694 IMPROVING OPIATE PRESCRIBING IN OLDER ADULTS WITH HIP FRACTURES TO COMBAT THE IATROGENIC FALLOUT

Background

The number of opioid prescriptions in older patients has increased dramatically and it is recognised that opioids are the fourth most likely drug to cause preventable hospital admissions. The adverse effects of opioids occur more frequently in the geriatric population. Little is known about the impact of postoperative pain in older adults. NICE recommends paracetamol with additional opioids if there is insufficient postoperative pain relief. Multidisciplinary management with early and then daily physiotherapy is critical. We have assessed pre-morbid, immediate and prolonged use of opioids in patients following hip fracture. Local problem Pre-intervention analysis identified 79% (57/72) of all patients being discharged on opiates. At 4-months, 37% (17/46) of those were still using them. This represents 28% (17/61) of all patients.

Methods

Analysis of all patients (excluding poly-trauma) with hip fractures over the age of 60 years admitted to St Mary’s Hospital. Interventions Development of local guideline on analgesia prescribing; particularly focusing senior geriatrician led decision making. Prescribing oxycodone for first 72-hours and initially using nerve block. Avoidance of transdermal preparations and withdrawing stronger opioids prior to discharge. Clear instructions for GP’s on a stop date and need for community review. Patient information leaflet dispensed with all discharge opioid prescriptions.

Results

Post-intervention cycle; 17% (11/63) of patients were taking prescribed opioids prior to admission (similar to the pre-cohort). 52% (33/63) were discharged on opiates, down from 79%. At 4-months, of those discharged on opioids, 30% (9/30) were still using them; lower than in the first cycle (37%). Overall reduction from 28% to 16% of patients on opioids at 4-months.

Conclusion

The use of specific hip fracture analgesia guideline, senior geriatrician decision-making and support to community colleagues can reduce in-patient and community opiate prescribing, and stem the growing problem of opioid addiction, misuse and iatrogenic re-admission.

Polyradiculopathy in a patient of systemic lupus erythematosus

The relationship of the neurological manifestations to the lupus disease process is not always clear. We present a case of systemic lupus erythematosus (SLE) with subacute onset muscle weakness, which was due to polyradiculopathy, a rarely described neurological manifestation of SLE.

Seasonal variation in the incidence of hyponatremia

AIM

To study the seasonal variation in the incidence of hyponatremia and to correlate it with the rainfall pattern.

METHOD

Retrospective analysis of patients having serum sodium of less than 120 meq/L was done during the 24 months from March, 1995. Patients with fever, renal failure, cardiac failure, cirrhosis, hyperlipidemia, hyperproteinemia, patients taking diuretics and postoperative patients were also excluded. Average inpatient number and rainfall for each month was noted. Daily incidence of hyponatremia was expressed as percentage of total inpatients for each day and was compared with the rainfall.

RESULTS

A total of 353 patients had hyponatremia during the two years from March, 1995; 174 cases during the first year and 179 during the second year. Average inpatient strength was 302.17 +/- 21.41 during the first year and 313.67 +/- 12.94 during the next year. The incidence of hyponatremia was 0.24 +/- 0.096% between June and August and 0.1 +/- 0.04% between December and February (95% confidence interval 0.045-0.235, p < 0.01). Statistically significant correlation was observed between rainfall pattern and hyponatremia, r = 0.711, 95% confidence interval 0.478-0.913, p = 0.01 during 95-96 and r = 0.825, 95% confidence interval 0.478-0.949, p < 0.001, during 96-97.

CONCLUSION

Incidence of hyponatremia is higher during the peak southwest monsoon season with similar pattern for the study period of two years. Humidity and temperature may have important role in the manifestation of hyponatremia.

Blood sugar profile in diabetics receiving plain insulin

Blood sugar profile was studied by checking multiple plasma venous samples at 1/2 hr interval after porcine plain insulin. Mean blood sugar was the highest (198.8 +/- 24.6 mg%) at 1 1/2 hrs and the lowest (86.3 +/- 18.4) at 4 1/2 hrs after breakfast. 52% of the patients had hypoglycemias between 4 and 5 hrs. It is recommended that pre-lunch blood sugar be checked in those receiving plain insulin.

Vogel-fulcher dependence of relaxation rates in a nematic monomer and elastomer

Dielectric relaxation spectroscopy is used to study the relaxation processes in a nematic monomer and the corresponding cross-linked polymer nematic liquid crystal (elastomer). In the frequency window 10 mHz to 2 GHz the monomer liquid crystal shows a single relaxation whereas the polymer exhibits three relaxation processes, two of which are quantitatively analyzed. The temperature dependence of relaxation times in both the monomer and polymer follows a Vogel-Fulcher behavior. The relaxation processes are identified with specific molecular motions and activation energies are calculated in a linear approximation for comparison with literature data.

Noninvasive blood pressure measurement on the temporal artery using the auscultatory method

Blood pressures in the temporal artery of five normotensive subjects were recorded using a modified auscultatory setup. The setup comprised a pediatric cuff to occlude the artery and a piezoelectric contact microphone to record the Korotkoff sounds. Both the cuff and microphone were held in their respective positions with an adjustable head band. The recordings were taken under four different conditions: the subject lying supine, the subject sitting at rest, the subject sitting immediately after exercise and the subject moving the head gently. These recordings were compared with readings from the brachial artery, obtained with a commercially available automatic blood pressure measuring device. Korotkoff sounds were analyzed in the time and frequency domain. Results indicate that Korotkoff sounds in the temporal artery are much smaller in amplitude, and do not exhibit the same distinctive phases as those of the brachial artery. Despite these differences, these sounds can be used to detect blood pressures at head level. The accuracy of the readings was within +/- 10%. Successful readings were also obtained with gentle head motions, demonstrating that this setup has the potential to be developed into an ambulatory blood pressure monitoring system.

Calcified hypernephroma. A case report

Pattern of classification in an renal neoplasm is variable. If calcium is located nonperipherally (within the mass) it is more likely to be a renal cell carcinoma. But peripheral calcification does not rule out malignancy.