Feasibility for non-invasive prenatal fetal blood group and platelet genotyping by massively parallel sequencing: A single test system for multiple atypical red cell, platelet and quality control markers

Non-invasive prenatal tests (NIPT) to predict fetal red cell or platelet antigen status for alloimmunised women are provided for select antigens. This study reports on massively parallel sequencing (MPS) using a red cell and platelet probe panel targeting multiple nucleotide variants, plus individual identification single nucleotide polymorphisms (IISNPs). Maternal blood samples were provided from 33 alloimmunised cases, including seven with two red cell antibodies. Cell-free and genomic DNA was sequenced using targeted MPS and bioinformatically analysed using low-frequency variant detection. The resulting maternal genomic DNA allele frequency was subtracted from the cell-free DNA counterpart. Outcomes were matched against validated phenotyping/genotyping methods, where available. A 2.5% subtractive allele frequency threshold was set after comparing MPS predictions for K, RhC/c, RhE/e and Fya /Fyb against expected outcomes. This threshold was used for subsequent predictions, including HPA-15a, Jka /Jkb , Kpa /Kpb and Lua . MPS outcomes were 97.2% concordant with validated methods; one RhC case was discordantly negative and lacked IISNPs. IISNPs were informative for 30/33 cases as controls. NIPT MPS is feasible for fetal blood group genotyping and covers multiple blood groups and control targets in a single test. Noting caution for the Rh system, this has the potential to provide a personalised service for alloimmunised women.

Comparing the unified protocol for transdiagnostic treatment of emotional disorders to prolonged exposure for the treatment of PTSD: Design of a non-inferiority randomized controlled trial

Background

Prolonged Exposure (PE), a trauma-focused therapy, is one of the most efficacious treatments available for PTSD. However, many people with PTSD do not lose their diagnosis following delivery of PE. The Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders is a non-trauma focused treatment that may offer an alternative treatment for PTSD.

Methods

This paper describes the study protocol for IMPACT, an assessor-blinded randomized controlled trial that examines the non-inferiority of UP relative to PE for participants who meet DSM-5 criteria for current PTSD. One hundred and twenty adult participants with PTSD will be randomized to receive either 10 × 90-min sessions of UP or PE with a trained provider. The primary outcome is severity of PTSD symptoms assessed by the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) at post-treatment.

Discussion

While evidence-based treatments are available for PTSD, high levels of treatment dropout and non-response require new approaches to be tested. The UP is based on emotion regulation theory and is effective in treating anxiety and depressive disorders, however, there has been limited application to PTSD. This is the first rigorous study comparing UP to PE in a non-inferiority randomized controlled trial and may help improve clinical outcomes for those with PTSD.

Trial registration

This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry, Trial ID (ACTRN12619000543189).

92 CONTINUING TO ‘BE HIP’: ORTHOGERIATRIC SERVICE IMPROVEMENTS IN 2021

Background

Scotland first demonstrated that adherence to nationally agreed hip fracture standards improve patient survival, reduces the duration of admission, and reduces the need for high dependency care. Our study aims to assess adherence to the Irish Hip Fracture Standards (IHFS) in our hospital for 2021 amidst the COVID-19 pandemic, translating to improved clinical outcomes for our patients.

Methods

The IHF database was retrospectively analysed, comparing quarters 1-4 in 2021 with our 2020 results.

Results

IHFS1, patient time to the ward < 4hours, was maintained at 67% in 2021 versus 71% overall in 2020. There was improvement in IHFS2, time to surgery within 48 hours, up to 73% in 2021 versus 66% in 2020. IHFS3 was 4% in 2021 versus 3% overall in 2020. Further improvements were noted for IHFS4, with 95% of patients reviewed by a Geriatrician in 2021 versus 87% in 2020. IHFS5 also improved with 97% of patients receiving a bone health assessment in 2021 versus 87% in 2020. Moreover, IHFS6, improved with 97% of patients undergoing a specialised falls assessment in 2021 versus 87% in 2020.

Conclusion

The improvement in 2021 figures is reflective of the return of redeployed services during the COVID-19 pandemic inclusive of the Orthogeriatric Service, the Fracture Liaison Service Advanced Nurse Practitioner, the Trauma Co-ordinator, and the specialist Orthopaedic ward complete with its Orthopaedic nurses and Multi-Disciplinary Team, and improved Emergency Department pathways. These continued improvements in the IHFS further emphasise that success is dependent on a team that is joined at the hip

258 RISING TO THE CHALLENGE: ORTHOGERIATRIC SERVICE IMPROVEMENT AND COVID-19

Background

Nationally agreed hip fracture standards have contributed to the improvement of outcomes in hip fracture patients. In 2020, our hospital was awarded “The Golden Hip” for achieving highest compliance with Irish Hip Fracture Standards (IHFS) nationally for 2019.

Methods

Data from the Irish Hip Fracture Database (IHFD)was retrospectively analysed to assess our performance in 2020 versus 2019 in hip fracture patients over sixty. Multiple quality improvement interventions were put in place throughout 2019 to ensure improvement in IHFS1-6 compliance: Creation of the Hip Fracture Pathway Subgroup, IHFS 1 Breaches Audit, Orthogeriatric input at Orthopaedic inductions, weekly Multi-disciplinary Team meetings, a Nutritional Hip Fracture Pathway and addition of the Fracture Liaison Service Advanced Nurse Practitioner.

Results

There were 239 hip fracture patients in 2020 vs 249 in 2019. IHFS1 compliance improved with the percentage of patients admitted to the Orthopaedic ward within 4 hours increasing to 71% in 2020 from 56% in 2019. There was improvement in IHFS2-time to surgery &lt;48 hours- 66% in 2020 vs 60% in 2019. IHFS3-pressure ulcer rate-was at the national average, 3% in 2020 vs 2% in 2019. IHFS4 (reviewed by a Geriatrician), IHFS5 (received a bone health assessment) and IHFS6 (received a specialised falls assessment) were lower overall; 87% in 2020 vs 98% in 2019. For all quarters (Q),43% of patients met all IHFS in our hospital in 2020 vs 32% in 2019, resulting in €90,000 in Best Practice Tariff funding.

Conclusion

Lower results for IHFS 4,5 and 6 reflect the arrival of the COVID-19 pandemic which led to redeployment of the Orthogeriatric Service and redeployment of the MDT from end of Q1 to Q3. When services in 2020 were preserved,1 in 2 hip fracture patients met all IHFS, vs 1 in 3 patients in 2019. Despite the pandemic, we continued to achieve the highest level of IHFS compliance nationally, being awarded a second consecutive “Golden Hip” for 2020.

250 EXPANSION OF THE ORTHOGERIATRIC SERVICE: EARLY EXPERIENCES

Background

The introduction of hip fracture standards has led to improvement in outcomes for hip fracture patients. Other osteoporotic fragility fractures also lead to significant morbidity. They are associated with a high risk of future hip fracture. The Orthogeriatric Service at a model 3 hospital was expanded to proactively undertake comprehensive geriatric assessment(CGA) for patients over 65 with non-hip fragility fractures(NHFF) admitted to the Orthopaedic Ward. Electronic discharge summaries were created for all patients. This study aimed to characterise patients reviewed by Orthogeriatrics and review discharge summary documentation of CGA.

Methods

Patients reviewed by Orthogeriatrics during the period Jan-June 2021 were retrospectively analysed. Discharge summaries of these patients were retrospectively reviewed. The prevalence of documentation of frailty status, delirium screening and bone health plan was recorded.

Results

A total(n = 126) of 91 patients with hip fractures and 35 with NHFF were included. Other fracture types were excluded. The mean age of hip fracture patients was 82.43 compared to 78.2 in the NHFF group. 71%(n = 65) of hip fracture patients were female compared to 80% (n = 28) of NHFF. 80%(n = 73) of hip fracture patients were reviewed within 48 hours of admission, compared to 65%(n = 23) of NHFF. 52.7%(n = 48)of hip fracture patients had frailty status documented on their discharge summary, compared to 37.1%(n = 13) of NHFF. Delirium screening was documented for 58.2%(n = 53) of the hip fracture patients, compared to 40%(n = 14) of NHFF. Bone health plans were documented for 62.6%(n = 57) of hip fracture patients compared to 60%(n = 21) of NHFF.

Conclusion

Expansion of the Orthogeriatric Service to proactively review all NHFF patients will lead to reduced incidence of repeat fracture for this population. A lower percentage of NHFF patients had clear discharge documentation of CGA outcomes and a lower percentage were reviewed within 48 hours. Expansion of hip fracture standards to include all fragility fracture patients should be considered to incentivise improved care for all.

103 ORTHOGERIATRIC SERVICES IN THE FACE OF COVID-19

Background

Nationally agreed standards improve the level of care delivered to all older, frail, multi-morbid patients presenting with hip fractures. Dedicated Orthogeriatric services allow for these standards to be achieved in a multi-disciplinary team (MDT) setting. As the COVID-19 pandemic reached our shores, the model of care set out by the Irish Hip Fracture Standards (IHFS) was under threat. Our dedicated Orthopaedic Trauma ward became an acute COVID ward and the Orthogeriatric service was re-deployed to acute medicine for Quarter 2.

Methods

Using the Irish Hip Fracture Database, local data was analysed and compared with national data from Quarter 1 to 4 (Q1–4) in 2020.

Results

When comparing local IHFS’s with national figures, ongoing challenges and future goals are highlighted.

In 2020, there were 222 hip fracture patients (mean age 81.8 years) in our hospital. Standard 1, time to the ward <4 hours, stands at 71% locally (national average 33%). Standard 2, time to theatre <48 hours, is an ongoing challenge and remains at 66% (national average 75%). Standard 3, pressure ulcer rate, was the same as the national average at 3%. Standards 4, 5 and 6 in our hospital stand at 87% (national averages of 82%, 91% and 85% respectively).

In Q1, 56%, or over 1 in every 2 patients with hip fractures, met all of the Irish Hip Fracture Standards in our hospital. In Q2, only 18% of patients met all of the IHFS’s. Q3 saw improvements with 47% of all hip fracture patients achieving all IHFS’s. Q4 showed maintenance with 45% of all patients achieving all IHFS’s.

Conclusion

These findings highlight the need for a dedicated Orthogeriatric Service and Orthopaedic ward at all times. Going forward with the risk of future waves and the emergence of new variants, every effort should be made to maintain a comprehensive orthogeriatric service to minimise a negative impact on patient care.

The role of non-invasive prenatal testing (NIPT) for fetal blood group typing in Australia

Maternal alloimmunisation against red blood cell antigens can cause haemolytic disease of the fetus and newborn (HDFN). Although most frequently caused by anti-D, since the implementation of rhesus D (RhD) immunoglobulin prophylaxis, other alloantibodies have become more prevalent in HDFN. Recent advances in non-invasive prenatal testing (NIPT) have allowed early prediction of HDFN risk in alloimmunised pregnancies and allow clinicians to focus health resources on those pregnancies that require intervention. This article aims to provide updates on the current status of NIPT in Australia as both a diagnostic and screening tool in pregnancy.

Screening for risky drinkers among hospitalised inpatients using the AUDIT: A feasibility, point prevalence and data linkage study

INTRODUCTION

Risky drinking frequently remains undiagnosed or untreated, including in hospitalised inpatients. Using the Alcohol Use Disorders Identification Test (AUDIT), we assessed the feasibility of screening for risky drinking and whether screening results aligned with alcohol-attributable diagnoses in an inpatient population.

METHODS

We conducted a cross-sectional survey across a tertiary health service in Melbourne, Australia. Researchers collected demographics, AUDIT scores and acceptability from all eligible adult inpatients available on day of survey. Main outcomes were prevalence of risky drinking (AUDIT ≥8), mean AUDIT score and patient acceptability. Identification of risky drinking by the abbreviated 'AUDIT-C' or discharge diagnoses (extracted by data-linkage with medical records) was compared.

RESULTS

Of 473 eligible inpatients, 61% (n = 289) participated, 22% (n = 103) were unavailable and 17% (n = 81) declined. Median age was 64 years (IQR = 48, 76); 54% (n = 157) were male. Mean AUDIT score was 4.4 (SD = 5.5). Risky drinking prevalence was 20% (n = 57), 2% (n = 7) had scores suggestive of dependence (AUDIT ≥20, a subset of risky drinkers). Odds of risky drinking were reduced in females (OR 0.19, 95% CI 0.09, 0.41; P < 0.001) and participants ≥70 years (OR 0.22, 95% CI 0.07, 0.71; P = 0.01). Alcohol-attributable diagnoses did not consistently align with risky drinking, with half of inpatients with wholly attributable diagnoses classified as low risk. Most inpatients considered screening acceptable (89%, n = 256).

DISCUSSION AND CONCLUSIONS

Pre-admission risky drinking was evident in one-fifth of hospital inpatients, but alcohol-attributable diagnoses were unreliable proxy measures of risky drinking. Screening in-patients with the AUDIT was acceptable to inpatients and can be feasibly implemented in an Australian tertiary hospital setting.

Population patterns in Alcohol Use Disorders Identification Test (AUDIT) scores in the Australian population; 2007-2016

OBJECTIVES

Despite widespread use of the Alcohol Use Disorders Identification Test (AUDIT), there are no published contemporary population-level scores for Australia. We examined population-level AUDIT scores and hazardous drinking for Australia over the period 2007-2016.

METHODS

Total population, age- and gender-specific AUDIT scores, and the percentage of the population with an AUDIT score of 8 or more (indicating hazardous drinking), were derived from four waves of the nationally representative National Drug Strategy Household Survey, weighted to approximate the Australian population.

RESULTS

In 2016, the mean AUDIT score was 4.58, and 22.22% of the population scored ≥8. Both measures remained stable from 2007 to 2010 but declined in 2013 and 2016. Scores were highest in those aged 18-24 years, the lowest in those aged 14-17 or 60+. A downward trend in AUDIT scores was seen in younger age groups, while the 40-59 and 60+ groups increased or did not change.

CONCLUSIONS

Despite an overall decline in AUDIT scores, nearly one-quarter of Australians reported hazardous drinking. Implications for public health: The marked declines in hazardous drinking among young people are positive, but trends observed among those aged 40-59 and 60+ years suggests targeted interventions for older Australians are needed.

Non-invasive prenatal testing for management of haemolytic disease of the fetus and newborn induced by maternal alloimmunisation

Anti-D immunoglobulin prophylaxis reduces the risk of RhD negative women becoming alloimmunised to the RhD antigen and is a major preventative strategy in reducing the burden of haemolytic disease of the fetus and newborn (HDFN). HDFN also arises from other maternal red cell antibodies, with the most clinically significant, after anti-D, being anti-K, anti-c and anti-E. Among the 39 human blood group systems advanced genomic technologies are still revealing novel or rare antigens involved in maternal alloimmunisation. Where clinically significant maternal antibodies are detected in pregnancy, non-invasive prenatal testing (NIPT) of cell-free fetal DNA provides a safe way to assess the fetal blood group antigen status. This provides information as to the risk for HDFN and thus guides management strategies. In many countries, NIPT fetal RHD genotyping as a diagnostic test using real-time PCR has already been integrated into routine clinical care for the management of women with allo-anti-D to assess the risk for HDFN. In addition, screening programs have been established to provide antenatal assessment of the fetal RHD genotype in non-alloimmunised RhD negative pregnant women to target anti-D prophylaxis to those predicted to be carrying an RhD positive baby. Both diagnostic and screening assays exhibit high accuracy (over 99 %). NIPT fetal genotyping for atypical (other than RhD) blood group antigens presents more challenges as most arise from a single nucleotide variant. Recent studies show potential for genomic and digital technologies to provide a personalised medicine approach with NIPT to assess fetal blood group status for women with other (non-D) red cell antibodies to manage the risk for HDFN.

148 Orthogeriatrics, Just the Beginning

Background

The most common cause of admission to the orthopaedic ward are low trauma falls resulting in a hip fracture. These fragility fractures occur in older, frail, multi-morbid patients and they are associated with a high mortality rate and significant loss of independence. The Irish Hip Fracture Database is a national clinical audit that aims to improve hip fracture care and patient outcomes. Using the Irish Hip Fracture Standards, we aimed to audit the care of hip fracture patients in an Irish Model 3 Hospital pre- and post- implementation of an orthogeriatrics service.

Methods

Local Irish Hip Fracture Database was reviewed to assess the six Irish Hip Fracture Standards prior and 4 months following the introduction of a consultant-led dedicated orthogeriatrics service.

Results

There were 63 hip fracture patients (mean age 81) in the pre-service group and 69 (mean age 81) in the post-service group. Standard 1: 3.2% of hip fractures were admitted to the orthopaedic ward within 4 hours in the pre-service group versus 18.8% post-service introduction (national average 11%, 2017). Standard 2: 67.9% underwent surgery within 48 hours and during working hours versus 67.8% (national average 69%, 2017). Standard 3: 3.5% developed a pressure ulcer during their stay pre-service versus 1.6% post-service (national average 3%, 2017). Standard 4: 4.8% were assessed by a Geriatrician pre-service versus 84% post-service (national average 50%, 2017). Standard 5: 24.6% received a bone health assessment versus 87.5% post-service (national average 73%, 2017). Standard 6: 1.8% received a falls assessment prior to discharge versus 82.8% post-service (national average 47%, 2017).

Conclusion

The introduction of a dedicated orthogeriatrics service has led to a more collaborative multi-disciplinary approach to patient care with evidence of improvements in all Irish Hip Fracture Standards. Commitment to a resourced orthogeriatric service providing rapid comprehensive geriatric assessments is essential to advance improvements in older patients’ care.

327 The Impact of Implementation of Recommendations from the IFHD 2017 Annual Report in an Irish Model 3 Hospital

Background

Hip fractures in the older person are associated with high mortality rates (NICE, 2011). Up to 40% of patients never regain their pre-fracture mobility, 10-20% never return to live at home. The Irish Hip Fracture Database (IHFD) National Report 2017 recommends appointment of an orthogeriatric consultant in this hospital to achieve IHFD standards 4 to 6.

Methods

We analysed a subset of HIPE data collected for the IHFD in patients over 60 years over a three month period from September – November 2017 and compare it to September – November 2018 after introduction of an orthogeriatric service. We looked at geriatrician review, bone health assessment, falls assessment, discharge destination, 30-day re-admission rate and mortality during admission.

Results

There were 45 hip fracture patients in each group. In the 2017 group, mean age was 79, female 64%; compared to mean age of 80, female 62.2% in 2018. In 2018, after the appointment of an orthogeriatrician, 95.6% of patients were seen by a geriatrician compared to 4.4% in 2017. In 2018, 97.7% received bone health assessment compared to 26.8% in 2017. In 2018 95.3% received specialist falls assessment, compared to 2.4% in 2017. Mean length of stay was 18 days in 2018 versus 13 days in 2017. 2.2% of patients were discharged to convalescence in 2018, 26.7% in 2017. 57.8% of patients were discharged to off-site rehabilitation in 2018 compared to 40% in 2017. 2.2% patients died during admission in 2018, 8.9% in 2017. In 2018, 6.7% of patients were readmitted within 30 days, 8.8% in 2017.

Conclusion

Provision of rapid Comprehensive Geriatric Assessment to all hip fracture patients, reduces falls and fracture risk. There is evidence of improvement in IHFD standards 4-6, mortality rate and 30-day readmission rate. Moreover, the orthogeriatric service has led to increased referral to rehabilitation services ensuring optimal functional recovery.

250 Delirium, Common but Forgotten

Background

Delirium is a medical emergency prevalent amongst hospitalised older patients and associated with prolonged hospital stay, functional and cognitive decline, institutionalisation and increased mortality. In Irish hospitals, multiple strategies, e-learning courses, delirium guidelines and prevention programs have aimed to improve delirium care with better diagnosis and prevention. With the increasing awareness campaigns, we aimed to review the prevalence, screening and management of delirium in our cohort of older patients.

Methods

A review of medical notes of all patients admitted under medical teams to an acute geriatric ward was carried out. Data was collected over a 3 week period in an Irish model 3 hospital. The following information was obtained from medical records: 1) Previous diagnosis of delirium/dementia 2) Documentation of a diagnosis of delirium 3) Features of delirium 4) Development of delirium as an inpatient 5) Formal screening for delirium 6) Cause and management of delirium 7) Length of stay.

Results

Of 79 consecutive admissions to an acute geriatric ward (mean age 81.4, 57% female, 30% previous history of delirium or dementia), 25% (n=20) had a diagnosis of delirium documented. 22% (n=18) of patients had confusion and features of delirium highlighted but no formal diagnosis of delirium made during their inpatient stay. A further 20% (n=16) developed delirium on admission. Only 2.5% (n=2) of admissions had formal screening for delirium with the 4AT. 27.5% (n=11) of patients with delirium had a cause and management plan recorded. 70% (n=28) of patients with delirium had a length of stay of over 15 days.

Conclusion

This review showed delirium recognition, screening, prevention and management were overlooked to an alarming extent in our cohort of older patients. The next step is introduction of the 4AT screening tool and regular education sessions to increase the awareness of delirium amongst medical teams looking after older patients and improve care and outcomes.

245 Delirium Incidence in Hip Fracture Patients: Awareness on the Orthopaedic Ward

Background

Postoperative delirium is a serious neuropsychiatric condition that occurs in up to 65% of hip fracture patients(1). However, it remains poorly recognised as a postoperative surgical complication despite its association with increased mortality, longer length of stay (LOS), cognitive decline and increased risk of discharge institutionalisation.

Methods

As part of the delirium audit, all hip fracture patient notes were reviewed from Oct-Nov 2017 pre-implementation of an Orthogeriatric Service and Oct-Nov 2018 post-implementation. Documentation of delirium or use of the terms ‘new confusion, altered attention, change in behaviour’ in the orthopaedic, orthogeriatric and allied health professional notes were reviewed. The 4AT was used to routinely screen for delirium in the pre-and post-operative period by the Orthogeriatrics team(2).

Results

The number of patients in the 2017 group was 24, mean age 78, female 76% compared with 25 in the 2018 group, mean age 75.9, female 81%. In 2017, delirium was diagnosed in 4% of patients by the Orthopaedic surgeons and 37.5% by Allied Health Professionals. In 2018 delirium was diagnosed in 4% by the Orthopaedic surgeons, 40% by Allied Health Professionals and 44% by the Orthogeriatrics team in 2018. Pre-operative delirium occurred in 16% of patients and postoperative delirium occurred in 44% of patients in 2018. A clear delirium management plan was documented in 0% of charts in 2017 versus 100% in 2018. LOS in 2017 was 12.7 days vs 12.4 in 2018. However, discharge location varied greatly with 33.3% discharged to convalescence in 2017 versus 19% in 2018, 12.5% to Longterm care in 2017 versus 4% in 2018, 20.8% to rehabilitation in 2017 vs 52% in 2018 and 16.7% home in 2017 vs 24% in 2018.

Conclusion

Prompt diagnosis and management of delirium is essential in optimising postoperative cognitive function and preserving independence. Our study highlights the need for routine delirium screening and improved awareness of delirium amongst all healthcare professionals.

284 Improving Adherence to Irish Hip Fracture Database Standards 1 and 2

Background

The Irish Hip Fracture Database (IHFD) National Report 2017 demonstrated poor performance across all six IHFD standards in our hospital. For the purpose of this study we focused on standards 1 and 2. IHFD standard 1: All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of ED presentation/ brought directly to theatre from ED within 4 hours, and IHFD standard 2: All patients with hip fracture who are medically fit should have surgery within 48 hours of admission and during normal working hours.

Methods

We examined IHFD standards 1 and 2 from August 2017-January 2018 and August 2018-January 2019 after the appointment of an orthogeriatrician and use of the first Hip Fracture Pathway in August 2018. We also analysed data collected from February-April 2019 after amendment of the hip fracture pathway for patients presenting to the ED.

Results

IHFD Standard 1: From August to January 2017, 2.5% of patients were admitted to an orthopaedic ward within 4 hours versus 18.1% in 2018. IHFD Standard 2: in 2017, 64.8% underwent surgery within 48 hours during working hours, versus 65.3% in 2018. From February to April 2019, 32.1% of patients were admitted to an orthopaedic ward within 4 hours (IFHD 1) and 56.6% of patients underwent surgery within 48 hours and during working hours (IFHD 2).

Conclusion

Close collaboration between Emergency Medicine, Orthopaedic Surgery, Radiology, Nursing colleagues, Allied Health Professionals and Orthogeriatrics and amendment of the Hip Fracture Pathway have led to improvements in Standards 1 and 2. The addition of an orthogeriatric service in the hospital has resulted in an improvement in adherence to all IFHD standards. However, there are ongoing challenges to achieving Standard 2 including limited theatre access and increasing numbers of older patients on novel oral anticoagulants.

Resistant syndrome of inappropriate antidiuretic hormone (SIADH) secondary to atonic bladder in an older woman

Syndrome of inappropriate antidiuretic hormone (SIADH) is the most common cause of hyponatraemia. There are many causes of SIADH, but investigation tends to focus around the most common causes-particularly diseases of the brain and lung, malignancy and medication-induced SIADH [Ellison and Berl (2007, The Syndrome of Inappropriate Antidiuresis. N Engl J Med., 356, 2064-72]. We describe a case of SIADH secondary to atonic bladder in an 83-year old woman, which was discovered on MRI of the abdomen, performed for further characterisation of a known pancreatic lesion. Insertion of a urinary catheter alleviated retention and resulted in prompt resolution of hyponatraemia. This is an under-recognised cause of this common condition, with important implications for investigation and management.

Hospitalisation and surgery: Is exposure associated with increased subsequent depressive symptoms? Evidence from The Irish Longitudinal Study on Ageing (TILDA)

BACKGROUND

The dramatic shift in the global population demographic has led to increasing numbers of older people undergoing hospitalisation and surgical procedures. While necessary, these exposures may lead to an increase in depressive symptoms.

OBJECTIVES

To determine whether hospitalisation or hospitalisation with surgery under general anaesthesia is associated with an increase in depressive symptoms in adults over the age of 50.

METHODS

Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale in 8036 individuals at waves 1 and 2 of The Irish Longitudinal Study on Ageing (TILDA), 2 years apart. Mixed-effects models were used to investigate the hypothesis after adjustment for risk factors for depression and potential confounders.

RESULTS

During the 12 months preceding wave 1, a total of 459 participants were hospitalised (mean age, 67.0; 55.3% female), and a further 548 participants (mean age, 64.6; 51.8% female) were hospitalised and underwent surgery with general anaesthesia; 6891 (mean age, 63.5; 54.3% female) were not hospitalised. Analysis of waves 1 and 2 data using mixed-effects models demonstrated that there was a 7% increased adjusted incidence rate of depressive symptoms (IRR [95% CI] = 1.07 [1.02-1.11]) in the Center for Epidemiologic Studies Depression Scale in the hospitalisation group and a 4% increased adjusted incidence rate of depressive symptoms (IRR [95% CI] = 1.04 [1.00-1.08]) in the surgery group compared with those with no hospitalisation.

CONCLUSION

Hospitalisation and hospitalisation with surgery and general anaesthesia are associated with increased depressive symptoms. This is the first time a longitudinal population-representative study has demonstrated this relationship for both exposures simultaneously.

Do-not-attempt-resuscitation (DNAR) orders: understanding and interpretation of their use in the hospitalised patient in Ireland. A brief report

Following the introduction of do-not-resuscitate (DNR) orders in the 1970s, there was widespread misinterpretation of the term among healthcare professionals. In this brief report, we present findings from a survey of healthcare professionals. Our aim was to examine current understanding of the term do-not-attempt-resuscitate (DNAR), decision-making surrounding DNAR and awareness of current guidelines. The survey was distributed to doctors and nurses in a university teaching hospital and affiliated primary care physicians in Dublin via email and by hard copy at educational meetings from July to December 2014. A total of 519 completed the survey. The response rate in the hospital doctors group was 35.5% (187/527), 19.8% (292/1477) in the nurses group but 68.8% (150/218) in the specialist nurses group and 40% (40/100) in the primary care physician group.Alarmingly, our results demonstrate that 26.8% of staff nurses and 30% of primary care physicians surveyed believed that a patient with a DNAR order could not receive any/at least one of a list of simple treatments including antibiotics, physiotherapy, intravenous fluids, pain relief, oxygen, nasogastric feeding or airway suctioning, which were higher percentages compared to the other hospital doctors and experienced nurses groups with statistically significant differences (p<0.001). Furthermore, a higher percentage of staff nurses (26.8%) and primary care physicians (22.5%) believed that a patient with a DNAR order could not be referred to hospital from home/a nursing home, when compared with other healthcare groups (p<0.001). Our findings highlight continued misunderstanding and over-interpretation of DNAR orders. Further collaboration and information is required for meaningful Advance Care Plans.

A DEL phenotype attributed to RHD Exon 9 sequence deletion: slipped-strand mispairing and blood group polymorphisms

BACKGROUND

The RhD blood group antigen is extremely polymorphic and the DEL phenotype represents one such class of polymorphisms. The DEL phenotype prevalent in East Asian populations arises from a synonymous substitution defined as RHD*1227A. However, initially, based on genomic and cDNA studies, the genetic basis for a DEL phenotype in Taiwan was attributed to a deletion of RHD Exon 9 that was never verified at the genomic level by any other independent group. Here we investigate the genetic basis for a Caucasian donor with a DEL partial D phenotype and compare the genomic findings to those initial molecular studies.

STUDY DESIGN AND METHODS

The 3'-region of the RHD gene was amplified by long-range polymerase chain reaction (PCR) for massively parallel sequencing. Primers were designed to encompass a deletion, flanking Exon 9, by standard PCR for Sanger sequencing. Targeted sequencing of exons and flanking introns was also performed.

RESULTS

Genomic DNA exhibited a 1012-bp deletion spanning from Intron 8, across Exon 9 into Intron 9. The deletion breakpoints occurred between two 25-bp repeat motifs flanking Exon 9 such that one repeat sequence remained.

CONCLUSION

Deletion mutations bordered by repeat sequences are a hallmark of slipped-strand mispairing (SSM) event. We propose this genetic mechanism generated the germline deletion in the Caucasian donor. Extensive studies show that the RHD*1227A is the most prevalent DEL allele in East Asian populations and may have confounded the initial molecular studies. Review of the literature revealed that the SSM model explains some of the extreme polymorphisms observed in the clinically significant RhD blood group antigen.

Non-invasive fetal RHD genotyping for RhD negative women stratified into RHD gene deletion or variant groups: comparative accuracy using two blood collection tube types

Non-invasive fetal RHD genotyping in Australia to reduce anti-D usage will need to accommodate both prolonged sample transport times and a diverse population demographic harbouring a range of RHD blood group gene variants. We compared RHD genotyping accuracy using two blood sample collection tube types for RhD negative women stratified into deleted RHD gene haplotype and RHD gene variant cohorts. Maternal blood samples were collected into EDTA and cell-free (cf)DNA stabilising (BCT) tubes from two sites, one interstate. Automated DNA extraction and polymerase chain reaction (PCR) were used to amplify RHD exons 5 and 10 and CCR5. Automated analysis flagged maternal RHD variants, which were classified by genotyping. Time between sample collection and processing ranged from 2.9 to 187.5 hours. cfDNA levels increased with time for EDTA (range 0.03-138 ng/μL) but not BCT samples (0.01-3.24 ng/μL). For the 'deleted' cohort (n=647) all fetal RHD genotyping outcomes were concordant, excepting for one unexplained false negative EDTA sample. Matched against cord RhD serology, negative predictive values using BCT and EDTA tubes were 100% and 99.6%, respectively. Positive predictive values were 99.7% for both types. Overall 37.2% of subjects carried an RhD negative baby. The 'variant' cohort (n=15) included one novel RHD and eight hybrid or African pseudogene variants. Review for fetal RHD specific signals, based on one exon, showed three EDTA samples discordant to BCT, attributed to high maternal cfDNA levels arising from prolonged transport times. For the deleted haplotype cohort, fetal RHD genotyping accuracy was comparable for samples collected in EDTA and BCT tubes despite higher cfDNA levels in the EDTA tubes. Capacity to predict fetal RHD genotype for maternal carriers of hybrid or pseudogene RHD variants requires stringent control of cfDNA levels. We conclude that fetal RHD genotyping is feasible in the Australian environment to avoid unnecessary anti-D immunoglobulin prophylaxis.

Targeted exome sequencing defines novel and rare variants in complex blood group serology cases for a red blood cell reference laboratory setting

BACKGROUND

We previously demonstrated that targeted exome sequencing accurately defined blood group genotypes for reference panel samples characterized by serology and single-nucleotide polymorphism (SNP) genotyping. Here we investigate the application of this approach to resolve problematic serology and SNP-typing cases.

STUDY DESIGN AND METHODS

The TruSight One sequencing panel and MiSeq platform was used for sequencing. CLC Genomics Workbench software was used for data analysis of the blood group genes implicated in the serology and SNP-typing problem. Sequence variants were compared to public databases listing blood group alleles. The effect of predicted amino acid changes on protein function for novel alleles was assessed using SIFT and PolyPhen-2.

RESULTS

Among 29 unresolved samples, sequencing defined SNPs in blood group genes consistent with serologic observation: 22 samples exhibited SNPs associated with varied but known blood group alleles and one sample exhibited a chimeric RH genotype. Three samples showed novel variants in the CROM, LAN, and RH systems, respectively, predicting respective amino acid changes with possible deleterious impact. Two samples harbored rare variants in the RH and FY systems, respectively, not previously associated with a blood group allele or phenotype. A final sample comprised a rare variant within the KLF1 transcription factor gene that may modulate DNA-binding activity.

CONCLUSION

Targeted exome sequencing resolved complex serology problems and defined both novel blood group alleles (CD55:c.203G>A, ABCB6:c.1118_1124delCGGATCG, ABCB6:c.1656-1G>A, and RHD:c.452G>A) and rare variants on blood group alleles associated with altered phenotypes. This study illustrates the utility of exome sequencing, in conjunction with serology, as an alternative approach to resolve complex cases.

Interlaboratory Reproducibility of Droplet Digital Polymerase Chain Reaction Using a New DNA Reference Material Format

Use of droplet digital PCR technology (ddPCR) is expanding rapidly in the diversity of applications and number of users around the world. Access to relatively simple and affordable commercial ddPCR technology has attracted wide interest in use of this technology as a molecular diagnostic tool. For ddPCR to effectively transition to a molecular diagnostic setting requires processes for method validation and verification and demonstration of reproducible instrument performance. In this study, we describe the development and characterization of a DNA reference material (NMI NA008 High GC reference material) comprising a challenging methylated GC-rich DNA template under a novel 96-well microplate format. A scalable process using high precision acoustic dispensing technology was validated to produce the DNA reference material with a certified reference value expressed in amount of DNA molecules per well. An interlaboratory study, conducted using blinded NA008 High GC reference material to assess reproducibility among seven independent laboratories demonstrated less than 4.5% reproducibility relative standard deviation. With the exclusion of one laboratory, laboratories had appropriate technical competency, fully functional instrumentation, and suitable reagents to perform accurate ddPCR based DNA quantification measurements at the time of the study. The study results confirmed that NA008 High GC reference material is fit for the purpose of being used for quality control of ddPCR systems, consumables, instrumentation, and workflow.

Evaluation of targeted exome sequencing for 28 protein-based blood group systems, including the homologous gene systems, for blood group genotyping

BACKGROUND

Blood group single nucleotide polymorphism genotyping probes for a limited range of polymorphisms. This study investigated whether massively parallel sequencing (also known as next-generation sequencing), with a targeted exome strategy, provides an extended blood group genotype and the extent to which massively parallel sequencing correctly genotypes in homologous gene systems, such as RH and MNS.

STUDY DESIGN AND METHODS

Donor samples (n = 28) that were extensively phenotyped and genotyped using single nucleotide polymorphism typing, were analyzed using the TruSight One Sequencing Panel and MiSeq platform. Genes for 28 protein-based blood group systems, GATA1, and KLF1 were analyzed. Copy number variation analysis was used to characterize complex structural variants in the GYPC and RH systems.

RESULTS

The average sequencing depth per target region was 66.2 ± 39.8. Each sample harbored on average 43 ± 9 variants, of which 10 ± 3 were used for genotyping. For the 28 samples, massively parallel sequencing variant sequences correctly matched expected sequences based on single nucleotide polymorphism genotyping data. Copy number variation analysis defined the Rh C/c alleles and complex RHD hybrids. Hybrid RHD*D-CE-D variants were correctly identified, but copy number variation analysis did not confidently distinguish between D and CE exon deletion versus rearrangement.

CONCLUSION

The targeted exome sequencing strategy employed extended the range of blood group genotypes detected compared with single nucleotide polymorphism typing. This single-test format included detection of complex MNS hybrid cases and, with copy number variation analysis, defined RH hybrid genes along with the RHCE*C allele hitherto difficult to resolve by variant detection. The approach is economical compared with whole-genome sequencing and is suitable for a red blood cell reference laboratory setting.

Delusions of pregnancy in older women: a case series

BACKGROUND

Delusions of pregnancy have been reported in a wide variety of functional and organic psychiatric conditions but rarely with dementia. Most such delusions arise in women of child-bearing age. We report five cases in older women all of whom had severe constipation that probably precipitated this delusion.

CASE REPORTS

Of the five women (age 74-89 years), two had dementia, two had delirium and one had both. All patients had borne healthy children. Three women reported that they were in labour, and one was concerned that the baby was not moving. All had severe constipation on examination or imaging, and three had faecal impaction. All were treated with laxatives or enemas, and only one patient required brief antipsychotic therapy. The delusions lasted from a few hours to 5 days. In general, resolution of the delusion occurred in concert with improvement in bowel function, although in one case a large bowel movement was followed by the delusion that a baby had been born.

CONCLUSION

These cases suggest that misinterpretation of abdominal symptoms due to severe constipation in cognitively impaired women may trigger the delusion of being pregnant and that treatment of constipation often leads to resolution of the delusion.

Space magnetometer based on an anisotropic magnetoresistive hybrid sensor

We report on the design and development of a low resource, dual sensor vector magnetometer for space science applications on very small spacecraft. It is based on a hybrid device combining an orthogonal triad of commercial anisotropic magnetoresistive (AMR) sensors with a totem pole H-Bridge drive on a ceramic substrate. The drive enables AMR operation in the more sensitive flipped mode and this is achieved without the need for current spike transmission down a sensor harness. The magnetometer has sensitivity of better than 3 nT in a 0-10 Hz band and a total mass of 104 g. Three instruments have been launched as part of the TRIO-CINEMA space weather mission, inter-calibration against the International Geomagnetic Reference Field model makes it possible to extract physical signals such as field-aligned current deflections of 20-60 nT within an approximately 45,000 nT ambient field.

Coping resources and self-rated health among Latina breast cancer survivors

PURPOSE/OBJECTIVES

To examine relationships between coping resources and self-rated health among Latina breast cancer survivors.

DESIGN

Cross-sectional telephone survey.

SETTING

Four northern California counties.

SAMPLE

330 Latina breast cancer survivors within one to five years of diagnosis.

METHODS

Telephone survey conducted by bilingual and bicultural interviewers.

MAIN RESEARCH VARIABLES

Predictors were sociodemographic and clinical factors, cancer self-efficacy, spirituality, and social support from family, friends, and oncologists. Outcomes were functional limitations and self-rated health.

FINDINGS

Twenty-two percent of women reported functional limitations (n = 73) and 27% reported poor or fair self-rated health (n = 89). Unemployment (adjusted odds ratio [AOR] = 7.06; 95% confidence interval [CI] [2.04, 24.46]), mastectomy (AOR = 2.67; 95% CI [1.06, 6.77]), and comorbidity (AOR = 4.09; 95% CI [1.69, 9.89]) were associated with higher risk of functional limitations; cancer self-efficacy had a protective effect (AOR = 0.4, 95% CI [0.18, 0.9]). Comorbidity was associated with higher risk of poor or fair self-rated health (AOR = 4.95; 95% CI [2.13, 11.47]); cancer self-efficacy had a protective effect (AOR = 0.3; 95% CI [0.13, 0.66]).

CONCLUSIONS

Comorbidities place Latina breast cancer survivors at increased risk for poor health. Cancer self-efficacy deserves more attention as a potentially modifiable protective factor.

IMPLICATIONS FOR NURSING

Nurses need to assess the impact of comorbidity on functioning and can reinforce patients' sense of control over cancer and clinician support.

Clinician ratings of interpreter mediated visits in underserved primary care settings with ad hoc, in-person professional, and video conferencing modes

Linguistic interpretation ameliorates health disparities disfavoring underserved limited English-proficient patients, yet few studies have compared clinician satisfaction with these services. Self-administered clinician post-visit surveys compared the quality of interpretation and communication, visit satisfaction, degree of patient engagement, and cultural competence of visits using untrained people acting as interpreters (ad hoc), in-person professional, or video conferencing professional interpretation for 283 visits. Adjusting for clinician and patient characteristics, the quality of interpretation of in-person and video conferencing modes were rated similarly (OR 1.79, 95% CI 0.74, 4.33). The quality of in-person (OR 5.55, 95% CI 1.50, 20.51) and video conferencing (OR 3.10, 95% CI 1.16, 8.31) were rated higher than ad hoc interpretation. Self-assessed cultural competence was better for in-person versus video conferencing interpretation (OR 2.32, 95% CI 1.11, 4.86). Video conferencing interpretation increases access without compromising quality, but cultural nuances may be better addressed by in-person interpreters. Professional interpretation is superior to ad hoc (OR 4.15, 95% CI 1.43, 12.09).

Interpersonal processes of care and patient satisfaction: do associations differ by race, ethnicity, and language?

OBJECTIVE

Describe association of patient satisfaction with interpersonal processes of care (IPC) by race/ethnicity.

DATA SOURCES/STUDY SETTING

Interview with 1,664 patients (African Americans, English- and Spanish-speaking Latinos, and non-Latino Whites).

STUDY DESIGN/METHODS

Cross-sectional study of seven IPC measures (communication, patient-centered decision making, and interpersonal style) and three satisfaction measures (satisfaction with physicians, satisfaction with health care, and willingness to recommend physicians). Regression models explored associations, controlling for patient characteristics.

PRINCIPAL FINDINGS

In all groups: patient-centered decision making was positively associated with satisfaction with physicians (B=0.10, p<.0001) and health care (B=0.07, p<.001), and "recommend physicians" (OR=1.23, 95 percent CI 1.06, 1.43); discrimination was negatively associated with satisfaction with physicians (B=0.09, p<.05) and health care (B=0.17, p<.001). Unclear communication was associated with less satisfaction with physicians among Spanish-speaking Latinos. Explaining results was positively associated with all satisfaction outcomes for all groups with one exception (no association with satisfaction with physicians for Latino Spanish-speakers). Compassion/respect was positively associated with all outcomes for all groups with two exceptions (no association with satisfaction with health care among English-speaking Latinos and Whites).

CONCLUSIONS

All IPC measures were associated with at least one satisfaction outcome for all groups except for unclear communication.

Developing a culturally competent peer support intervention for Spanish-speaking Latinas with breast cancer

Little research exists on the need for, barriers to, and acceptability and effectiveness of psychosocial support services among Latinas with breast cancer, despite their increased risks of psychosocial distress. This formative research study identifies barriers to and benefits and components of an effective peer support counselor intervention for Spanish-speaking Latinas recently diagnosed with breast cancer. Analysis was based on interviews of 89 Latino cancer patients referred to psychosocial services; 29 Spanish-speaking survivors of breast cancer; and 17 culturally competent advocates for Latinos with cancer. Results indicate that interventions should begin close to diagnosis; build self-care skills; be culturally competent and emotionally supportive; provide language appropriate cancer information; encourage self-expression; and address lack of access to and knowledge of services. Creating such psychosocial programs with input from survivors and advocates who have similar self-identities to patients would improve quality of life in diverse and underserved populations.

Using cognitive interviews to develop surveys in diverse populations

BACKGROUND

Conceptual equivalence of measures is essential in research that compares health across diverse racial/ethnic groups. Cognitive interviews are pretest methods to explore the conceptual equivalence of survey items. Systematic approaches for using these methods are emerging.

OBJECTIVE

We describe an interaction analysis (IA) approach using qualitative data analysis software to analyze transcripts of cognitive interviews in a study to develop a survey instrument of the quality of interpersonal processes of care of diverse patients. Cognitive interviews included standard administration of the survey followed by retrospective probes for selected items.

SUBJECTS

Interviews were completed with 48 Latino, black, and non-Latino white respondents 18 years of age or older with at least one doctor's visit in the past 12 months. Participants averaged 45.8 years in age (standard deviation [SD] = 18.4), 58% were women, and mean education was 14.7 years (SD = 4.0).

RESULTS

Problems were identified in 126 of 159 items (79%). Behavior coding identified 32 problematic items (20%). IA of the transcript of the survey and retrospective probes identified 94 additional problematic items (59%). IA often revealed the nature of the problems, enabling decisions to modify or drop items based on respondents' comments. Behavior coding and IA identified ethnic and language similarities and differences in the use of response sets and the interpretation of items.

CONCLUSIONS

IA and behavior coding of cognitive interview transcripts can identify efficiently problems with items and their source to increase the likelihood of the revised items being conceptually equivalent across ethnic groups.

A comparison of molecular and enzyme-based assays for the detection of thiopurine methyltransferase mutations

S-Methylation by thiopurine methyltransferase (TPMT) is an important route of metabolism for the thiopurine drugs. About one in 300 individuals are homozygous for a TPMT mutation associated with very low enzyme activity and severe myelosuppression if treated with standard doses of drug. To validate the use of molecular genetic techniques for the detection of TPMT deficiency, we have determined red blood cell TPMT activity in 240 adult blood donors and 55 normal children. Genotype was determined by restriction fragment length analysis of polymerase chain reaction products in a cohort of 79 of the blood donors and five cases of azathioprine-induced myelosupression, and this confirmed a close relationship between genotype and phenotype. In 17 of the 24 cases in which mutations were found, DNA was also available from remission bone marrow. In one of these cases, DNA from the remission marrow sample indicated the presence of a non-mutated allele that had not been seen in the blast DNA sample obtained at presentation. These results indicate that polymerase chain reaction-based assays give reliable and robust results for the detection of TPMT deficiency, but that caution should be exercised in relying exclusively on DNA obtained from lymphoblasts in childhood leukaemia.

K-ras mutations, rectal crypt cells proliferation, and meat consumption in patients with left-sided colorectal carcinoma

It has been suggested that N-nitroso compounds derived from meat may increase the risk of K-ras mutations in the human colon. We sought evidence of associations between red meat consumption, frequency and type of K-ras mutations in resected tumours, and the rate of crypt cell proliferation (CCP) in the normal mucosa of patients with left-sided colorectal carcinoma. Meat consumption was assessed by food frequency questionnaire, and CCP was determined in rectal biopsies obtained prior to surgery. K-ras mutations in the resected tumours were determined using a PCR-based oligonucleotide hybridization assay. Fifteen K-ras mutations were detected in tumours from 43 patients; 13/15 in codon 12, 3/15 in codon 13, and 1/15 in both codons 12 and 13. All mutations were G-->A or G-->T transitions. There was no statistically significant difference between intakes of red meat in patients with a K-ras mutation (92.4 +/- 9.7 g/day) and those without (82.3 +/- 7.7 g/day). Rectal CCP was significantly higher in patients than in healthy controls, but there was no correlation with meat consumption or K-ras mutation. These data do not support the hypothesis that meat consumption is a risk factor for acquisition of K-ras mutations during colorectal carcinogenesis.