bluuebunny/crossref_metadata_2025 huggingface dataset:
1354 USING REALIST PROGRAMME THEORY TO DESIGN A NEW INTERVENTION FOR IMPROVING RECOVERY AFTER DELIRIUM
Authors: Raghuraman S , Richards E , Morgan-Trimmer S , Clare L , Anderson R , Goodwin V , Allan L
Published: January 2023

Introduction

People who recover poorly after delirium are likely to require an increased level of care. It is presently unknown whether interventions to improve recovery after delirium are effective and cost-effective. This research aimed to develop a programme theory to inform the design of an intervention to improve recovery after delirium.

Method

A rapid realist review of literature was conducted to develop an initial programme theory. Following this, a qualitative investigation of the perceived rehabilitation needs of older people who have experienced delirium during a hospital stay was conducted via semi-structured interviews with 41 key stakeholders (older people (5), carers (12), and healthcare professionals (24)). Data were analysed using a realist approach to identify what works, for whom, and in what context. This was deductively informed by the initial programme theory while also employing an inductive analysis to identify novel insights. Through an iterative, retroductive process, context-mechanism-outcome configurations (CMOCs) were coded to reflect stakeholders’ views to refine the programme theory.

Results

The initial programme theory highlighted the importance of cognitive and physical rehabilitation and emotional support as key domains of recovery. New CMOCs included optimisation of good medical care to manage delirium and monitoring and management of underlying medical conditions to promote recovery. Others included developing educational resources and support networks for older people and their carers to aid sense-making, and encouraging social interaction to reduce isolation and empower independent functioning. These recovery elements should be addressed in a person-centred manner that is tailored to individual needs and preferences, engages carers, integrates intervention goals into daily functioning, and ensures continuity of care.

Conclusion

A refined programme theory was developed and is currently being used to design a manualised intervention to improve recovery after delirium. The acceptability of the intervention will be tested in a multi-centre, single-arm feasibility study.
1145 RTMS TREATMENT IMPROVED COGNITIVE DYSFUNCTION THROUGH ADULT NEUROGENESIS IN ICV-STZ RAT MODEL OF SPORADIC ALZHEIMER'S DISEASE
Authors: Roy A , Kumar A , Kakkadi V , Nag T C , Katyal J , Gupta Y K , Jain S
Published: January 2023

Background

Intracerebroventricular streptozotocin injection at 3mg/kg of b/w causes phenotypes similar to that of sporadic Alzheimer’s disease (sAD) from 14th day post-injection. On the other hand, the body of evidence indicated that impairment in the sAD is the major contributor for cognitive decline. Taken together, we tested the adult neurogenesis hypothesis in streptozotocin model of sAD in female Wistar rats after extremely low magnetic stimulation (MF: 17.96, 50Hz, 2hr/day, 21days).

Method

33 rats were randomly divided into three groups viz. Sham+MF, AD and AD+MF. Consequently, animals were first induced AD with stereotaxic manipulation and then they were exposed to low frequency magnetic field stimulation, followed by terminal cognitive behavioural tasks brain tissue being isolated for both biochemical and subcellular expression experiments (ethical no. 12/IAEC-1/2017).

Results

Showed reduction in latency to the goal quadrant (p= 0.002) and transfer latency (p= 0.045) in AD+MF group versus AD. Even, Dirichlet distribution of time spent in 4 quadrants indicated un-uniform in all the groups except AD group (p= 0.067, LRS= 7.35). Further, cell count in CA3 and DG exhibited increase in cell density in AD+MF group (p<0.05). However, we found significant reduction in SOD1 activity after MF treatment (p= 0.035) but no change in GSH level in hippocampus and frontal cortex. Interestingly, these changes in AD+MF animals are associated with increase in density of BrdU+/Nestin+ cells in granular layer (p= 0.002) and hilus region (p= 0.0005) of DG along with increase in expression of L-type Ca2+ channels as compared to AD group.

Conclusion

This experimental evidence suggests that non-invasive brain stimulation can promote adult neurogenesis by activating L-type ca2+ channels in the hilus, which intern helps in retention of long-term memory even after sAD.
1362 ANTICHOLINERGIC PRESCRIBING HABITS AND ITS ASSOCIATIONS IN A COMMUNITY POPULATION OF PEOPLE LIVING WITH DEMENTIA
Authors: Curtis F , Li L , Kolanko M , Lai H , Daniels S , True J , Del Giovane M , Golemme M , Lyall R , Raza S , Hassim N , Patel A , Beal E , Walsh C , Purnell M , Whitethread N , Nilforooshan R , Norman C , Wingfield D , Barnaghi P , Sharp D , Dani M , Fertleman M , Parkinson M
Published: January 2023

Introduction

Many commonly prescribed medications have inadvertent anticholinergic effects. People with Dementia (PwD) are more vulnerable to these effects and at risk of adverse outcomes, the risk being higher with a greater degree of anticholinergic exposure. We investigated prescribing patterns and Anticholinergic burden (ACB) in a cohort of community-dwelling older adults with dementia and aimed to explore the effect of ACB on cognition, mood, and quality of life(QoL).

Method

The medication and demographic information for 87 (39 female) community-dwelling PwD were obtained from Electronic Care Summaries. We used the German Anticholinergic Burden Scale (GABS) to measure ACB. Additionally, we investigated associations between ACB and cognitive (ADAS-Cog), functional (BADL) and QoL (DemQoL) assessments.

Results

28.7% of participants had a clinically significant score (ACB> 2). The most commonly prescribed medications with ACB were Lansoprazole(18.3%), Mirtazapine(12.6%) and Codeine(12.6%). ACB was higher in males and negatively correlated with age, r(87)=-.21,p=.03. There was no association between ACB and cognition, QoL, functional independence, and neuropsychiatric symptoms. Over six months, PLWD with no ACB had a greater negative change in neuropsychiatric symptoms[t(18)=2.27,p=.04] and functional independence[t(23)=-3.8,p=.001], indicating greater dependence and worsening neuropsychiatric symptoms.

Conclusion

A third of PLWD in the community had clinically significant ACB. No ACB was associated with worsening neuropsychiatric symptoms and functional dependence over a six-month period. Community prescribers should consider regular medication reviews with PLWD and carers to ensure medications are prescribed safely and appropriately.
1219 INFORMAL CAREGIVERS OF PEOPLE WITH PARKINSONISM IN THE PRIME-UK CROSS-SECTIONAL STUDY
Authors: Tenison E , Cullen A , Pendry-Brazier D , Smith M D , Ben-Shlomo Y , Henderson E J
Published: January 2023

Introduction

Many people with parkinsonism require care as the disease progresses with much provided unpaid by family and friends. Caring for someone can have a negative impact on physical and psychosocial wellbeing. Caregiver burden can impact ability to continue this role, which can precipitate hospitalisation or institutionalisation of the recipient.

Methods

In this single-site study, primary, informal caregivers, defined as those providing any care or support, were enrolled alongside the person with parkinsonism or individually. Self-reported questionnaires included the 22-item Zarit Burden Interview (ZBI), which can range from 0-88, with higher scores representing greater burden. Linear regression was used to explore the association between recipient characteristics/need and caregiver burden.

Results

Of 1,032 eligible patients approached, 813 participants indicated whether they had an informal caregiver (708) or not (105). 376 caregivers consented (53.1%), of whom 321 have returned questionnaires, with patient data available for 296. The median age of caregivers was 73.0 (range 27.0- 91.1 years), 237 (73.8%) female. 274 (85.4%) were the spouse/partner of the patient. 215 (67.0%) were the sole caregiver. The median time per week spent caring was 21 hours (interquartile range 7, 41 hours). 18 (5.6%) of caregivers provided 24-hour care daily and 113 (35.2%) had provided support for over 5 years. Median ZBI score was 17, (interquartile range 7-29). The care recipient’s duration of parkinsonism was associated with higher burden score (0.38 increase per year of parkinsonism; 95% CI 0.07, 0.69; p value 0.015), as was the time per week spent caring (0.16 increase for each additional hour; 95% CI 0.11, 0.20; p value <0.0001).

Conclusions

Many informal caregivers in this study were the sole caregiver and many were themselves older adults. Burden increased with increasing duration of parkinsonism and as time spent caring increased. This highlights the ongoing need to improve support for this group.
1207 EXPLORING AUDIO-RECORDING IN TERMINAL ILLNESS - THE HOSPICE BIOGRAPHERS MODEL
Authors: Halton-Hernandez E , Ali K , Cooney G , Abrams R
Published: January 2023

Introduction

The therapeutic benefits of narrative in terminally ill patients is widely studied and evidenced in the research literature. The Hospice Biographers are a charity offering a professional free service for end-of-life patients the opportunity to audio-record their life story in a memory stick and to keep copies for themselves and for their families. The objective of this qualitative study is to explore the experience of a group of people either recording or listening to an audio-biography.

Methods

Five semi-structured in-depth interviews with terminally ill adults who recorded an audio-biography and another interview with a family member were conducted virtually. Transcripts of the zoom interviews were coded using thematic analysis.

Results

Our findings showed that patients found talking to a trained audio-biographer provided a neutral, non-judgemental interlocutor. The biographer helped them reminisce in a guided conversation navigating their life stories in chronological order. The experience of planning for the recording varied from preparing a mind-map, to writing down some guide notes or no preparation at all. Patients reported a feeling of catharsis while telling their stories as well as being able to reflect on and analyse significant life events. However, it was challenging to convey difficult emotions whilst being mindful of how patients’ life stories might be perceived by families. Although there was a degree of uncertainty about impact of the recording upon listeners, it was felt that leaving a voice-recorded account would still be informative and beneficial. A personal narrative could also provide a wider historical account of the relevant time period. Some individuals fed back that they would have valued the opportunity to edit their recording after listening and include a visual element.

Conclusions

Recording an audio-biography in terminal illness allows patients a space for reflection and provides a valued connection with immediate family members and future generations.
1178 RETROSPECTIVE SURVEY OF DIFFERENTIAL DIAGNOSES IN A NEUROVASCULAR CLINIC
Authors: Awatramani S , Kulendran A , Umasankar U , Patel M
Published: January 2023

Introduction

Diagnosis of Transient Ischaemic Attack [TIA] is important to minimise risk of future strokes. This retrospective descriptive study aimed to describe frequency of alternative diagnoses in a busy inner-city neurovascular clinic and evaluate processes of assessment and investigations of ‘true’ TIA patients.

Methods

Data was obtained over a 2-year period [2019-2020] for all new patients assessed in a busy consultant-provided daily week-day neurovascular service that serves a million multi-ethnic, population. Data collected included socio-demographic details, final clinical diagnoses, and process measures including speed of assessment and rate of neurological and cardiological investigations.

Results

Of 1764 patients, 39.3%[694] were diagnosed as TIA; 60.7%[1070] had 40 distinct differential diagnoses. Top ten diagnoses included migraine including ocular migraine [9.5%], Syncope [5.5%], Local Eye conditions (non-neurological)[5.3%], non-cervical radiculopathy [4.0%], Benign Paroxysmal Positional Vertigo [4.0%], Previous/Incidental Stroke [3.7%], Transient Global Amnesia [2.4%], Orthostatic Hypotension [1.8%], Non-migraine Headache syndromes [1.6%], Cervical Neuropathy [1.3%]. 10.9%[193] had no organic pathological diagnosis. For 694 TIA patients, 100% had neuroimaging [CT/MRI] and 98% had carotid dopplers on or before day of clinic. Non-urgent cardiovascular investigations performed included echocardiogram [83%], Holter monitoring [75%] and bubble echocardiogram [5%].

Discussion

This large survey has described the frequency of TIA and alternative diagnoses in a dedicated neurovascular service. The study highlights the importance of accurate diagnosis of TIA by experienced clinicians for appropriate secondary prevention. We also described the efficiency, and speed of assessment and proportion of investigations undertaken in these patients. This study provides valuable information to clinicians, researchers and commissioners of stroke services in future.
1190 QUALITY IMPROVEMENT PROJECT ON MEDICAL DISCHARGE LETTERS
Authors: Wee K C , Alicehajic-Becic D
Published: January 2023

Introduction

The aim of this quality improvement project was to assess the medical discharge letters written by medical colleagues at this trust against the guidelines set by the Royal College of Physicians. The target was to achieve at least 90% compliance across the components evaluated at the end of this project.

Method

This quality improvement project evaluated medical discharge letters from three medical wards. Following the application of filtering criteria, a sample size of approximately 20 patients was randomly selected for data collection. Sections that were evaluated in the discharge letter included areas of clinical summary information, investigative results, medication changes, follow-ups and GP actions. Information obtained from the letters were reported as ‘yes’, ‘no’ or ‘non-applicable’ on an Excel spreadsheet. Data collected was analysed and areas of strengths and weaknesses were identified. They were used to form action plans, following which the cycle of evaluation was repeated.

Results

Two cycles were carried out in this project. Issues were identified in the sections of clinical summary, documentation of blood results, medication changes and their indication, and follow-ups. Action plans such as education (leaflet, emails and education session), introduction of a discharge letter checklist and acronym expansion were used. By the end of the third round of data collection, all components achieved at least 90% compliance, with the exception of changes in regular medications and differentiation of follow-ups into booked and those which needed booking.

Conclusion

This project has resulted in an increase in adherence to the standards set by the College when completing medical discharge letters. Periodic evaluation will be beneficial to ensure that a high standard of compliance is consistently achieved. Sample size could be increased to improve the significance of evaluation. This study can be expanded to other specialties to increase coverage.
1271 A NOVEL PRESSURE INJURY CARE BUNDLE FOR DEPENDENT PATIENTS WITH PRESSURE INJURIES IN BERMUDA
Authors: Myint H , Simmons M , De La Cruz J , Diaz B , Baldonado G , Edwards B , Kiriyadoss D , Drummond K , Mulkerrin E C
Published: January 2023

Introduction

Pressure injury (PI) management is a challenge in dependent patients in acute care wards (ACW) despite standard care (regular pressure relief measures, incontinence management, debridement, optimisation of hydration and nutrition).

Method

A Pressure Injury Care Bundle (PICB), introduced by the Department of Geriatrics, enhanced standard care by diligent and regular interdisciplinary team monitoring of patients with PIs following transfer to Long Term Care (LTC) wards and thus may improve outcomes. The PICB was delivered by multiple PI Nurse Champions with education of all nurse assistants and medical staff into PI aetiology/management. Progress was monitored with weekly PI measurements/photography and Nurse Champion-lead team review of all PIs. Data are presented as mean+/-1SD. After 96+/-103 days in the ACW, the PICB was applied to 30 consecutive patients aged 80+/-14 years, (19(60 %) were female). All had stage 2-4 PIs (present in 25(83%) on admission to ACW). On transfer to LTC wards, all patients had severe physical dependency with a mean Charlson Comorbidity Index of 7+/-3, 27(90%) had palliative needs and 24(80%) were bedfast. Cognitive impairment was present in 22(68%) patients with 12(37%) dying due to advanced dementia. Patients were followed for 116+/-274 days.

Results

PI improvement by >2 stages occurred in 11(36%) patients after a mean of 103 days. Ulcers closed fully after 154+/-48 days in a further 15(50 %) patients. However, new ulcers emerged or preterminal (<21 days prior to death) deterioration occurred in 5(17%) patients, related to severe contractures, preterminal poor nutrition and sarcopenia with 16(54%) patients dying.

Conclusion

These results suggest that an intensive multimodal intervention involving best practice enhanced by PI Nurse Champions and delivered by educated staff with regular PI team progress reviews results in significant improvement/healing of PIs in severely dependent patients with palliative needs. Expansion of the PICB to other wards with prospective evaluation has been planned.
1304 LAXATIVES PRESCRIPTION MONITORING FOR AN OVERLOOKED PROBLEM
Authors: Wong E , Payab Q , Justin J , Nadir R , Aung N , O’Malley F , Gamble E
Published: January 2023

Introduction

Constipation is a common diagnosis among hospitalized patients. It results in considerable morbidity in elderly patients, healthcare utilization and economic burden. Laxatives are commonly prescribed but poorly monitored due to benign side effect perception.

Aim

We undertook a review of the quality of laxative prescribing and subsequent monitoring amongst an inpatient cohort. We propose new standards:

- Medication review at least once weekly;

- Documented rationale for choice of medication

- Specified timeframe review and outcome documentation

We reviewed current hospital trust policy of laxative prescribing and produced a new constipation management guideline in response to early audit data.

Method

Data collected across medical wards in Trafford General Hospital, Manchester. Data was collected on types of laxatives, reason for prescription, date of review, length of course, compliance and effect of laxatives. Two rounds of audit were performed 6 months apart, with an interim intervention of staff education and local introduction of a new constipation management guideline. The guideline consisted of decision algorithm and suggested treatment.

Results

47 individual prescriptions were audited in round 1 and 72 prescriptions in round 2, this represented 23 and 32 patients respectively. Review of medications within first week of prescription improved from 17% to 83.7% across the two cycles. Documentation of constipation diagnosis improved from 52.2% to 97.2%. There were large percentage improvements in documentation of specified treatment outcomes across all audited fields, despite overall poorer medication compliance among patients in round 2 (56.9% versus 66% in round 1). The average length of laxative use decreased from 18.6 days to 15.3 with overall percentage of patient with constipation resolved increased from 65% in round 1 to 73% in Round 2

Conclusion

Staff education and implementation of treatment guidelines made a substantial improvement to the medical management of constipation in hospitalized patients.
1307 IMPLEMENTING THE HEE COMPREHENSIVE GERIATRIC ASSESSMENT (CGA) FOR FALLS IN CARE HOME PATIENTS– A QUALITY IMPROVEMENT PROJECT
Authors: Jones K , Tekkis N , Dronfield S , Munslow N
Published: January 2023

Introduction

According to the Health Education England (HEE) Framework for Enhanced Health in Care Homes 2020, 33% of people over 65 and 50% of people over 80 have one or more fall a year, figures which significantly increase in care home residents. Prevention of falls promotes the quality of life of elderly patients and could significantly reduce the burden on primary and secondary care stemming from fall induced fractures, loss of mobility and community follow up. The Comprehensive Geriatric Assessment (CGA) for falls includes a full falls assessment questionnaire, medication review, lying/standing blood pressure and frailty index. The HEE set out a requirement that all care home patients should have a CGA assessment within 7 days of readmission to a care home following a hospital episode because of a fall. This audit examined the compliance of Four Counties primary care network (PCN) to the 7-day CGA HEE guideline for falls.

Methods

Retrospective analysis of 68 eligible patients from Four Counties PCN between 31st March 2021 and 1st March 2022. Analysis indicated a poor compliance to the HEE CGA guidelines (15%). After presenting to the MDT, we formulated a system-wide plan to improve reporting of care home falls to OTs, creating protected time for pharmacists to conduct care home medication reviews and promoting in-person weekly care-coordinator meetings. The PCN was audited for a second time after 3 months.

Results

A significant improvement (15% to 57%) in adherence to the HEE CGA framework was noted after implementation of above changes. Medication review in 7 days improved from 42% to 80% and falls assessment questionnaire in 7 days compliance improved from 23% to 70%.

Conclusion

Creating clear protocols for reporting falls and clarifying MDT roles in the CGA are essential to identifying and preventing falls in at-risk care home residents.
1326 IMPROVING THE QUALITY OF BOWEL CARE ON GERIATRIC WARDS BY INCREASING COMPLIANCE OF DAILY DOCUMENTATION OF BOWEL MOTIONS
Authors: Bamgboye J , Mithani P , Bafhadel L , Whitear J , Kaneshamoorthy M
Published: January 2023

Introduction

Bowel health is affected in acutely admitted patients due to illness, change in diet, dehydration, and reduced mobility. Constipation is common and older patients are particularly at risk of constipation due to reduced bowel transit speed. Bowel motion monitoring can help improve bowel health and reduce complications including delirium, which can prolong hospital admission. To increase detection of constipation, a quality improvement project was carried out in the Department of Medicine for the Elderly at Southend Hospital, with aims to increase compliance of daily stool chart entries. Early detection will prompt patient review, investigation, and treatment of constipation, thereby managing symptoms and preventing complications.

Method

Stool charts of patients across the geriatric wards were reviewed weekly for daily entries up to the last 7 days of their admission. Baseline compliance was determined on day 0 by dividing total days of stool chart entries over total days of admission (up to 7 days). Patients newly admitted or transferred to the ward on the day of stool chart review were excluded from the data. Interventions included verbal reminders to stakeholders (nurses, HCAs, doctors) at morning handovers, an electronic reminder with emails to stakeholders, and lastly a visual reminder with copies of a poster around the ward. The interventions were implemented separately on a weekly basis to quantify their effectiveness on compliance through further stool charts reviews on days 7, 14 and 21, and compared to baseline data.

Results

Overall compliance increased by 16.9%, and the largest improvement was in response to the poster strategically placed next to all patient charts.

Conclusion

The QIP was time and resource efficient, helping to identify constipation early and flag patients at risk for or for treatment of constipation. It is also easily repeatable and similar principles can be applied across other wards and specialties.
1339 IMPROVING INPATIENT MANAGEMENT OF DELIRIUM IN A DISTRICT GENERAL HOSPITAL
Authors: Juwarkar A , Ahmed S , Franks S , Ring A
Published: January 2023

Background

Delirium is a common clinical condition associated with increased morbidity and mortality, and prolonged hospital stay. Early detection is vital to improving management of the condition and improving outcomes.

Aims

Improve delirium detection using the 4AT screening tool as a validated approach; Improve delirium management across multiple domains using the PINCH ME approach; documented attempt at collateral history within 24 hours of recognition of delirium; obtain serological confusion screen in patients with recognised delirium. (100% each)

Method

Plan Do Study Act (PDSA) method was used to conduct this Quality Improvement (QI) project over 12 months. Data was obtained from paper and electronic records in the medical wards with regards to 'at risk patients' (i.e. over 65y, acutely unwell, background of cognitive impairment and/or acute fracture). The use of 4AT or alternative delirium screens from the emergency department (ED) and medical teams were noted. Assessment for pain, urinalysis, serological screens, bowel and nutrition review including MUST scores, medication reviews were looked for. Interventions included presentation and education at the medicine grand round, publishing a poster, and a PINCHME alert sticker for the medical notes to use at time of assessment. 2 PDSA cycles were completed and post sticker results obtained.

Results

Baseline data shows that collateral history was attempted for 70% patients - improved to 100% after sticker use. Use of validated screening test from 15% to 100% after sticker use. Nutrition assessment improved from 15% to 40%. Serological testing improved from 40% to 53%. 100% patients received a medication review after sticker use.

Conclusion

Introduction of PINCHME sticker serves as a prompt to ensure holistic management. Currently delirium management is clinician dependent as there is lack of formal delirium management pathway. Further plan includes involving nursing staff and 'delirium champions' to bring about a formal pathway for lasting change.
1292 MEDICALLY SAFE FOR DISCHARGE (MSFD): REDUCING DOCTOR INPUT IN MSFD PATIENTS ACROSS GERIATRIC MEDICINE WARDS AT A DGH IN SOMERSET
Authors: Parker H , Asher G
Published: January 2023

Introduction

Large numbers of geriatric inpatients within acute settings are deemed medically safe for discharge (MSFD) but stranded within the hospital due to a lack of community services and social care packages, leading to increasing length of patient stay and reduced hospital flow. These patients do not require inpatient care and would otherwise be discharged to their home or residential care. This project aimed to identify these patients and rationalise their medical input to mirror a community setting (without routine daily medical reviews).

Methods

MSFD patient were identified by the multi-disciplinary team (MDT). Patients identified received standard nursing and therapy input, alongside daily MDT discussion at a board round to progress discharge planning. If the MDT expressed concern about a MSFD patient, they would receive a medical review. A sticker placed in the notes identified patients deemed MSFD.

Results

A 3-week trial on a 19-bedded geriatric ward showed 46% of bed days were occupied by MSFD patients. On average, 8 MSFD patients did not require daily review. 0.6 unplanned reviews/day were needed due to MDT concern, saving an average of 7.4 patient reviews/day, equating to 3.3 hours/day doctor time saved.

Conclusions

Doctor time saved allowed redistribution of staff to busier wards with more unwell patients, with no detriment to patient care noted. The trust formalised a SOP and the MSFD pathway was introduced across the geriatric medicine department. A MSFD ward has now been opened, to cohort patients awaiting discharge to community pathways. This ward should require minimal doctor input to allow continued redistribution of medical staff across the hospital, as well as facilitating patient flow by admitting patients who reside on the acute frailty unit who require increased community care.
1293 A MULTIDISCIPLINARY TEAM DERIVED QUALITY IMPROVEMENT PROJECT TO IMPROVE THE EFFICIENCY AND EFFECTIVENESS OF THEIR HYBRID MEETING
Authors: Scaife J , Walters E , Fisher N , Kumar S
Published: January 2023

Introduction

Working in a small district general hospital in Llanelli, West Wales, a weekly hybrid multi-disciplinary team (MDT) meeting is held on the stroke and care of the elderly unit. There are 3 separate geriatric teams covering the ward. Typically, these meetings are attended by physiotherapists, occupational therapists, speech and language therapists, discharge nurses, social workers, nurses and a doctor. The main agenda is to discuss the patients’ current medical issues, rehabilitation needs and likely discharge destination/complexities. Medically, these meetings were attended by a single doctor who often found it difficult to concisely summarise the patient’s medical problems from the notes of patients not under their care. Our aim was to streamline the MDT meeting with regards to quality of content, understanding of patient issues and general efficiency.

Intervention

An initial questionnaire was used to gather prospective data. 90% of MDT members suggested that a doctor from each team should attend to present patients under their care and engage in onward discussions. This was implemented over the period of a month. A follow-up questionnaire collected quantitative data by asking MDT members to retrospectively rate, on a scale of 1 to 10, the efficiency of the meeting and the understanding of patient’s medical conditions before and after implementing the change.

Results

The average efficiency was rated at 4.8/10 before the change was implemented and 8.8/10 afterwards, a 40% improvement. Understanding of patient medical issues had a 28% improvement, from an average rating of 6 to 8.8. Qualitative and free text data was also collected highlighting a secondary benefit of reciprocal communication between the therapy MDT and the appropriate medical doctors hopefully improving the timeliness of any required action.

Conclusions

Suggestions of further changes include making the meeting fully face-to-face, providing a “proforma” to document what was discussed and introducing other members of community teams.
1282 EVALUATION OF THE IDENTIFICATION BONE HEALTH OF PATIENTS ON GERIATRIC WARDS
Authors: Amoah J K , Than H P , Phyu E E , Kaneshamoorthy M
Published: January 2023

Introduction

NICE guidelines state that fracture risk assessment should occur in all women aged ≥65 and all men aged ≥75. This includes assessing patients’ FRAX score, measuring serum vitamin D and calcium levels. Early detection and treatment can prevent complications like fragility fractures. We conducted a Quality Improvement Project to improve bone health assessments on Geriatric Wards.

Methods

A baseline audit assessed: admission reason, falls history, FRAX score, CFS, previous DEXA scans, whether vitamin D and calcium levels were checked during the admission, and if treatment was commenced (bone resorption medication and vitamin D/calcium supplements). Data was collected two further times following interventions over a 5-month period. The first intervention was an announcement at the morning departmental meeting reminding clinicians. The second intervention was an email reminder.

Results

There were 56, 51, and 58 patients per cycle. 19, 15, and 17 patients were admitted with falls. 23, 14, and 10 patients had a falls history. Average CFS was 5.4, 5.4, and 5.5. Average major osteoporotic fracture FRAX score was 15.8, 16.4, and 12.9. Checking serum calcium was 88%, 100%, and 100%. Checking vitamin D was 30%, 43%, and 60%. 28%, 43%, and 47% of patients were prescribed calcium and vitamin D supplements. Patients on bone resorptive treatment dropped from 7% to 3% to 2%. 8, 12, and 11 patients had a previous DEXA.

Discussion

Verbal announcement had the greatest impact. Visible reminders help sustainability. This QIP highlighted the lack of bone protection treatment with multiple contributing factors including some patients lacking the capacity to follow instructions to take weekly medications or patients requiring vitamin D being replaced initially, with initiation later. This QIP feeds into a larger trust project in developing a ‘Fracture Liaison Service’, which could improve adherence and provide a pathway in utilising annual and bi-annual treatments.
1192 FALLS PREVENTION: COMMUNITY EXERCISE PROGRAMME; REDUCING RISK OF FALLS, DECONDITIONING AND LONELINESS IN FRAIL ELDERLY PATIENTS
Authors: Butler J , Shalev Greene L
Published: January 2023

Introduction

Covid has had a devastating effect on the Elderly, resulting in deconditioning, increased falls and loneliness. Tailored exercises can reduce falls in people aged over 65 by 54% and participation in physical activity reduces the risk of hip fractures by 50%, currently costing the NHS £1.7 billion per year in England. This 8-week intervention delivered by trained volunteers in patient’s homes, aims to reduce deconditioning, loneliness and the risk, incidence and fear of falling (FOF) amongst frail patients post-discharge from hospital.

Method

A gap in service was identified in Frail patients discharged from hospital, at risk of falling and awaiting community physiotherapy. A steering group was set up including acute and community therapists, volunteers and carers to design a collaborative intervention to bridge the gap. At risk patients were identified and referred by ward therapists supported by the hospital volunteering team. Volunteers were trained to deliver an 8 weeks programme of progressive exercises in patients’ homes with additional signposting to appropriate statutory and voluntary services. Qualitative and quantitative outcome measures were taken at week 1 and week 8 of the intervention

Results

91.5% total health outcomes improved or maintained by average:

- FOF reduced by 22.5%

- 180 degree turn improved by 43%

- 60 sec Sit to Stand improved by 14.75%

- Timed Up And Go improved by 15.5%

- Confidence to cope at home improved by 15%

- Pain / discomfort (self-reported) improved by 18.75%

- Overall health (self-reported) improved by 8.5%

Conclusion(s)

Targeted exercise at home with skilled volunteers can improve functional fitness and health outcomes in a frail elderly population at risk of falls when discharged home from hospital. The programme increases patients’ connectivity to local voluntary and community sector services. Volunteers’ mental health improves by engaging in meaningful service.
1231 MANAGING THE DETERIORATING PATIENT IN A REHABILITATION HOSPITAL: THE ROLE OF TREATMENT ESCALATION PLANNING
Authors: Brown R , Connelly H , McCrae K , Manners R , Waddell G
Published: January 2023

Introduction

The pandemic has shown how vital patient-centred treatment escalation planning (TEP) is for older people. Locally we have seen inappropriate transfer of dying patients to acute hospitals from rehabilitation units. Mortality review found a lack of useful TEPs in these cases. Baseline data in our rehabilitation hospital showed 54% of patients had a TEP and 16% a decision made about repatriation during acute illness. We aimed to increase the proportion of patients in this setting with a TEP to 80% over six months.

Methods

A multidisciplinary team of doctors, ANPs and senior nurses worked together. We conducted stakeholder engagement to understand the factors that result in transfer of patients and found that completion of TEPs was felt to be an effective way to improve communication out of hours. Our first test of change involved an ANP raising the CPR status and TEP for all new patients at the weekly MDT. We measured the process of what decisions were made once a fortnight. Outcome data on the overall completion of TEPs and repatriation decisions was collected each month.

Results

New decisions were made at each MDT – for example, on one date two new DNACPRs and six new TEPs were completed. Overall TEP completion rate varies however since our first intervention we have seen a sustained increase in the number of TEPs which include consideration of repatriation – from 16% to 60%. Ongoing conversation with doctors in training reveals challenges with ward staff awareness of TEP content and their ability to guide unexpected events out of hours.

Conclusion

Involvement of motivated permanent staff across disciplines has allowed us to ensure escalation plans are being made each week and see a sustained increase.
1357 THE ‘CONSULTATION COMMUNICATION’ PROFORMA: ENHANCING EFFECTIVE COMMUNICATION BETWEEN OUTPATIENTS AND INTERMEDIATE CARE
Authors: Mahmood K , Hussain A , Packer S , Edwards S , Gupta A
Published: January 2023

Introduction

The Norman Power Centre (NPC) is a 32 bedded Intermediate Care Unit, run by an acute hospital trust in Birmingham, UK, for patients who require ongoing 24-hour care, rehabilitation or further assessment, but do not need to be in an acute hospital setting. These frail patients attend numerous outpatient hospital appointments, but rarely do staff receive communication back from these outpatient reviews. This can lead to delays in implementing specialist management plans, with potential for adverse outcomes for patients and increased staff workload in seeking out the required information. A ‘Consultation Communication’ proforma was designed, to be filled in at the appointment and brought back to NPC with the patient.

Method

Patients and escorts took proformas to outpatient appointments between March and June 2022. The information on the forms was then analysed to assess completeness and usefulness.

Results

Appointments were in surgical and medical specialities, as well as imaging in three hospitals within one trust. Proformas were taken to 19/20 appointments. 100% of these were at least partially completed, with only two forms being largely incomplete. 17/19 provided information about the assessment carried out. 12/19 included recommendations relevant to admission at NPC. 13/19 had information on medication changes. 14/19 stated whether follow up was required. Eight out of nine required follow-ups had specific details included. 13/19 had the professional’s details, 11 with contact numbers. Of those without details, two were imaging appointments where contact details were not relevant.

Conclusions

This easy to implement, simple intervention, with an excellent engagement rate from both NPC and outpatient appointment staff, has led to improved continuity of care for patients. The proforma has scope to be improved based on staff feedback, and its use could be expanded across other off-site facilities such as community hospitals or care homes.
1193 CWTCH IN THE COMMUNITY - IMPROVING EDUCATION TO REDUCE ADVERSE OUTCOMES FOR PATIENTS WHO FALL IN NURSING HOMES (NH)
Authors: Burgess A J , Clee D , Davies E A , Burberry D J , Keen L
Published: January 2023

Introduction

Falls have significant morbidity and mortality in Nursing Home (NH) residents. By improving education to NH staff we aim to reduce 999 calls and associated adverse outcomes. NH residents are more likely to fall than people living in the community and are more at risk of further falls as interventions and risk factor modification is more difficult.

Methods

Phase 1 - Ambulance calls, where a vehicle attended the scene, between 01/01/2020-28/02/2022 from NH in Swansea Bay University Health Board (SBUHB) concerning Falls/?Falls (Haemorrhage/lacerations, Unconscious/fainting, traumatic injuries, sick person, convulsions/fitting) were analysed and survey was sent out to all NH.

Phase 2 - Education was provided about CWTCH (hug in Welsh) and staff were surveyed post intervention. Can you move them, Will it harm them? - new neck/back pain, anticoagulation, Treat them – analgesia, wound-care, Cup of Tea – can eat and drink, Help – when contact 999.

Results

Phase 1 - Between 01/01/2020-28/02/2022, of 4907 calls, 866 were falls (17.65%) and 1032 ?Falls (21.07%), 60.49% conveyed to hospital. 47% of NH do not have falls guidelines and 100% patients are Nil by Mouth and 88.24% are not moved. Emergency services were contacted 88.24%. Phase 2 - Education was delivered to all NH in Swansea (122 staff). Feedback showed 100% feel more confident in giving food and drink, moving patients, with 90.98% less likely to contact 999 and 75.40% not having previous training with 96.72 % more confident in giving analgesia.

Conclusions

Falls remain a significant burden and a rapid service would improve care with conveyance reduction to 53.1% post education (60.55% pre-education). Future directions include offering this education to NH in Neath/Port Talbot. From March 2022, we offer same-day assessment for NH residents (and others) from primary care and ambulances and are developing a PRN analgesia pathway e.g. PENTHROX.
A unified mediation analysis framework for integrative cancer proteogenomics with clinical outcomes
Authors: Huang Licai , Long James P , Irajizad Ehsan , Doecke James D , Do Kim-Anh , Ha Min Jin
Published: January 2023

Motivation

Multilevel molecular profiling of tumors and the integrative analysis with clinical outcomes have enabled a deeper characterization of cancer treatment. Mediation analysis has emerged as a promising statistical tool to identify and quantify the intermediate mechanisms by which a gene affects an outcome. However, existing methods lack a unified approach to handle various types of outcome variables, making them unsuitable for high-throughput molecular profiling data with highly interconnected variables.

Results

We develop a general mediation analysis framework for proteogenomic data that include multiple exposures, multivariate mediators on various scales of effects as appropriate for continuous, binary and survival outcomes. Our estimation method avoids imposing constraints on model parameters such as the rare disease assumption, while accommodating multiple exposures and high-dimensional mediators. We compare our approach to other methods in extensive simulation studies at a range of sample sizes, disease prevalence and number of false mediators. Using kidney renal clear cell carcinoma proteogenomic data, we identify genes that are mediated by proteins and the underlying mechanisms on various survival outcomes that capture short- and long-term disease-specific clinical characteristics.

Availability and implementation

Software is made available in an R package (https://github.com/longjp/mediateR).

Supplementary information

Supplementary data are available at Bioinformatics online.
Preoperative visualization of congenital lung abnormalities: hybridizing artificial intelligence and virtual reality
Authors: Bakhuis Wouter , Kersten Casper M , Sadeghi Amir H , Mank Quinten J , Wijnen René M H , Ciet Pierluigi , Bogers Ad J J C , Schnater J Marco , Mahtab Edris A F
Published: January 2023

OBJECTIVES

When surgical resection is indicated for a congenital lung abnormality (CLA), lobectomy is often preferred over segmentectomy, mostly because the latter is associated with more residual disease. Presumably, this occurs in children because sublobar surgery often does not adhere to anatomical borders (wedge resection instead of segmentectomy), thus increasing the risk of residual disease. This study investigated the feasibility of identifying eligible cases for anatomical segmentectomy by combining virtual reality (VR) and artificial intelligence (AI).

METHODS

Semi-automated segmentation of bronchovascular structures and lesions were visualized with VR and AI technology. Two specialists independently evaluated via a questionnaire the informative value of regular computed tomography versus three-dimensional (3D) VR images.

RESULTS

Five asymptomatic, non-operated cases were selected. Bronchovascular segmentation, volume calculation and image visualization in the VR environment were successful in all cases. Based on the computed tomography images, assignment of the CLA lesion to specific lung segments matched between the consulted specialists in only 1 out of the cases. Based on the three 3D VR images, however, the localization matched in 3 of the 5 cases. If the patients would have been operated, adding the 3D VR tool to the preoperative workup would have resulted in changing the surgical strategy (i.e. lobectomy versus segmentectomy) in 4 cases.

CONCLUSIONS

This study demonstrated the technical feasibility of a hybridized AI–VR visualization of segment-level lung anatomy in patients with CLA. Further exploration of the value of 3D VR in identifying eligible cases for anatomical segmentectomy is therefore warranted.
Le Tapis magique immobile: détail colonial et ambiguïté narrative dans le roman-fleuve de l’entre-deux-guerres
Authors: Panaïté Oana , Achille Étienne
Published: January 2023

This article engages with the narrative, rhetorical, and ideological manifestations of the colonial illusion in French interwar serialized novels (
romans-fleuves
) while focusing on Jules Romains’s
Les Hommes de bonne volonté
(initially published in twenty-seven instalments or
livres
between 1932 and 1946). In discussing key narrative scenes and strategies of characterization as they relate to notions of empire, exoticism, colonial spaces and destinies, as well as critiques of colonialism, it contends that this overlooked corpus of French literature, which also includes authors such as Roger Martin du Gard and Romain Rolland, deserves closer scrutiny for both aesthetic and ideological reasons, and it invites reflection on the implicit criteria that exclude such work from the usual corpus of literary representations of colonialism. The study of these texts reveals both changes and continuities between the interwar period and late twentieth- and early twenty-first-century modes of literary representation of key social and cultural issues, such as the universalist vocation of France, the (post-)colonial elsewhere, and the debate over national identity.
Ethnicity and Parkinson’s Disease: Motor and Nonmotor Features and Disease Progression in Latino Patients Living in Rural California
Authors: Duarte Folle Aline , Flores Marie E S , Kusters Cynthia , Paul Kimberly C , Del Rosario Irish , Zhang Keren , Ruiz Cristina , Castro Emily , Bronstein Jeff , Ritz Beate , Keener Adrienne M
Published: January 2023

Background

Parkinson’s disease (PD) is the second most common neurodegenerative disorder among older adults worldwide. Currently, studies of PD progression rely primarily on White non-Latino (WNL) patients. Here, we compare clinical profiles and PD progression in Latino and WNL patients enrolled in a community-based study in rural Central California.

Method

PD patients within 5 years of diagnosis were identified from 3 counties between 2001 and 2015. During up to 3 visits, participants were examined by movement disorders specialists and interviewed. We analyzed cross-sectional differences in PD clinical features severity at each study visit and used linear mixed models and Cox proportional hazards models to compare motor, nonmotor, and disability progression longitudinally and to assess time to death in Latinos compared to WNL patients.

Results

Of 775 patients included, 138 (18%) self-identified as Latino and presented with earlier age at diagnosis (63.6 vs 68.9) and death (78.6 vs 81.5) than WNL. Motor (hazard ratio [HR] = 1.17 [0.71, 1.94]) and nonmotor symptoms did not progress faster in Latino versus WNL patients after accounting for differences in baseline symptom severity. However, Latino patients progressed to disability stages according to Hoehn and Yahr faster than WNL (HR = 1.81 [1.11, 2.96]). Motor and nonmotor symptoms in Latino patients were also medically managed less well than in WNL.

Conclusions

Our PD study with a large proportion of Latino enrollees and progression data reveals disparities in clinical features and progression by ethnicity that may reflect healthcare access and structural socioeconomic disadvantages in Latino patients with PD.