25 EVALUATION OF PATIENTS PRESENTING WITH TIA IN THE AMAU AND TIA FAST ASSESSMENT CLINICS - ARE WE MEETING ESO GUIDELINES?

Background

The European Stroke Organisation published guidelines on the management of Transient Ischaemic Attack (TIA) in 2021. Specialist review of suspected TIA is recommended within 24-hours of symptom onset in a TIA clinic. They suggest using CT or MR angiogram for additional confirmation of large artery stenosis of >50%. They advise against the use of prediction tools alone e.g. ABCD2 score when identifying high-risk patients. Dual antiplatelet therapy is recommended short-term in high risk, non cardio-embolic TIA patients. This audit evaluates if these guidelines are being followed in our institution.

Methods

We evaluated all patients attending the TIA clinic and the Acute Medical Assessment Unit (AMAU) with suspected TIA over a three-week period in 2021 in a single tertiary referral centre. Retrospective data was collected based on chart review.

Results

Twenty patients underwent review in the TIA clinic and eight in the AMAU with suspected TIA in the chosen time period. One patient (3.5%) was seen within 24 hours from symptom onset, 2 were seen within 24-36 hours (7.1%), 4 patients (14.2%) were seen within 36-72 hours, 21 patients (75%) were seen >72 hours after symptom onset. In all patients who had a doppler US showing >50% carotid stenosis, a CT angiogram was performed. ABCD2 scores were recorded but used in combination with clinical judgment. All patients with high-risk, non-cardioembolic TIA received early, short-term dual antiplatelet therapy.

Conclusion

The diagnostic methods and treatment strategies in place for patients attending the TIA clinic or AMAU with TIA were in keeping with the recently published ESO guidelines. However, there was a time delay from symptom onset to time of review in many patients. Further studies are indicated to identify the potential mechanisms behind these delays. Interventions to ensure that we are meeting this ‘time-to-review’ target in patients could be implemented, ensuring high quality, evidence-based care.

219 IMPROVING DELIRIUM SCREENING AND MANAGEMENT IN POST-ACUTE REHABILITATION: A MULTI-STAGE QUALITY IMPROVEMENT INITIATIVE

Background

There is risk of delirium among older patients on transition from acute care to post-acute rehabilitation (Marcantonio et al. 2003). The 4AT is the recommended delirium detection tool for clinical practice (Tieges et al. 2020). A multi-disciplinary led quality improvement project was undertaken to standardise and improve delirium screening and management in the older person’s rehabilitation service of a post-acute rehabilitation hospital.

Methods

A retrospective audit of medical charts was completed for all patients admitted to a post-acute older person’s rehabilitation service from October 2019 to December 2019. Following that audit, there was a staff education intervention focusing on delirium awareness, screening and management. Furthermore, a dedicated ‘Delirium Champions Group’ was formed with representatives from the multi-disciplinary team. A Delirium Screen pro-forma was developed and implemented by this group. It included an attached 4AT sticker for all new admission medical charts. A post intervention medical chart audit was completed for all admissions to the same ward from October to December 2020.

Results

The pre-intervention chart audit showed 0% compliance with any form of formal delirium screening tool. The majority of patients had at least 2 delirium risk factors at the time of admission. The post-intervention audit recorded 92% compliance with 4AT use at the time of admission as well as full completion of the Delirium Screen pro-forma which included the documentation of risk factors for delirium. The Delirium Champions Group provide ongoing staff education, resources and are now exploring hospital environmental design and its role in delirium prevention.

Conclusion

This initiative lead to a significant improvement in the completion of delirium screening in post-acute rehabilitation. This project had the secondary benefit of prompting the formation of a dedicated delirium improvement group focusing on delirium awareness, screening, documentation, management and ultimately prevention.

The role of the nurse in screening asymptomatic male and female patients in a sexual health clinic

We allocated 278 patients, who said they were asymptomatic and agreed to be randomized to a nurse or doctor clinic, to appointments using a random number system. In all, 35 patients did not attend and 16 were excluded because they did not meet the entry criteria. We used a screening protocol which excluded microscopy from the immediate assessment of patients. The outcome measures were completeness of documentation, proportion of patients accepting HIV tests, infections detected and patient satisfaction. Overall, 3% of items were not completed by doctors and 6% by nurses. HIV tests were carried out on 65% of patients who saw a doctor and 52% who saw a nurse. Thirteen infections were detected by doctors and 27 by nurses. No new cases of gonorrhoea, syphilis or HIV infection were identified. Eighty-eight patients completed a questionnaire after their attendance. Almost all patients were very satisfied with the service and most were prepared to see a nurse on a subsequent visit. We concluded that there are few differences between the performance of doctors and nurses in routine screening of asymptomatic patients.

Out of America: tracing the genetic footprints of the global diffusion of maize

Maize was first domesticated in a restricted valley in south-central Mexico. It was diffused throughout the Americas over thousands of years, and following the discovery of the New World by Columbus, was introduced into Europe. Trade and colonization introduced it further into all parts of the world to which it could adapt. Repeated introductions, local selection and adaptation, a highly diverse gene pool and outcrossing nature, and global trade in maize led to difficulty understanding exactly where the diversity of many of the local maize landraces originated. This is particularly true in Africa and Asia, where historical accounts are scarce or contradictory. Knowledge of post-domestication movements of maize around the world would assist in germplasm conservation and plant breeding efforts. To this end, we used SSR markers to genotype multiple individuals from hundreds of representative landraces from around the world. Applying a multidisciplinary approach combining genetic, linguistic, and historical data, we reconstructed possible patterns of maize diffusion throughout the world from American "contribution" centers, which we propose reflect the origins of maize worldwide. These results shed new light on introductions of maize into Africa and Asia. By providing a first globally comprehensive genetic characterization of landraces using markers appropriate to this evolutionary time frame, we explore the post-domestication evolutionary history of maize and highlight original diversity sources that may be tapped for plant improvement in different regions of the world.

Paths across generations: academic competence and aggressive behaviors in young mothers and their children

This research compared the social and cognitive development of young mothers when they were children with the social and cognitive development of their offspring. Intergenerational development was investigated over a 17-year period for 57 women who had been studied longitudinally from childhood to adulthood and who became young mothers (R. B. Cairns & B. D. Cairns, 1994). The children of these women, in turn, were followed prospectively from 1 to 2 years old through the early school years. The academic competence of mothers when they were children was significantly linked to the academic competence of their children at school age. In contrast, the across-generation correlations between measures of aggressive behavior of the mothers when they were children and measures of aggressive behavior of their children in early school grades were modest and unreliable. Certain within-generation continuities were observed in both cognitive and aggressive development.

Comparison of DNA adducts and sister chromatid exchange in lung cancer cases and controls

In a molecular epidemiological study of lung cancer cases (n = 81) and noncancer controls (n = 67), polycyclic aromatic hydrocarbon (PAH)-DNA adducts were evaluated in peripheral blood leukocytes from all subjects and in a smaller number of lung tissue specimens collected prior to or at surgery. Sister chromatid exchanges (SCE) in lymphocytes were also studied in a subset of cases and controls. Questionnaire, medical record, or tumor registry data provided a family history of cancer, as well as information on cigarette smoking, dietary and occupational exposure to PAHs, and other factors related to SCEs. In both cases and controls PAH-DNA adducts in leukocytes measured by an enzyme-linked immunosorbent assay were not significantly related to age, sex, ethnicity, amount of cigarette smoking, passive smoking, dietary charcoal, or caffeine consumption. Nor did family history of cancer or histological type of cancer significantly affect adduct levels. However, when subjects were stratified by smoking status (current, former, and nonsmoker), lung cancer cases who were current smokers had significantly higher levels of covalent adducts than current smoker controls. A seasonal variation was observed in PAH-DNA binding, with a peak in adduct levels during July-October. This peak corresponds to that seen in a prior study of aryl hydrocarbon hydroxylase inducibility by other investigators. The finding of significant levels of PAH-DNA adducts in former smokers and non-smokers supports an earlier observation that this marker is not smoking specific but reflects a pervasive and variable "background" exposure to PAH. These results are consistent with a genetically determined enhancement of PAH-DNA adduct formation in leukocytes of lung cancer cases which is evident in current smokers. The results in lung tissue are limited by the small number of samples. Adduct levels were not significantly increased in lung tissue of smokers compared with nonsmokers. An inverse linear correlation was seen between adduct values in lung tissue and age of the donors. SCEs were significantly related to pack years of smoking. However, there was no difference in the frequency of SCE between cases and controls; nor were SCE and DNA adducts significantly correlated in this small sample.