CGAs were reviewed regarding frailty scores, social/falls history, medications and diabetes complications including hypoglycaemia.

Results

CGAs were reviewed for 213 patients from September to November 2019. Fifty eight patients had a diagnosis of diabetes (27.2%), and all were type 2. The median age was 84. The average Clinical Frailty Scale score was 5.4 indicating mild to moderate frailty. Over two thirds of patients (n = 137) were on more than 5 medications. Seventy-six patients had a history of falls, and 24 (31.5%) of those had diabetes. Twenty-one patients were prescribed either sulphonylureas and/or insulin, and 7 of these were living alone. One patient had a sulphonylurea stopped on admission following CGA. Five patients had a documented history of hypoglycaemia, 2 of these patients were on insulin and 1 was on a sulphonylurea. The median HbA1c was 49 mmol/mol. Fifteen patients had diabetes complications, including 3 with retinopathy and 6 with neuropathy. The median duration of diabetes was 9.5 years. The majority of patients were managed at primary care level (n = 48, 82.75%).

Conclusion

The management of frail older adults with diabetes is complicated by multimorbidity and increased risk of adverse effects of treatment such as hypoglycaemia. Frailty assessment should be a routine component of a diabetes review for all older adults, and then glycaemic targets and medication choices should be adjusted accordingly.
61 AUDIT: MEDICATION REVIEW POST INPATIENT FALLS
Authors: Gibbons C , Gaynor E , Duggan J , Blackstock J , Mullen M , Keena A , Buckley R , Callaly E
Published: February 2023

Background

Falls are the most commonly reported incident in the Health Service Executive (HSE). Inappropriate medications and polypharmacy in the elderly can contribute to increased falls risk.

Our aim was to assess whether a medication review was being completed at the time of the post-fall clinician review.

Methods

We completed a retrospective chart review using an audit tool of consecutive inpatient falls, resulting in serious injury, from March–December 2019.

Standards measured against were: HSE Guideline—Service User Falls: A Practical Guide for Review, Medicines and Falls in Hospital: British Society Guidelines, STOPP & START criteria and NICE Guidelines: Falls in Older People 2013.

Results

We identified 33 charts for review (n = 33)—54.55% (18) female and 45.45% (15) male. Average age was 81 ± 11.2 years. The immediate post-fall review was mainly completed by interns (48.49% (16)) and SHO’s (39.39% (13)). A medication review was carried out 9.09% (3) of the time.

A total of n = 28 (84.85%) had poly pharmacy. When analysed for medications known to increase risk of falling, 51.52% (n = 17) were on anti-hypertensives, 45.45% (n = 15) on laxatives, 24.24% (n = 8) on sedative medications, 18.18% (n = 6) on hypnotics/anxiolytics, 15.15% (n = 5) on opioids and 15.15% (n = 5) on diuretics at the time of fall. The majority of these medications (77.42% (n = 24)) were commenced prior to admission. None of these medications were discontinued or the dose changed on review post fall.

Conclusion

Our audit demonstrates that in a cohort of patients who had an inpatient fall medication discontinuation and dose reductions were not performed. Yet, a high burden of polypharmacy and high-risk falls medication were found. This may result in missing a pertinent opportunity to prevent future falls. We advise a structured medication review is carried out for each patient who suffers an in-patient fall to efficiently modify such an easily identifiable risk factor.
77 INCONTINENCE AND DECONDITIONING IN A NONFRAIL SAMPLE OF INPATIENTS AT A UNIVERSITY TEACHING HOSPITAL
Authors: Gorey S , McAteer C , Antonenko A , Abrahams E , Cameron S , Egan A , Ero A , Fraser C , Tey Z H , Boochoon L , Koay W J , Sitram R , Deegan K , Quinn C
Published: February 2023

Background

Incontinence occurs in 26% of hospitalised adults1. Deconditioning in hospitalised adults is common and contributes to increased hospital stay2. The #endpjparalysis movement motivates us to reduce harms of hospitalisation older adults.

Methods

We surveyed inpatients to capture the point prevalence of incontinence. We also collected information regarding functional status, continence status and use of continence wear. Local ethical review-board approval was obtained. All participants provided informed consent.

Results

There were 86 responses. Mean age of participants was 71.5 years. 45.4% were female, >95% were admitted from home and were functionally independent. Mean length of stay for respondents was 7.4 days ±12. The median Clinical Frailty Scale, for respondents aged >65 years, was 3, indicating this cohort is not frail.

17 respondents reported incontinence on the day of survey; 8 of these reported that incontinence was a new experience for them since their admission. 24 respondents wore incontinence wear at home, 31 were wearing incontinence wear on the day of survey.

Of 80 respondents who could toilet independently at home, 23 (26%) reported a new dependency to toilet. Of 83 respondents who mobilised independently at home (with or without an aid), 11 reported needing assistance of one-person to walk, 3 needed the assistance of two-people to walk or stand, five people required a hoist, while 3 were bedbound on the day of survey.

Conclusion

We describe increased dependency in mobility, toileting and increased use of continence wear in non-frail hospitalised older adults. Future work is needed to maintain function during admission to hospital.

References

1. Condon, M., et al. (2019). ‘Urinary and Faecal Incontinence: Point Prevalence and Predictors in a University Hospital.’ Int J Environ Res Public Health 16.

2. Guilcher, S., et al. (2021). ‘A qualitative study exploring the lived experiences of deconditioning in hospital in Ontario, Canada.’ BMC Geriatrics 21.
79 SIMULATION-BASED MEDICAL EDUCATION: A ‘HIP’ WAY TO LEARN ABOUT ORTHO-GERIATRICS!
Authors: Murphy B , Laffan S , Sullivan S O , Ballester G W , Meagher M K , Noone I , Cassidy T , Murphy T , Cooke J , Pope G , Mulcahy R , O'Regan N
Published: February 2023

Background

Simulation-based medical education (SBME) is emerging as a key method of medical education, particularly in the setting of the COVID-19 pandemic. As part of a simulation development competition (SimStars) run by the National Doctors Training and Planning Unit and the South–South West Hospital Group, we brought together an inter-disciplinary team to develop a simulation scenario on hip fracture.

Methods

Our development team consisted of members of the Geriatric Medicine and Orthopaedic Departments. We developed a scenario that can be adapted to suit the needs of learners in orthopaedics, medicine, or nursing. We ran the simulation on a medical ward with one candidate and four facilitators from the Geriatric Medicine Department. The candidate (medical SHO) was presented with a patient (facilitator one), who had sustained a hip fracture following a fall. The candidate was directed to elicit a falls and bone health history, screen for delirium, and suggest further investigations and management. Subsequently, feedback was sought from all participants.

Results

The simulation took twenty minutes, debriefing took fifteen minutes. All considered, the simulation an enjoyable and feasible method for teaching and learning, and a novel way to promote team-building. The candidate felt competent in some areas, reporting that the scenario provided positive reinforcement. She reported feeling supported in identifying areas for further learning. The facilitators also considered this method a useful way to highlight a candidate’s learning needs and direct further teaching. The candidate requested further SBME-based sessions.

Conclusion

This SBME session in Ortho-Geriatrics was well-received by the candidate and facilitators. All participants enjoyed teaching and learning through this medium. Areas of high competency were reinforced and areas for future learning were identified. Further SBME was requested across more topics and for simulation training to be brought in as part of formal training.
85 ESTABLISHING AN EMERGENCY PERIOPERATIVE FOR OLDER PERSONS SERVICE (POPS) IN A TERTIARY HOSPITAL SETTING: EARLY DATA
Authors: Plant R , Stanley E , Dukelow T , Kayyal Y , Aherne E
Published: February 2023

Background

Evidence supports the role of geriatricians in perioperative settings. The success of orthogeriatrics has encouraged geriatric input into other surgical services. The British Geriatrics Society recommends early geriatric assessment for patients undergoing laparotomy as a means to improve older adult outcomes. We present the initial data of our Perioperative Older Person Service (POPS) that aims to standardise a clinical pathway for older adults admitted under an emergency surgical service using Comprehensive Geriatric Assessment (CGA).

Methods

We obtained an additional a whole-time equivalent geriatric registrar to facilitate establishing the POPS.

Inclusion criteria for assessment included those over 75 either admitted under an emergency surgical consultant, or awaiting a surgical assessment in the emergency department. A geriatrician performed a CGA for these patients.

We collected data including; demographics, diagnosis; premorbid frailty status (Clinical Frailty Scale (CFS) score 2 weeks prior to admission); polypharmacy; 4AT score; admission and discharge destination; procedure performed; 30-day readmission rate; ICU admission; and 90-day mortality. Extra information was gathered using free-text to identify additional geriatric interventions.

Results

At time of submission the service has assessed 15 patients over 21 days. 46% (7/15) were female, 54% (8/15) were male.

53% (8/15) of patients underwent CGA on the day of admission. 100% patients were assessed within 72 hours of their admission.

46% (7/15) had a CFS ≥4.

26% (4/15) were identified as delirious as per 4AT.

18.7% (3/16) had a procedure performed during their admission.

We identified polypharmacy in 73% (11/15).46% (7/15) were discharged with reduced medication burden.

CGA prompted new advanced care planning decisions in 40% (6/15) of patients.

Conclusion

Although the service is in its infancy, the above data is encouraging. Through early identification of frailty and timely CGA, we anticipate this service will ensure the delivery of geriatrically-attuned care to frail older people and improve outcomes.
86 CELEBRATING TEN YEARS OF COMMUNITY LIAISON SPEECH AND LANGUAGE THERAPY SERVICE: BETTER PATHWAYS BETWEEN THE ACUTE HOSPITAL AND NURSING HOMES
Authors: McDonagh S , Duffy F
Published: February 2023

Background

The Community Liaison Speech and Language Therapy (CL SLT) service was established in July 2010. The aim of this new model of care was to provide a fast track home visit service to older persons with communication and swallowing difficulties living in one of the 27 nursing homes in the region. The service facilitates a safer discharge from hospital and admission avoidance with aspiration pneumonia due to rapid SLT follow up in the nursing home.

Methods

This is a retrospective analysis of the CL SLT service over the last ten years. Activity data, key performance indicators (KPIs) and staff and service user feedback were reviewed both quantitatively and qualitatively. How the service operated during the COVID- 19 pandemic was also examined to explore if new creative ways of working emerged.

Results

Analysis of the data showed a total of 5,699 SLT visits over the ten year period. Review of the KPIs showed that priority 1 referrals were seen within the ten working day target which meant that in some incidences residences were not kept on overly modified diets unnecessarily and in other cases the Speech and Language Therapist could respond rapidly to support decision making around quality of life feeding. User feedback showed high satisfaction with the service. Virtual clinics provided an adjunct to the service during COVID-19 and of note, face to face service was only stopped for two 6 week periods in the first and third waves of the pandemic.

Conclusion

The CL SLT model provides a quality, person centred service for older persons living in a nursing home. The care pathways from the acute hospital have allowed for admission avoidance with effective SLT management decisions, including around end of life feeding being made in the nursing home so that residences receive the right service in the right place and time.
92 THE RISE OF SIMULATION BASED TRAINING IN GERIATRIC MEDICINE?
Authors: Buckley E , O'Regan N , Pope G , Mulcahy R , Cooke J
Published: February 2023

Background

Simulation-based training (SBT) offers opportunities for teaching and learning in safe spaces, while learners navigate the acquisition of these complex skills, and work in clinically-realistic teams, supported by faculty. Geriatric medicine is a diverse speciality, requiring trainees to navigate complex social, medical, and ethical issues, necessitating a multifaceted and interdisciplinary approach. Studies describing SBT in geriatric medicine are limited.

Methods

We hosted an in-situ competition designed to encourage participation in simulation and to develop a simulation faculty network across a hospital group. All healthcare professionals in the hospital group were eligible to enter. Contestants designed a simulation case scenario within a speciality of their choice. Entrants participated in five virtual workshops on core elements of SBT. Six cases were selected to participate in the virtual final. The finalists submitted a video summarising the performance of and evaluation of the learners’ experience of the scenario.

Results

Thirty-four teams submitted initial SBT proposals and participated in the five virtual SBT workshops over a three-week period. Of these,17.6% (n = 6) were geriatric medicine teams, comprising seven geriatric medicine consultants, four advanced nurse practitioners and 13 non-consultant hospital doctors (five registrars, six senior house officers and two interns). Case scenarios submitted by geriatric medicine teams included acute stroke care, diagnosis and management of delirium, management of perioperative delirium post hip fracture and capacity assessment.

Conclusion

The level of interest in SBT generated amongst geriatric medicine faculty and trainees suggests this may be a useful tool to enhance the training experience. SBT offers geriatric medicine trainees the opportunity to practice the technical and non-technical skills required to navigate complex, interdisciplinary and challenging patient scenarios, in a protected environment. In this innovation, we identified a range of geriatric medicine-related topics for which SBT was deemed to be valuable by both faculty and trainees and could be facilitated through in-situ simulation settings.
97 AGEING POPULATION: THE IMPACT ON ADMISSIONS TO LONG-TERM CARE
Authors: McCormack R , McNally S , O'Shea D
Published: February 2023

Background

The aging population of Ireland continues to increase rapidly. As the age continues to increase, so too does the need for long-term care (LTC). In 2006 LTC utilisation was estimated between 4.4%–4.8% of the over 65s population. It was proposed that this would increase to between 4.8%–5.3% by 2021 (Wren et al., 2012). This study intended to explore if this projection was evident in discharges from an acute Care of the Older Person’s setting between 2016 and 2021.

Methods

A random selection approach was used to retrospectively review 45 patients seen by occupational therapy in an Irish acute Care of the Older Person’s service in 2016. Discharge destinations were recorded. These were then compared to the discharge destinations of 45 randomly selected patients open to occupational therapy in the same service during the first half of 2021.

Results

The review of 2016 found that 15.56% (n = 7) of those seen by occupational therapy discharged to a LTC facility, and 4.45% (n = 2) discharged home with a back-up LTC plan. Additionally, 33.33% (n = 15) transferred to a rehabilitation facility and 42.22% (n = 19) went home with community supports, 4.44% (n = 2) passed away.

Contrastingly, in 2021, 28.89% (n = 13) patients discharge to LTC with an additional 6.66% (n = 3) going home with 24/7 private care in place, and 4.45% (n = 2) went home with a LTC back-up plan. Just 22.22% (n = 10) went for rehabilitation and 26.67% (n = 12) went home with community supports. In 2021, 11.11% (n = 5) of those randomly selected passed away during their admission.

Conclusion

A significant increase of the number of inpatients discharging to LTC between 2016 and 2021 was found. These findings are greater than that previously proposed and may suggest that COVID-19 has caused a further increase in individuals requiring LTC. However, this sample size was small and other factors such as age, physical ability and cognition were not explored. Further studies are recommended.
98 SCHEDULED MEDICATION REVIEWS AND EDUCATION ON SEDATIVE PRESCRIBING FOR RESPONSIVE BEHAVIOURS IN NURSING HOME RESIDENTS, A 3 YEAR FOLLOW-UP STUDY
Authors: Killeen E , Horan S , Pollock A , Lee A , Martin A
Published: February 2023

Background

Sedative medications including neuroleptics, benzodiazepines, opioids, ‘z’ drugs and trazadone are commonly prescribed for older adults. Nursing home residents are three times more likely to be prescribed benzodiazepines. Sedative medications are associated with significant risks including falls and delirium in older adults. Neuroleptics also increase risk of cerebrovascular disease and functional decline. Regular medication review and education have been shown to reduce rates of sedative use in nursing homes. Scheduled medication reviews were introduced in an Irish nursing home with a specific focus on reduction or discontinuation of these target medications in combination with education of management of Behavioural and Psychological symptoms (BPSD). We demonstrated previously a significant reduction in prescribing following these interventions. This audit examines the prescribing patterns 3 years on from the initial audit.

Methods

Point prevalence study of sedative prescriptions and BPSD on 6/5/21 of all 95 nursing home residents. Data compared with two preceding audits in 2018 in the same unit. All data anonymised. Data analysed with SPSS statistical software.

Results

Significant reduction in quetiapine use sustained from 30% of residents pre-intervention to 14% post-intervention in 2018 and 2021 (p = 0.06).

Neuroleptic prescription reduced from 39% to 25% (p = 0.06).

‘Z’ drug prescribing increased from 8% to 17% (p = 0.03).

33% of residents had BPSD reported compared to 49% pre-intervention.

Conclusion

3 year follow-up showed regularly scheduled medication reviews and education in a nursing home can effectively rationalise sedative prescription rates. Sustained reduction in neuroleptics and increased ‘z’ drug prescriptions may represent appropriate replacement. Reduced BPSD may be due to changing nursing home resident cohort or reporting bias of staff since the introduction of regular education.
Potential therapeutic targets for sarcopenia identified by Mendelian randomisation
Authors: Jiang Wei , Zhan Wenli , Zhou Luoqi , Dong Minghao , Liu Liang , Xu Xiangshang , Cao Zhixin
Published: February 2023

Background

Identifying sarcopenia’s causally associated plasma proteins would provide potential therapeutic targets.

Methods

We screened out sarcopenia-related proteins with genome-wide association studies (GWAS) summary data and cis-protein loci genetic instruments. Summary data of sarcopenia were obtained from a GWAS of 256,523 Europeans aged 60 years and over. The causal effects of the proteins were investigated by cis-Mendelian Randomisation (MR) and multiverse sensitivity analysis. We also explored the robust proteins’ causal associations with appendicular lean mass (ALM) and surveyed their druggability and clinical development activities.

Results

In sum, 60 proteins from plasma proteome analysis studies and 12 from other studies were enrolled for MR analysis. In the whole population, four proteins (HPT, AT1B2, ISLR2 and TNF12) showed causal associations with the risk of sarcopenia according to the European Working Group on Sarcopenia in Older People (EWGSOP) criterion. In the female population, AT1B2 and TNFSF12 revealed causal associations with sarcopenia risk according to the EWGSOP criterion; HGF revealed a negative association according to the National Institutes of Health criterion. All of them were druggable, and the inhibitors of TNF12 and HGF were evaluated in clinical trials for other diseases. TNF12 also revealed a negative causal association with ALM, whereas HGF was positively causally associated with ALM.

Conclusions

Five druggable plasma proteins revealed causal associations with sarcopenia in the whole or female populations. TNF12 and HGF were the targets of therapeutic agents evaluated in clinical trials, and they were also causally associated with ALM. Our study suggested the potential mechanisms and therapeutic targets for sarcopenia.
A Mixed-Methods Study of Clinicians’ Attitudes Toward Pathology Explanation Clinics
Authors: Bergholtz Sarah E , Kurnot Sophia R , DeJonckheere Melissa , Hawley Sarah T , Owens Scott R , Lapedis Cathryn J
Published: February 2023

Objectives

To characterize the attitudes of treating clinicians toward pathology explanation clinics (PECs).

Methods

Clinicians from a tertiary care academic medical center were asked, “How interested would you be in having your patient meet with a pathologist to discuss their pathology report and see their tissue under the microscope?” Clinicians ranked their interest, then expanded on concerns and benefits in a semistructured interview. Audio recordings of interviews were transcribed and analyzed using a qualitative thematic approach.

Results

A total of 35 clinicians were interviewed, with 83% reporting some level of interest in PECs. Clinicians felt that highly educated and motivated patients were most likely to benefit from a PEC. Clinicians recognized that PECs could improve understanding and emotional processing but that the patient’s information needs must be balanced with the potential for cognitive overload and emotional distress. When integrating the pathologist into the care team, clinicians worried about the pathologist’s communication skills, care fragmentation, and increased clinician workload. If performed well, clinicians felt PECs had the potential to increase clinician efficacy and improve quality of care.

Conclusions

Overall, clinicians are interested in PECs when they fulfill a patient’s information needs and are optimally performed.
How Choice of Effect Measure Influences Minimally Sufficient Adjustment Sets for External Validity
Authors: Webster-Clark Michael , Keil Alexander P
Published: February 2023

Epidemiologic researchers generalizing or transporting effect estimates from a study to a target population must account for effect-measure modifiers (EMMs) on the scale of interest. However, little attention is paid to how the EMMs required may vary depending on the mathematical nuances of each effect measure. We defined 2 types of EMMs: a marginal EMM, where the effect on the scale of interest differs across levels of a variable, and a conditional EMM, where the effect differs conditional on other variables associated with the outcome. These types define 3 classes of variables: class 1 (conditional EMM), class 2 (marginal but not conditional EMM), and class 3 (neither marginal nor conditional EMM). Class 1 variables are necessary to achieve a valid estimate of the RD in a target population, while an RR requires class 1 and class 2 and an OR requires classes 1, 2, and 3 (i.e., all variables associated with the outcome). This does not mean that fewer variables are required for an externally valid RD (because variables may not modify effects on all scales), but it does suggest that researchers should consider the scale of the effect measure when identifying an EMM necessary for an externally valid treatment effect estimate.
Complexity defying macroeconomics
Authors: Paniagua Pablo
Published: February 2023

This article contributes to the literature on complexity and macroeconomic models by exploring the analytical relationship and tensions between complex phenomena and macroeconomics. By evaluating the properties of organised complexity, this article suggests alternative strategies for analysing the macroeconomy. Drawing on F. A. Hayek’s notion of organised complexity, I examine how its causal properties relate to the analytical criteria and assumptions that contemporary macroeconomic models use. The purpose is twofold: first, I associate the properties of complexity to the idea of the macroeconomy as an emergent totality arising from the causal interplay between individuals and the organising structure. This conceptually challenges modern macro and frames analytical tensions between complexity and macroeconomic analysis. Second, introducing complexity facilitates breaking away from current analytical and conceptual straitjackets in macroeconomics. Economic inquiry requires looking for alternative ways beyond standard models to analyse the macroeconomy as an emergent totality. This suggests stepping away from current formalistic methods and radical reductionism, in favour of unconventional strategies and approaches that are sensitive to rules, structures, and the causal properties of organised complexity.
Angela Carter’s Metaleptic Turn: The Possibilities of “a Mutation, of a Revolution in the Propriety of the Symbolic System”
Authors: Thomas Karima
Published: February 2023

Angela Carter’s experiences in Japan molded her post-Japan writing: she became more preoccupied with the nature of reality and the status of the subject, which operates for her like Roland Barthes’s empty sign, whose sole reality is its appearance. Carter sought a new model of writing too, which she found partly in bunraku. This paper analyzes the role of bunraku in triggering Carter’s overlapping narrative and ontological frames. That metaleptic turn enables her to disclose the constructedness of the subject in general and the gendered subject in particular. In “The Loves of Lady Purple” and “Flesh and the Mirror,” Carter draws on bunraku for a system of representation that metatextually discloses itself as an aesthetic construction and of its subjects as discursive productions of subjectivity.
Changes in pulmonary artery index and its relation to outcome after stage II palliation in patients with hypoplastic left heart syndrome
Authors: Euringer Caecilia , Schaeffer Thibault , Heinisch Paul Philipp , Burri Melchior , Georgiev Stanimir , Lemmer Julia , Ewert Peter , Hager Alfred , Hörer Jürgen , Ono Masamichi
Published: February 2023

OBJECTIVES

This study aimed to prove if pulmonary artery (PA) size influences survival and if an additional aortopulmonary shunt (APS) promotes left PA growth after bidirectional cavopulmonary shunt (BCPS) in patients with hypoplastic left heart syndrome.

METHODS

The medical records of patients with hypoplastic left heart syndrome who underwent Norwood procedure and BCPS between 2007 and 2020 were reviewed. Right, left and total (right + left) PA indices were calculated according to Nakata and colleagues.

RESULTS

A total of 158 patients were included in this study. The median age at Norwood and BCPS was 8 (7–11) days and 3.6 (3.1–4.6) months, respectively. There were 7 hospital deaths and 12 late deaths. Survival after BCPS was 90.3% at 1 year and 86.2% at 2 years. Total, right and left PA indices were 238 (195–316), 136 (101–185) and 102 (75–130) mm2/m2 at the time of BCPS, and they were 237 (198–284), 151 (123–186) and 86 (69–108) mm2/m2 at the time of Fontan. Left PA index decreased significantly between the time of BCPS and Fontan (P < 0.01). Nine patients needed partial takedown and additional APS due to failing BCPS, but the additional APS did not promote the PA growth significantly.

CONCLUSIONS

Preoperative PA index did not affect the mortality after BCPS. The partial takedown and additional APS for failing BCPS were unable to improve left PA size.
An alluring sight of music: the musical ‘courtesan’ in the Cinquecento
Authors: Ventura Nieto Laura
Published: February 2023

The figure of the courtesan features in many literary and artistic productions of the Italian Cinquecento. The term ‘musical courtesan’ has been widely used to describe several portraits produced in the first half of the 16th century representing beautiful young women (belle) in different attires playing the lute. This article problematizes the notion of the ‘musical courtesan’ and argues instead that these depictions of belle should be understood in terms of the varied interpretations that might be reached by 16th-century viewers. Such portraits could convey higher ideals such as the institution of marriage of the contemplation of beauty. Case-studies are offered of portraits by Andrea Solario (1460–1524), Bartolomeo Veneto (1502–55), Parrasio Micheli (c.1516–78) and Palma Vecchio (c.1480–1528) that show beautiful, young female lutenists in different attires.
Double-gene targeting with preassembled Cas9 ribonucleoprotein for safe genome editing in the edible mushroomPleurotus ostreatus
Authors: Boontawon Tatpong , Nakazawa Takehito , Choi Yeon-Jae , Ro Hyeon-Su , Oh Minji , Kawauchi Moriyuki , Sakamoto Masahiro , Honda Yoichi
Published: February 2023

CRISPR/Cas9 has potential for efficient molecular breeding. Recently, a foreign-DNA-free gene-targeting technology was established by introducing a preassembled Cas9 ribonucleoprotein (RNP) complex into the oyster mushroom Pleurotus ostreatus. However, the target gene was restricted to such a gene like pyrG, since screening of a genome-edited strain was indispensable and could be performed via examination of 5-fluoroorotic acid (5-FOA) resistance caused by the disruption of the target gene. In this study, we simultaneously introduced the Cas9 RNP complex targeting fcy1, a mutation that conferred P. ostreatus resistance to 5-fluorocytosine (5-FC), together with that targeting pyrG. A total of 76 5-FOA resistant strains were isolated during the first screening. Subsequently, a 5-FC resistance examination was conducted, and three strains exhibited resistance. Genomic PCR experiments followed by DNA sequencing revealed that mutations were successfully introduced into fcy1 and pyrG in the three strains. The results indicated that double gene-edited mutants could be obtained in one experiment employing 5-FOA resistance screening for strains with Cas9 RNP incorporation. This work may pave the way for safe CRISPR/Cas9 technology to isolate mutant strains in any gene of interest without an ectopic marker gene.
Tectonic stress of northeastern Indian region derived from seismic focal mechanisms and the effect of focal mechanism on stress drop: a comparative analysis with Kachchh intraplate region of India
Authors: Kamra Charu , Chopra Sumer , Yadav R B S
Published: February 2023

In this study, the focal mechanism solutions and source parameters of recent earthquakes that occurred in the northeastern region of India have been determined. The region has very complex tectonics as it is subjected to the compressional forces from all sides, due to the collision of the Indian Plate with the Eurasian, Burma and Tibetan plates. Waveform data from deployed broad-band seismographs (BBS) and strong motion accelerographs (SMA) in the northeastern India are used to determine the focal mechanism solutions and source parameters of moderate earthquakes, respectively. The estimated focal mechanisms are used to understand the existing stress field in the region. It is found that the Shillong-Plateau as well as the Indo-Burma subduction zone is dominated by the compressional tectonic regime, Mikir Hills and Bengal basin are dominated by the trans-tension tectonic regime, and the easternmost Himalayan region is dominated by the strike-slip tectonic regime. The maximum horizontal stress direction Shmax is also determined for above subregions. The direction of Shmax is southeast in the Bengal basin, northeast in Mikir Hills and Indo-Burma subduction zone whereas it is NNE in Shillong Plateau and SSW in the eastern Himalayas. The estimated stress drop value of the earthquakes in the region ranges from 2.11 to 23.89 MPa. The relationship between the source parameters and focal mechanisms is also explored. It is found that the earthquakes with a strike-slip mechanism have the highest average stress drop (7.05 MPa) followed by reverse (6.82 MPa) and normal (5.12 MPa) in the northeastern region of India. According to the examined data set, the stress drop is found to be dependent on the type of focal mechanism, seismic moment and hypocentral depths. The comparison of the results with the Kachchh intraplate region in western India shows earthquakes in Kachchh have larger mean stress drop for all types of mechanisms. In both intraplate and interplate regions of India, the stress drop of earthquakes depends on the type of focal mechanism solution.
A double-edged sword: Constitutional dialogue confined
Authors: Yosef Bell E
Published: February 2023

Dialogic judicial review is a dialectic interaction between supreme courts and legislatures regarding the constitutionality of legislation, in which each institution preserves its constitutional authority, and yet performs it while considering the other institution’s stance and its ability to respond. This interaction is based on reciprocity and upon the contribution of both institutions to the constitutional design and interpretation of legislation. This dialogic interaction has much value at the institutional and instrumental level. Unfortunately, constitutional dialogue sometimes has a negative influence on petitioners and similar groups, as their rights are being trampled under a dialogic veil. This article argues that constitutional dialogue can (and sometimes must) be restricted to avoid hindering human rights during the constitutional institutional interaction. It sketches a doctrine designed to prevent impairing human rights in the name of dialogic interaction, through three arguments: (i) the constitutional dialogue must be restricted, since reality shows that courts in many cases prefer legitimacy considerations over protecting human rights; (ii) in the case of under-represented groups, there is no reason to trust legislatures to take human rights into consideration while formulating a legislative response; and (iii) courts can restrict the dialogic interaction by declaring the constitutional purpose to be unconstitutional or by using judicial decisiveness which strives for full and coercive judicial constitutional review.