104 SPONTANEOUS ILIOPSOAS TENDON RUPTURE AND PSOAS HAEMATOMA ON ASPIRIN MONOTHERAPY: A CASE REPORT

Background

Spontaneous Iliopsoas Tendon (IPT) rupture is a rare condition, with a prevalence of 0.66%, occurring most commonly in athletes. Risk factors for non-athletic IPT rupture include age, female gender and steroid use. Psoas haematomas are associated with surgery, anticoagulation and coagulopathies. Only a handful of case reports have associated psoas haematoma with single antiplatelet use. We present the case of a patient who developed psoas tendon rupture and psoas haematoma.

Methods

A 77-year-old female presented with a four week history of declining mobility and left hip pain, without history of trauma. Past medical history included chronic lymphoedema and an NSTEMI, for which she was taking aspirin monotherapy. On examination, she had reduced power on left hip flexion and a tender anterior thigh, with normal sensation. CT showed asymmetric thickening of the left iliacus muscle and surrounding fat stranding. MRI demonstrated partial IPT tear with oedema extending into the iliacus muscle.

Results

After several weeks of rehabilitation, her mobility deteriorated again. A second CT was performed, which showed new expansion and fat stranding of the right iliopsoas muscle and tendon compatible with acute haemorrhage. Aspirin was held for four weeks, and she was discharged after completing rehabilitation. Her baseline mobility had disimproved and she required assistance and a frame on discharge.

Conclusion

IPT rupture and psoas haematoma are atypical causes of atraumatic hip pain in older adults. Nevertheless, they can cause significant disability. MRI is recommended as the gold standard for diagnosis. Treatment is commonly conservative, focused on physiotherapy and pain control to maintain mobility. While aspirin is not commonly associated with tendon rupture or haemorrhage, it is widely used in primary prevention of cardiovascular disease and due consideration should be given to stopping it following the occurrence of haemorrhage.

158 AN AUDIT ON DISCHARGE SUMMARIES IN A MEDICAL GERONTOLOGICAL WARD

Background

Discharge summaries are an integral part of communication within healthcare to ensure safe care across settings. Alterations are documented and relayed between relevant healthcare professionals. This audit evaluates quality of discharge summaries from a medical gerontology ward against the National Standard for Patient Discharge Summary Information (HIQA)

Methods

A retrospective audit was carried out with data collected from a ward discharge registry over 3-months (February-April 2022) and associated discharge summaries.

Results

A total of 31 discharges (including death) were identified during the set period, 97% (n=30) of which had completed discharge summaries. Upon assessment against the standard, 100% (n=30) included details vital to patient identification including name, date of birth, gender and address. In addition,100% (n=30) included information on date of admission-discharge, clinical course, relevant investigations, treatments, procedures, discharge medications and details of the doctor completing the discharge summary. The audit identified that 20% (n=6) of summaries stated referral source, which is mandatory according to the standard. 13% (n=4) included dietary interventions and 0% included immunization information (whether as an inpatient or prior). Regarding information on further management, 77% (n=23) had guidance on follow-up hospital care, 27% (n=8) had information about social care actions, 20% had advice, recommendations and future plans documented and in 10% information was documented to be given to patient and carer.

Conclusion

Compliance with mandatory information including patient details, admission/discharge date, diagnoses, hospital course, and author fully met the standard. However, there was poor compliance with information relevant to continuation of patient care in the community. This is particularly relevant for older patients with multiple co-morbidities and complex care needs. Doctors working on this ward are receiving education regarding the importance of documentation of functional status, social care needs and diet at discharge. In future, mandatory documentation as part of electronic discharge summaries may improve compliance and continuity of care across settings.

219 A SOLITARY AWARENESS - PROFILING TIME TO RECOGNITION OF MEMORY LOSS IN A TERTIARY MEMORY SERVICE

Background

Approximately 64,000 people live with dementia in Ireland with expected increases to 150,000 by 2045. Best practice recommends that patients benefit from timely diagnosis. Whilst the presence of cognitive impairment should prompt early referral for diagnostic clarity, patients frequently present with well-established symptoms. In order to understand this phenomenon it is important to understand the way in which symptoms are recognised by the person, companions and casual observers.

Methods

A chart review was carried out on a convenience sample of patients (n=61) diagnosed with dementia where scores were available from Clinical Dementia Rating Scale (CDR) and AD8. Data extracted included global scores and answers to direct questions regarding symptom recognition by patient and companion. Diagnosis was confirmed using the Electronic Patient Record.

Results

Mean age was 75 (range 57-87). Diagnostic breakdown comprised: Alzheimer Dementia (AD) in 67% (n=41), mixed AD/Vascular Dementia (VaD) in 19.6% (n=12); behavioural variant Fronterotemporal Dementia (bvFTD) in 1.6% (n=1), Dementia with Lewey Bodies (DLB) in 1.6% (n=1), Primary Progressive Aphasia (PPA) in 4.9% (n=3), Primary Parkinson’s Dementia (PPD) in 1.6% (n=1) and VaD in 1.6% (n=1). Average CDR Global Scale was 1.0 and average AD8 score 6/8. Family noticed symptoms of dementia an average of 12 months longer than the person themself. The incidence of anosognosia was 19% (n=12) and associated with a diagnosis of AD (91.6 %, n=11). Where anosognosia existed, symptoms of memory loss had been identified by family up to 60 months before diagnosis, with average time to recognition of 24 months. For 75% of this anosognosia group, family reported indiscernible symptoms on casual inspection (n=9).

Conclusion

Where symptoms of memory loss go unrecognised by patients and casual inspection, family may notice changes for up to five years. It is important to educate and empower the public regarding the benefit of a timely dementia diagnosis. Education should focus on supporting family to navigate sensitive conversations in the event of anosognosia and explore ways in which they might encourage timely review.

16 SARS-COV-2 INFECTION AND VACCINATION PATTERNS DETERMINE LONG-TERM ANTIBODY RESPONSES IN NURSING HOME RESIDENTS: DATA FROM NH-COVAIR

Background

Older Nursing Home Residents (NHRs) are at greatest risk of morbidity and mortality from SARS-CoV-2, particularly in the context of both waning vaccine efficacy and the emergence of Variants-of-Concern (VOCs). However, the determinants of long-term vaccine-induced protective antibody responses are yet to be determined in this group.

Methods

NH-COVAIR recruited older NHRs for comprehensive clinical and frailty (NH-FRAIL) assessment. Blood samples were obtained pre-vaccination, at 6-weeks and 6-months following primary vaccination and 6-months following booster vaccination. Antibody titres were measured using both an electrochemiluminescence assay and a custom bead-based array (Luminex™) to measure antibody titre and avidity for Wuhan strain/major VOC antigens. Stepwise adjusted linear regression (log-transformed) assessed longitudinal determinants of vaccine-induced antibody responses.

Results

Of 86 participants (81.1 ± 10.8 years; 65% female), just under half (45.4%) had evidence of previous SARS-CoV-2 infection. All NHRs mounted a significant antibody-response to vaccination at 5 weeks followed by a significant decrease in antibody titre by 6 months. Previous SARS-CoV-2 infection was the strongest predictor of antibody waning at all timepoints (β: 3.59; 2.89, 4.28; P < 0.001 for 6-months). Independent of infection history, both age (β: –0.05; –0.08, –0.02; p<0.001) and frailty (β: –0.22; –0.33, –0.11; p<0.001) were associated with faster antibody waning at 6-months. Cross-reactivity and avidity were significantly lower for Beta (B.1.351) and Gamma (P.1) VOC strains (all p<0.001). Additionally, there was faster antibody waning and significantly reduced antibody avidity to Beta and Gamma VOCs in SARS-CoV-2 naïve NHRs.

Conclusion

Older NHRs are capable of mounting protective antibody responses to SARS-CoV-2 vaccination. Responses were more durable, with a greater cross-reactivity to and avidity for VOCs in those with previous SARS-CoV-2 infection. Increasing age and greater frailty in NHRs was associated with faster antibody waning. Our findings support ongoing serological surveillance and use of additional vaccine doses in older NHRs, particularly in those without previous SARS-CoV-2 exposure.

341 ROLE AND TOLERANCE OF LUMBAR PUNCTURE TESTS FOR CSF BIOMARKERS OF ALZHEIMER'S DEMENTIA IN A SPECIALIZED MEMORY CLINIC

Background

People living with mild cognitive symptoms often require clarity on the underlying aetiology of their symptoms, and with the advent of disease modifying therapies for Alzheimer’s Disease (AD), establishing diagnostic accuracy for amyloid and tau pathology in AD will become more clinically relevant. CSF biomarker analysis via Lumbar Puncture (LP) is the most accurate and cost-effective means of establishing AD pathology. This study aimed to assess memory clinic patients’ tolerance of LP as a diagnostic tool in the work-up of memory symptoms.

Methods

A consecutive sample of patients offered CSF analysis as part of their diagnostic plan in a tertiary memory service of a University Teaching Hospital were included. After clinician discussion, an LP for AD biomarker detection is offered to all patients with amnestic/non-amnestic mild cognitive impairment, or those with atypical motor-cognitive symptoms in this service.

Results

119 patients offered an LP from 2019-2020 were contacted, fifty-four (45%) of whom participated in this study. The average age was 70.1 (±7.5) years, 50% female. Forty-two (42/54, 78%) had an LP performed. More women declined an LP than men (8/12, 66%). Almost all of those who had an LP, (38/42, 90.4%) thought it yielded useful information and would recommend it for others. Side effects included mild back pain relieved with simple analgesia (11/42, 26%) and headache (3/42, 7%). There were no incidences of neurological sequelae or requirements for dural patch. Of the 12/54 (22%) who declined CSF analysis; reasons for same were pre-existing back pain (3/12, 25%), needle-phobia (3/12, 25%), and only 2/12, (16%) declined because they did not wish to know the results of the investigation.

Conclusion

This study highlights high levels of acceptance of CSF analysis when offered as part of routine care, with infrequent side effects. Most patients found the clinical information yielded was useful.

130 CHARACTERISTICS AND OUTCOMES OF OLDER NURSING HOME RESIDENTS ATTENDING AN EMERGENCY DEPARTMENT

Background

Older nursing home (NH) residents are among the most vulnerable members of society, often with multiple comorbidities and complex care needs. The Emergency Department (ED) is a common point of access to the acute hospital for NH residents. This study aims to review characteristics and outcomes of older NH residents presenting to ED over one year.

Methods

A prospective cohort study was carried out. NH residents aged 50 years and older attending ED of a university teaching hospital over one year (01/10/2019-30/09/2020) were included. Data on demographics, comorbidities, functional status, frailty and details of ED attendance were collected.

Results

There were a total of 515 ED attendances by 341 NH residents over one year. Mean age was 76.3 years (50-103 years; SD ± 10.9). 50.9% (n=262) were female. Mean Charlson Comorbidity Index (CCI) was 5 (0-12; SD ± 2.1). 46.6% (n=240) had a dementia diagnosis. A mean of 12.6 medications (0-31; SD ± 5.3) were prescribed in the NH. Mean Clinical Frailty Score (CFS) was 6.5 (3-9; SD ± 0.9). Mean Barthel Index (BI) was 8.9 (0-20; SD ± 6.0). 38.3% (n=197) of presentations occurred “in-hours”. Mean Manchester Triage Score (MTS) was 2.54 (1-5; SD ± 0.7) with 92.0% (n=474) scoring 1-3. Delirium was documented in 31.8% (n=164). Mean ED Length of Stay (LOS) was 13.7hours (0-80hours; SD ± 11.0). 14.6% (n=75) were discharged without follow-up. 61.2% (n=315) were admitted to hospital. Mean hospital (LOS) was 9.7days (0-191 days) and 8.7% (n=47) of those admitted died in hospital. 12 months after ED presentation, 40.4% (n=138) of the cohort had died.

Conclusion

NH residents are a frail group, with high levels of multimorbidity, polypharmacy and significant care needs. This complexity is reflected in the numbers requiring urgent review on attendance, rates of delirium, ED LOS and hospital admission rates. Dedicated NH liaison teams may enhance care and improve outcomes for this cohort.

231 NURSING HOME RESIDENTS PRESENTING TO THE EMERGENCY DEPARTMENT WITH FALLS

Background

Nursing Home Residents (NHR) are the most-frail group of older persons, with many comorbidities that increase their risk of falling. Falls are a frequent reason for ED attendance by NHR’s as it is for all older persons, but little is reported on their characteristics and outcomes specifically.

Methods

A prospective cohort study of all NH presentations with falls to the ED of a university teaching hospital over a one-year period. Detailed operational and clinical phenotype characteristics, and outcomes were recorded in all instances.

Results

There were 519 ED presentations by 344 NHR over one year. Almost half of all presentations (48.2%, 250/519), were as result of a fall, by 172 residents. The majority were female (137/250, 55%), with an average age of 77.8 years (±10.8). Many, 84.3% (145/172), had a prior fall in the past six-months. Almost half had a diagnosis of dementia (124/250, 49.6%). A third mobilised with a Zimmer-frame (83/250), and 10.8% (27/250) wheelchair. 33.2% (83/250) had visual impairment. The mean Barthel Index was 9.55 (±5.12) indicating high-dependency. NHRs fallers frequently attended ED outside routine working hours, with 36.8% (92/250) and 27.6% (69/250) presenting after 5pm (Monday to Friday), or at the weekend respectively. 54.8% of patients were admitted (137/250), and only 25.6% of patients had review by a GP prior to ED-referral (64/250). The average Length Of Stay (aLOS) for admitted NHR fallers was 10.4 (±9.1) days. Injurious falls were noted in only 10.4% (26/250) presentations. aLOS for those admitted with documented injuries (14/26, 54%) was 5.0 days (±7.0, n=14).

Conclusion

NH residents have complex clinical needs and falls is a frequent reason for attending ED. Better access to “out of hours” clinical support within the NH, and better integrated falls prevention programmes/ care pathways between NHs and primary/secondary services are necessary to enhance care and optimise falls prevention.

81 IMPROVING THE ASSESSMENT AND PREVENTION OF FALLS AND FRACTURES ON A REHABILITATION WARD

Background

The National Steering Group and The National Institute for Health and Care Excellence provide guidelines on medical assessment and prevention of falls and fractures. This audit assesses and compares quality of practice on an Age-Related rehabilitation ward against these guidelines.

Methods

A retrospective audit, including all patients (n=31) on an off-site, Age-Related rehabilitation ward was completed. Data on falls and fractures at emergency department presentation and during admission was obtained through chart review. Following education and implementation of a falls pro-forma, a re-audit was completed at four months including all patients (n=40).

Results

In cycle 1, mean age of patients was 80 years (range 56-94), 39 Percent (%) (n=12) were admitted with a fall of whom 66.7% (n=8) had a resulting fracture. In cycle 2, mean age was 82 years (range 63–95), 48% (n=19) were admitted due to a fall, of whom 53% (n=10) had a fracture.

A falls assessment and bone health review was completed in 39% (n=12) of all patients in cycle 1, and in 37% (n=3) admitted with a fall. This increased to 83% (n=33) of all patients in cycle 2 and 100% (n=40) of those admitted with a fall. Pre-intervention, 23% (n=7) had an inpatient fall compared to 18% (n=7) post-intervention; of these, 43% (n=3) and 14% (n=1) resulted in fractures respectively.

Conclusion

Compliance with national guidelines for prevention of falls and fractures improved with education and implementation of a falls pro-forma. This resulted in a reduction in falls, particularly injurious falls, on a rehabilitation ward. In future, this pro-forma may be implemented in other hospital wards.

1062 GAIT SPEED AND EXECUTIVE PERFORMANCE IN PEOPLE WITH MILD COGNITIVE IMPAIRMENT

Introduction

The Motoric Cognitive Risk Syndrome has highlighted the link between cognitive and motor performance, and the associated incremental higher risk of developing dementia. There is considerable debate regarding what aspects of cognition (working memory, executive function, attention) are most associated with gait changes. This study investigates the relationship between mobility scores and cognitive profiles in individuals with Mild Cognitive Impairment (MCI) specifically with regard to executive performance and amnestic/non-amnestic profiles.

Method

Participants diagnosed with MCI, (Clinical Dementia Rating scale global score of ≤0.5, sum of boxes score ≤ 4.0), attending a regional specialist memory service had a three-meter Timed Up and Go (TUG) gait assessment and multi-domain neuropsychiatric assessment undertaken. Amnestic neuropsychiatric profile was defined as Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) delayed memory subset score &lt; 1SD i.e. ≤16th centile below norm for age/education. Executive function performance was assessed using the Executive Interview (EXIT-25) where higher scores reflect poorer executive performance.

Results

Data was reviewed for 161 patients with MCI; 53% (86/161) women. 80% (129/161) had an amnestic neuropsychiatric profile, mean age 73.8 ± 7.2 (51–94). 20% (32/161) had non-amnestic MCI, mean age 74 ± 7.07 (60–87). There was no significant difference in TUG results between amnestic and non-amnestic MCI patients (11.2 ± 3.3 vs 10.7 ± 3.1 p = NS). There was a significant increase in TUG values with worsening executive function performance [EXIT-25 score 0–9 (88/161) mean TUG = 10.5 ± 3.3 seconds vs EXIT-25 score 10–14 (43/161) mean TUG =11.9 ± 2.8 seconds vs EXIT-25 score 15–25 (30/161) mean TUG = 12.1 ± 3.9 seconds; p = 0.021] which persisted after controlling for age, gender and other relevant cofactors.

Discussion

Reflective of the importance of frontal lobe integration to the respective tasks, subtle differences in gait performance are associated with executive function performance regardless of predominant amnestic or non-amnestic MCI profile.

953 PREVIOUS SARS-COV2 INFECTION, AGE AND FRAILTY PREDICT 6-MONTH BNT162B2 VACCINE-INDUCED ANTIBODY TITRE IN NURSING HOME RESIDENTS

Introduction

Older nursing home residents are the population at greatest risk of morbidity and mortality from SARS-CoV-2 infection. No studies have examined the determinants of long-term antibody responses post-vaccination in this group.

Method

Longitudinal cohort study in residents of 5 nursing homes assessed prior to vaccination and at both 5-weeks and 6-months post SARS-CoV2 vaccine (BNT162b2). Comprehensive clinical assessment was performed, including assessment for comorbidity, frailty (NH-FRAIL) and SARS-CoV-2 infection history. Serum Nucleocapsid and Anti-Spike Receptor Binding Domain (RBD) antibodies were analysed at all timepoints and an in vitro Angiotensin Converting Enzyme (ACE2) Receptor-Spike RBD neutralisation assay used to assess serum neutralisation capacity.

Results

Of 86 participants (81.1 ± 10.8 years; 65% female), just-under half (45.4%; 39/86) had evidence of previous SARS-CoV-2 infection. All participants demonstrated a significant antibody response to vaccination at 5-weeks and a significant decline in this response by 6-months. SARS-CoV-2 infection history was the strongest predictor of antibody titre (log-transformed) at both 5-weeks (β: 3.00; 95% CI [Confidence Interval]: 2.32, 3.70; p &lt; 0.001) and 6-months (β: 3.59; 95% CI: 2.89, 4.28; p &lt; 0.001). Independent of SARS-CoV-2 infection history, both age in years (β: -0.05; 95% CI: −0.08, −0.02; p &lt; 0.001) and frailty (β: -0.22; 95% CI: −0.33, −0.11; p &lt; 0.001) were associated with a lower antibody titre at 6-months. Antibody titres at both 5-weeks and 6-months significantly correlated with in vitro neutralisation capacity.

Conclusion and Implications

In older nursing home residents, SARS-CoV-2 infection history was the strongest predictor of anti-spike antibody titres at 6-months, whilst age and frailty were independently associated with lower titres at 6-months. Antibody titres significantly correlated with in vitro neutralisation capacity. Whilst older SARS-CoV-2 naïve nursing home residents may be particularly vulnerable to breakthrough SARS-CoV-2 infection, the relationship between antibody titres, SARS-CoV-2 infection and clinical outcomes remains to be fully elucidated in this cohort.

89 CSF BIOMARKER UTILITY IN SUPPORTING ALZHEIMER’S DISEASE DIAGNOSIS: CLINICAL PERSPECTIVES FROM AN IRISH REGIONAL SPECIALIST MEMORY SERVICE

Background

CSF (cerebrospinal fluid) biomarkers [amyloid- beta-42 (AB-42), phosphorylated tau (p-tau)] are increasingly used in supporting clinical diagnosis of Alzheimer’s Disease (AD). Both elevated CSF p-tau and reduced AB-42 are necessary for pathological diagnosis of AD. The aim of this study is to apply recent international recommendations to patients attending a regional specialist memory service, evaluating consistency with detailed clinical, neuroimaging, and neuropsychological ad-phenotype profiling.

Methods

All patients age &lt; 80, with mild/subjective cognitive and/or atypical neurobehavioral symptoms, non-significant vascular burden on neuroimaging, and without contraindication to lumbar puncture are offered CSF analysis. Clinical diagnosis was ascribed on the basis of specialist multi-disciplinary consensus review. We undertook a case-note and database retrospective review of those who had ad-biomarker CSF analysis, collecting demographic, clinical phenotype diagnosis, and neuropsychological performance. Data was extracted and analysed using SPSS v.25.

Results

One-hundred-sixteen patients underwent CSF biomarker testing. Forty-nine patients (42%) had positive AD-CSF biomarkers, 41/49 (84%) of whom presented with common ad phenotypes (Amnestic/Logopenic PPA/PCA). Twenty patients (17%) had negative ad-CSF (elevated AB-42, and low p-tau) studies, and half of those (10/20, 50%) had a consistent atypical non-AD clinical phenotype. Patients with negative ad-CSF were younger and tended to have non-amnestic neuropsychological profile. Therefore there was a mismatch in 18/69 (26%) people in these groups with definitive +/− ad biomarker results and ad/Non-ad clinical phenotype. A further forty seven (40%) patients had indeterminate CSF studies with one or other changes in AB-42 or p-tau, but not both as is necessary for definitive diagnosis.

Conclusion

Incorporation of CSF biomarker analysis is quickly being established as a key component of the neurocognitive/dementia diagnostic pathway. However, there are challenges and limitations arising as they are applied in clinical settings, and further research is warranted to explore variations between pathological results and clinical phenotype presentation.

144 DEVELOPING AN INTEGRATED POST DIAGNOSTIC PATHWAY FOR PERSONS LIVING WITH DEMENTIA—EXPERIENCES OF A REGIONAL SPECIALIST MEMORY SERVICE

Background

The frequently heterogeneous nature of a dementia presentation confers the need for a personalised approach to post-diagnostic supports. It’s an essential right for persons living with dementia (PlwD) and their families/supporters to have access to a comprehensive diagnosis and a responsive holistic pathway of care thereafter. We report our development of an integrated specialist-clinic/community post-diagnostic pathway responsive to the evolving personal needs of PlwD and their care-supporters.

Methods

This pathway was developed in an iterative inclusive-design methodology with input from hospital/community clinical specialists, health and social care professionals, senior nursing, PlwD and their care supporters. The post-diagnostic process starts at diagnosis disclosure, followed for all six-weeks later with a designated post diagnostic clinic, where a single point of contact to address any concerns in between visits is established.

Results

Iterative review cycles have identified integral components of an effective pathway: Guidance to live well with their personal manifestation of dementia; Acknowledgment of biopsychosocial elements of care; Timely access to comprehensive geriatric assessment via ambulatory hub MDT and/or and Integrated care team for older persons offering home assessment & intervention; Prevention of ‘harmful-events’ e.g. falls/delirium/hospitalisation; Timely access to therapies e.g. SLT/OT focussed on enhanced life at home/assistive technology; facilitation and planning of palliative care.

Other aspects include signposting to community resources and forward planning e.g. Citizen’s Information Centres; Peer support and education through designated training; Promotion of brain health- Exercise Programmes; social/cognitive stimulation e.g. Men’s sheds, Walking groups & Memory Resource Rooms; Opportunities for research involvement; Enhanced relationships with national organisations e.g. embedded ASI dementia advisor.

Conclusion

This approach has developed into a fully integrated holistic care-pathway where specialist-clinic, ambulatory-hospital, community older persons, and third sector services work together to provide the right care, at the right time, in the right place for PlwD and their families.

140 FAMILY DEMENTIA SUPPORT TRAINING—AN INTEGRATED CARE APPROACH

Background

There are approximately 64,000 people living with a diagnosis of dementia in Ireland. This number is expected to double to 150,000 by 2045. The growing need for post diagnostic support has been accentuated by the fact that we are living through an unprecedented Pandemic. Our Dementia Training Network identified the need for a localised educational resource for families supporting those diagnosed with dementia across our service.

Methods

Following a successful pilot in association with the Alzheimer’s Society of Ireland, staff from the Specialist Memory Service, Integrated Care Team, and Primary Care created a service-informed 6 week course aimed at supporting families. A focus group preceded the first course to establish preferred content. The course delivered education on Dementia; Post Diagnostic Steps; Communication; Non cognitive symptoms; Nutrition & hydration; Assistive Technology; Forward planning and Self-care. The multi-dimensional nature of staff delivering the course creates a rich tapestry of advice and information. All staff involved work together to identify, refer and support families living with dementia in the local area. The group takes place in an accessible location and time which accommodates families. Each course attendee completes a questionnaire prior to and after commencing the group. The level of satisfaction will be measured following every course.

Results

By the end of 2021, the group will have delivered education and support to 36 families. The automatic referral of all families to this resource will assist in building up confidence to support and enhance self-care. The combined participants from the catchment area will become a network of families joined together on their journey.

Conclusion

This innovative service collaboration enhances the integrated nature of the Post Diagnostic Care pathway. The Integrated care approach has served to enrich the programme and allow for timely support and advice regarding localised supports.

66 BRAIN HEALTH CLINIC: DEVELOPING INNOVATIVE OPPORTUNITIES TO INTERVENE IN MODIFIABLE VASCULAR RISK FACTORS (VRF) TO IMPROVE COGNITIVE AGEING

Background

It is now well established that VRF place immense burden on cognition, including white matter changes, decreased cerebral perfusion and neuro-inflammation.

An innovative Brain Health Clinic (BHC) was developed aligned to a specialist memory service to educate people at risk of or living with mild cognitive symptoms, about positive brain health and subsequently design a ‘Personalised Prevention Plan’ to optimise cognitive ageing.

The aim of this study is to report the opportunities identified and addressed to mitigate vascular risk-related cognitive decline in people attending the Brain Health Clinic.

Methods

Modifiable VRF (including HbA1c, cholesterol, Body Mass Index (BMI), smoking, alcohol intake and hypertension) were examined in people who attended the BHC between October 2019 and July 2021. In addition to VRFs, sleep, physical activity, sensory, social, and psychological measures are measured and reported to individuals.

The VRF values were examined based on current guidelines from the European Society of Cardiology (2018).

Results

Forty-five people (mean age 72.6 years, 62.2% females) were included. The average number of modifiable VRF’s per person was 3, and a total of 119 VRF’s were identified overall. One patient had six modifiable VRF’s identified, and 2/45 had none.

The most common VRF was elevated BMI present in 33/45 (73.3%). 12/45 (27%) patients were ex-smokers, while 5/45 (11%) still smoked. 5/45 (11%) consumed excess alcohol. 15/45 (33.3%) had elevated cholesterol.

29/45 (64.4%) had elevated systolic blood pressure. Of these, 10/45 (22.2%) were known but poorly-controlled and 19/45 (42.2%) were identified de novo. Similarly, only 1/45 (2.2%) had known diabetes but poorly-controlled, while 9/45 (20.0%) had impaired glucose tolerance identified de novo.

Conclusion

The BHC aligned to a memory service provides an opportunity to identify modifiable VRF for declining cognition, and supports people in addressing these by sign-posting to relevant services.

Cardiac magnetic resonance in COVID-19 positive and probable cases: A report from a high volume CMR centre in Ireland

Funding Acknowledgements

Type of funding sources: None.

Introduction

Coronavirus disease 2019 (COVID-19) infection can have multisystem involvements. The inflammation sequelae can cause myocarditis. The COVID-19 pandemic has impacted Ireland significantly. Understanding of myocardial involvement in COVID-19 is not fully elucidated but has been reported. The Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic in Ireland is a high volume CMR centre with approximately 4500 cases per year and accepting referral from all hospital in Ireland. These analyses are to describe the CMR findings in COVID-19 positive and probable cases attending the centre.

Methods

Consecutive 65 referrals with mention of "COVID-19" from March 2020 to December 2020 was assessed. 56 cases were included in this analysis. Cases were categorised as COVID-19 positive cases or probable (viral illness like symptoms) cases. The demography and CMR parameters were collected. Serial imaging of selected cases was included. Descriptive analyses methods were applied.

Results

In the period of 10 months, there was 49 COVID-19 positive cases (65.3% male; median age 49 [32 : 61] years) and 7 COVID-19 probable cases (42.9% male; median age 39 [37 : 59] years). In the COVID-19 positive cases, 25 had normal CMR, 11 has evidence of myocarditis, 1 with pericarditis, 2 with infarction/ischaemia, 3 with dilated cardiomyopathy, 2 with hypertrophic cardiomyopathy and 5 with other findings. There were 3 COVID-19 positive cases with serial imaging showing resolving myocarditis (100% female; median age 41 [30 : 47] years). 2 professional athletes with COVID-19 positive test showed no evidence of myocarditis. There are no significant differences in the age of male COVID-19 positive versus female group (p= 0.0752). Different demography and CMR parameters and tissue characterisation are described in Table 1 and Table 2.

Conclusions

The prevalence of myocarditis in this cohort is approximately 1 in 5 (21.4%). Within the COVID-19 positive cases, the prevalence is 22.4%. These observations may reflect selection bias for CMR referral in those with cardiac symptoms or cardiac enzymes leak.

Screening for frailty in older emergency department patients: the utility of the Survey of Health, Ageing and Retirement in Europe Frailty Instrument

BACKGROUND

Greater numbers of older patients are accessing hospital services. Specialist geriatric input at presentation may improve outcomes for at-risk patients. The Survey of Health, Ageing and Retirement in Europe Frailty Instrument (SHARE-FI) frailty measure, developed for use in the community, has also been used in the emergency department (ED).

AIM

To measure frailty, review its prevalence in older patients presenting to ED and compare characteristics and outcomes of frail patients with their non-frail counterparts.

DESIGN

Patient characteristics were recorded using symphony® electronic data systems. SHARE-FI assessed frailty. Cognition, delirium and 6 and 12 months outcomes were reviewed.

METHODS

A prospective cohort study was completed of those aged ≥70 presenting to ED over 24 h, 7 days a week.

RESULTS

Almost half of 198 participants (46.7%, 93/198) were classified as frail, but this was not associated with a significant difference in mortality rates (OR 0.89, 95% CI 0.58-1.38, P = 0.614) or being alive at home at 12 months (OR 1.07, 95% CI 0.72-1.57, P = 0.745). Older patients were more likely to die (OR 2.34, 95% CI 1.30-4.21, P = 0.004) and less likely to be alive at home at 12 months (OR 0.49, 95% CI 0.23-0.83, P = 0.009). Patients with dementia (OR 0.24, P = 0.005) and on ≥5 medications (OR 0.37, 95% CI 0.16-0.87, P = 0.022) had a lower likelihood of being alive at home at 12 months.

CONCLUSIONS

Almost half of the sample cohort was frail. Older age was a better predictor of adverse outcomes than frailty as categorized by the SHARE-FI. SHARE-FI has limited predictability when used as a frailty screening instrument in the ED.

Proteomic analysis of a mosquito host cell response to persistent Wolbachia infection

Wolbachia pipientis, an obligate intracellular bacterium associated with arthropods and filarial worms, is a target for filarial disease treatment and provides a gene drive agent for insect vector population suppression/replacement. We compared proteomes of Aedes albopictus mosquito C/wStr1 cells persistently infected with Wolbachia strain wStr, relative to uninfected C7-10 control cells. Among approximately 2500 proteins, iTRAQ data identified 815 differentially abundant proteins. As functional classes, energy and central intermediary metabolism proteins were elevated in infected cells, while suppressed proteins with roles in host DNA replication, transcription and translation suggested that Wolbachia suppresses pathways that support host cell growth and proliferation. Vacuolar ATPase subunits were strongly elevated, consistent with high densities of Wolbachia contained individually within vacuoles. Other differential level proteins had roles in ROS neutralization, protein modification/degradation and signaling, including hypothetical proteins whose functions in Wolbachia infection can potentially be manipulated by RNAi interference or transfection. Detection of flavivirus proteins supports further analysis of poorly understood, insect-specific flaviviruses and their potential interactions with Wolbachia, particularly in mosquitoes transinfected with Wolbachia. This study provides a framework for future attempts to manipulate pathways in insect cell lines that favor production of Wolbachia for eventual genetic manipulation, transformation and transinfection of vector species.

Characteristics and Outcomes of Older Patients Attending an Acute Medical Assessment Unit

The care of older persons accounts for an increasing proportion of the unscheduled care workload for acute hospitals. The recent development of acute medical assessment units (AMAU) has provided an alternative model for acute unscheduled care for all medical patients. Screening instruments have been developed to capture the higher levels of clinical complexity and medical comorbidities that older patients present with. The aim of this study was to report on the characteristics and outcomes for older patients reviewed in the AMAU of a tertiary referral university teaching hospital. Data on 3071 patients attending the unit over one year was prospectively collected and information on characteristics and outcomes for older patients retrieved. Older patients represented over one third (1066/3071, 35%) of those attending AMAU, and had an admission rate of nearly twice that of younger patients (60.5% vs 32%), highlighting the increased complexity of this group. Gerontologically attuned AMAUs have great potential to enhance care for frail older patients from the time of their acute presentation to hospital.

Effects of body mass index on sleep patterns during pregnancy

The purpose of this study was to profile sleep patterns during pregnancy according to body mass index (BMI) and to correlate labour outcomes with both BMI and hours sleep. Data were collected from 200 postpartum women detailing sleep characteristics before and during pregnancy. A validated sleep questionnaire was employed, which comprised of questions about sleep apnoea, snoring, subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication and daytime dysfunction. Descriptive analyses were used. With advancing gestation, the mean (SD) number of hours sleep per night declined: pre-pregnancy 8.1 (SD 1.4); 1st trimester 8.3 (SD 1.8); 2nd trimester 7.7 (SD 1.7) and 3rd trimester 6.7 (SD 2.2). In the 18.5-24.9 BMI group, there was a marked difference in hours sleep per night from pre-pregnancy to 1st (8.6 h, p = 0.007), 2nd (7.9 h, p = 0.023) and 3rd (6.4 h, p = 0.000) trimesters in primiparous women. In the 25-29.9 BMI group, there was a difference from pre-pregnancy to 3rd trimester (p = 0.000). These changes were not reflected in a clinically significant difference in birth weight or mode of delivery.

Nursing skill mix and nursing time: the roles of registered nurses and clinical nurse specialists

OBJECTIVE

The roles of clinical nurse specialists (CNS) and registered nurses, while similar, should also be quite different, with the CNS functioning as an advanced practice nurse. Differences in roles can be partially explained and understood by examining the use of their time. Adjustments to skill mix usually involve using more plentiful but less-skilled workers, and there is a growing body of overseas research in this field. In contrast, little research has examined and compared the use of nursing time for the RN and CNS role, particularly in an Australian context. Comparing work activities enables employers to begin to answer the question: Are skilled nursing personnel being used effectively and efficiently?

DESIGN

A work-sampling study conducted over eight weeks. Data were analysed descriptively using SPSS, v.9.

SETTING

Six wards in a large private not-for-profit hospital.

MAIN OUTCOME MEASURE

To determine whether there is a differentiation in the roles of CNS and RN by examining the percentage of time spent in 25 specific activities.

RESULTS

In some activities it is not possible to distinguish differences in the amount of time spent by RNs and CNSs. In other activities such as clerical, meetings and administration, CNSs are spending more time than anticipated. Consideration needs to be given to employing clerical staff to relieve the CNS of these non-clinical aspects.

CONCLUSION

The study extends the understanding of the roles of registered nurses and clinical nurse specialists and provides a basis on which to begin to understand similarities and differences in their roles.

Activation of the erythropoietin receptor by the gp55-P viral envelope protein is determined by a single amino acid in its transmembrane domain

The spleen focus forming virus (SFFV) gp55-P envelope glycoprotein specifically binds to and activates murine erythropoietin receptors (EpoRs) coexpressed in the same cell, triggering proliferation of erythroid progenitors and inducing erythroleukemia. Here we demonstrate specific interactions between the single transmembrane domains of the two proteins that are essential for receptor activation. The human EpoR is not activated by gp55-P but by mutation of a single amino acid, L238, in its transmembrane sequence to its murine counterpart serine, resulting in its ability to be activated. The converse mutation in the murine EpoR (S238L) abolishes activation by gp55-P. Computational searches of interactions between the membrane-spanning segments of murine EpoR and gp55-P provide a possible explanation: the face of the EpoR transmembrane domain containing S238 is predicted to interact specifically with gp55-P but not gp55-A, a variant which is much less effective in activating the murine EpoR. Mutational studies on gp55-P M390, which is predicted to interact with S238, provide additional support for this model. Mutation of M390 to isoleucine, the corresponding residue in gp55-A, abolishes activation, but the gp55-P M390L mutation is fully functional. gp55-P is thought to activate signaling by the EpoR by inducing receptor oligomerization through interactions involving specific transmembrane residues.

The anemic Friend virus gp55 envelope protein induces erythroid differentiation in fetal liver colony-forming units-erythroid

The gp55 envelope proteins of the spleen focus-forming virus initiate erythroleukemia in adult mice. Because the gp55 from the polycythemic strain (gp55-P), but not from the anemic strain (gp55-A), activates the erythropoietin receptor (EpoR) for proliferation of hematopoietic cell lines, the mechanism by which gp55-A initiates erythroleukemia has remained a mystery. We show here that gp55-A activates the EpoR in fetal liver cells. In contrast to previous studies using bone marrow cells from phenylhydrazine-treated, anemic mice, we find that both gp55-A and gp55-P induce erythroid differentiation from colony-forming unit-erythroid (CFU-E) progenitors in fetal liver cells. The effects on CFU-Es of both gp55-A and -P are mediated by the EpoR, because no colonies are seen upon expression of either gp55 in EpoR-/- fetal liver cells. However, only gp55-P induces erythroid bursts from burst-forming unit-erythroid progenitors and only gp55-P induces Epo independence in Epo-dependent cell lines. Using chimeric gp55 P/A proteins, we extend earlier work showing that the transmembrane sequence determines the capacity of gp55 proteins to differentially activate EpoR signaling. We discuss the possibilities for different signaling capacities of gp55-A and -P in fetal liver and bone marrow-derived erythroid progenitor cells.

Termination in inpatient groups

This article provides the therapist with a three-factor framework for understanding and constructively responding to members' termination in the inpatient group. The first factor is the context in which the inpatient group takes place. It will be argued that how the broader system defines and treats termination affects the group process at the time of termination. The second factor is the therapist's countertransference. Three especially common reactions (disappointment, abandonment anxiety, and powerlessness) will be described. The third factor is the characteristic need of inpatients at termination time. Each factor is described in terms of its potential impact on the termination process. Techniques and suggestions are offered that aim to mitigate the destructive forces of each factor and to enhance the therapeutic value of the termination event for the patient.

Geographic variation in human immunodeficiency virus seroconversion rates in the U.S. Navy

The Navy population is centered around 19 U.S. home ports and several inland duty stations. This is a study of variation in human immunodeficiency virus (HIV) seroconversions in Navy enlisted men by location in the United States, based on 949,570 enzyme-linked immunosorbent assays and 812 seroconversions during 1987-90. Seroconversion rates were higher in personnel in San Francisco (p = 0.0004), Washington, D.C. (p = 0.001), and Orlando, FL (p = 0.04) than in other areas. They were lower in Charleston, SC, New London, CT, Seattle; and Brunswick, ME (p < 0.05). Black men had triple the seroconversion rate of all other men (p < 0.0001). After adjustment for race, age, marital status, and occupation, risk of seroconversion remained high in San Francisco (p = 0.02) and Orlando (p = 0.03). The risk of seroconversion in San Francisco was twice that of other areas in a cohort that did not change location (p = 0.01). In contrast to declining trends overall in the Navy, rates did not decrease in Washington, D.C., a result consistent with previous calculations indicating a delayed second wave of HIV infection in the region.

Characterization of the structure and conformation of platelet-derived growth factor-BB (PDGF-BB) and proteinase-resistant mutants of PDGF-BB expressed in Saccharomyces cerevisiae

A detailed biophysical study of the secondary and tertiary structures of recombinant platelet-derived growth factor (PDGF)-BB produced in yeast has been carried out. The secondary structure of the molecule is composed of 54% beta-sheet with less than 5% ordered helix. The single tryptophan residue has been shown to be solvent-accessible; however, the ability of the side chain to rotate is severely restricted. The fluorescence emission is quenched at pH 7.0 and in the presence of high salt, but dequenched by titration to lower pH with a pK of 5.8. Two proteinase-resistant mutants of PDGF [( Ser28]- and [Pro32]-PDGF-BB) have also been characterized and shown to have secondary and tertiary structures indistinguishable from wild-type PDGF-BB. These are, therefore, suitable stable background molecules in which to carry out structure-activity-relationship studies on PDGF-BB.

Purification and analysis of proteinase-resistant mutants of recombinant platelet-derived growth factor-BB exhibiting improved biological activity

Recombinant platelet-derived growth factor (PDGF)-BB was expressed and secreted from yeast in order to study the structure-function relationships of this mitogen. A simple purification scheme has been developed which yields greater than 95% pure PDGF-BB. Analysis of this recombinant PDGF-BB shows partial proteolysis after arginine-32. Substitution of this arginine residue, or arginine-28 [a potential KEX2 (lysine-arginine endopeptidase) cleavage site], prevents or reduces cleavage of PDGF-BB respectively. These mutations result in a 5-fold increase in expression levels of PDGF-BB, and the resulting mutant proteins show higher activity in a number of biological assays than the cleaved wildtype PDGF-BB. These data are in accord with previous work by Giese, LaRochelle, May-Siroff, Robbins & Aaronson [(1990) Mol. Cell Biol. 10, 5496-5501] suggesting that the region isoleucine-25-phenylalanine-37 is involved in PDGF-receptor binding.

Two PDGF-B chain residues, arginine 27 and isoleucine 30, mediate receptor binding and activation

PDGF may be involved in the pathogenesis of a variety of disorders including atherosclerosis and certain types of cancer. There is currently little understanding of the molecular structure of PDGF and of the critical amino acid residues involved in receptor binding and cell activation. Two such PDGF-B chain residues, arginine 27 and isoleucine 30, have been identified by a site-directed mutagenesis programme. Substitutions in these positions can lead to PDGF mutants defective in both receptor affinity and cell activation as judged by displacement of [125I]PDGF-BB, mitogenic assay and inositol lipid turnover. Circular dichroism and fluorescence spectroscopy show that such mutations do not disrupt the structure of PDGF.

Structure-function relationships in human epidermal growth factor studied by site-directed mutagenesis and 1H NMR

In order to elucidate the mechanism of interaction between human epidermal growth factor (EGF) and its receptor, selected variants of EGF, differing by single amino acid substitutions, have been made by site-directed mutagenesis. The receptor affinity of these mutants was determined by a receptor binding competition assay, and the effects of the substitution on the structure of the protein were assessed by 1H nuclear magnetic resonance techniques. Various substitutions of Arg-41 resulted in substantial reduction in receptor affinity of EGF whereas change of Tyr-13 did not affect binding to the receptor. The 1H resonances of all nonexchangeable protons of the Tyr-13----Leu, Arg-41----His, and Leu-47----Glu variants were assigned and compared in order to assess the structural integrity of these mutants, which possess very different spectral and biological properties. In the case of the Leu-47----Glu mutant, only minor localized spectral changes were observed, confirming that the tertiary structure of the protein is preserved upon mutation. In contrast, for both the Arg-41----His and Tyr-13----Leu variants, significant and strikingly similar spectra changes were observed for many residues located far away from the mutated residues. This implies that similar structural alterations have taken place in both proteins, an idea further supported by hydrogen-exchange experiments where the exchange rates of hydrogen-bonded amide protons for both the Tyr-13----Leu and the Arg-41----His mutants were found to be about 4 times faster than in the wild-type protein.(ABSTRACT TRUNCATED AT 250 WORDS)

Structure-function relationships in epidermal growth factor (EGF) and transforming growth factor-alpha (TGF-alpha)

The solution structures of the homologous growth factors human epidermal growth factor (hEGF) and human transforming growth factor-alpha (hTGF-alpha), as determined by high resolution NMR and various computational methods, are described. Knowledge of these structures and the sequences of other homologous proteins leads to predictions about growth factor residues which may be involved in the receptor/ligand interface. Recent experiments designed to check these predictions are described briefly. These involve site-specific mutagenesis, receptor binding assays and high resolution NMR studies.

Structure-function analysis of epidermal growth factor: site directed mutagenesis and nuclear magnetic resonance

The role of leucine-47 in determining the structure and activity of human epidermal growth factor was examined using site-directed mutagenesis. Wild type protein and four variants in which Leu47 was replaced by valine, glutamate, aspartate and alanine were produced from yeast. 1H NMR experiments demonstrated that substitution of Leu47 had little effect on the protein structure. The observed reduction in receptor binding affinity caused by the substitutions could thus be attributed to perturbation of a residue directly involved in receptor interactions.

Collagen stimulating factors in hepatic fibrogenesis

Four factors which stimulate collagen synthesis and prolyl hydroxylase activity in cultures of human and mouse fibroblasts have been isolated by molecular sieve chromatography from animal and human fibrotic and cirrhotic livers. These factors do not stimulate protein or DNA synthesis or total DNA in these cultures. It has also been shown that these factors, designated collagen stimulating factors F1-F4, do not owe their activity to ascorbate or glutamine. Collagen stimulating factors are heat stable, and F1 and F2 have apparent molecular weights of about 4000 and 1000 respectively. Since these factors are not present in normal animal or human liver it is suggested that they may be responsible for increased collagen production in vivo in hepatic fibrosis and cirrhosis.

Investigation of the parameters for reversed-phase high-performance liquid chromatography of collagen types I and III

A detailed study was carried out on the behaviour of collagen and its subcomponents on large pore size reversed-phase high-performance liquid chromatographic columns. Investigation of laboratory-prepared C18 and CN 50-nm pore size supports using a simple solvent system showed that heat-denatured collagen chains could be retained and resolved and that the C18 packing had a greater selective capacity. However, because of inconsistencies in the chromatography obtained using laboratory-prepared supports commercial 33-nm pore size packings were subsequently studied with both pyridine-based and trifluoroacetic acid-based solvent systems. An optimised solvent was defined and used to check the resolving capacity of both C18 and CN commercial columns. These studies led to the description and interpretation of the effects of pH, counter-ion concentration, solvent strength, type of support and molecular weight of protein solutes on the chromatographic behaviour of this large protein and its CNBr peptides. An explanation of the major forces acting to bring about retention and resolution is presented and suggestions are made for the application of this methodology to other proteins.

Isolation of collagen stimulating factors from healing wounds

Five factors (collagen stimulating factors) have been isolated from healing murine skin wounds which stimulate prolyl hydroxylase activity and collagen synthesis in mouse fibroblasts in vitro. These factors stimulate general protein synthesis to a much smaller extent. Collagen stimulating factors are detectable in wounds three days after healing begins and disappear after six days when healing is complete. These data indicate that these factors may modulate collagen production during wound healing.

Separation of native types I and III collagens and denatured chains by reverse-phase high-performance liquid chromatography

A simple and effective high-performance-liquid-chromatography system has been developed for the separation of the native forms of Types I and III collagens. This separation is achieved on a commercially available 330-A-pore-size C18 reverse-phase support using a solvent system consisting of ammonium bicarbonate (0.05 M) and trifluoroacetic acid (0.4%) with tetrahydrofuran as the eluting solvent. This simple system can also be applied to the separation of mixtures of the denatured chains of both collagen types.

Hepatic cirrhosis--a collagen formative disease?

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