665 NECK OF FEMUR FRACTURE: POST OPERATIVE DELIRIUM SCREENING

Introduction

Delirium is common yet preventable in hip fracture patients. Adverse implications include: increased length of admission, hospital acquired infection, functional decline and mortality. NICE/NHFD guidance recommends early assessment using the 4AT tool. We aim to assess compliance with this guidance and to identify and initiate changes to improve screening and patient outcomes.

Method

Two loop audit with data collection from NHFD and electronic patient records. Initial retrospective assessment of 77 patients over 3 months. Timing of assessment, who performed it, complications and length of hospital admission were recorded. Recommendations included: all members of MDT to complete 4AT, adding 4AT as a task on nursing and doctor handovers, posters on ward, incorporating 4AT into ward round, 4AT as instruction on operation notes and departmental education session on delirium. Second audit loop of 38 patients with comparable demographics (gender, age, cognitive impairment, AMTS and ASA) over 6 weeks to assess impact of recommendations.

Results

Out of the original 77, 14 patients were diagnosed with delirium. They had more complications (50% vs 23.8%), reduced discharge to own home (28.5% vs 46%) and increased mean length of admission (15.1 vs 11.2 days) compared to non-delirium group. Recommendations improved overall compliance from 79.3% to 92.1%. T&O team completed 15% of assessments in first loop, improving to 53%. Earlier completion of 4AT assessment (mean 2.11 to 1.63; median 2 to 1 days). Improvement in 4AT screening led to reduced rates of post-operative complications (40% vs 46%) and reduced length (days) of hospital admission (median 10 to 8.2); mean (11.8 to 8.5).

Conclusion

Recommendations improved 4AT compliance and proportion completed by T&O juniors (reducing burden on orthogeriatricians who only review patients 1–2 times per week). Greater compliance with 4AT screening in the post-operative period was associated with reduction of post-operative complications and reduced length of admission.

Prevalence estimation of intellectual disability using national administrative and household survey data: The importance of survey question specificity

Background

Variability in prevalence estimation of intellectual disability has been attributed to heterogeneity in study settings, methodologies, and intellectual disability case definitions. Among studies based on national household survey data specifically, variability in prevalence estimation has partly been attributed to the level of specificity of the survey questions employed to determine the presence of intellectual disability.

Specific aims & method

Using standardised difference scoring, and ‘intellectual disability’ survey data from the 2007 Northern Ireland Survey on Activity Limitation and Disability (NISALD) (N=23,689) and the 2011 Northern Ireland Census (N=1,770,217) the following study had two aims. First, we aimed to demonstrate the effects of survey question specificity on intellectual disability prevalence estimation. Second, we aimed to produce reliable estimates of the geographic variation of intellectual disability within private households in Northern Ireland while also assessing the socio-demographic, health-related and disability characteristics of this population.

Findings

Prevalence estimates generated using the more crudely classified intellectual disability Census data indicated a prevalence of 2% for the overall population, 3.8% for children aged between 0 and 15 years, and 1.5% for citizens aged 16 years or older. Intellectual disability prevalence estimates generated using the more explicitly defined 2007 NISALD data indicated a population prevalence of 0.5% for the overall population, 1.3% for children aged between 0 and 15 years, and 0.3% for citizens aged 16 years or older. The NISALD estimates were consistent with most recent international meta-analysis prevalence estimates. According to the NISALD data, the majority of those with an intellectual disability were male, lived outside Belfast, and experienced severe intellectual disability, with multiple comorbid health conditions.

Discussion

The current findings highlight the importance of survey question specificity in the estimation of intellectual disability prevalence and provide reliable prevalence estimates of intellectual disability in Northern Ireland. The findings also demonstrate the utility of administrative data for detecting and understanding intellectual disability, and inform recommendations on how to maximise use of future intellectual disability Census data

Cardiac structure and diastolic function in mild primary hyperparathyroidism

CONTEXT

Data on the presence, extent, and reversibility of cardiovascular disease in primary hyperparathyroidism (PHPT) are conflicting.

OBJECTIVE

To evaluate the heart in PHPT, we assessed cardiac structure and diastolic function in patients with mild PHPT compared with age- and sex-matched controls.

DESIGN

This was a case-control study.

SETTINGS

The study was conducted in a university hospital Metabolic Bone Diseases Unit.

PARTICIPANTS

Fifty-four men and women with PHPT and 76 controls without PHPT participated in the study.

OUTCOME MEASURES

We measured left ventricular mass index (LVMI), the presence of mitral annular calcification, the ratio of early to late diastolic mitral inflow velocities (E/A), and early diastolic velocity of the lateral mitral annulus using Doppler tissue imaging (tissue Doppler e').

RESULTS

Patients had mild disease with mean (+/-sd) serum calcium 10.5 +/- 0.5 mg/dl and PTH 96 +/- 45 pg/ml. LVMI and diastolic function were normal in PHPT. There was no difference in LVMI (98 +/- 23 vs. 96 +/- 24 g/m(2), P = 0.69) or the frequency of mitral annular calcification between PHPT cases and controls. Diastolic function variables (E/A and tissue Doppler e') were higher (better) in cases compared with controls, although both were within the reference range. PHPT patients with low E/A had higher serum PTH (121 +/- 36 vs. 89 +/- 46 pg/ml, P = 0.03) and calcium (10.8 +/- 0.4 vs. 10.5 +/- 0.5 mg/dl, P = 0.05) than those with normal values. Finally, we found LVMI to be inversely associated with serum 25-hydroxyvitamin D in PHPT (r = -0.29, P < 0.05). All findings persisted after adjustment for group differences in cardiovascular risk factors.

CONCLUSIONS

Patients with biochemically mild PHPT do not have evidence of increased left ventricular mass, diastolic dysfunction, or increased valvular calcifications. However, the data support an association between low vitamin D levels and the development of left ventricular hypertrophy in this disorder. Finally, the increased serum calcium and PTH levels in those with diastolic dysfunction suggest that disease severity may determine the presence of cardiac manifestations in PHPT.

The use of vancomycin-impregnated cement beads in the management of infection of prosthetic joints

Although the incidence of infection associated with hip and knee prostheses is low, with the increasing number of arthroplasties being carried out, the total number of such cases is increasing. The pattern of infecting organisms after total joint arthroplasty has changed and gentamicin-resistant organisms are becoming increasingly common. In conjunction with surgical debridement, vancomycin added to a bone-cement carrier can be very effective in the treatment of infection caused by such organisms. We report the results of its use in proven deep infection in 26 hip and seven knee arthroplasties. After a mean follow-up of 67 months, 32 patients remained clinically and radiologically free from infection. There was one recurrence and positive second-stage cultures of uncertain significance in three other patients. Vancomycin is potentially very useful in the management of deep infection after arthroplasty.

The use of vancomycin-impregnated cement beads in the management of infection of prosthetic joints

Although the incidence of infection associated with hip and knee prostheses is low, with the increasing number of arthroplasties being carried out, the total number of such cases is increasing. The pattern of infecting organisms after total joint arthroplasty has changed and gentamicin-resistant organisms are becoming increasingly common. In conjunction with surgical debridement, vancomycin added to a bone-cement carrier can be very effective in the treatment of infection caused by such organisms.

We report the results of its use in proven deep infection in 26 hip and seven knee arthroplasties. After a mean follow-up of 67 months, 32 patients remained clinically and radiologically free from infection. There was one recurrence and positive second-stage cultures of uncertain significance in three other patients. Vancomycin is potentially very useful in the management of deep infection after arthroplasty.

c-erbB2 and p53 expression are not associated with stage progression of gastric cancer in Britain or Japan

The results of surgical treatment for gastric cancer are apparently better in Japan than in Western countries. It has been proposed that this is because of a biological difference between the tumours in Japan and in the West. We have previously reported very similar frequencies of positive immunohistochemical staining for the c-erbB2 oncogene and mutant p53 proteins in British and Japanese gastric cancers, findings which do not seem to support the 'biological difference' hypothesis. We realized that these studies did not rule out differences in the mechanism of cancer progression which might show themselves by a different association between p53 and c-erbB2 expression and stage in the two populations. We therefore re-analysed our data to look for differences in the frequency of p53 and c-erbB2 expression in the British and Japanese populations. Comparison of fixed tissue from 88 British and 89 Japanese tumours showed no significant association of c-erbB2 or p53 with stage progression in either population. Logistic regression showed no difference between the two populations in the relationship between stage and oncogene expression. These results do not support the idea of biologically different cancers in Japan and Britain. Other possible explanations for the difference in results such as the stage migration effect, better efficacy of Japanese-style surgery, or a difference in the host resistance to cancer in the two countries should be considered.

Sport related injuries attending the accident and emergency department

Of new patients attending our hospital, 7.1% had injured themselves playing sport. The majority had been playing football and had sustained a soft tissue injury. Many of the patients presented late, i.e. after 24 h or longer. These patients would be best dealt with in a sports clinic, staffed by personnel with an interest in this field.

Localization of the genetic defect in multiple endocrine neoplasia type 1 within a small region of chromosome 11

Multiple endocrine neoplasia type I (MEN-1), a Mendelian disorder with an autosomal dominant mode of inheritance, causes hyperplasia in the parathyroid glands and hyperplasia or neoplasm in the anterior pituitary gland and/or the pancreatic islets. The genetic defect responsible for MEN-1 in three families was recently mapped to the long arm of chromosome II by linkage between the MEN-1 locus and the gene for skeletal muscle glycogen phosphorylase (PYGM) at 11q13. We have constructed a genetic linkage map of seven markers in the vicinity of the MEN-1 locus that has allowed us to map more precisely the gene associated with MEN-1; the target region has been narrowed to about 12 cM. The closely linked markers will be useful also for identification of likely carriers in families in which an allele responsible for MEN-1 segregates.