Susceptibility weighted imaging for qualitative grading of persistent arteriovenous shunting in deep-seated arteriovenous malformations after stereotactic radiation surgery

BACKGROUND AND PURPOSE

To investigate Susceptibility Weighted Imaging (SWI) signal changes in the draining vein of deep-seated arterio-venous malformations (AVMs) following stereotactic radiosurgery (SRS).

METHODS AND MATERIALS

This is a retrospective study of 32 patients with deep-seated AVMs who were treated with SRS. Pre-SRS treatment and post-SRS treatment MRI were performed at 6, 12, and 24-month intervals. Deep-seated AVMs were classified based on their anatomical location and venous drainage pattern. AVM nidal volume (cm3) was estimated using the ABC/2 method. AV shunting of the AVM draining veins were graded according to its SWI signal intensity: hyperintense (grade III), mixed signal intensity (grade II), hypointense (grade I) and absent (grade 0). Conventional time-of-flight (TOF)-MRA and contrast enhanced (CE)-MRA sequences were performed to document the patency of the vein.

RESULTS

Pre-SRS treatment AVM draining veins were either grade III 18/32 (56%) or grade II 14/32 (44%). Using mixed effects analysis, we demonstrate that each month following the SRS treatment nidal volumes decreased at the rate of 0.51 cm3/per month (CI -0.61 to (-0.40)) p =.00. Following the treatment, there was a clinically significant relationship between the signal and nidal volume: signal 0 corresponded with average nidal volume of 1.81 cm3 (CI 1.40-2.21), signal 1 with nidal volume of 2.06 cm3 (CI 1.69-2.44), signal 2 with nidal volume 2.73 cm3 (CI 2.35-3.11) and signal 3 with nidal volume 3.13 cm3 (CI 2.70-3.56) p = .00.

CONCLUSION

Post-SRS AVM draining veins shows a stepwise regression of the SWI signal grades which can be reliably used as a surrogate to monitor the reduction of AV shunting.

331 THE USE OF BODY MASS INDEX IN PREDICTING ORTHOSTATIC HYPOTENSION IN OLDER ADULTS

Background

The presence of Orthostatic Hypotension (OH) is known to be associated with an increased mortality risk. Previous Irish research has shown that elevated Body Mass Index (BMI) may be protective against OH, with overweight and obese patients having significantly smaller Systolic Blood Pressure (SBP) drops during Head-Up-Tilt (HUT) Testing.

Methods

Demographics, including age, height and weight, were obtained retrospectively from all head up tilt testing performed in a tertiary Irish hospital between 2000 and 2021. All incomplete records were excluded. A total of 4,717 patients were analysed. Linear regression models were used to examine the relationship between BMI and change in tilt SBP.

Results

2,089 males and 2,628 females over the age of 60 years old were examined. The mean age is 77 years ± 7.8 (S.D.), with majority (51.5%) of the cohort overweight or obese. 69.7% of individuals demonstrated OH. The mean change in tilt SBP was –7mmHg in the underweight and healthy weight group, and –10mmHg in the overweight or obese group. The linear regression model established that BMI significantly predicted a change in tilt SBP (beta=0.394, 95% CI: 0.235 to 0.554, p<0.001), but remains a poor predictive variable (R2=0.004) for this cohort. This correlation was similar for both genders (male: r=0.08, female: r=0.07).

Conclusion

Our findings confirmed a correlation between BMI and its predictive impact on OH in older adults. Future studies should explore targeted populations with multivariate analysis, taking into consideration age and gender, to reduce the heterogeneity of data.

220 RELATIONSHIP BETWEEN HEIGHT AND SYSTOLIC BLOOD PRESSURE IN OLDER ADULTS

Background

Hypertension is common amongst older adults in Ireland and is a major risk factor for both ischaemic and haemorrhagic stroke. Several studies have investigated the relationship between height and hypertension, however results have been inconsistent. In our Irish tertiary hospital patients undergoing tilt table testing have resting blood pressure measured prior to the test, and height recorded. Our aim was to assess whether there is a relationship between height and resting Systolic Blood Pressure (SBP) in patients aged over 60 years.

Methods

All tilt table test results between 2000 and 2021 in a single centre were reviewed retrospectively, collecting data on age, height and resting SBP. Any incomplete records were excluded, as were those from patients under 60 years old. Linear regression modelling was used to assess relationship between height and resting SBP.

Results

A total of 4,729 complete records were included for patients over 60 years old. 2630 (61.5%) of the patients were female. Mean age was 77 ± 7.8 years. 57.7% patients had either an elevated resting systolic and/or diastolic BP ≥130/80 and 28.4% ≥140/90. The linear regression model established that while height could be used to predict resting systolic blood pressure (beta=-0.166, 95% CI: –0.219 to –0.113, p<0.001), height only accounted for 0.8% of variability in resting SBP (R2 = 0.008).

Conclusion

Our large dataset establishes an association but no meaningful causation between height and resting systolic blood pressure. Current antihypertensive treatment was not recorded, which may have affected the results. Future studies will include further multivariate analysis accounting for antihypertensive use and other factors that may impact hypertension such as age, weight and gender.

228 GENDER DISPARITIES IN DIAGNOSING OSTEOPOROSIS

Background

It is estimated that up to 300,000 people in Ireland have osteoporosis, however it is a disease most commonly associated with women. Women aged over 50 years have a four times greater rate of osteoporosis and are twice as likely to have osteopenia as men.1 However the recognition and treatment of osteoporosis in men cannot be forgotten. The Irish Hip Fracture Database National Report 2019 showed that 31% of 3,701 hip fractures that year were in males. Hip fractures have been shown to result in higher overall mortality in men than in women.2

Methods

A retrospective observational study was carried out by analysing the reports of all dual-energy X-ray absorptiometry (DEXA) scans performed in a large university teaching hospital from January 1998 to August 2021, collecting data on gender, age, bone mineral density and osteoporosis risk factors.

Results

A total of 39,611 patients having their first DEXA scan in our hospital were included. 85.2% were female and 14.8% male. In all patients over 75 years, only 12.9% of all patients getting a first DEXA scan were male. Of all women who had DEXA scans, 29.1% were diagnosed with osteoporosis and 38.4% with osteopenia and in men 16.6% osteoporosis and 40.7% osteopenia.

Conclusion

Our results highlight that men have DEXA scans performed much less frequently than women. This is seen in all age groups, especially in patients over 75 years old. As in women, the prevalence of osteoporosis in men increases with age. This study demonstrates the importance of evaluating for and treating osteoporosis in men as well as women, as fragility fractures can cause significant mortality and morbidity in both genders.

References

1. Alswat KA. Gender Disparities in Osteoporosis. J Clin Med Res.2017;9(5):382–387. doi: 10.14740/jocmr2970w.

2. Kanis JA et al. The components of excess mortality after hip fracture. Bone.2003;32(5):468–473.

241 IMPLEMENTATION OF AN INTRACEREBRAL CEREBRAL HAEMORRHAGE CARE BUNDLE

Background

Mortality for Intracerebral haemorrhage (ICH) is 31% (Irish National Audit Stroke, 2019). An ICH care bundle focusing on acute anticoagulation reversal, blood pressure lowering, and a neurosurgical care pathway was associated with improved survival. Translating evidence-based medicine into clinical practice is challenging. The aim of this study was to determine feasibility and outcomes of implementation of a care bundle.

Methods

An ICH care bundle was developed using an iterative process involving expert stakeholder review of the evidence-based literature. A pre-and-post quasi-experimental research design was employed to evaluate this intervention. Baseline data were collected before implementation (January 2016-June 2018). Implementation took place in a staged manner in a single university teaching hospital with multiple ‘Plan Do Study Act cycles’ (June 2018 to January 2021). Data on compliance, process measures and outcomes were collected.

Results

Systolic blood pressure (first 24-hours) and anticoagulant reversal were significantly better controlled post-implementation (χ2 (1, N = 91) = 5.34, P = 0.02), (χ2 (1, N = 25) = 5.85, P = 0.016), respectively. DNAR orders were significantly lower in the post-implementation group (χ2 (1, N = 25) = 5.85, P = 0.029). However, ‘Do Not Actively Resuscitate’ status did not significantly differ when accounting for low GCS as a surrogate measure for poor prognosis (χ2 (1, N = 34) = 0.00, P = 0.966). Modified Rankin Scale on discharge did not differ significantly pre-and-post-implementation (z = −0.075, P = 0.94). A greater proportion of patients survived in the post-implementation group; however, this was not statistically significant (χ2 (1, N = 133) = 0.77, P = 0.38). Length of stay significantly increased post implementation.

Conclusion

An ICH care bundle was developed based on expert stakeholder feedback. The feasibility of implementing this bundle of care was demonstrated in a real-world clinical practice setting. A cluster-randomized trial or a large registry study is the next step to evaluate the overall impact of this care bundle on patient outcomes.

247 BENCHMARKING STROKE SERVICES TO INFORM A QUALITY IMPROVEMENT INIAITIVE

Background

Stroke is a leading cause of death and disability in Ireland. Continuous audit and quality improvement is essential in the delivery of stroke care where the evidence basis is constantly changing. This helps to ensure the delivery of high quality stroke care and compliance with evidenced based guidelines. We aimed to assess stroke care at an Irish university teaching hospital.

Methods

Patients with a HIPE discharge diagnosis of Cerebral Infarction or Cerebral Haemorrhage (1st January-31st December 2019) were identified through both the HIPE database and the institutional Stroke Portal. Data was benchmarked against national (Irish National Audit of Stroke 2019) and international (6th SSNAP Annual Report; American Heart Association, 2013) practice and used to inform a quality improvement strategy.

Results

419 patients were included (56.6% male, median 57 years). 75.9% were aged 65 years or older. We compared favourably with Irish National Audit of Stoke national indicators on the following: thrombolysis rates-10%; median door to needle time-60 mins; stroke unit admissions- 78.5%; median duration of symptoms- 3 hours 6 minutes; swallow assessment- 81.1%; in-patient mortality- 10.5%; rates of institutionalisation- 3.8%. Areas identified for improvement were: thrombectomy rates- 1.9%; median length of stay- 12 days; door to imaging time- median 104 minutes; mood screening- 11.5%.

Conclusion

International and national data is a useful benchmark against which local hospitals can assess the quality of their service. By completing this quality improvement initiative we identified areas to target resources in our centre, including mood screening, swallow screening, thrombectomy rates, length of stay and time to neuroimaging. An ongoing quality improvement process using ‘PDSA’ methodology is being carried out with an annual audit to monitor progress.

235 THROMBOLYSIS DOSING AND WEIGHT ESTIMATION IN ACUTE STROKE: A SINGLE CENTRE AUDIT

Background

Stroke is a leading cause of death and disability. Thrombolysis with intravenous (IV) alteplase is the mainstay management of ischaemic stroke. It has a narrow therapeutic window with a high potential for adverse outcomes such as intracranial haemorrhage. The efficacy of alteplase is time and dose dependent with weight-based dosing. National clinical guidelines recommend a dose of 0.9 mg/kg, up to a maximum of 90 mg. (Irish Heart Foundation Council for Stroke 2015). In most hospitals in Ireland however, patients are not weighed prior to thrombolysis. Time pressure and lack of available suitable equipment are factors.

Methods

This retrospective clinical audit evaluated the dosing of alteplase, estimated and actual weight for a convenience sample of stroke thrombolysis patients treated between 2016–2020 at an Irish University Teaching Hospital.

Results

107 patients were audited (62 males, 45 females). Actual and estimated weights were available in 92/107. Weight was not documented (n = 15) due to severe stroke/palliative management (n = 6) or omission (n = 9). 21% (19/92) received the correct dose of 0.9 mg/kg. A further 54% (50/92) received a dose within the range of 0.81–0.99 mg/kg (±10%). 25% received a dose outside this range (> ± 10%). 11% (10/92) were under-thrombolysed and 14% (13/92) over-thrombolysed. 17/92 patients had an intracranial haemorrhage. 35% (n = 6/17) of patients who had an intracranial haemorrhage received a higher dose of thrombolysis (>10%).

Conclusion

A quarter of patients received inappropriate dosing of alteplase that was outside the range of ±10% of 0.9 mg/kg. While stroke thrombolysis must be completed urgently, an accurate weight should be determined to avoid errors in dosing. A process evaluation of stroke thrombolysis would provide information on how best to incorporate an objective means of weight measurement without delaying treatment.

The nipple-areolar complex: comprehensive imaging review

The nipple-areolar complex can be affected by a variety of benign and malignant entities that can present with non-specific symptoms. Benign pathologies commonly affecting the nipple-areolar complex include nipple calcifications, nipple adenoma, abscess of Montgomery tubercles, ductal ectasia, periductal mastitis, and papilloma. Malignant pathologies that affect the nipple-areolar complex include Paget's disease of the breast, ductal carcinoma in-situ, and invasive ductal carcinoma. Clinical history and examination, imaging, and tissue sampling when appropriate are co-dependent factors that guide the assessment of nipple-areolar pathologies. This article provides a review of the normal anatomy, common anatomical variants, benign and malignant pathologies, and imaging techniques to guide the diagnostic assessment of the nipple-areolar complex.

Mass and the Dangers of Syncope

Introduction Syncope is defined as a transient, self-limited loss of consciousness with an inability to maintain postural tone that is followed by spontaneous recovery. We revisit situational syncope focusing on one situation, Mass. Methods We interrogated our electronic syncope database for key terms associated with situational syncope. From the most commonly encountered situation, Mass, we interrogated the results of tilt testing performed to identify evidence of orthostatic hypotension. Results There were 110 cases of situational syncope identified with 56.3% (n=62) taking place at mass. All had tilt table testing performed and 15.4% (n=17) had evidence of orthostatic hypotension. Conclusion The multiple sudden changes in position during mass from sitting to kneeling to standing can precipitate an episode of orthostatic hypotension. Consideration should be given as to whether it is safe for older mass goers to be subjected to such significant orthostatic stress.

A Rare Case of Mainly Unilateral Focal Dermal Hypoplasia (Goltz Syndrome) in an Adult Male: A Case Report and Review of the Literature

Focal dermal hypoplasia (Goltz syndrome), is an exceedingly rare X-linked dominant genetic disorder. It is a multisystem disease, but it is hallmarked by characteristic skin changes. Focal dermal hypoplasia typically occurs in females (90%), and males are thought to only survive through having either a sporadic new mutation or somatic mosaicism. This report details a 48-year-old male diagnosed with predominately unilateral focal dermal hypoplasia that was reviewed decades post his initial diagnosis. He presented with multiple atrophic hyperpigmented macules and fat herniation along the lines of Blaschko, across primarily the right side of the body. Skin biopsy is the mainstay for the diagnosis and therefore dermatologists need to be aware of the classical cutaneous findings of familial dermal hypoplasia to ensure accurate diagnosis. Familial dermal hypoplasia is best managed through the collective minds of multidisciplinary teams.

Bilateral middle cerebral artery occlusions: Case report detailing successful treatment with timely mechanical thrombectomy

Bilateral middle cerebral artery occlusion is a very rare and dangerous pathology, accounting for less than 1% of stroke presentations. Unless treated, the natural course of the disease leads to coma or death and thus is extremely important to be detected early and managed appropriately. We present the case of a 69-year-old lady who woke with right-sided weakness and was found to have a left middle cerebral artery stroke on arrival to her local hospital, which progressed to bilateral paresis and dysarthria whilst on transfer to a tertiary hospital for definitive management. The patient underwent emergent mechanical thrombectomy of bilateral middle cerebral artery occlusions and made a complete recovery. This case emphasis the importance of the early recognition of rare bilateral middle cerebral artery occlusions and demonstrates that timely and effective treatment can have favorable outcomes for patients.

Large gastric trichobezoar causing failure to thrive and iron deficiency anaemia in an adolescent girl: a case report emphasising the imaging findings and review of the literature

Failure to thrive, iron deficiency anaemia and abdominal pain are common paediatric presentations to general practitioners, outpatient clinics and are often referred to emergency departments. When young female patients suffering from psychiatric disorders, such as trichotillomania and trichophagia present to medical practitioners, the rare diagnosis of a trichobezoar, which is an accumulation of indigestible human hair in the gastrointestinal tract (90 % occurring in the stomach) needs to be suspected. Imaging is the mainstay of trichobezoar diagnosis and requires accurate interpretation to prevent complications. A case of a 14-year-old girl is presented, who was referred from paediatric outpatient clinics for an elective admission to the emergency department. She presented with abdominal pain, iron deficiency anaemia, failure to thrive and an epigastric/left upper quadrant mass felt on examination. A large trichobezoar was found on CT images, confirmed on endoscopy and removed with an open laparotomy. However, on the work-up imaging modalities, the radiologists missed the subtle findings of a trichobezoar. Although uncommon, trichobezoars should be considered as a differential diagnosis in female paediatric patients with a psychiatric history, who present with abdominal pain and epigastric mass. Imaging is the mainstay for trichobezoar diagnosis. As such, radiologists need to be familiar with the apparent, and subtler, pathological findings of this diagnosis and possible differential diagnoses across all imaging modalities. After successful treatment, psychiatric consultation and treatment is imperative in order to prevent reoccurrence.

Long-term mobility monitoring of older adults using accelerometers in a clinical environment

Objective: To assess the accuracy of accelerometer-based mobility monitoring during extended measurements on older adults in a clinical setting and to evaluate two different approaches to thresholding.

Design: The monitoring device consisted of two Analog Devices ADXL202 accelerometers, an ambulatory data-logger and associated cabling. The monitoring system used custom-designed analysis software to detect activities of daily living, namely duration of sitting, standing, lying and moving during the period monitored. An investigator shadowed the subjects throughout the recording period.

Subjects and setting: This study monitored five older adults, with varying degrees of mobility, resident in a rehabilitation clinic, over four days.

Interventions: The accelerometer data were analysed using a MATLABÒ program that allowed trunk and thigh threshold angles to be set to distinguish between sitting, standing, lying and moving. Two different approaches to setting these thresholds were investigated: (1) using a midpoint tolerance value of 458 and (2) using a `best estimate' tolerance value. The analysis program generates a summary of activities, which is then compared line-by-line with the manual summary created by the observer. The result was a hit/miss ratio representative of the system's accuracy.

Results: The detection accuracies for sitting and lying using a mid-point tolerance value were poor, with an average detection accuracy of 75% obtained. The `best estimate' approach improved the detection accuracies for sitting and lying by approximately 18% to an average value of 93%.

Conclusion: In a population of older adults, the static activities of sitting, standing and lying and dynamic activities can be distinguished using the technique and threshold values outlined here to a degree of accuracy of 92% and higher.

Dedicated Orthogeriatric Service Saves the HSE a Million Euro

Hip fracture is common in older adults and is associated with high morbidity, mortality and significant health care costs. A pilot orthogeriatrics service was established in an acute hospital. We aimed to establish the cost effectiveness of this service. Length of hospital stay, discharge destination and rehabilitation requirements were analysed for a one year period and compared to patients who received usual care prior to the service. We calculated the costs incurred and savings produced by the orthogeriatric service. Median length of stay was reduced by 3 days (p < 0.001) saving €266,976. There was a 19% reduction in rehabilitation requirements saving €192,600. Median rehabilitation length of stay was reduced by 6.5 days saving €171,093. Reductions in long term care requirements led to savings of €10,934 per week. Costs to establish such a service amount to €171,564. The introduction of this service led to improved patient outcomes in a cost effective manner.

Acute stroke unit improves stroke management-four years on from INASC

The Irish Heart Foundation carried out the Irish National Audit of Stroke Care (INASC) in 2008. Management practices were significantly poorer than those in the UK Sentinel audits. Since then an acute stroke unit has been established in University Hospital Limerick. A stroke database was established. 12 key indicators of stroke management audited by INASC were identified. Results were compared to those in INASC. 89 stroke patients were admitted. 8 of the 12 key indicators scored significantly better than in INASC. 92.5% had a brain scan within 24hrs (INASC-40%, p = < 0.001). 100% of ischaemic strokes received anti-thrombotics (INASC-85%, p = 0.001). 94% had rehab goals agreed by MDT (22% in INASC p = 0.0000). 55% were treated in stroke unit (2% in INASC, p = 0.0000). MDT input improved with regard to physiotherapy (87% vs 43% in INASC, p = < 0.02) and SALT (74% vs 26%, p = < 0.02). Stroke management has significantly improved from 2008, however some deficiencies remain.

Abstract P4-19-02: Early experience of patient donation and researcher use of tissues donated to a national breast cancer tissue bank

The need for a specialist breast cancer biobank was recognised through a Gap Analysis conducted by the UK charity, Breast Cancer Campaign (Thompson AM et al., Breast Cancer Res 2008: 10(2); R26). As a result The Breast Cancer Campaign Tissue Bank (www.breastcancertissuebank.org) was launched in 2010 as a coalition of 4 centres of excellence for breast cancer research in the UK. Breast cancer patients presenting to these centres are offered the opportunity to donate surplus tissue and bloods to The Breast Cancer Campaign Tissue Bank. Researchers can apply for these samples by completing a simple on line application form. Here we describe our early experience of patient donation to The Breast Cancer Campaign Tissue Bank and outline the sample requests received from researchers to date. Most of the first year of operation (2010) was spent developing SOPs and ensuring collection protocols were robust, with some limited prospective collection. The collection was pump-primed from existing resources. By 2011 all sites were operational and working to the same standards. Over a 2 year period (Jan 2011 - Dec 2012), over 90% of suitable patients (1803) consented to tissue donation. From these we derived 3951 frozen tissue aliquots, 1517 formalin-fixed paraffin-embedded cases and 2012 blood derivatives (serum, plasma and whole blood). Asian patients were less likely to consent while younger patients tended not to donate blood, but were happy to donate tissue. All male patients consented to tissue and blood donation. At Dec 2012, the total numbers of sample aliquots derived from these donated tissue and blood samples was 22, 127. This includes frozen and formalin-fixed paraffin-embedded tissues, serum, plasma and whole blood. At present, application for tissue samples is restricted to the UK and Ireland but we aim to open to international applications in the near future. All applications are reviewed by an international Tissue Access Committee which includes appropriate clinical and scientific expertise plus representation by patient advocates. At 1st June 2013, seventeen applications had been received, of which 14 were approved. Three applications were rejected, made on the basis that the applicants were not making the best use of the donated material. Thus far, tissues have been dispatched to 9 researchers with 5 in preparation. These include 465 formalin-fixed paraffin-embedded cases and 158 frozen samples, all provided with a basic minimum dataset. Early experience of patient consent was encouraging with patients overall very enthusiastic and willing to donate to our biobanking programme. More research is needed to help understand the barriers in preventing ethnic minorities to donate and the reluctance in some young people to donate blood samples. Interest by the breast cancer research community in accessing samples is steadily rising as the resource becomes more widely known and increased website traffic is translating into applications for tissues. This has been an ambitious multidisciplinary endeavour but we are building a valuable resource to service the needs of the breast cancer research community with the goal of helping translate laboratory results into clinical benefit.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-19-02.

Dynamics of a High Speed Melter/Mixer

A first attempt at studying the internal dynamics of the Gelimat high shear polymer melter/mixer has been made, using slow motion photography of the inside of the fluxing chamber of the device during operation. Based upon these observations, a satisfactory mathematical model has been developed for the melting process which incorporates an energy balance and energy dissipation resulting from drag flow through a fluid bed. This model is a first step towards a more complete and rigorous theoretical treatment of the device, and allows for the prediciton of the time to melt a powdered polymer based on angular velocity of the mixing paddles, mixer geometry, polymer charge size, desired discharge temperature and the thermal properties of the polymer.

20-year-old injury: an unusual cause of stroke

A 62-year-old man presented with a 2-day history of headache, nausea and dizziness on a background of recently diagnosed stage 2c prostate carcinoma and controlled hypertension. Imaging confirmed bilateral cerebellar strokes; on further investigations, he was found to have undiagnosed subclavian steal syndrome following severe injury to his left arm more than 20 years earlier.

The changing face of orthostatic and neurocardiogenic syncope with age

AIM

Reports of the outcomes of syncope assessment across a broad spectrum of ages in a single population are scarce. It is our objective to chart the varying prevalence of orthostatic and neurocardiogenic syncope (NCS) as a patient ages.

METHODS

This was a retrospective study. All consecutive patients referred to a tertiary referral syncope unit over a decade were included. Patients were referred with recurrent falls or orthostatic intolerance. Tilt tests and carotid sinus massage (CSM) were performed in accordance with best practice guidelines.

RESULTS

A total of 3002 patients were included (1451 short tilt, 127 active stand, 1042 CSM and 382 prolonged tilt). Ages ranged from 11 to 91 years with a median (IQR) of 75 (62-81) years. There were 1914 females; 1088 males. Orthostatic hypotension (OH) was the most commonly observed abnormality (test positivity of 60.3%). Those with OH had a median (IQR) age of 78 (71-83) years. Symptomatic patients were significantly younger than asymptomatic (P = 0.03). NCS demonstrated a bimodal age distribution. Of 194 patients with carotid sinus hypersensitivity, the median age (IQR) was 77 (68-82) years. Those with vasovagal syncope (n = 80) had a median (IQR) age of 30 (19-44) years. There were 57 patients with isolated postural orthostatic tachycardia syndrome. Of the total patients, 75% were female. They had a median (IQR) age of 23 (17-29) years.

CONCLUSION

We have confirmed, in a single population, a changing pattern in the aetiology of syncope as a person ages. The burden of disease is greatest in the elderly.

CPR in the nursing home: fool's errand or looming dilemma?

BACKGROUND

The indications for CPR (cardiopulmonary resuscitation) have expanded greatly since the technique was introduced and theoretically it can be attempted on all prior to death. Policy initiatives (such as the British Medical Association/Royal College of Nursing guidelines) have attempted to provide a clinical rationale for the withholding of inappropriate CPR. Traditionally a care home was felt to be an inappropriate environment to attempt CPR but increased use of advance directives may bring the issue to the fore in this setting.

AIMS

We elicited the views of managers of care homes regarding resuscitation strategies in hypothetical situations and in actual practice.

METHOD

A purpose designed questionnaire in two parts was compiled, gathering factual information and employing a Likert scale to gauge opinion about this issue. The survey was conducted among 187 continuing care homes in South London the subjects being the care managers of the homes surveyed.

RESULTS AND CONCLUSION

Responses were obtained from 86 care homes. Care managers would resuscitate 66% of cases of witnessed cardiac arrest but few efforts were reported. Policies in assigning 'Do not resuscitate' orders were referred to by only 9% of homes but 80% of facilities would welcome them, yet 50% would exclude the patient from this discussion. Clear policy guidelines are required for continuing care homes, and advance statements about CPR as part of residents care plans could reduce inappropriate resuscitative efforts and hospital transfers.

Sitting and standing blood pressure measurements are not accurate for the diagnosis of orthostatic hypotension

INTRODUCTION

Orthostatic hypotension (OH) is associated with troublesome symptoms and increased mortality. It is treatable and deserving of accurate diagnosis. This can be time consuming. The current reference standard for its diagnosis is head-up tilt (HUT) testing with continuous beat-to-beat plethysmography. Our objective was to assess the accuracy of sit-stand testing with semi-automatic sphygmomanometry for the diagnosis of OH.

DESIGN

Retrospective test of diagnostic accuracy.

METHODS

This was a retrospective study performed using a database maintained by a busy syncope unit. HUT testing was performed using an automated tilt table with Finometer monitoring. A 3 min 70 degrees HUT was performed following 5 min supine. Sitting blood pressure (BP) was measured following 3 min rest. Standing BP was measured within 30 s of assuming the upright posture. The results of sit-stand testing were compared with HUT testing as a reference standard. Both tests happened within 5 min of each other and patients underwent no intervention between tests.

RESULTS

From a total of 1452 consecutive HUTs, we identified 730 with pre-test measures of sitting and standing BP. The mean age of this group was 70.57 years (SD = 15.1), 62% were female. The sensitivity of sit-stand testing was calculated as 15.5%, specificity as 89.9%, positive predictive value as 61.7%, negative predictive value as 50.2% and the likelihood ratio as 1.6. The area under the Receiver Operator Curve was 0.564.

CONCLUSION

We have demonstrated that sit-stand testing for OH has very low diagnostic accuracy. We recommend that the more time-consuming reference standard method of diagnosis be used if the condition is suspected.

A footswitch evaluation of the gait of elderly fallers with and without a diagnosis of orthostatic hypotension and healthy elderly controls

Gait abnormalities are a recognised risk factor for falling in the elderly and variability in gait has been shown to be a measurable predictor of falls. We carried out a footswitch evaluation of the temporal parameters of gait of elderly fallers with a primary diagnosis of Orthostatic Hypotension, elderly fallers without a diagnosis of Orthostatic Hypotension and a control group of healthy elderly non-fallers. We hypothesized that elderly persons with Orthostatic Hypotension are falling purely as a consequence of their vascular abnormalities and are not falling for the same reasons as regular elderly fallers, including biomechanical irregularities. Therefore it was assumed that their gait pattern would not be similar to that of regular elderly fallers but instead would resemble that of healthy elderly non-fallers. Results show that elderly fallers with or without a diagnosis of Orthostatic Hypotension tend to spend more time in the stance phase of gait, possibly due to a fear of falling. Elderly fallers with a diagnosis of Orthostatic Hypotension have similar levels of gait variability as healthy elderly Controls. These are significantly less than elderly fallers without Orthostatic Hypotension. Therefore elderly fallers with a diagnosis of Orthostatic Hypotension may not be falling for the same reasons as regular elderly fallers.

Quality of stroke care at an Irish Regional General Hospital and Stroke Rehabilitation Unit

BACKGROUND

Robust international data support the effectiveness of stroke unit (SU) care. Despite this, most stroke care in Ireland are provided outside of this setting. Limited data currently exist on the quality of care provided.

AIM

The aim of this study is to examine the quality of care for patients with stroke in two care settings-Regional General Hospital (RGH) and Stroke Rehabilitation Unit (SRU).

METHODS

A retrospective analysis of the stroke records of consecutive patients admitted to the SRU between May-November 2002 and April-November 2004 was performed applying the UK National Sentinel Audit of Stroke (NSAS) tool.

RESULTS

The results of the study reveal that while SRU processes of care was 74% compliant with standards; compliance with stroke service organisational standards was only 15 and 43% in the RGH and SRU, respectively.

CONCLUSION

The quality of stroke care in our area is deficient. Comprehensive reorganisation of stroke services is imperative.

Accelerometer versus footswitch evaluation of gait unsteadiness and temporal characteristics of gait in two elderly patient groups

We examined anterior-posterior and medio-lateral head and trunk movements during gait using accelerometers, and a footswitch evaluation of temporal gait parameters of elderly fallers with a primary diagnosis of Orthostatic Hypotension, elderly fallers without Orthostatic Hypotension, and a control group of healthy elderly non-fallers. We wanted to evaluate whether both sets of measures can be used to differentiate between patient groups. We were able to significantly differentiate between the three elderly groups to the same extent using both sets of measures.

Stroke unit care: recurrence, mortality and institutionalisation rates-a four year follow-up study

BACKGROUND

he benefits of stroke unit care in terms of reducing mortality, morbidity and the need for institutional care in the short term are clear. Less evidence exists of its longer term benefits.

AIM

The aim of this study was to measure the rates of mortality, institutionalisation and stroke recurrence over a4-year period following stroke unit care.

METHODS

Discharge and 4-year follow-up data were examined on all patients admitted to the Stroke Rehabilitation Unit between September 2000 and August 2002. There results were compared with previously published data.

RESULTS

After 4 years 8% of patients had sustained are current stroke, 40% were deceased and 40% were in institutional care.

CONCLUSIONS

Compared to international data care at our unit appears to be associated with a lower rate of recurrent stroke and mortality but a higher institutionalisation rate after 4 years. The reasons for this are unclear.

Orthostatic hypotension: a new classification system

AIMS

Orthostatic hypotension (OH) is a common condition, which is defined as a reduction in systolic blood pressure of >or=20 mmHg or diastolic blood pressure of >or=10 mmHg within 3 min of orthostatic stress. Utilizing total peripheral resistance (TPR) and cardiac output (CO) measurements during tilt-table testing (Modelflow method), we classified OH into three categories, namely arteriolar, venular, and mixed. The principle defect in arteriolar OH is impaired vasoconstriction after orthostatic stress, reflected by absence of the compensatory increase in TPR. In venular OH, the predominant defect is excessive reduction in venous return, reflected by a large drop in CO after orthostatic stress with marked tachycardia. Mixed OH is due to a combination of both these mechanisms.

METHODS AND RESULTS

We analysed haemodynamic parameters of 110 patients with OH and categorized them as arteriolar, venular, or mixed. Significant differences between the groups were found for the magnitude and time to reach nadir of the systolic blood pressure drop post-head-up tilt. The mixed OH category had the largest systolic blood pressure reduction (42.5, 31.9, 53.3 mmHg, P < 0.001) and the longest nadir time (18.6, 20, 30.7 s, P = 0.002).

CONCLUSION

This is a practical classification tool and when validated physiologically, this system could be useful in directing treatment of OH.

Preliminary work on the development of a novel detection method for osteoporosis

Osteoporosis affects both the organic and mineral phases of bone resulting in a decrease in resistance to fracture. Dual x-ray absorptiometry (DEXA) scans are used for diagnosing osteoporosis, which is conventionally characterised by a decrease in mineral density. Unfortunately, some patients who suffer osteoporotic fractures have normal bone density, because both the organic and the mineral phase are affected. However, there are currently no methods of evaluating the health of the organic phase. Patients undergoing treatment for osteoporosis have reported hardening of their fingernails. As the properties of nail and bone may be linked in a comparable, measurable way, this work used both mechanical (nano-indentation) and chemical (Raman spectroscopy) methods to evaluate differences between fingernails sourced from osteoporotic and non-osteoporotic patients. The difference in mean modulus between the nails sourced from the groups was 1.1 GPa. The disulphide bond content of fingernail samples from each group was measured by Raman spectroscopy and disulphide bond content of fingernail was found to be significantly lower in the osteoporotic group. It can be concluded that a relationship between the mechanical and chemical properties of nail and bone may exist in a measurable way. This work has suggested that changes in the organic phase of bone are reflected in similar proteins, such as keratin, from which fingernails are composed. Collagen and keratin are two distinct structural proteins, but they share the need for protein sulphation and disulphide bond formation, via cysteine, for their structural integrity. A disorder of either process should lead to disordered collagen and keratin synthesis.

Selective AT1 Receptor Antagonism Enhances Sympathetically Mediated Vasoconstriction in Man

The vasoconstrictive action of angiotensin II (AII) is partly, sympathetically mediated and angiotensin-converting enzyme (ACE) inhibitors appear to exert a sympatholytic effect. We examine the effect of an orally administered, selective AT(1) receptor antagonist (losartan 50 mg) on sympathetically mediated vasoconstriction in healthy volunteers in an observer blind crossover study. Seven healthy, normotensive volunteers (21-32 years), were studied on two occasions at the end of each 6-week treatment period (losartan or placebo). Forearm blood flow (FABF) (ml/dl forearm/min) was measured by venous occlusion plethysmography during the application of lower body negative pressure (LBNP) (-20 cm H(2)O) and at the end of each incremental infusion of norepinephrine (60, 120, and 240 pmol/min). Comparison of blood flow changes was by repeated measures analysis of variance; P<0.05 was taken as statistically significant. Losartan did not alter blood pressure compared to placebo. It did significantly enhance LBNP-induced vasoconstriction in both the left arm compared to placebo (-36.6+/-3.4 vs -23.5+/-3.3%; P=0.017) and the right arm compared to placebo (-39.5+/-3.8 vs -21.0+/-3.6%; P=0.005). The FABF response to all doses of infused norepinephrine (60, 120, and 240 pmol/min) was also enhanced by losartan compared to placebo (-35.0+/-2.7 vs -18.2+/-6.0%; -43.6+/-4.3 vs -28.6+/-5.8%, and -53.9+/-3.2 vs -42.5+/-6.8%; P=0.057, respectively. Losartan enhances locally mediated sympathetic vasoconstriction in the forearm circulation of man, probably through its effect on circulating AII concentrations and we postulate that the adrenergic sympathetic constrictor action of AII is not mediated by the AT(1) receptor or is surmountable at this receptor.