Feasibility for non-invasive prenatal fetal blood group and platelet genotyping by massively parallel sequencing: A single test system for multiple atypical red cell, platelet and quality control markers

Non-invasive prenatal tests (NIPT) to predict fetal red cell or platelet antigen status for alloimmunised women are provided for select antigens. This study reports on massively parallel sequencing (MPS) using a red cell and platelet probe panel targeting multiple nucleotide variants, plus individual identification single nucleotide polymorphisms (IISNPs). Maternal blood samples were provided from 33 alloimmunised cases, including seven with two red cell antibodies. Cell-free and genomic DNA was sequenced using targeted MPS and bioinformatically analysed using low-frequency variant detection. The resulting maternal genomic DNA allele frequency was subtracted from the cell-free DNA counterpart. Outcomes were matched against validated phenotyping/genotyping methods, where available. A 2.5% subtractive allele frequency threshold was set after comparing MPS predictions for K, RhC/c, RhE/e and Fya /Fyb against expected outcomes. This threshold was used for subsequent predictions, including HPA-15a, Jka /Jkb , Kpa /Kpb and Lua . MPS outcomes were 97.2% concordant with validated methods; one RhC case was discordantly negative and lacked IISNPs. IISNPs were informative for 30/33 cases as controls. NIPT MPS is feasible for fetal blood group genotyping and covers multiple blood groups and control targets in a single test. Noting caution for the Rh system, this has the potential to provide a personalised service for alloimmunised women.

Comparing the unified protocol for transdiagnostic treatment of emotional disorders to prolonged exposure for the treatment of PTSD: Design of a non-inferiority randomized controlled trial

Background

Prolonged Exposure (PE), a trauma-focused therapy, is one of the most efficacious treatments available for PTSD. However, many people with PTSD do not lose their diagnosis following delivery of PE. The Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders is a non-trauma focused treatment that may offer an alternative treatment for PTSD.

Methods

This paper describes the study protocol for IMPACT, an assessor-blinded randomized controlled trial that examines the non-inferiority of UP relative to PE for participants who meet DSM-5 criteria for current PTSD. One hundred and twenty adult participants with PTSD will be randomized to receive either 10 × 90-min sessions of UP or PE with a trained provider. The primary outcome is severity of PTSD symptoms assessed by the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) at post-treatment.

Discussion

While evidence-based treatments are available for PTSD, high levels of treatment dropout and non-response require new approaches to be tested. The UP is based on emotion regulation theory and is effective in treating anxiety and depressive disorders, however, there has been limited application to PTSD. This is the first rigorous study comparing UP to PE in a non-inferiority randomized controlled trial and may help improve clinical outcomes for those with PTSD.

Trial registration

This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry, Trial ID (ACTRN12619000543189).

92 CONTINUING TO ‘BE HIP’: ORTHOGERIATRIC SERVICE IMPROVEMENTS IN 2021

Background

Scotland first demonstrated that adherence to nationally agreed hip fracture standards improve patient survival, reduces the duration of admission, and reduces the need for high dependency care. Our study aims to assess adherence to the Irish Hip Fracture Standards (IHFS) in our hospital for 2021 amidst the COVID-19 pandemic, translating to improved clinical outcomes for our patients.

Methods

The IHF database was retrospectively analysed, comparing quarters 1-4 in 2021 with our 2020 results.

Results

IHFS1, patient time to the ward < 4hours, was maintained at 67% in 2021 versus 71% overall in 2020. There was improvement in IHFS2, time to surgery within 48 hours, up to 73% in 2021 versus 66% in 2020. IHFS3 was 4% in 2021 versus 3% overall in 2020. Further improvements were noted for IHFS4, with 95% of patients reviewed by a Geriatrician in 2021 versus 87% in 2020. IHFS5 also improved with 97% of patients receiving a bone health assessment in 2021 versus 87% in 2020. Moreover, IHFS6, improved with 97% of patients undergoing a specialised falls assessment in 2021 versus 87% in 2020.

Conclusion

The improvement in 2021 figures is reflective of the return of redeployed services during the COVID-19 pandemic inclusive of the Orthogeriatric Service, the Fracture Liaison Service Advanced Nurse Practitioner, the Trauma Co-ordinator, and the specialist Orthopaedic ward complete with its Orthopaedic nurses and Multi-Disciplinary Team, and improved Emergency Department pathways. These continued improvements in the IHFS further emphasise that success is dependent on a team that is joined at the hip

258 RISING TO THE CHALLENGE: ORTHOGERIATRIC SERVICE IMPROVEMENT AND COVID-19

Background

Nationally agreed hip fracture standards have contributed to the improvement of outcomes in hip fracture patients. In 2020, our hospital was awarded “The Golden Hip” for achieving highest compliance with Irish Hip Fracture Standards (IHFS) nationally for 2019.

Methods

Data from the Irish Hip Fracture Database (IHFD)was retrospectively analysed to assess our performance in 2020 versus 2019 in hip fracture patients over sixty. Multiple quality improvement interventions were put in place throughout 2019 to ensure improvement in IHFS1-6 compliance: Creation of the Hip Fracture Pathway Subgroup, IHFS 1 Breaches Audit, Orthogeriatric input at Orthopaedic inductions, weekly Multi-disciplinary Team meetings, a Nutritional Hip Fracture Pathway and addition of the Fracture Liaison Service Advanced Nurse Practitioner.

Results

There were 239 hip fracture patients in 2020 vs 249 in 2019. IHFS1 compliance improved with the percentage of patients admitted to the Orthopaedic ward within 4 hours increasing to 71% in 2020 from 56% in 2019. There was improvement in IHFS2-time to surgery &lt;48 hours- 66% in 2020 vs 60% in 2019. IHFS3-pressure ulcer rate-was at the national average, 3% in 2020 vs 2% in 2019. IHFS4 (reviewed by a Geriatrician), IHFS5 (received a bone health assessment) and IHFS6 (received a specialised falls assessment) were lower overall; 87% in 2020 vs 98% in 2019. For all quarters (Q),43% of patients met all IHFS in our hospital in 2020 vs 32% in 2019, resulting in €90,000 in Best Practice Tariff funding.

Conclusion

Lower results for IHFS 4,5 and 6 reflect the arrival of the COVID-19 pandemic which led to redeployment of the Orthogeriatric Service and redeployment of the MDT from end of Q1 to Q3. When services in 2020 were preserved,1 in 2 hip fracture patients met all IHFS, vs 1 in 3 patients in 2019. Despite the pandemic, we continued to achieve the highest level of IHFS compliance nationally, being awarded a second consecutive “Golden Hip” for 2020.

250 EXPANSION OF THE ORTHOGERIATRIC SERVICE: EARLY EXPERIENCES

Background

The introduction of hip fracture standards has led to improvement in outcomes for hip fracture patients. Other osteoporotic fragility fractures also lead to significant morbidity. They are associated with a high risk of future hip fracture. The Orthogeriatric Service at a model 3 hospital was expanded to proactively undertake comprehensive geriatric assessment(CGA) for patients over 65 with non-hip fragility fractures(NHFF) admitted to the Orthopaedic Ward. Electronic discharge summaries were created for all patients. This study aimed to characterise patients reviewed by Orthogeriatrics and review discharge summary documentation of CGA.

Methods

Patients reviewed by Orthogeriatrics during the period Jan-June 2021 were retrospectively analysed. Discharge summaries of these patients were retrospectively reviewed. The prevalence of documentation of frailty status, delirium screening and bone health plan was recorded.

Results

A total(n = 126) of 91 patients with hip fractures and 35 with NHFF were included. Other fracture types were excluded. The mean age of hip fracture patients was 82.43 compared to 78.2 in the NHFF group. 71%(n = 65) of hip fracture patients were female compared to 80% (n = 28) of NHFF. 80%(n = 73) of hip fracture patients were reviewed within 48 hours of admission, compared to 65%(n = 23) of NHFF. 52.7%(n = 48)of hip fracture patients had frailty status documented on their discharge summary, compared to 37.1%(n = 13) of NHFF. Delirium screening was documented for 58.2%(n = 53) of the hip fracture patients, compared to 40%(n = 14) of NHFF. Bone health plans were documented for 62.6%(n = 57) of hip fracture patients compared to 60%(n = 21) of NHFF.

Conclusion

Expansion of the Orthogeriatric Service to proactively review all NHFF patients will lead to reduced incidence of repeat fracture for this population. A lower percentage of NHFF patients had clear discharge documentation of CGA outcomes and a lower percentage were reviewed within 48 hours. Expansion of hip fracture standards to include all fragility fracture patients should be considered to incentivise improved care for all.

103 ORTHOGERIATRIC SERVICES IN THE FACE OF COVID-19

Background

Nationally agreed standards improve the level of care delivered to all older, frail, multi-morbid patients presenting with hip fractures. Dedicated Orthogeriatric services allow for these standards to be achieved in a multi-disciplinary team (MDT) setting. As the COVID-19 pandemic reached our shores, the model of care set out by the Irish Hip Fracture Standards (IHFS) was under threat. Our dedicated Orthopaedic Trauma ward became an acute COVID ward and the Orthogeriatric service was re-deployed to acute medicine for Quarter 2.

Methods

Using the Irish Hip Fracture Database, local data was analysed and compared with national data from Quarter 1 to 4 (Q1–4) in 2020.

Results

When comparing local IHFS’s with national figures, ongoing challenges and future goals are highlighted.

In 2020, there were 222 hip fracture patients (mean age 81.8 years) in our hospital. Standard 1, time to the ward <4 hours, stands at 71% locally (national average 33%). Standard 2, time to theatre <48 hours, is an ongoing challenge and remains at 66% (national average 75%). Standard 3, pressure ulcer rate, was the same as the national average at 3%. Standards 4, 5 and 6 in our hospital stand at 87% (national averages of 82%, 91% and 85% respectively).

In Q1, 56%, or over 1 in every 2 patients with hip fractures, met all of the Irish Hip Fracture Standards in our hospital. In Q2, only 18% of patients met all of the IHFS’s. Q3 saw improvements with 47% of all hip fracture patients achieving all IHFS’s. Q4 showed maintenance with 45% of all patients achieving all IHFS’s.

Conclusion

These findings highlight the need for a dedicated Orthogeriatric Service and Orthopaedic ward at all times. Going forward with the risk of future waves and the emergence of new variants, every effort should be made to maintain a comprehensive orthogeriatric service to minimise a negative impact on patient care.

The role of non-invasive prenatal testing (NIPT) for fetal blood group typing in Australia

Maternal alloimmunisation against red blood cell antigens can cause haemolytic disease of the fetus and newborn (HDFN). Although most frequently caused by anti-D, since the implementation of rhesus D (RhD) immunoglobulin prophylaxis, other alloantibodies have become more prevalent in HDFN. Recent advances in non-invasive prenatal testing (NIPT) have allowed early prediction of HDFN risk in alloimmunised pregnancies and allow clinicians to focus health resources on those pregnancies that require intervention. This article aims to provide updates on the current status of NIPT in Australia as both a diagnostic and screening tool in pregnancy.

Screening for risky drinkers among hospitalised inpatients using the AUDIT: A feasibility, point prevalence and data linkage study

INTRODUCTION

Risky drinking frequently remains undiagnosed or untreated, including in hospitalised inpatients. Using the Alcohol Use Disorders Identification Test (AUDIT), we assessed the feasibility of screening for risky drinking and whether screening results aligned with alcohol-attributable diagnoses in an inpatient population.

METHODS

We conducted a cross-sectional survey across a tertiary health service in Melbourne, Australia. Researchers collected demographics, AUDIT scores and acceptability from all eligible adult inpatients available on day of survey. Main outcomes were prevalence of risky drinking (AUDIT ≥8), mean AUDIT score and patient acceptability. Identification of risky drinking by the abbreviated 'AUDIT-C' or discharge diagnoses (extracted by data-linkage with medical records) was compared.

RESULTS

Of 473 eligible inpatients, 61% (n = 289) participated, 22% (n = 103) were unavailable and 17% (n = 81) declined. Median age was 64 years (IQR = 48, 76); 54% (n = 157) were male. Mean AUDIT score was 4.4 (SD = 5.5). Risky drinking prevalence was 20% (n = 57), 2% (n = 7) had scores suggestive of dependence (AUDIT ≥20, a subset of risky drinkers). Odds of risky drinking were reduced in females (OR 0.19, 95% CI 0.09, 0.41; P < 0.001) and participants ≥70 years (OR 0.22, 95% CI 0.07, 0.71; P = 0.01). Alcohol-attributable diagnoses did not consistently align with risky drinking, with half of inpatients with wholly attributable diagnoses classified as low risk. Most inpatients considered screening acceptable (89%, n = 256).

DISCUSSION AND CONCLUSIONS

Pre-admission risky drinking was evident in one-fifth of hospital inpatients, but alcohol-attributable diagnoses were unreliable proxy measures of risky drinking. Screening in-patients with the AUDIT was acceptable to inpatients and can be feasibly implemented in an Australian tertiary hospital setting.

Population patterns in Alcohol Use Disorders Identification Test (AUDIT) scores in the Australian population; 2007-2016

OBJECTIVES

Despite widespread use of the Alcohol Use Disorders Identification Test (AUDIT), there are no published contemporary population-level scores for Australia. We examined population-level AUDIT scores and hazardous drinking for Australia over the period 2007-2016.

METHODS

Total population, age- and gender-specific AUDIT scores, and the percentage of the population with an AUDIT score of 8 or more (indicating hazardous drinking), were derived from four waves of the nationally representative National Drug Strategy Household Survey, weighted to approximate the Australian population.

RESULTS

In 2016, the mean AUDIT score was 4.58, and 22.22% of the population scored ≥8. Both measures remained stable from 2007 to 2010 but declined in 2013 and 2016. Scores were highest in those aged 18-24 years, the lowest in those aged 14-17 or 60+. A downward trend in AUDIT scores was seen in younger age groups, while the 40-59 and 60+ groups increased or did not change.

CONCLUSIONS

Despite an overall decline in AUDIT scores, nearly one-quarter of Australians reported hazardous drinking. Implications for public health: The marked declines in hazardous drinking among young people are positive, but trends observed among those aged 40-59 and 60+ years suggests targeted interventions for older Australians are needed.

Non-invasive prenatal testing for management of haemolytic disease of the fetus and newborn induced by maternal alloimmunisation

Anti-D immunoglobulin prophylaxis reduces the risk of RhD negative women becoming alloimmunised to the RhD antigen and is a major preventative strategy in reducing the burden of haemolytic disease of the fetus and newborn (HDFN). HDFN also arises from other maternal red cell antibodies, with the most clinically significant, after anti-D, being anti-K, anti-c and anti-E. Among the 39 human blood group systems advanced genomic technologies are still revealing novel or rare antigens involved in maternal alloimmunisation. Where clinically significant maternal antibodies are detected in pregnancy, non-invasive prenatal testing (NIPT) of cell-free fetal DNA provides a safe way to assess the fetal blood group antigen status. This provides information as to the risk for HDFN and thus guides management strategies. In many countries, NIPT fetal RHD genotyping as a diagnostic test using real-time PCR has already been integrated into routine clinical care for the management of women with allo-anti-D to assess the risk for HDFN. In addition, screening programs have been established to provide antenatal assessment of the fetal RHD genotype in non-alloimmunised RhD negative pregnant women to target anti-D prophylaxis to those predicted to be carrying an RhD positive baby. Both diagnostic and screening assays exhibit high accuracy (over 99 %). NIPT fetal genotyping for atypical (other than RhD) blood group antigens presents more challenges as most arise from a single nucleotide variant. Recent studies show potential for genomic and digital technologies to provide a personalised medicine approach with NIPT to assess fetal blood group status for women with other (non-D) red cell antibodies to manage the risk for HDFN.

148 Orthogeriatrics, Just the Beginning

Background

The most common cause of admission to the orthopaedic ward are low trauma falls resulting in a hip fracture. These fragility fractures occur in older, frail, multi-morbid patients and they are associated with a high mortality rate and significant loss of independence. The Irish Hip Fracture Database is a national clinical audit that aims to improve hip fracture care and patient outcomes. Using the Irish Hip Fracture Standards, we aimed to audit the care of hip fracture patients in an Irish Model 3 Hospital pre- and post- implementation of an orthogeriatrics service.

Methods

Local Irish Hip Fracture Database was reviewed to assess the six Irish Hip Fracture Standards prior and 4 months following the introduction of a consultant-led dedicated orthogeriatrics service.

Results

There were 63 hip fracture patients (mean age 81) in the pre-service group and 69 (mean age 81) in the post-service group. Standard 1: 3.2% of hip fractures were admitted to the orthopaedic ward within 4 hours in the pre-service group versus 18.8% post-service introduction (national average 11%, 2017). Standard 2: 67.9% underwent surgery within 48 hours and during working hours versus 67.8% (national average 69%, 2017). Standard 3: 3.5% developed a pressure ulcer during their stay pre-service versus 1.6% post-service (national average 3%, 2017). Standard 4: 4.8% were assessed by a Geriatrician pre-service versus 84% post-service (national average 50%, 2017). Standard 5: 24.6% received a bone health assessment versus 87.5% post-service (national average 73%, 2017). Standard 6: 1.8% received a falls assessment prior to discharge versus 82.8% post-service (national average 47%, 2017).

Conclusion

The introduction of a dedicated orthogeriatrics service has led to a more collaborative multi-disciplinary approach to patient care with evidence of improvements in all Irish Hip Fracture Standards. Commitment to a resourced orthogeriatric service providing rapid comprehensive geriatric assessments is essential to advance improvements in older patients’ care.

327 The Impact of Implementation of Recommendations from the IFHD 2017 Annual Report in an Irish Model 3 Hospital

Background

Hip fractures in the older person are associated with high mortality rates (NICE, 2011). Up to 40% of patients never regain their pre-fracture mobility, 10-20% never return to live at home. The Irish Hip Fracture Database (IHFD) National Report 2017 recommends appointment of an orthogeriatric consultant in this hospital to achieve IHFD standards 4 to 6.

Methods

We analysed a subset of HIPE data collected for the IHFD in patients over 60 years over a three month period from September – November 2017 and compare it to September – November 2018 after introduction of an orthogeriatric service. We looked at geriatrician review, bone health assessment, falls assessment, discharge destination, 30-day re-admission rate and mortality during admission.

Results

There were 45 hip fracture patients in each group. In the 2017 group, mean age was 79, female 64%; compared to mean age of 80, female 62.2% in 2018. In 2018, after the appointment of an orthogeriatrician, 95.6% of patients were seen by a geriatrician compared to 4.4% in 2017. In 2018, 97.7% received bone health assessment compared to 26.8% in 2017. In 2018 95.3% received specialist falls assessment, compared to 2.4% in 2017. Mean length of stay was 18 days in 2018 versus 13 days in 2017. 2.2% of patients were discharged to convalescence in 2018, 26.7% in 2017. 57.8% of patients were discharged to off-site rehabilitation in 2018 compared to 40% in 2017. 2.2% patients died during admission in 2018, 8.9% in 2017. In 2018, 6.7% of patients were readmitted within 30 days, 8.8% in 2017.

Conclusion

Provision of rapid Comprehensive Geriatric Assessment to all hip fracture patients, reduces falls and fracture risk. There is evidence of improvement in IHFD standards 4-6, mortality rate and 30-day readmission rate. Moreover, the orthogeriatric service has led to increased referral to rehabilitation services ensuring optimal functional recovery.

250 Delirium, Common but Forgotten

Background

Delirium is a medical emergency prevalent amongst hospitalised older patients and associated with prolonged hospital stay, functional and cognitive decline, institutionalisation and increased mortality. In Irish hospitals, multiple strategies, e-learning courses, delirium guidelines and prevention programs have aimed to improve delirium care with better diagnosis and prevention. With the increasing awareness campaigns, we aimed to review the prevalence, screening and management of delirium in our cohort of older patients.

Methods

A review of medical notes of all patients admitted under medical teams to an acute geriatric ward was carried out. Data was collected over a 3 week period in an Irish model 3 hospital. The following information was obtained from medical records: 1) Previous diagnosis of delirium/dementia 2) Documentation of a diagnosis of delirium 3) Features of delirium 4) Development of delirium as an inpatient 5) Formal screening for delirium 6) Cause and management of delirium 7) Length of stay.

Results

Of 79 consecutive admissions to an acute geriatric ward (mean age 81.4, 57% female, 30% previous history of delirium or dementia), 25% (n=20) had a diagnosis of delirium documented. 22% (n=18) of patients had confusion and features of delirium highlighted but no formal diagnosis of delirium made during their inpatient stay. A further 20% (n=16) developed delirium on admission. Only 2.5% (n=2) of admissions had formal screening for delirium with the 4AT. 27.5% (n=11) of patients with delirium had a cause and management plan recorded. 70% (n=28) of patients with delirium had a length of stay of over 15 days.

Conclusion

This review showed delirium recognition, screening, prevention and management were overlooked to an alarming extent in our cohort of older patients. The next step is introduction of the 4AT screening tool and regular education sessions to increase the awareness of delirium amongst medical teams looking after older patients and improve care and outcomes.

245 Delirium Incidence in Hip Fracture Patients: Awareness on the Orthopaedic Ward

Background

Postoperative delirium is a serious neuropsychiatric condition that occurs in up to 65% of hip fracture patients(1). However, it remains poorly recognised as a postoperative surgical complication despite its association with increased mortality, longer length of stay (LOS), cognitive decline and increased risk of discharge institutionalisation.

Methods

As part of the delirium audit, all hip fracture patient notes were reviewed from Oct-Nov 2017 pre-implementation of an Orthogeriatric Service and Oct-Nov 2018 post-implementation. Documentation of delirium or use of the terms ‘new confusion, altered attention, change in behaviour’ in the orthopaedic, orthogeriatric and allied health professional notes were reviewed. The 4AT was used to routinely screen for delirium in the pre-and post-operative period by the Orthogeriatrics team(2).

Results

The number of patients in the 2017 group was 24, mean age 78, female 76% compared with 25 in the 2018 group, mean age 75.9, female 81%. In 2017, delirium was diagnosed in 4% of patients by the Orthopaedic surgeons and 37.5% by Allied Health Professionals. In 2018 delirium was diagnosed in 4% by the Orthopaedic surgeons, 40% by Allied Health Professionals and 44% by the Orthogeriatrics team in 2018. Pre-operative delirium occurred in 16% of patients and postoperative delirium occurred in 44% of patients in 2018. A clear delirium management plan was documented in 0% of charts in 2017 versus 100% in 2018. LOS in 2017 was 12.7 days vs 12.4 in 2018. However, discharge location varied greatly with 33.3% discharged to convalescence in 2017 versus 19% in 2018, 12.5% to Longterm care in 2017 versus 4% in 2018, 20.8% to rehabilitation in 2017 vs 52% in 2018 and 16.7% home in 2017 vs 24% in 2018.

Conclusion

Prompt diagnosis and management of delirium is essential in optimising postoperative cognitive function and preserving independence. Our study highlights the need for routine delirium screening and improved awareness of delirium amongst all healthcare professionals.

284 Improving Adherence to Irish Hip Fracture Database Standards 1 and 2

Background

The Irish Hip Fracture Database (IHFD) National Report 2017 demonstrated poor performance across all six IHFD standards in our hospital. For the purpose of this study we focused on standards 1 and 2. IHFD standard 1: All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of ED presentation/ brought directly to theatre from ED within 4 hours, and IHFD standard 2: All patients with hip fracture who are medically fit should have surgery within 48 hours of admission and during normal working hours.

Methods

We examined IHFD standards 1 and 2 from August 2017-January 2018 and August 2018-January 2019 after the appointment of an orthogeriatrician and use of the first Hip Fracture Pathway in August 2018. We also analysed data collected from February-April 2019 after amendment of the hip fracture pathway for patients presenting to the ED.

Results

IHFD Standard 1: From August to January 2017, 2.5% of patients were admitted to an orthopaedic ward within 4 hours versus 18.1% in 2018. IHFD Standard 2: in 2017, 64.8% underwent surgery within 48 hours during working hours, versus 65.3% in 2018. From February to April 2019, 32.1% of patients were admitted to an orthopaedic ward within 4 hours (IFHD 1) and 56.6% of patients underwent surgery within 48 hours and during working hours (IFHD 2).

Conclusion

Close collaboration between Emergency Medicine, Orthopaedic Surgery, Radiology, Nursing colleagues, Allied Health Professionals and Orthogeriatrics and amendment of the Hip Fracture Pathway have led to improvements in Standards 1 and 2. The addition of an orthogeriatric service in the hospital has resulted in an improvement in adherence to all IFHD standards. However, there are ongoing challenges to achieving Standard 2 including limited theatre access and increasing numbers of older patients on novel oral anticoagulants.

Resistant syndrome of inappropriate antidiuretic hormone (SIADH) secondary to atonic bladder in an older woman

Syndrome of inappropriate antidiuretic hormone (SIADH) is the most common cause of hyponatraemia. There are many causes of SIADH, but investigation tends to focus around the most common causes-particularly diseases of the brain and lung, malignancy and medication-induced SIADH [Ellison and Berl (2007, The Syndrome of Inappropriate Antidiuresis. N Engl J Med., 356, 2064-72]. We describe a case of SIADH secondary to atonic bladder in an 83-year old woman, which was discovered on MRI of the abdomen, performed for further characterisation of a known pancreatic lesion. Insertion of a urinary catheter alleviated retention and resulted in prompt resolution of hyponatraemia. This is an under-recognised cause of this common condition, with important implications for investigation and management.

Hospitalisation and surgery: Is exposure associated with increased subsequent depressive symptoms? Evidence from The Irish Longitudinal Study on Ageing (TILDA)

BACKGROUND

The dramatic shift in the global population demographic has led to increasing numbers of older people undergoing hospitalisation and surgical procedures. While necessary, these exposures may lead to an increase in depressive symptoms.

OBJECTIVES

To determine whether hospitalisation or hospitalisation with surgery under general anaesthesia is associated with an increase in depressive symptoms in adults over the age of 50.

METHODS

Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale in 8036 individuals at waves 1 and 2 of The Irish Longitudinal Study on Ageing (TILDA), 2 years apart. Mixed-effects models were used to investigate the hypothesis after adjustment for risk factors for depression and potential confounders.

RESULTS

During the 12 months preceding wave 1, a total of 459 participants were hospitalised (mean age, 67.0; 55.3% female), and a further 548 participants (mean age, 64.6; 51.8% female) were hospitalised and underwent surgery with general anaesthesia; 6891 (mean age, 63.5; 54.3% female) were not hospitalised. Analysis of waves 1 and 2 data using mixed-effects models demonstrated that there was a 7% increased adjusted incidence rate of depressive symptoms (IRR [95% CI] = 1.07 [1.02-1.11]) in the Center for Epidemiologic Studies Depression Scale in the hospitalisation group and a 4% increased adjusted incidence rate of depressive symptoms (IRR [95% CI] = 1.04 [1.00-1.08]) in the surgery group compared with those with no hospitalisation.

CONCLUSION

Hospitalisation and hospitalisation with surgery and general anaesthesia are associated with increased depressive symptoms. This is the first time a longitudinal population-representative study has demonstrated this relationship for both exposures simultaneously.

Do-not-attempt-resuscitation (DNAR) orders: understanding and interpretation of their use in the hospitalised patient in Ireland. A brief report

Following the introduction of do-not-resuscitate (DNR) orders in the 1970s, there was widespread misinterpretation of the term among healthcare professionals. In this brief report, we present findings from a survey of healthcare professionals. Our aim was to examine current understanding of the term do-not-attempt-resuscitate (DNAR), decision-making surrounding DNAR and awareness of current guidelines. The survey was distributed to doctors and nurses in a university teaching hospital and affiliated primary care physicians in Dublin via email and by hard copy at educational meetings from July to December 2014. A total of 519 completed the survey. The response rate in the hospital doctors group was 35.5% (187/527), 19.8% (292/1477) in the nurses group but 68.8% (150/218) in the specialist nurses group and 40% (40/100) in the primary care physician group.Alarmingly, our results demonstrate that 26.8% of staff nurses and 30% of primary care physicians surveyed believed that a patient with a DNAR order could not receive any/at least one of a list of simple treatments including antibiotics, physiotherapy, intravenous fluids, pain relief, oxygen, nasogastric feeding or airway suctioning, which were higher percentages compared to the other hospital doctors and experienced nurses groups with statistically significant differences (p<0.001). Furthermore, a higher percentage of staff nurses (26.8%) and primary care physicians (22.5%) believed that a patient with a DNAR order could not be referred to hospital from home/a nursing home, when compared with other healthcare groups (p<0.001). Our findings highlight continued misunderstanding and over-interpretation of DNAR orders. Further collaboration and information is required for meaningful Advance Care Plans.