Purpose To examine the association between body mass index (BMI) and the severity of orthostatic hypotension (OH) during head-up tilt (HUT) testing using continuous phasic haemodynamic measurements in a large cohort of patients with unexplained falls, blackouts, and (pre)syncope. Methods We conducted a retrospective observational cohort study of consecutive HUT tests performed between 1998 and 2024 at a single tertiary centre. Adults referred for HUT testing were included, and analyses were restricted to patients with a measurable systolic blood pressure change during tilt. Participants were categorised by World Health Organization BMI groups. Outcomes included change in systolic blood pressure (ΔSBP), diagnosis of OH (≥ 20 mmHg systolic fall), and heart-rate response during tilt. Results Among 6,610 participants (mean BMI 25.8 ± 4.7 kg/m²), 3% were underweight, 46% normal weight, 34% overweight, and 17% obese. Median ΔSBP was − 18 mmHg (IQR − 30 to − 9) and differed significantly across BMI categories (p = 0.008). Underweight participants had the greatest median systolic BP fall (–23.5 mmHg) compared with overweight participants (–17 mmHg, p = 0.01). OH was most frequent in the underweight group (58%) and similar across other BMI categories (46–50%, p = 0.004). Heart-rate responses did not differ meaningfully between BMI groups. Conclusion Low BMI was associated with greater orthostatic systolic blood pressure drops, while higher BMI did not confer measurable protection. These findings suggest that the obesity paradox does not extend to autonomic haemodynamic responses and that low BMI may serve as a marker of vulnerability to orthostatic hypotension.

The safe administration of solid oral dose forms in hospital inpatients with swallowing difficulties is challenging. The aim of this study was to establish the prevalence of difficulties in swallowing solid oral dose forms in acute hospital inpatients. A point prevalence study was completed at three time points. The following data were collected: the prevalence of swallowing difficulties, methods used to modify solid oral dose forms to facilitate administration, the appropriateness of the modification, and patient co-morbidities. The prevalence of acute hospital inpatients with swallowing difficulties was an average of 15.4% with a 95% CI [13.4, 17.6] across the three studies. On average, 9.6% of patients with swallowing difficulties had no enteral feeding tube in situ, with 6.0% of these patients receiving at least one modified medicine. The most common method of solid oral dose form modification was crushing, with an administration error rate of approximately 14.4%. The most common co-morbid condition in these patients was hypertension, with dysphagia appearing on the problem list of two (5.5%) acute hospital inpatients with swallowing difficulties. Inappropriate modifications to solid oral dose forms to facilitate administration can result in patient harm. A proactive approach, such as the use of a screening tool to identify acute hospital inpatients with swallowing difficulties, is required, to mitigate the risk of inappropriate modifications to medicines to overcome swallowing difficulties.

The aim of this systematic review was to identify and critically appraise the available evidence regarding solid oral dosage forms (SODFs), e.g., tablets, and challenges regarding the oral administration of medicine to inpatients in a variety of healthcare settings such as (1) hospitals, (2) nursing homes and (3) long-term stay units (LTSUs). A literature search was undertaken in September 2021 and repeated in June 2023 in the following databases: PubMed, EMBASE, CINAHL, Scopus, Web of Science, The Cochrane Library, PsycINFO and ProQuest. A Microsoft Excel® spreadsheet was devised to collate the following data from each eligible study: study author and year, country, number of participants, title, duration (follow-up period), study design, inclusion and exclusion criteria, method and data collection, relevant outcomes, and key findings. A total of 3023 records were identified, with 12 articles being included in the final systematic review. Seven of the twelve studies reported on the prevalence of difficulties swallowing SODFs, which varied from 10–34.2%. Nine of the twelve studies reported the methods used to manipulate SODFs, with the most reported method being tablet crushing. Given the prevalence of swallowing difficulties and the subsequent crushing of medicines in response to this, it is evident that concerns should be raised regarding the potential for a medication administration error to occur.

Background We aimed to assess stroke care at an Irish university teaching hospital and benchmark against national (Irish National Audit of Stroke 2019) and international (6th SSNAP Annual Report; American Heart Association, 2013) practice to inform a quality improvement strategy. Methods All patients with a HIPE discharge diagnosis of Cerebral Infarction or Cerebral Haemorrhage (1 January to 31 December 2019) were identified through both the HIPE database and the institutional Stroke Portal. Results A total of 419 patients were included (56.6% male, mean age 72). The following were comparable/better than findings from the Irish National Audit of Stroke: median duration of symptoms-3 h 6 min; 10% received thrombolysis; median door to needle time-60 min; 78.5% admitted to the stroke unit; 81.1% had a swallow assessment; in-patient mortality rate-10.5%; rates of institutionalisation-3.8%. The following areas were below the national average: overall door to imaging time-median 104 min; rate of thrombectomy-4%; 11.5% had mood screening; median length of stay- 12 days. Discussion Using national and international audit data as an institutional benchmark provides a standard with which a service can be compared to highlight areas for improvement. We identified mood screening, swallow screening, thrombectomy rates, length of stay and time to neuroimaging as key areas for development in our centre. We are currently completing a process map to determine cause, effect, and solutions, and we will implement change using PDSA methodology as per SQUIRE 2.0 guidelines. The results of the re-audit cycle for 2020 will be available in 2021 to inform our progress. Ongoing quality improvement is essential for stroke care, which is a leading cause of death and disability in Ireland.

Objectives: The correlation between atherosclerosis and osteoporosis, independent of age, is clear. Multifactorial co-dependence between bone mineral density (BMD) and statin dose has been proposed. It is hypothesised that inhibition of the synthesis of cholesterol will also inhibit the synthesis of sex hormones and Vitamin D, negatively affecting BMD. This study aims to evaluate hydrophilic and non-hydrophilic statins effect on osteoporosis and analyse any possible superiority of one agent over the other within the group. Methods: We identified 538 caucasian females who had a DEXA scan performed between 2002 and 2016 (age 60-89) in one DEXA center in Mid-West Ireland. A DEXA T-score results were analysed in the current study. Two hundred fifty females were not on statin therapy, and 323 females were on statin therapy. Females on therapy were separated into the atorvastatin group (N = 190), msuvastatin group (N = 97), and pravastatin group (N = 36), comprising low dose and high dose groups. All anonymised data were analysed with SPSS statistical. To test the hypothesis that lower bone density is associated with high dose statins, an independent sample t-test was performed. The one-way between-groups ANOVA test was used to test the hypothesis that the BMD level depended on the statin's potency. Results: Statin-naive females have a statistically higher bone mineral density in the lumbar spine, t (538) = 3.42, p < 0.05 and in hip t (538) = 4.99, p < 0.05 than females on statin therapy. There was a significant difference in patient's age between the group, and no significant correlation was found between the patient's age and type of statin or bone density. In the atorvastatin group statistically, significant results were obtained both for spine and hip bone mineral density, t (188) = -5.61, p < 0.05 and t (188) = -3.62, p < 0.05, respectively. In the rosuvastatin group, statistically, a significant result was noted for bone mineral density of hip t (95) = -3.52, p < 0.05. This demonstrates a dose-dependency between bone mineral density and the dose of the statin. The independent between-group ANOVA yielded a statistically significant effect, F (2, 59) = 6.69, p < 0.05, eta 2 = 0.21 in the spine. Thus, patients on lipophilic statins had statistically lower BMD than females on hydrophilic statins. Multilinear regression analysis identified that age is not a statistically significant contributor in our analysis; however, the trend of decrease in bone mineral density with women's age is acknowledged by authors. Conclusions: The study results support the theory that bone mineral density decreases with an increase in a statin dose, and hydrophilic statins, like pravastatin, have a better metabolic profile in the lumbar spine than lipophilic agents.

Background: Delirium is a common condition with poorly understood pathophysiology. Various theories have been proposed including that delirious patients have reduced cerebral blood flow. We hypothesised that patients with delirium could have abnormal autonomic nervous system function, as assessed by tilt table testing, which would explain the alteration in blood flow. Methods: A prospective cohort study of medical inpatients aged 65 years and older was undertaken. Delirium was assessed using DRS-R98 and DSM-IV criteria. Beat-to-beat blood pressure (BP) was recorded during tilt testing. Differences in BP changes between the two groups (those with delirium and those without) were explored. The association between severity of delirium and magnitude of BP changes was also examined. Results: 64 participants were recruited during hospitalisation. 29 completed follow-up Head-Up Tilt testing. The mean age of participants was 80.8 years (SD 6.2 years). The control group (n = 12) had a median decrease in systolic BP of 17.5 mmHg (IQR 20.75). The delirium group (n = 17) had a median decrease in systolic BP of 1 mmHg (IQR 38.5), p = 0.04. As delirium severity scores increased, systolic BP change during tilting also increased (rs = 0.42, p = 0.03). Conclusion: Participants in the delirium group showed different BP responses to tilt test which may represent abnormal sympathetic response. This would be consistent with other features of delirium such as treatment response to centrally acting alpha-2 blockers. Equity of access to research for older, frail and delirious cohorts is essential but feasibility and acceptability needs to be optimised and factored into study design.

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.

Abstract Background Generic Prescribing is an essential component of prescribing, however it is often overlooked. Use of brand names can led to poor recognition of the correct medications. It can also led to medication error. It is part of the policy of our hospital group that generic prescribing is used at all times. We performed a similar audit in 2018 and 79% of drug kardexes had brand names used. Prescribing education is an integral part of NCHD teaching. We wished to re-audit to determine rates of generic prescribing now. Methods We reviewed all drug kardexes in 14 wards both medical and surgical in a 48 hour period. Each drug was reviewed and if any prescription had brand names, the entire kardex was deemed non-compliant. Results 285 Drug kardexes were assessed across 14 separate wards. 41% were on surgical wards, 59% were on medical wards. 31 (11%) of kardexes had complete generic prescribing. Only 3 kardexes on the surgical ward had complete generic prescribing. Conclusion The low rates of generic prescribing remain an issue in our university teaching hospital. A similar audit was performed in 2018 with average rates of 20% of generic prescribing. This has decreased in the last year. The failure to generic prescribe puts patients at risk of medication error and also increases cost to the HSE. Education on prescribing is part of the NCHD induction, however, 9 months on there continues to be issues with compliance with generic prescribing. Education alone is not enough to improve current practice. The use of e prescribing offers the potential to alleviate this problem.

Abstract Background Medication records are essential components of patient care and a source of medical error. The HSE Code of Practice for Healthcare Records Management has highlighted criteria which must be complied with in these records. In the HSE Clinical Strategy and Programmes Division, “Test your care” is used to promote a code of practice and a set of metrics which need to be adhered to. Methods We reviewed all drug kardexes in 14 wards both medical and surgical in a 48 hour period. We assessed the drug kardexes based on 9 different metrics. (Generic names used, capital letters used, start date recorded, legible dosing, route and frequency of medication documented, minimum dosing documented, legible prescriptions and discontinued drugs crossed off) Results 285 drug kardexes were reviewed. No drug kardex was fully compliant with the 9 standards. The main deficits were in relation to use of brand names, no documentation of frequency and omission of IMC numbers. The average number of metrics met was lower on surgical wards than medical wards - 3.6 vs 4.7 respectively, and this difference was statistically significant (p< .00001; 2 sample t test). Conclusion The universal poor compliance with these standards highlights both the poor design of the current drug kardex and poor awareness with prescribers of these standards. In the current drug kardex, there is no dedicated space for frequency or IMC number and therefore these are often forgotten. The use of brand names consistently highlights poor prescribing practice and more education is required to improve this. We plan to improve current prescribing education sessions for all doctors to highlight the current deficiencies and to increase compliance with standards.

Abstract Background Patients with unexplained falls, syncope and dizziness frequently present acutely. There are multiple IT systems in operation across the acute hospital network with varying functionality relating to activity capture. MAXIMS is an electronic healthcare record used to capture attendances in our ED. Within our department a digital patient management system Electronic Patient Management System (EPMS) records clinical information from admission through to discharge. The Hospital Inpatient Enquiry System (HIPE) is the principal national source of discharge information from acute hospitals. We aimed to look at this cohort of patients and compare the clinical data available on each of these information sources used in a Model 4 teaching hospital. Methods MAXIMS database was interrogated to examine patients who presented to the ED with the search terms “falls”, “syncope” and “dizziness”. We conducted a review of all patients who met our search terms over two non-consecutive weeks in 2018. For the same period EPMS was interrogated and HIPE data were requested and analysed. Results MAXIMS, EPMS and HIPE records over the two-week period captured 190, 104 and 24 patients respectively. Mean age was 62, 75 and 72 years. Of 190 records on MAXIMS, 107 (56%) were not coded on HIPE following discharge. Of these 107 patients, 93 (87%) did not require a hospital admission and 14 (13%) patients self-discharged. Conclusion Current available digital systems provide inconsistent information relating to patients presenting acutely with falls, dizziness and syncope. How these conditions are captured electronically can vary between systems due to which parameters are recorded. HIPE stats were lower than Maxims/EPMS which may reflect the fact that HIPE only captures discharge diagnosis as opposed to presenting symptoms. In order to get a clearer picture of these conditions, and for planning purposes, an approach amalgamating the data from all systems into one electronic source would be required.

Abstract Background Illegible prescribing can lead to medication error and adverse drug reactions. The HSE Standards and Recommended Practices for Healthcare Records Management and the Practice Standards and Guidelines for Nurses for Prescriptive Authority have highlighted criteria which should be adhered to in relation to prescribing. We set out to audit compliance with these standards in relation to legibility of prescriptions in an Irish University Teaching Hospital. Methods Over a 48 hour period, drug kardexes were reviewed on 14 separate in-patient wards. Legibility was judged by a single assessor on each ward. A drug kardex was deemed legible if all of the following criteria were met: The chi squared test was used to determine the significance of the difference in proportions for categorical variables. Results 285 drug kardexes were reviewed over the 48 hour period. 41% were on surgical wards, 59% were on medical wards. The median patient age was 70 (IQR:55-78), and 56% were male. 48% of drug kardexes were deemed legible. A higher proportion were deemed legible on medical wards compared to surgical wards (68% vs 19% p<0.05). Upper case was used in 13% of kardexes, with similar proportions on medical and surgical wards. Conclusion Poor legibility of drug kardexes may increase risk of medication errors and adverse drug reactions. We plan to commence targeted prescribing education sessions to highlight the current deficiencies and improve current practice. Changes to kardex layout may also aid legibility. Long term planning for electronic prescribing would also help resolve issues in this area.

Delirium is common among unwell older adults. Despite this the pathophysiology remains poorly understood. We hypothesised that autonomic dysfunction may be associated with the development of delirium. 35 participants completed a case-control study. Delirium was assessed using DSM-IV and DRS-R98. Autonomic function was assessed with Head-Up Tilt testing (HUT), baroreflex sensitivity (BRS) testing using Baroreflex Effectiveness Index (BEI), 24-hour blood pressure variability (BPV), nocturnal blood pressure dipping status and 24-hour heart rate variability (HRV). A subgroup analysis of those without pre-existing cognitive impairment (CI) was completed. During tilting the delirium group (DG) had a median decrease of 1mmHg (IQR 38.5) in systolic blood pressure (SBP) compared to a median decrease of 17.5mmHg (IQR 20.75) in the control group (CG) (p=0.04). Increased delirium severity correlated with a reduction in the decrease in SBP (rs= -0.42, p=0.03). In those without CI, BRS testing during HUT showed that increases in blood pressure were not followed by an appropriate reduction in heart rate with a mean BEI of 36.87% (SD 22.26) in the DG and 56.03% (SD 23.04) in the CG (p=0.05). Nocturnal dipping differed during subgroup analysis. 58.3% (7) of DG were reverse dippers, 33.3% (4) were non-dippers and 8.3% (1) had a normal dipping pattern. In CG 57.1% (4) were non-dippers, 14.3% (1) had a normal dipping pattern and 28.6% (2) were extreme dippers (p=0.01). BPV was measured by average real variability (ARV). In those without CI mean ARV was 13.81 (SD 5.98) in the CG and 9.69 (SD 2.75) in the DG (p=0.05). No difference was detected in HRV. We identified differences in autonomic function between the DG and CG. This is the first study to look at several components of autonomic function in delirium and thus can provide insights into physiological abnormalities present during, or contributing to delirium.

Background: Low body mass index has long been highlighted as a risk factor for osteoporosis.The association between obesity and osteoporosis has been studied with conflicting results with some indicating a positive correlation due to increased mechanical load leading to increasing bone mass.However there has been conflicting studies indicating a negative correlation.We performed an observational study of all patients who had a DEXA performed from June 2003 to March 2018.Methods: We conducted a retrospective observational study of 18,691 patients referred for DEXA scan in the Mid-Western Region from June 2004 to March 2018 collecting data on body mass index (BMI), history and type of fractures as well as bone mineral density (BMD).Data was collected from the regional database for DEXA scans in University Hospital Limerick and St. Camillus Hospital Limerick.Results: 49% of patients referred for DEXA had osteoporosis with 89% of patients female.22% of patients who had osteoperosis were obese on formal BMI testing with 7.6% underweight.13.1% of patients had a fracture with forearm fractures being the most common at 60% followed by femur (26%), vertebral(9.6%),humerus (8.9%) and pelvis (2.4%).A similar trend was noted in patients with osteopaenia, constituting 38.6% of the sample, with 15.9% being obese compared with 8.9% who were underweight.6.6% of osteopaenic patients had a history of fracture.Conclusion: Our observational study showed a positive correlation between osteoporosis and obesity.Both obesity and osteoporosis have overlap in the genetic and environmental factors influencing these diseases.Adipocytes and osteoblasts derive from a common progenitor -the mesenchymal stem cell.The purpose of this study is to highlight this relationship and review our current understanding of this new area for research.

Background In a busy stroke centre in Ireland, care for acute stroke was provided by a mixture of general physicians. In acute ischaemic stroke, speed is essential for good outcomes.Aim To improve acute stroke services and decrease door-to-needle (DTN) time to less than 60 min by December 2016 in patients with acute ischaemic stroke who are eligible for intravenous thrombolysis.Design: A quality improvement (QI) project was undertaken in a 438 bed, acute, university hospital.Methods Mixture of qualitative and quantitative data collected. A process map and driver diagram were created. Interventions tested with Plan-Do-Study-Act cycles. Times compared between July and December 2015, January and July 2016, July and December 2016, when a new stroke team and pathway were introduced.Results Between July and December 2015, the total number of ischaemic strokes was 216. 17 were thrombolysed (7.8%). Median door-to-CT (DTCT) time was 36 min (range 21–88). Median DTN time was 99 min (range 52–239). Between July and December 2016, there were 214 ischaemic strokes. 29 were thrombolysed (13.5%). 9 were seen directly by the stroke team during normal hours. With stroke team involvement, median DTCT time was 34 min (range 14–60) and DTN time was 43.5 min (range 24–65).Conclusions This project led to a significant and sustained improvement in acute stroke care in our hospital with the use of quality improvement techniques. A comprehensive protocol, recurrent and ongoing staff education, and good communication helped to mitigate delays and further enhance care provided to patients presenting with stroke. The approach described may be valuable to the improvement of other services.’

Background: Lightning injuries are, fortunately, an uncommon phenomenon with there being little research surrounding the topic and its potential long-term sequelea.However, despite this, several autonomic disorders have been noted to be caused by these electrical traumas, including postural hypotension and they are thought to be secondary to thermal damage.Some research has even been able to show a quantitative disturbance in the autonomic nervous system, post electrical injury, by measuring the sympathetic skin response.We present a case of an 83-year-old gentleman who presented to the Emergency Department after suffering a fall with a head injury and associated dizziness.

Background: Most of the primary autonomic disorders are chronic in nature, with symptoms often initiating in an insidious fashion.However, in acute autonomic neuropathies, the onset can be dramatic with presentation as a generalized dysautonomia.We present a case where the initial presentation in retrospect was small bowel atony.A fit, healthy, active 75 year old patient presented initially to the surgical service with an acute abdomen.A plain abdominal film showed small bowel dilatation consistent with small bowel obstruction.There were no obvious pathogenic basis for this.The patient