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Hypernatraemia is associated with high morbidity and mortality and is more common in patients of older age, nursing home residents and those with cognitive impairment and restricted mobility. The most common cause in hospital settings is water dehydration due to reduced intake although other causes should be identified. Once identified, prompt management is necessary to avoid delayed correction as prolonged hypernatremia is associated with increased hospital stay and mortality. Comprehensive history-taking and physical examination, basic investigations and medication review are essential to identify causative and remediable factors in those admitted with hypernatraemia. Accurate calculation of fluid deficit and ongoing losses is essential in order to ensure adequate fluid replacement, The administration of appropriate, usually hypotonic, fluids is also essential to the timely restoration of eunatraemia. Although evidence of definite harm resulting from rapid correction is lacking, a serum sodium reduction rate of <12 mmol/l day is advised with the caveat that close monitoring of electrolytes is required to ensure the desired correction rate is being achieved. Medical and nursing professionals should have access to a local hospital protocol to guide management of patients with hypernatraemia to improve patient outcomes and mitigate the risk of harm, particularly from under-recognition and slow correction. [ABSTRACT FROM AUTHOR]

An optical fibre sensor based on radioluminescence, using the scintillation material terbium doped gadolinium oxysulphide (Gd2O2S:Tb) is evaluated, using a 3D printed anthropomorphic phantom for applications in low dose-rate (LDR) prostate brachytherapy. The scintillation material is embedded in a 700 µm diameter cavity within a 1 mm plastic optical fibre that is fixed within a brachytherapy needle. The high spatial resolution dosimeter is used to measure the dose contribution from Iodine-125 (I-125) seeds. Initially, the effects of sterilisation on the sensors (1) repeatability, (2) response as a function of angle, and (3) response as a function of distance, are evaluated in a custom polymethyl methacrylate phantom. Results obtained in this study demonstrate that the output response of the sensor, pre- and post-sterilisation are within the acceptable measurement uncertainty ranging from a maximum standard deviation of 4.7% pre and 5.5% post respectively, indicating that the low temperature sterilisation process does not damage the sensor or reduce performance. Subsequently, an LDR brachytherapy plan reconstructed using the VariSeed treatment planning system, in an anthropomorphic 3D printed training phantom, was used to assess the suitability of the sensor for applications in LDR brachytherapy. This phantom was printed based on patient anatomy, with the volume and dimensions of the prostate designed to represent that of the patient. I-125 brachytherapy seeds, with an average activity of 0.410 mCi, were implanted into the prostate phantom under trans-rectal ultrasound guidance; following the same techniques as employed in clinical practice by an experienced radiation oncologist. This work has demonstrated that this sensor is capable of accurately identifying when radioactive I-125 sources are introduced into the prostate via a brachytherapy needle. [ABSTRACT FROM AUTHOR]

Background: Vitamin D is the one of the most common nutritional deficiencies worldwide, and insufficiency or deficiency can be associated with musculoskeletal and non-skeletal conditions such as cancer, cardiovascular disease and diabetes mellitus. Objective: Recent data suggests that Vitamin D is relatively safe and toxicity is rarer than previously indicated. However, international guidelines regarding dosage and target plasma levels are conflicting. Moreover multiple well-designed studies of healthy older adults, unselected in terms of Vitamin D status, have revealed largely negative results (with the possible exception of older patients in care homes/hospitals) in terms of improvement in musculoskeletal and non-skeletal conditions to date. Conclusion: On that basis, it is suggested that future trials regarding Vitamin D supplementation should be carried out in high-risk groups. The use of published criteria for evaluating the effect of nutrients and targeting of individuals with Vitamin D insufficiency and deficiency for inclusion in such studies is also proposed. The identification of specific subgroups that will benefit from supplementation and replacement, and the establishment of a scientific basis for such therapy, should be possible with this approach. [ABSTRACT FROM AUTHOR]

Objectives: Vitamin D plays an important role in calcium homeostasis and is essential for normal bone growth and remodeling. Previous studies of acutely ill and institutionalized older women in Galway revealed that vitamin D insufficiency is extremely common. We aimed to evaluate age and gender-related rates of vitamin D insufficiency and deficiency in adult patients attending their General Practitioners in the same region. Design: A retrospective cohort study. Setting: General practices in Galway, a city located on the west coast of Ireland, latitude 53.17 North. Participants: A total of 15,708 consecutive blood samples from adults attending their General Practitioners between January 2013 and December 2014 were sent to the Clinical Biochemistry Laboratory in the University Hospital Galway for vitamin D level testing. 73% were from women. Intervention: Data were collected and grouped according to age, sex and season. Vitamin D levels (25OHD) were categorised into deficiency (<25nmol/L), insufficiency (25-50nmol/L) and sufficiency (>50nmol/L). Measurements: Median and interquartile range were reported as vitamin D levels were not normally distributed. Descriptive statistics were performed using STATA/MP 13.1 for Mac. Results: While vitamin D levels were sufficient in 56.4% (n=8,496), they were insufficient in 32.4% (n=4,891) and deficient in 11.2% (n=1,691). Of the deficient group, 19%(325) had levels <15nmol/L consistent with profound deficiency. Men were more likely than women to be deficient (12% (n=489) vs. 10.9% (n=1,202)) and insufficient (38.0% (n=1,550) vs. 30.4% (n=3,341)) (p<0.01). Highest rates of deficiency were seen in those 81-97 years (19.4% (n=136)) and 18-40 years (13.8% (n=543)), the former group showing less seasonal variation. Conclusion: Overall prevalence of insufficiency is similar to those in national and European studies published recently. However, there is a high possibility that those most vulnerable to vitamin D deficiency were underrepresented in this cohort, when results from previous studies in the same region are considered. Further prospective studies are needed to guide treatment with supplementation of vitamin D for appropriate subgroups. [ABSTRACT FROM AUTHOR]

Review is made of dosimetric studies of current optical fibre technology in radiotherapy for therapeutic applications, focusing particularly on in vivo dosimetry for prostate radiotherapy. We present the various sensor designs along with the main advantages and disadvantages associated with this technology. Optical fibres are ideally placed for applications in radiotherapy dosimetry; due to their small size they are lightweight and immune to electromagnetic interferences. The small dimensions of optical fibres allows it to be easily guided within existing brachytherapy equipment; for example, within the seed implantation needle for direct tumour dose analysis, in the urinary catheter to monitor urethral dose, or within the biopsy needle holder of the transrectal ultrasound probe to monitor rectal wall dose. The article presents the range of optical fibre dosimeter designs along with the main dosimetric properties required for a modern in vivo dosimetry system to be utilised in a clinical environment. [ABSTRACT FROM AUTHOR]

Spontaneous insufficiency fractures are caused by normal or physiological stress on weakened bone. The leading cause of insufficiency fractures is osteoporosis which has a propensity to affect older patients. Other causes or associated factors are disorders which affect bone metabolism, collagen formation, bone remodelling and medications such as bisphosphonates and glucocorticoids. Pathological fractures and abuse are important causes of unexplained fractures which warrant careful consideration. Spontaneous fractures of the long bones affect on average 1% of nursing home residents per year and tend to occur in patients who are bed-bound with joint contractures. Preventative measures for spontaneous insufficiency fractures include optimising nutrition to include an adequate intake of protein, calcium and vitamin D, maintaining mobility and preventing long periods of bed-rest and treatment of underlying pre-disposing conditions. [ABSTRACT FROM AUTHOR]

This case describes a 103-year-old lady who presented from home with an incidental diagnosis of a left femoral fracture. She had no history of trauma and denied pain. She had a known diagnosis of osteoporosis, and sustained a fracture of the contralateral femur aged 93 which was managed conservatively. She was bed-bound with fixed contractures, poor oral intake and was non-compliant with prescribed calcium/vitamin D supplementation. Clinical biochemical measurements showed severe vitamin D deficiency and mild hypocalcaemia. Secondary hyperparathyroidism in the setting of an inappropriately normal phosphate suggested concurrent renal bone disease. Biomarkers of bone turnover were also consistent with bone remodelling. The history of prior fragility fractures, severe vitamin D deficiency and immobility supports a diagnosis of osteoporotic fracture, however other causes of spontaneous fracture were also considered. This case highlights the complexity of interpreting clinical biochemistry results in the setting of multi-morbidity and addresses the challenges of bone health management in the frail older person. [ABSTRACT FROM AUTHOR]

Objectives: The Z0011 trial questioned the role of axillary ultrasound (AxUS) in preoperative staging of breast cancer in patients with ≤2 positive sentinel lymph nodes (SLN). The purpose of this study was to correlate the number of abnormal nodes on AxUS with final nodal burden and determine the utility of AxUS with sampling (AxUS + S) in preoperative staging. Methods: Six hundred and seventy-nine patients underwent pre-operative AxUS. Suspicious nodes were sampled. Negative axillae proceeded to SLN biopsy. The number of abnormal nodes identified on ultrasound and final histology as well as sensitivity and specificity for AxUS + S were calculated. Subgroup analysis was performed on Z0011 eligible patients. Results: Two hundred and ninety-six patients had positive axillary nodes on final histology with 169 detected by AxUS + S (sensitivity 86.2 %, specificity 100 %, PPV 100 %, NPV 71.9 %). Patients with nodal metastases identified by AxUS had a mean burden of 7.3 nodes on histology (1 node on AxUS = 5.2 nodes on histology, 2 nodes on AxUS = 7.5 nodes, >2 nodes = 10.1 nodes). Patients diagnosed on SLNB had a mean burden of 2.2 nodes. Conclusion: A single nodal metastasis detected on AxUS + S correlated with a mean of 5.2 nodes on final histology highlighting that AxUS remains essential in guiding appropriate management of the axilla in breast cancer. Key Points: • Axillary ultrasound +/- sampling is an essential technique in preoperative axillary staging. • Axillary ultrasound findings correlate with final histological axillary node disease burden. • Axillary ultrasound can help triage patients who require axillary lymph node dissection. • The role of axillary ultrasound in breast cancer staging continues to evolve. [ABSTRACT FROM AUTHOR]

Background: Informed consent requires good communication. Patient information leaflets (PILs) may be helpful, although some PILs are too hard to read for the average patient. Aims: We sought to examine the readability of PILs provided for patients prior to endoscopic procedures in 24 gastrointestinal and 16 respiratory departments of 24 Irish public hospitals. Methods: Readability, measured using the Flesch Reading Ease and the Flesch-Kincaid Grade Level scores, and content of all PILs were examined. Results: We received 61 PILs from 17 gastrointestinal and 7 respiratory departments, a response rate of 60 % (24/40). Overall, 38 (62 %) PILs met a minimum standard of a Reading Ease score of 60 or more. Only two (3 %) PILs met the optimal reading standard of being comprehensible to an average 10- to 11-year-old, while 35 (57 %) PILs would be comprehensible to an average 13- to 14-year-old. There were striking differences between PILs (and particular departments) in the amount of information given regarding potential complications-in particular, serious complications. With the exception of PILs for endoscopic retrograde cholangiopancreatography, less than half of PILs mentioned death as a possible rare outcome. Conclusions: This study raises significant concerns about the readability and content of current Irish PILs, and it is unlikely that these issues are restricted to leaflets given prior to endoscopy. A standardised approach to developing PILs for common elective procedures, with minimum standards for readability and a uniform approach, based on current Irish legal requirements, to risk disclosure, might be helpful. [ABSTRACT FROM AUTHOR]

Unplanned readmissions of medical hospital patients have been increasing in recent years. We examined the frequency and associates of emergency medical readmissions to Galway University Hospitals (GUH). Readmissions during the calendar year 2006 were examined using hospital in-patient enquiry data. Associations with clinical and demographic factors were determined using univariate and multivariate analyses. The medical emergency readmission rate to GUH, after correction for death during the index admission, was 19.5%. Age 65 years or more, male gender, length of stay more than 7 days and primary diagnoses of chronic obstructive pulmonary disease, myocardial infarction, alcohol-related disease and heart failure during the index admission were significantly associated with readmission in univariate and multivariate analyses. The medical emergency readmission rate in GUH is comparable to other acute hospitals in Ireland and Britain. Further evaluation is needed to estimate the proportion of readmissions that are potentially avoidable. [ABSTRACT FROM AUTHOR]

In 2002, a survey of stroke management was conducted in our institution benchmarked against the UK National Stroke Audit 2002. The conclusion was that management of stroke patients lacked organised and specialised care. The introduction of a stroke care pathway was recommended. This audit assessed the clinical impact of implementation of a stroke care pathway by the general medical teams in an acute teaching hospital. A random sample of 48/131 patients were surveyed in 2002 compared to 55 consecutive patients admitted with stroke in 2005. Despite introduction of a stroke care pathway, marked deficits persisted in acute management including delays in brain imaging and aspirin administration, assessment of acute parameters and interdisciplinary care. Optimal care of stroke patients cannot be achieved by introducing a stroke care pathway alone. We recommend the urgent establishment of a stroke unit with a specialist consultant-led multidisciplinary stroke team. [ABSTRACT FROM AUTHOR]

Patient falls are a common complication of hospitalisation. Use of restraints in patients who are perceived to be at risk for falling may lead to injury and even death. To determine the frequency of falls and fall-related injuries and the contribution of restraints in a hospital population. We analysed incident reports of falls for a single year from a large teaching hospital. The fall rate per 10,000 patient days was 13.2 (95%Cl 11.6 -14.8). Fall rate increased dramatically with increased age. Eighty-two (30.7%) falls resulted in injury of which 6 (7.3%) were serious. Injuries occurred in 71/247 (29%) unrestrained falls and in 11/20 (55%) falls in patients who were restrained. Injuries were more severe in falls with restraints in place (p<0.0001). Restraint use is associated with increased severity of injury in hospital patients who fall. [ABSTRACT FROM AUTHOR]

Normal variation in temporal orientation has been examined in community dwelling, healthy older subjects but not in elderly hospital patients. We examined the validity of errors in different aspects of temporal orientation as a guide to the presence or absence of cognitive impairment orientation in elderly hospital patients in 150 consecutive patients on the day after admission to an acute geriatric unit. Cognitive impairment (delirium or dementia or both) was diagnosed without reference to temporal orientation. Optimum cutoffs for error scores on the different aspects of temporal orientation (date/year/month/day of the week/time of day) were calculated to maximize the sum of sensitivity and specificity for detection of cognitive impairment. Of the 150 patients, 45 (30%) had cognitive impairment. The best cutoffs for detection of cognitive impairment were an error of more than 3 days in the date; any error in the year, month, or day of the week; and an error of more than 1 h in identifying the time of day. Error in identifying the year had the highest positive likelihood ratio (6.4 [95% confidence interval 4.0–10.3]) for detecting cognitive impairment and the lowest negative likelihood ratio (0.1 [0.04–0.3]) for the exclusion of cognitive impairment. Failure to identify the year correctly is the aspect of temporal orientation most closely related to cognitive impairment. [ABSTRACT FROM AUTHOR]

Most patients with acute stroke are admitted to hospital. If stroke services in this country are to be improved, we need accurate and reliable information about the types of stroke patients being admitted, their present management and outcome. To examine the demography, severity, level of investigation, length of stay, mortality and discharge location of prospectively identified consecutive stroke admissions to three general hospitals in South East Dublin. Three hundred and twenty nine consecutive stroke admissions to three general hospitals in South East Dublin were registered using the European Stroke Database over 50 weeks. The mean age was 73.3 years, whilst 20.1% patients were under 65 years. Prior to admission, 90% of patients were community dwelling with 14.9% of patients being dependent in activities of daily living. 22.4% of patients had some depression in level of consciousness on admission. The overall mortality rate was 26.1% whilst 136 (41.3%) were discharged home, 50 (15.2%) went to institutional care and 45 (13.7%) went to non general hospitals secondary rehabilitation units. The mean length of stay was 31.3 days. The combined poor outcome measure (mortality plus percentage of patients discharged to institutional care), was lower in one hospital compared to the other two hospitals (29.3% versus 44.65%, p≥ 0.05) probably reflecting case mix. Stroke accounted for 4.2% of all bed days in the major general hospital in this area. The overall CT scan rate was 84.5%, with 18.2% of CT scans showing a haemorrhagic component and two patients (0.8%) having brain tumours. Carotid doppler examinations were carried out in 37% of patients. The results demonstrate the high mortality and prolonged hospital stay for stroke patients in this area and emphasise the need for co-ordinated stroke care and regular audit to ensure most effective use of hospital resources. [ABSTRACT FROM AUTHOR]

Little is known of how cardiopulmonary resuscitation (CPR) decisions are made in Irish long-term care settings. To examine how CPR decisions are made in Irish long-stay units and those factors associated with use or non-use of CPR. We surveyed each public long-stay unit and a random sample of private nursing homes across the country. Of the 84 long-stay units that responded (response rate 58%), basic CPR had been performed in 32% and advanced CPR (including defibrillation) in 10%. Only 13% of the units had a written CPR policy. Units performing CPR ( N = 35) were closer to an acute hospital, more likely to have short-term residents and more likely to have a CPR policy (all P < 0.05). There were no significant differences between public and private units. The widely disparate approaches to CPR in different Irish long-stay units suggest the need for national guidelines on this issue. [ABSTRACT FROM AUTHOR]

Many studies have reported excessive use of antipsychotic medications in long stay institutions in Britain and America. We examined the frequency and appropriateness of antipsychotic prescribing in a variety of extended care settings in the west of Ireland. Clinical details of 345 residents (211 public and 134 private) were obtained from medication sheets and medical notes and by interviewing nursing staff. American prescribing guidelines were applied for those residents taking antipsychotic medications. Of the 345 residents, 80 (23%) were prescribed regular antipsychotic medications of whom 41 (51%) were deemed to be receiving these agents inappropriately. There was no difference in the use of antipsychotic drugs (21.3% vs. 26.1%, Chi-sq = 1.1, p = 0.3) between residents of public and private units. However, inappropriate antipsychotic use was more common among those in private care (23/35 (66%) vs. 18/45 (40%); Chi-sq = 5.2, p = 0.02). Prominent inappropriate indications for antipsychotic use were: restlessness (26/41 (63%) patients); history of very intermittent aggression (23 (56%) patients); and wandering (19 (46%) patients). Inappropriate use of antipsychotic medications, as judged by American legislative guidelines, is common in long-stay units in the west of Ireland. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor on the use of percutaneous thrombin injection for the treatment of a post-pancreatitis pseudoaneurysm of the gastroduodenal artery.