Cardiovascular disease and the risk of incident falls and mortality among adults aged ≥ 65 years presenting to the emergency department: a cohort study from national registry data in Denmark

BACKGROUND

Falls cause 58% of injury-related Emergency Department (ED) attendances. Previous research has highlighted the potential role of cardiovascular risk factors for falls. This study investigated the impact of cardiovascular disease (CVD) risk on three-year incident falls, with presentation to the ED, and mortality.

METHODS

A matched cohort study design was employed using national registry data from 82,292 adults (33% male) aged ≥ 65 years living in Denmark who attended the ED in 2013. We compared age and gender matched ED attendees presenting with a fall versus another reason. The cohort was followed for three-year incident falls, with presentation to the ED, and mortality. The impact of falls-related CVDs was also examined.

RESULTS

Three-year incident falls was twofold higher among age and gender matched ED attendees aged ≥ 65 years presenting with a fall versus another reason at baseline. A presentation of falls with hip fracture had the highest percentage of incident falls in the 65-74 age group (22%) and the highest percentage mortality in all age groups (27-62%). CVD was not a significant factor in presenting with a fall at the ED, nor did it contribute significantly to the prediction of three-year incident falls. CVD was strongly associated with mortality risk among the ED fall group (RR = 1.81, 95% CI: 1.67-1.97) and showed interactions with both age and fall history.

CONCLUSION

In this large study of adults aged ≥ 65 years attending the ED utilising data from national administrative registers in Denmark, we confirm that older adults attending the ED with a fall, including those with hip fracture, were at greatest risk for future falls. While CVD did not predict incident falls, it increased the risk of mortality in the three-year follow up with advancing age. This may be informative for the provision of care pathways for older adults attending the ED due to a fall.

What does cognitive screening reveal about early cognitive performance following endovascular clot retrieval and intravenous thrombolysis in acute ischaemic stroke?

Background Little is known regarding cognitive outcomes following treatment with endovascular clot retrieval (ECR) and intravenous tissue plasminogen activator (t-PA). We aimed to determine if there were any differences on a measure of cognitive screening between patients treated with ECR, t-PA, and those who were managed conservatively. Methods The medical records of ischaemic stroke patients admitted to Monash Medical Centre between January 2019 and December 2019 were retrospectively reviewed. Information extracted from medical records included age, sex, National Institutes of Health Stroke Scale at presentation, location of occlusion, treatment type, medical history, and cognitive screening performance measured by the Montreal Cognitive Assessment (MoCA). Results Eighty-two patients met the inclusion criteria (mean age = 66.5 ± 13.9; 49 male, 33 female). Patients treated with ECR performed significantly better on the MoCA (n  = 36, 24.1 ± 4.3) compared to those who were managed conservatively (n  = 26, 20.7 ± 5.5). Performance for patients treated with t-PA (n  = 20, 23.9 ± 3.5) fell between the ECR and conservative management groups, but they did not significantly differ from either. Conclusion Our retrospective chart review found that ischaemic stroke patients treated with ECR appear to perform better on cognitive screening compared to patients who are managed conservatively. We also found that patients treated with ECR and t-PA appear to have similar cognitive screening performances in the acute stages following ischaemic stroke, although this finding is likely to have been impacted by group differences in stroke characteristics and may reflect the possibility that the ECR group performed better than expected based on their stroke severity.

302 MONITORING FALLS RISK IN THE COMMUNITY USING AN IMPLANTABLE CARDIAC MONITOR WITH EMBEDDED ACCELEROMETER

Background

Falls are the most common cause of injury amongst older adults. Falls can lead to hospitalisation, functional decline and are associated with increased morbidity and mortality. The holy grail for clinicians would be to predict increased likelihood of falls occurring and intervene before the event. Understanding underlying dynamic biophysiological changes may therefore inform novel predictor models and falls prevention. This study examines activity and cardiac data acquired from an implanted Medtronic Reveal LINQ™ Insertable Cardiac Monitor (ICM) with an embedded tri-axial accelerometer.

Methods

Thirty participants with at least one unexplained fall in the previous two years were prospectively recruited. All met criteria for ICM insertion following comprehensive assessment. Participants were followed for one year and attended every three-months for cardiac and gait assessment. Information pertaining to activity levels, posture changes and cardiac parameters were collected daily from the device. Summary metrics and trends were collected for inclusion in a continual assessment of falls risk.

Results

Mean age of participants was 68.0 years (±9.3). 19/30 (63.3%) were female. 22/30 (73.3%) had at least one cardiovascular condition documented in their medical history. There was seasonal variation in activity levels. Twelve participants had falls and cardiovascular, gait and activity variables were examined at the time of a fall to determine any trends in biophysiological changes.

Conclusion

Causes of falls are usually multifactorial. A holistic approach is necessary to manage and minimise risk factors. The use of an ICM with an embedded tri-axial accelerometer allows clinicians to formulate an algorithm to determine if a person is at an increased risk of falling based on biophysiological changes. This may create an opportunity for falls to be predicted and prevented.

Psychometric Deficits in Autoimmune Encephalitis: A retrospective study from the Australian Autoimmune Encephalitis Consortium

BACKGROUND

Despite the rapid increase in research examining outcomes in Autoimmune Encephalitis (AE) patients, there are few cohort studies examining cognitive outcomes in this population.

METHODS

This retrospective observational study collected psychometric data from 59 patients across six secondary and tertiary referral centres in metropolitan hospitals in Victoria, Australia between January 2008 and July 2019. Frequency and pattern analysis were employed to define and characterise psychometric outcomes. Univariable logistic regression was performed to examine predictors of intact and pathological psychometric outcomes.

RESULTS

Deficits in psychometric markers of executive dysfunction were the most commonly observed in this cohort, followed by deficits on tasks sensitive to memory. 54.2% were classified as having psychometric impairments across at least two cognitive domains. 29 patterns were observed, suggesting outcomes in AE are complex. None of the demographic data, clinical features, and auxiliary examination variables were predictors of psychometric outcome.

CONCLUSIONS

Cognitive outcomes in AE are complex. Further detailed and standardised cognitive testing in combination with MRI volumetrics and serum/CSF biomarkers is required to provide rigorous assessments of disease outcomes.

Is orthostatic hypotension and co-existing supine and seated hypertension associated with future falls in community-dwelling older adults? Results from The Irish Longitudinal Study on Ageing (TILDA)

Orthostatic hypotension (OH) often co-exists with hypertension. As increasing age affects baroreflex sensitivity, it loses its ability to reduce blood pressure when lying down. Therefore, supine hypertension may be an important indicator of baroreflex function. This study examines (i) the association between OH and future falls in community-dwelling older adults and (ii) if these associations persist in those with co-existing OH and baseline hypertension, measured supine and seated. Data from 1500 community-dwelling adults aged ≥65 years from The Irish Longitudinal Study on Ageing (TILDA) were used. Continuous beat-to-beat blood pressure was measured using digital photoplethysmography during an active stand procedure with OH defined as a drop in systolic blood pressure (SBP) ≥20 mmHg and/or ≥10 mm Hg in diastolic blood pressure (DBP) within 3 minutes of standing. OH at 40 seconds (OH40) was used as a marker of impaired early stabilisation and OH sustained over the second minute (sustained OH) was used to indicate a more persistent deficit, similar to traditional OH definitions. Seated and supine hypertension were defined as SBP ≥140 mm Hg or DBP ≥90 mm Hg. Modified Poisson models were used to estimate relative risk of falls (recurrent, injurious, unexplained) and syncope occurring over four year follow-up. OH40 was independently associated with recurrent (RR = 1.30, 95% CI = 1.02,1.65), injurious (RR = 1.43, 95% CI = 1.13,1.79) and unexplained falls (RR = 1.55, 95% CI = 1.13,2.13). Sustained OH was associated with injurious (RR = 1.55, 95% CI = 1.18,2.05) and unexplained falls (RR = 1.63, 95% CI = 1.06,2.50). OH and co-existing hypertension was associated with all falls outcomes but effect sizes were consistently larger with seated versus supine hypertension. OH, particularly when co-existing with hypertension, was independently associated with increased risk of future falls. Stronger effect sizes were observed with seated versus supine hypertension. This supports previous findings and highlights the importance of assessing orthostatic blood pressure behaviour in older adults at risk of falls and with hypertension. Observed associations may reflect underlying comorbidities, reduced cerebral perfusion or presence of white matter hyperintensities.

Impact of a specialist service in the Emergency Department on admission, length of stay and readmission of patients presenting with falls, syncope and dizziness

BACKGROUND

Up to half of patients presenting with falls, syncope or dizziness are admitted to hospital. Many are discharged without a clear diagnosis for their index episode, however, and therefore a relatively high risk of readmission.

AIM

To examine the impact of ED-FASS (Emergency Department Falls and Syncope Service) a dedicated specialist service embedded within an ED, seeing patients of all ages with falls, syncope and dizziness.

DESIGN

Pre- and post-cohort study.

METHODS

Admission rates, length of stay (LOS) and readmission at 3 months were examined for all patients presenting with a fall, syncope or dizziness from April to July 2018 (pre-ED-FASS) inclusive and compared to April to July 2019 inclusive (post-ED-FASS).

RESULTS

There was a significantly lower admission rate for patients presenting in 2019 compared to 2018 [27% (453/1676) vs. 34% (548/1620); X2 = 18.0; P < 0.001], with a 20% reduction in admissions. The mean LOS for patients admitted in 2018 was 20.7 [95% confidence interval (CI) 17.4-24.0] days compared to 18.2 (95% CI 14.6-21.9) days in 2019 (t = 0.98; P = 0.3294). This accounts for 11 344 bed days in the 2018 study period, and 8299 bed days used after ED-FASS. There was also a significant reduction in readmission rates within 3 months of index presentation, from 21% (109/1620) to 16% (68/1676) (X2 = 4.68; P = 0.030).

CONCLUSION

This study highlights the significant potential benefits of embedding dedicated multidisciplinary services at the hospital front door in terms of early specialist assessment and directing appropriate patients to effective ambulatory care pathways.

A Simple Membrane Immunobead Assay for Detecting Ciguatoxin and Related Polyethers from Human Ciguatera Intoxication and Natural Reef Fishes

A simple membrane immunobead assay (MIA) for detecting ciguatoxin (CTX) and related polyethers directly from fish tissue is presented. A membrane laminated onto a solid plastic support is immersed with a piece of fish tissue in methanol. The membrane is thoroughly dried and placed into an immunobead suspension containing polystyrene particles coated with monoclonal antibody to CTX (MAb-CTX). Two beads of different diameter and color are used. The color intensity of the membrane is related to the concentration of the toxin bound to the membrane. Twelve of 13 fish implicated in human ciguatera fish poisoning showed borderline or positive responses in the assay. A Sphyraena barracuda sample that tested negative with the MIA and was highly toxic with the mouse toxicity bioassay showed only weak CTX-like toxin activity in the guinea pig atrial assay, indicating that the major toxin in the sample was not CTX-like. Examination of 154 routinely caught reef fish from Hawaii, Kosrae, and Kwajalein by MIA found 132 (86℅) negative and 8 (5℅) positive for CTX, with 14 (9℅) giving a borderline response. Fish from Hawaii showed a higher frequency of borderline or positive responses than those from Kosrae and Kwajalein, probably because several species of fish from several islands of Hawaii were tested, whereas only one species from a single area was examined from each of the islands of Kosrae and Kwajalein.

Long-term changes in neurocognition and behavior following treatment of sleep disordered breathing in school-aged children

STUDY OBJECTIVES

Sleep disordered breathing (SDB) in children is associated with detrimental neurocognitive and behavioral consequences. The long term impact of treatment on these outcomes is unknown. This study examined the long-term effect of treatment of SDB on neurocognition, academic ability, and behavior in a cohort of school-aged children.

DESIGN

Four-year longitudinal study. Children originally diagnosed with SDB and healthy non-snoring controls underwent repeat polysomnography and age-standardized neurocognitive and behavioral assessment 4y following initial testing.

SETTING

Melbourne Children's Sleep Centre, Melbourne, Australia.

PARTICIPANTS

Children 12-16 years of age, originally assessed at 7-12 years, were categorized into Treated (N = 12), Untreated (N = 26), and Control (N = 18) groups.

INTERVENTIONS

Adenotonsillectomy, Tonsillectomy, Nasal Steroids. Decision to treat was independent of this study.

MEASUREMENTS AND RESULTS

Changes in sleep and respiratory parameters over time were assessed. A decrease in obstructive apnea hypopnea index (OAHI) from Time 1 to Time 2 was seen in 63% and 100% of the Untreated and Treated groups, respectively. The predictive relationship between change in OAHI and standardized neurocognitive, academic, and behavioral scores over time was examined. Improvements in OAHI were predictive of improvements in Performance IQ, but not Verbal IQ or academic measures. Initial group differences in behavioral assessment on the Child Behavior Checklist did not change over time. Children with SDB at baseline continued to exhibit significantly poorer behavior than Controls at follow-up, irrespective of treatment.

CONCLUSIONS

After four years, improvements in SDB are concomitant with improvements in some areas of neurocognition, but not academic ability or behavior in school-aged children.

Nanospiderwebs: artificial 3D extracellular matrix from nanofibers by novel clinical grade electrospinning for stem cell delivery

Novel clinical grade electrospinning methods could provide three-dimensional (3D) nanostructured biomaterials comprising of synthetic or natural biopolymer nanofibers. Such advanced materials could potentially mimic the natural extracellular matrix (ECM) accurately and may provide superior niche-like spaces on the subcellular scale for optimal stem-cell attachment and individual cell homing in regenerative therapies. The goal of this study was to design several novel "nanofibrous extracellular matrices" (NF-ECMs) with a natural mesh-like 3D architecture through a unique needle-free multi-jet electrospinning method in highly controlled manner to comply with good manufacturing practices (GMP) for the production of advanced healthcare materials for regenerative medicine, and to test cellular behavior of human mesenchymal stem cells (HMSCs) on these. Biopolymers manufactured as 3D NF-ECM meshes under clinical grade GMP-like conditions show higher intrinsic cytobiocompatibility with superior cell integration and proliferation if compared to their 2D counterparts or a clinically-approved collagen membrane.

A clinically-feasible protocol for using human platelet lysate and mesenchymal stem cells in regenerative therapies

The transplantation of human stem cells seeded on biomaterials holds promise for many clinical applications in cranio-maxillo-facial tissue engineering and regenerative medicine. However, stem cell propagation necessary to produce sufficient cell numbers currently utilizes fetal calf serum (FCS) as a growth supplement which may subsequently transmit animal pathogens. Human platelet lysate (HPL) could potentially be utilized to produce clinical-grade stem cell-loaded biomaterials as an appropriate FCS substitute that is in line with clinically-applicable practice. The goal of this study was to investigate whether HPL can be successfully used to propagate human mesenchymal stem cells (HMSCs) seeded on clinically-approved collagen materials under clinically-applicable conditions using FCS as a control. HMSCs were isolated from bone marrow and cultured in the presence of 10% FCS or 10% HPL. Characterization of HMSCs was performed by flow cytometry and through osteogenic and adipogenic differentiation assays. Proliferative capacity of HMSCs on both matrices was investigated by mitochondrial dehydrogenase assays (WST) and tissue coverage scanning electron microscopy (SEM). The isolated HMSC differentiated into osteogenic and adipogenic cells authenticating the multipotentiality of the HMSCs. WST tests and the SEM images demonstrated that HPL was generally superior to FCS in promoting growth of seeded HMSCs. For all other tests HPL supported HMSCs at least equal to FCS. In conclusion, HPL is an effective growth factor to allow expansion of clinical-grade HMSCs on clinically-approved biomaterials for maxillofacial and oral implantology applications.

Gender influences handwashing rates in the critical care unit

BACKGROUND

Nurses tend to wash their hands more often than physicians, and among nonhealth care workers, women tend to wash their hands more often than men. This study examined the influence of gender on the handwashing rates of health care workers (HCWs). The null hypotheses were that there would be no intergender difference in (a) handwashing rates in HCWs across professions and (b) within professional groups.

METHODS

Handwashing by nurses, physicians, wardspersons, x-ray technicians, and physiotherapists after patient contact in a critical care unit (CCU) was determined through covert observation. The gender and profession of the subjects were recorded, but their identity was not.

RESULTS

Female CCU staff washed their hands significantly more often than did their male counterparts after patient contact (P =.0001). When the results were examined for the influence of profession on handwashing, significant intergender differences remained for physicians (P =.0468) and wardspersons (P =.0001). There was also a nonsignificant trend (P =.07) toward higher rates of handwashing among female x-ray technicians. There were no statistically significant intergender differences in handwashing rates among nurses (P =.7588) and physiotherapists.

CONCLUSIONS

It appears that gender may influence handwashing rates in HCWs in the CCU, although this difference appears to be modified in particular professional groups. Further research should examine factors that modify handwashing rates within professional groups and in settings other than the CCU.

Maximising handwashing rates in the critical care unit through yearly performance feedback

Handwashing following patient contact reduces the incidence of nosocomial infections. Despite this, handwashing rates by health care workers (HCWs) are often poor. Feedback on handwashing has been shown to significantly improve its rates. This study determined the optimum time to repeat performance feedback on handwashing rates of hospital staff in order to maximise its incidence. The baseline incidence of handwashing by staff following patient contact was determined by covert observation. This was followed by a period of feedback on handwashing performance by means of histograms displayed in the unit. Handwashing incidence was reassessed 6 and 12 months after the feedback ended. Performance feedback induced significant increases in handwashing incidence amongst nurses (p = 0.0433), resident medical officers (p = 0.0134), specialists (p = 0.0021) and radiographers (p = 0.0001). Non-significant increases were noted in handwashing rates amongst wardsmen/women and physiotherapists. Overall, handwashing incidence declined significantly (p = 0.0001) 12 months post feedback. This study demonstrated that feedback should be repeated within 12 months in order to maximise handwashing rates with the minimum intervention.

The systemic absorption of adrenaline from posterior segment infusion during vitreoretinal surgery

BACKGROUND/PURPOSE

Adrenaline infused into the posterior segment of the eye during vitreoretinal surgery may be absorbed and give rise to unwanted cardiovascular effects. We sought to establish whether significant amounts of adrenaline are systematically absorbed.

METHODS

This study was prospective and double-masked, with patients randomised into two groups. The first group received a posterior segment infusion containing Hartmann's solution alone (Hs group) and the second group received a posterior segment infusion of Hartmann's solution containing 0.5 ml of 1:1000 (0.5 mg) adrenaline per 500 ml (Hs + Ad group). Pre-medication and anaesthetic techniques were standardised for all patients. Venous blood samples were collected prior to induction, 5 min following intubation and 5, 10, 15 and 30 min following the commencement of the infusion. Samples were analysed for adrenaline levels using high-performance liquid chromatography.

RESULTS

Ten patients were studied: 4 in the Hs group and 6 in the Hs + Ad group. The mean dose of adrenaline administered in the Hs + Ad group was 655.08 nmol (0.12 mg). The median serum adrenaline level following infusion for the Hs + Ad group was 0.15 nmol/l (LQ = 0.100, UQ = 0.360) and the median serum adrenaline level for the Hs group was 0.10 nmol/l (LQ = 0.100, UQ = 0.350). There was no overall statistical difference in the levels of serum adrenaline between the two groups, and furthermore adrenaline levels remained within physiological parameters for both groups.

CONCLUSION

There does not appear to be significant adrenaline absorption from posterior segment infusion. Continued caution should be exercised, however, as idiosyncratic reactions may still occur.

Intravitreal penetration of teicoplanin

Teicoplanin is a glycopeptide antibiotic, similar to vancomycin, but safer and better tolerated. The purpose of this study was to evaluate the penetration of teicoplanin into the vitreous when administered topically and intravenously. Twenty-five patients undergoing routine vitrectomy were recruited. Twenty were given intravenous teicoplanin: five 1 h pre-operatively, five 12 h pre-operatively, five 24 h pre-operatively and five 24 h as well as 48 h pre-operatively. Five received teicoplanin drops half-hourly for the 6 h immediately preceding vitrectomy. Undiluted vitreous specimens were obtained at the beginning of each vitrectomy procedure. Teicoplanin levels were measured using a biological assay with Staphylococcus aureus as the indicator organism. Teicoplanin activity was detected in 8 of the 20 specimens from those patients receiving the intravenous antibiotic. Teicoplanin did not penetrate readily into the vitreous cavities in these eyes despite the blood-ocular barrier being compromised in some patients, although there was evidence of accumulation with time. No activity was detected in the vitreous of those patients who received topical teicoplanin.

A simple membrane immunobead assay for detecting ciguatoxin and related polyethers from human ciguatera intoxication and natural reef fishes

A simple membrane immunobead assay (MIA) for detecting ciguatoxin (CTX) and related polyethers directly from fish tissue is presented. A membrane laminated onto a solid plastic support is immersed with a piece of fish tissue in methanol. The membrane is thoroughly dried and placed into an immunobead suspension containing polystyrene particles coated with monoclonal antibody to CTX (MAb-CTX). Two beads of different diameter and color are used. The color intensity of the membrane is related to the concentration of the toxin bound to the membrane. Twelve of 13 fish implicated in human ciguatera fish poisoning showed borderline or positive responses in the assay. A Sphyraena barracuda sample that tested negative with the MIA and was highly toxic with the mouse toxicity bioassay showed only weak CTX-like toxin activity in the guinea pig atrial assay, indicating that the major toxin in the sample was not CTX-like. Examination of 154 routinely caught reef fish from Hawaii, Kosrae, and Kwajalein by MIA found 132 (86%) negative and 8 (5%) positive for CTX, with 14 (9%) giving a borderline response. Fish from Hawaii showed a higher frequency of borderline or positive responses than those from Kosrae and Kwajalein, probably because several species of fish from several islands of Hawaii were tested, whereas only one species from a single area was examined from each of the islands of Kosrae and Kwajalein.