Introduction:Iron deficiency anaemia (IDA) is often attributed to gastrointestinal (GI) blood loss and warrants thorough investigation. In elderly, endoscopy carries increased risk, especially in those with multiple comorbidities and poor functional status. This study aimed to evaluate the outcomes of elderly patients with IDA, identify underlying causes, and assess one-year mortality. Methodology:Patients ≥75 years referred to gastroenterology for investigation of IDA were recruited. Demographics, comorbidities, antiplatelet/antithrombotic use, investigations performed, and one-year mortality were recorded. Results:92 patients were recruited. Mean patient age was 81.2 years (SD: +/- 4.02) with a female preponderance (70.7%). Mean Charlson Comorbidity Index (CCI) was 5.96 (SD +/- 1.93). Frailty precluded any investigation in 13% of patients. 26% underwent upper and lower GI assessment (14% had bidirectional endoscopy and 12% had oesophagogastroduodenoscopy (OGD) + computed tomography (CT) colonography). Malignancy was diagnosed in 6.5%. Overall, one-year mortality rate was 28% (CCI mean score: 6.7). Mortality was statistically significantly higher for patients living in care homes (p=0.03). Higher CCI was associated with increased risk of one-year mortality, and each additional CCI point increased odds of dying within one year by 40% (OR = 1.40, 95% CI: 1.10-1.79, p=0.007). Conclusion:Elderly patients referred for investigation of IDA frequently have a high CCI score, making endoscopy a high-risk procedure. A high CCI score and living in a care home are independent risk factors for one-year mortality. Alternative strategies including trans-nasal endoscopy and CT colonography, should be considered as first-line tests to balance diagnostic yield, prognosis and procedural safety.
Ophthalmologist Sir Benjamin W. Rycroft was a key figure in John Hedley-Whyte's early education and experiences at the RAMC's 31st General Hospital, later Harvard's 5th General Hospital at Musgrave Park outside Belfast, 1940-1942. Rycroft later served with distinction in the Mediterranean Theatre and was honored with the O.B.E. After his return to the UK post-war, he advanced reconstructive treatment of burns, corneal grafting, and the establishment of tissue banks. He was a Fellow of the Zoological Society of London, gifted organist, enthusiastic gardener, and close associate of the Royal Family. In 1964, Rycroft returned to Belfast to give the Craig Memorial Lecture at Queen's University, Belfast, titled "Plastic Surgery and Ophthalmology".
Background:Recent trials for treatments of direct oral anticoagulant (DOAC) related acute haemorrhage have highlighted incidences of post treatment thrombosis. Prothrombin complex concentrate (PCC) is widely used for reversal of anticoagulant associated bleeding, yet thrombotic risks following PCC administration, particularly for DOACs, remain incompletely characterised in real-world settings. Methods:This retrospective observational study analysed thrombotic and survival outcomes in 682 patients that received PCC for OAC associated haemorrhage in the Belfast Health and Social Care Trust between 2015-2021. Patients were categorised by OAC type (warfarin, rivaroxaban, apixaban and edoxaban). Primary outcome was thrombotic event rate at 30 days, while secondary outcomes included 30- and 90day mortality and anticoagulation resumption rates. Results:The cohort comprised 393 warfarin patients, 55 rivaroxaban, 221 apixaban and 13 edoxaban patients. Intracranial haemorrhage predominated (47-69% across DOAC groups vs. 49% warfarin). Thrombotic event rates were significantly higher in DOAC patients (rivaroxaban 13%, apixaban 8%, overall DOAC 8.7%) compared to warfarin (5%). Thirty-day mortality rates ranged from 13-23% across oral anticoagulant groups. Anticoagulation was resumed in only 29-47% of patients. Conclusions:The findings suggest that PCC may be as effective as specific antidotes for DOAC reversal. In the absence of universal access to specific reversal agents, PCC continues to serve an important role in managing life threatening anticoagulant associated haemorrhage. Systematic pathways for post reversal anticoagulation resumption should be implemented to optimise patient outcomes.
Background:Due to free and digital availability of scientific abstracts in medical journals, as well as search engines including PubMed, many patients are increasingly looking to these as reliable and trusted sources of information, amidst an information ecosystem of potential mis- and disinformation. However, such scientific abstracts are difficult-to-read by the lay community, as they are not written purposefully for a lay audience. The Plain Language Summary now offers such readers a new medium to engage with, thereby helping with their health literacy and understanding of the research findings being described. The aims and objectives of the present study were to: calculate the readability of all scientific abstracts published in the Ulster Medical Journal over the five year period 2020 - 2024 (n=48), (ii) using artificial intelligence, prepare a plain language summary of each scientific abstract (n=48) with (a) minimal prompts and (b) with extensive prompts and (iii) calculate the readability of AI-generated plain language summaries. Methods:Readability was calculated using Readable software, defined by the (i) Flesch Reading Ease (FRE), (ii) Flesch-Kincaid Grade Level (FKGL), (iii) Gunning Fog Index and (iv) SMOG Index and four text metrics [word count, sentence count, words/sentence, syllables/word] on abstracts from all original clinical papers (n=48) published in the Ulster Medical Journal in the last five years (2020-2024). Plain language summaries were created from the existing scientific abstract using artificial intelligence with (a) minimal prompts and (b) extensive prompts. The readability of all AI-created plain language summaries was further determined. Results:Scientific abstracts had a mean FRE and FKGL score of 24.2±14.1 (standard deviation) and 14.4±2.8, respectively (Reference target values of ≥60 and ≤8, respectively). AI created plain language summaries with improved readability scores of 59.8±7.4 and 8.9±1.6, respectively for summaries with minimal prompts, thereby almost meeting reference readability targets. AI-created summaries with extensive prompts had mean readability scores of 71.3±6.1 and 6.3±0.9, respectively, with 46/48 (96%) of scientific abstracts now reaching reference readability target values. Scientific abstracts and Plain Language Summaries were statistically different (p<0.0001) in terms of both FRE and FKGL scores. Inputting the necessary and appropriate prompts to the AI-tool is critical to attaining the desired readability values. Conclusions:Medical journals may reach out to lay readers, including service users, patients, family and friends, through new innovation with the inclusion of a Plain Language Summary. Scientific abstracts are written at a level which is beyond the average reading age of 11 years old in the UK. Computational creativity through the employment of AI platforms can successfully generate narrative text for specific reading ages, with optimal readability. Effective communication of medical research findings from medical and scientific papers is vital for service users to enhance their health literacy, thereby helping promote better clinical outcomes, as well as promoting inclusivity for lay readers. With thorough checks and controls by the authors of clinical papers, AI-created plain language summaries may provide a new medium for medical journals to communicate with patients and service users, the results of clinical and original studies. The ability to create fit-for-purpose and easy-to-read Plain Language Summaries allows the lay public and service users to now become included in the family of readers of the journal and further supports the health literacy of patients and service users.
Objectives:Whereas about 20% of emergency medical admissions in richer countries are neurological, the situation in poorer countries is less clear. To help clarify this we studied admissions data in a hospital in Nyala, Sudan and compared our findings with the results from a previous, methodologically similar study from Northern Ireland (NI). Methods:Over three months the numbers of emergency medical admissions to Nyala Teaching Hospital were recorded, along with the percentage with neurological symptoms. The following information was also noted: diagnosis, mortality, the use of investigations, and referral to neurologists and neurosurgeons. The results were compared to a study from the Downe Hospital, NI carried out in 1987. Results:Fifty-six (24%) of 234 medical admissions were neurological. Stroke (57%), infections (21%) and tumours (11%) made up 89% of neurological admissions, with epilepsy accounting for only 4%, a pattern quite different from the NI study. Mortality was 23% compared with 12% in the NI study. Referral to neurospecialists was similar. Conclusion:Although emergency neurological admissions were slightly commoner, the most striking difference between Nyala and the NI study was the high proportion of stroke admissions in Nyala to the near exclusion of other neurological conditions. The first priority to improving neurological care in Nyala, (and by implication, sub-Saharan Africa), is a stroke prevention program.
Introduction:This study assesses the implementation of the introduction of an electronic healthcare record (EHCR) into the South Eastern Trust (SET) in Northern Ireland. Aims:To address the effect of the introduction of EHCR on clinical efficiency, initial implications for patient care and staff wellbeing, and to provide guidance from lessons learnt for future implementation. Method:Doctors employed and medical students on placement within the SET were asked to complete an electronic Likert survey during the system's initial three months of implementation. Results:There were 151 responses across 25 specialties. Overall, 81% did not experience an improvement in working efficiency. 50% of respondents anticipated that inpatient efficiency would improve with time, while 19% did not. In the outpatient clinic environment, only 25% believe that efficiency will be improved with time and adaptation. Regarding administration, 45% believe that following introduction, administrative tasks placed on doctors are disproportionate to their clinical value for patient care. 67% stated that there was less time for medical education and training. Conclusions:Despite an initial overall negative response towards EHCR participants have a positive attitude towards its potential to improve patient care. Concerns relating to system usability and administrative burden imposed by Epic on senior staff remain apparent throughout the study. 'A perfect system would have doctors freed up to do what we are trained to do'. Usability issues were identified as contributory to this dissatisfaction. Inadequate training was identified as a factor which made adaptation more challenging. This in particular is a consideration for those trusts yet to implement Epic.
Background:Cystic fibrosis (CF), which is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene is the most common life-limiting autosomal recessive genetic disease in Northern Ireland. Currently, Northern Ireland has approximately 520 people with CF (PwCF) (312 adults, 208 children) and a defective gene carrier rate of 1 in 22 persons, with approximately 86,507 carriers within the general population. Advances in DNA sequencing technology has allowed for better genetic characterisation of CFTR mutations. The aim of this project was to (i) examine current CFTR mutation frequency and type in paediatric and adult CF populations in Northern Ireland, (ii) examine CFTR mutational trends in relation to CF patients' age groups, (iii) compare Northern Ireland CFTR most common allele frequencies with those documented globally and (iv) establish a reference/baseline of CFTR mutation information prior to the effect of CFTR modulator therapy. Methods:Anonymised data comprising of birth year, sex, and known alleles of adult and paediatric individuals (n=520) from the Northern Ireland CF population was examined. Alleles were recorded according to legacy, protein and cDNA name and organised by mutation class and type, in accordance with CFTR2 database nomenclature. Individual known alleles frequencies from the complete Northern Ireland CF population (n=1005) were calculated and compared with the CFTR2 database, globally with CFTR data obtained from CF national registries. Results:Within the Northern Ireland CF population, there were 61 different CFTR mutational variants identified in a population of 1005 alleles. In descending occurrence, the most common was F508del with 626 alleles (62.3%), followed by R117H (8.9%), G551D (5.0%), G542X (3.3%), R560T (2.8%) and P67L (2.2%). The remaining alleles were present at a frequency of <2.0%. The six most frequently detected CFTR mutations accounted for 84.4% of all alleles. Over approximately two and a half decades (1996-2021), 23 CFTR mutations remain shared. Six alleles, which were described in the 1996 CFTR analysis, were absent from the 2021 data, whilst there were additional descriptions of 39 allelic mutations, which occurred in the 2021 analysis, but which were not described in the 1996 analysis. Conclusion:Characterisation of CFTR mutation alleles from people with cystic fibrosis provides essential information to help predict disease severity and effect of targeted CFTR modulator therapy. These 2021 data provide a valuable genetic update from the 1996 data and a reference point on the status of the Northern Ireland CFTR mutation types and frequencies. CFTR modulator therapy has the potential to indirectly alter the current status quo and distribution of CFTR mutation types amongst children of PwCF, due to improved clinical status and fecundity. Revisiting this in a decade from now will allow an estimation of the indirect influence of CFTR modulator therapy on CFTR mutation evolution.
Background:Acute kidney injury (AKI) requiring intermittent haemodialysis (AKI-IHD) is associated with significant morbidity and high mortality. There is limited data regarding clinical outcomes in individuals with AKI-IHD in Northern Ireland. The aim of this study was to explore clinical outcomes in a cohort of individuals with AKI-IHD, including rates of recovery to self-sustaining kidney function, mortality rates at 30 days and 2 years from start of haemodialysis, and to investigate potential predictors of these key outcomes. Methods:The Acute Haemodialysis Unit in the Royal Victoria Hospital, Belfast, Northern Ireland, was established in 2011 to provide onsite inpatient intermittent haemodialysis (IHD) to individuals requiring this supportive treatment. A retrospective review of 188 incident IHD patients in the Royal Victoria Hospital from January 2018-December 2022 was undertaken. Demographic and clinical outcome information on 12th May 2023 was obtained from the nephrology electronic database eMed (Mediqal) and the Northern Ireland Electronic Care Record. Results:188 individuals commenced IHD for the first time as a consequence of life-threatening complications of AKI during the 5-year period (January 2018-December 2022).75% of these patients were not previously known to the nephrology service, (GROUP A, n=142, mean age 63 years, mean baseline serum creatinine 99 μmol/L) while 25% (GROUP B, n=46, mean age 67 years, mean baseline creatinine 278 μmol/L) had been attending a Nephrology Clinic for at least 12 months.A significant proportion of AKI developed during the inpatient admission rather than at initial presentation (GROUP A 47%, GROUP B 50%).92% of GROUP A recovered self-sustaining kidney function before discharge, compared to 59% of GROUP B. A lower baseline serum creatinine was the only predictor of kidney recovery in GROUP B, p value=0.02. No predictors for kidney recovery were identified in GROUP A.The diagnosis of either AKI and/or dialysis was documented in 80% of electronic discharge letters for patients in GROUP A but only 54% of letters for patients in GROUP B.The 30-day mortality (from IHD start) in GROUPA was 14% compared to 9% in GROUP B. Individuals with a diagnosis of heart failure were four times more likely to die before discharge (p value=0.02) and those aged ≥ 70 years twice as likely to die before discharge (p value=0.049). The two-year mortality rate in the two groups was similar (GROUP A 35% vs. GROUP B 37%) despite GROUP B being significantly older. Conclusion:In this cohort of individuals with AKI-IHD, managed in the Royal Victoria Hospital, Belfast, the majority recovered self-sustaining kidney function.The mortality rates at 30 days were lower than reported in the literature and may be due to careful patient selection. The poorer outcomes associated with AKI-IHD support and a concomitant diagnosis of heart failure or age ≥ 70 years (or both) are useful in guiding clinical and patient expectations and decision making.
