COS-Speech: protocol to develop a core outcome set for dysarthria after stroke for use in clinical practice and research.

BACKGROUND: Dysarthria after stroke is when speech intelligibility is impaired, and this occurs in half of all stroke survivors. Dysarthria often leads to social isolation, poor psychological well-being and can prevent return to work and social lives. Currently, a variety of outcome measures are used in clinical research and practice when monitoring recovery for people who have dysarthria. When research studies use different measures, it is impossible to compare results from trials and delays our understanding of effective clinical treatments. The aim of this study is to develop a core outcome set (COS) to agree what aspects of speech recovery should be measured for dysarthria after stroke (COS-Speech) in research and clinical practice. METHODS: The COS-Speech study will include five steps: (1) development of a long list of possible outcome domains of speech that should be measured to guide the survey; (2) recruitment to the COS-Speech study of three key stakeholder groups in the UK and Australia: stroke survivors, communication researchers and speech and language therapists/pathologists; (3) two rounds of the Delphi survey process; (4) a consensus meeting to agree the speech outcomes to be measured and a follow-up consensus meeting to match existing instruments/measures (from parallel systematic review) to the agreed COS-Speech; (5) dissemination of COS-Speech. DISCUSSION: There is currently no COS for dysarthria after stroke for research trials or clinical practice. The findings from this research study will be a minimum COS, for use in all dysarthria research studies and clinical practice looking at post-stroke recovery of speech. These findings will be widely disseminated using professional and patient networks, research and clinical forums as well as using a variety of academic papers, videos, accessible writing such as blogs and links on social media. TRIAL REGISTRATION: COS-Speech is registered with the Core Outcome Measures in Effectiveness Trials (COMET) database, October 2021 https://www.comet-initiative.org/Studies/Details/1959 . In addition, "A systematic review of the psychometric properties and clinical utility of instruments measuring dysarthria after stroke" will inform the consensus meeting to match measures to COS-Speech. The protocol for the systematic reviews registered with the International Prospective Register of Systematic Reviews. PROSPERO registration number: CRD42022302998 .

Osteoporotic fracture admissions compared to other major medical admissions in Irish public hospitals.

Multinational reports suggest Ireland has one of the greatest illness burdens related to osteoporosis. Hospital care represents the costliest portion of health services. We found public hospital bed days for fragility fractures in Ireland increased by 43% between 2008 and 2017 which exceeded those for other common diseases. INTRODUCTION: Recent multinational reports suggest Ireland has one of the greatest illness burdens related to osteoporosis, manifesting clinically as fragility fractures (FF). International reports show that FF incidence, rate of hospital admission and cost are similar or greater than those for breast cancer, myocardial infarction and stroke. Studies addressing the illness burden of osteoporosis in Ireland are few, and none compares fragility fractures to other common chronic diseases. METHODS: A retrospective analysis of national administrative data for all public hospital admissions was performed on adults aged 50 years and older from January 2008 to December 2017. RESULTS: In 2017, public hospital bed days for FF totalled 249,887 outnumbering Chronic Obstructive Pulmonary Disease (COPD): 131,897; 6 solid cancers (CA): 118,098; myocardial infarction (MI): 83,477; and diabetes mellitus (DM): 31,044. Bed days for FF increased by 43% between 2008 and 2017, in contrast to a 32%, 28% and 31% reduction for CA, MI and DM, respectively, and a 12% increase for COPD. Public hospital bed days for FF in 2016 were greater than MI, stroke, atrial fibrillation and chest pain combined but less than a combination of COPD, pneumonia and lower respiratory tract infection. CONCLUSION: Osteoporotic fractures represent a large and rapidly increasing illness burden amongst older Irish adults, with substantial care requirements and the resulting onus on our healthcare system. Urgent action is needed to address this public health issue and the services for those at risk of fracture.

The psychological impact of Stevens-Johnson syndrome and toxic epidermal necrolysis on patients' lives: a Critically Appraised Topic.

CLINICAL SCENARIO: A 65-year-old man presented with a 12-h history of deteriorating rash. Two weeks previously he had completed a course of neoadjuvant chemotherapy for ductal carcinoma of the breast. On examination there were bullae, widespread atypical targetoid lesions and 15% epidermal detachment. There was no mucosal involvement on presentation, but subsequently it did evolve. Skin biopsy showed subepidermal blistering with epidermal necrosis. This confirmed our clinical diagnosis of overlap Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN). On transfer to intensive care he was anxious and fearful. MANAGEMENT QUESTION: What are the psychological impacts of SJS/TEN on this man's life? BACKGROUND: SJS and TEN have devastating outcomes for those affected. OBJECTIVES: To conduct a Critically Appraised Topic to (i) analyse existing research related to the psychological impact of SJS and TEN and (ii) apply the results to the clinical scenario. METHODS: Seven electronic databases were searched for publications focusing on the psychological impact of SJS/TEN on adults over 18 years of age. RESULTS: Six studies met the inclusion criteria. Healthcare practitioners' (HCPs') lack of information around the disorder was highlighted. Patients experienced undue stress and fear. Some patients had symptoms aligned to post-traumatic stress disorder (PTSD), anxiety and depression. DISCUSSION AND RECOMMENDATION: The evidence suggests that SJS and TEN impact psychologically on patients' lives. Education of HCPs, to address their lack of awareness and information on SJS/TEN, should facilitate their capacity to provide information and support to patients, thereby reducing patient anxiety. On discharge, a follow-up appointment with relevant HCPs to reduce the possibility of PTSD occurring should be considered.

MRI-guidance for motion management in external beam radiotherapy: current status and future challenges.

High precision conformal radiotherapy requires sophisticated imaging techniques to aid in target localisation for planning and treatment, particularly when organ motion due to respiration is involved. X-ray based imaging is a well-established standard for radiotherapy treatments. Over the last few years, the ability of magnetic resonance imaging (MRI) to provide radiation-free images with high-resolution and superb soft tissue contrast has highlighted the potential of this imaging modality for radiotherapy treatment planning and motion management. In addition, these advantageous properties motivated several recent developments towards combined MRI radiation therapy treatment units, enabling in-room MRI-guidance and treatment adaptation. The aim of this review is to provide an overview of the state-of-the-art in MRI-based image guidance for organ motion management in external beam radiotherapy. Methodological aspects of MRI for organ motion management are reviewed and their application in treatment planning, in-room guidance and adaptive radiotherapy described. Finally, a roadmap for an optimal use of MRI-guidance is highlighted and future challenges are discussed.

MRI-Linear Accelerator Radiotherapy Systems.

The desire to utilise soft-tissue image guidance at the time of radiation treatment has led to the development of several hybrid magnetic resonance imaging (MRI) linear accelerators (linacs). These systems have the potential to realise the benefits of MRI on the treatment table with the ability of real-time motion management and adaption on a patient-specific basis. There are several MRI-linacs currently being implemented covering both low and high magnetic field strength and two beam-field orientations. Clinical trials have only recently begun with this technology, but their future use as standard radiotherapy practice seems assured. This review article summarises the challenges faced in developing such hybrid technology, the differences and advantages of each of the currently exploited solutions, and their current status.

Emerging trends in hospitalisation for fragility fractures in Ireland.

BACKGROUND: We analysed hospital admissions and bed occupancy for fragility fractures in Ireland over a 15-year period to assess fracture admission trends and to project admissions over the next three decades. METHODS: We used the Hospital In-Patient Enquiry (HIPE) scheme to extract data on fracture admissions to Irish hospitals between 2000 and 2014 inclusive. We calculated absolute numbers and age-standardised rates of hospitalisations for men and women ≥ 50 years for each osteoporotic-type fracture. We projected fracture numbers and bed days using these trends, and associated costs to 2046 based on 2014 rates. RESULTS: The absolute number of all fragility fracture admissions increased by 30% between 2000 and 2014, for both men (40%) and women (27%). In-patient bed days for osteoporotic fractures have increased by 51% in the same period. Hip fractures dominated admissions, accounting for 36.5% of all admissions and almost half (46.7%) of all bed days. Age-standardised rates of hip fracture admission decreased significantly (p < 0.001) in women, but not in men, while rates of non-hip osteoporotic fracture admissions have not changed significantly for men or women. Hospitalisations for all osteoporotic fractures are projected to increase by 150% to 31,605 in 2046, 58% of whom will be 80 years or older. CONCLUSIONS: There has been a significant increase in the number of fracture admissions in Irish men and women over the past 15 years. This is projected to increase further over the next three decades which will place a significant burden on the Irish healthcare system.

Development and application of FRAX in the management of osteoporosis in Ireland.

SUMMARY: The Irish Fracture Risk Assessment (FRAX) tool is the first fracture prediction model that has been calibrated using national hip fracture incidence data and Irish mortality rates. The Irish FRAX tool can be used to identify intervention thresholds for Ireland based on the fracture probability equivalent to that of a woman with a prior fracture. OBJECTIVES: The objective of the study is to describe the 10-year probability of osteoporotic fracture in men and women in Ireland by using the Irish version of the FRAX tool and to develop FRAX-based intervention thresholds. METHODS: The FRAX model for Ireland was constructed from the age- and sex-stratified hip fracture incidence rates from 2008 to 2010. For other major osteoporotic fractures, incidence rates were imputed, using age- and sex-specific Swedish ratios for hip to osteoporotic fracture risks. Lifetime fracture probabilities and 10-year probabilities of a major osteoporotic fracture were calculated in women to determine potential intervention thresholds. RESULTS: Based on the incidence of hip fracture and mortality, the average lifetime probability of hip fracture from the age of 50 years was 7.8% in men and 18.2% in women from Ireland. Probability-based intervention threshold derived from BMD T-scores were problematic. When a BMD T-score≤-2.5 standard deviations (SD) was used as an intervention threshold, the increase in risk associated with the BMD threshold decreased progressively with age such that, at the age of 80 years or more, a T-score of -2.5 SD was protective. The 10-year probability of a major osteoporotic fracture by age, equivalent to that of women with a previous fracture, rose with age, from 3.0% at the age of 40 years to 30% at the age of 90 years, and identified women at increased risk at all ages. CONCLUSION: The Irish FRAX tool is the first fracture prediction model that has been calibrated using national hip fracture incidence data and Irish mortality rates.

Comparison of prescribing and adherence patterns of anti-osteoporotic medications post-admission for fragility type fracture in an urban teaching hospital and a rural teaching hospital in Ireland between 2005 and 2008.

INTRODUCTION: Poor adherence reduces the potential benefits of osteoporosis therapy, lowering gains in bone mineral density resulting in increased risk of fractures. AIM: To compare prescribing and adherence patterns of anti-osteoporotic medications in patients admitted to an urban teaching hospital in Ireland with a fragility type fracture to patients admitted to a rural hospital in the North Western region. METHODOLOGY: We identified all patients >55 years admitted to Sligo General Hospital between 2005 and 2008 with a fragility fracture (N = 744) using the hospital in-patient enquiry system (HIPE). The medical card number of those patients eligible for the primary care reimbursement services scheme (PCRS) facilitated the linkage of the HSE-PCRS scheme database to the HIPE database which enabled a study to identify persistence rates of patients prescribed osteoporosis therapy after discharge. The results were compared to the findings of a similar study carried out in St. James's Hospital, Dublin. RESULTS: The 12 months post-fracture prescribing increased from 11.0 % (95 % CI 9.6, 12.4) in 2005 to 47 % (95 % CI 43.6, 50.3) in 2008 in the urban setting and from 25 % (95 % CI 21.5, 28.9) to 39 % (95 % CI 34.5, 42.7) in the rural setting. Adherence levels to osteoporosis medications at 12 months post-initiation of therapy was <50 % in both study groups. Patients on less frequent dosing regimes were better adherers. CONCLUSION: The proportion of patients being discharged on anti-osteoporosis medications post-fragility fracture increased between 2005 and 2008 in both patient groups. Sub-optimal adherence levels to osteoporosis medications continue to be a major concern.

Hospitalisations for fracture and associated costs between 2000 and 2009 in Ireland: a trend analysis.

UNLABELLED: In Ireland, the absolute numbers of hospitalisations for all osteoporotic-type fractures including hip fractures increased between 2000 and 2009 along with the mean length of stay. The cost of hospitalisations for these fractures also increased between 2003 and 2008. INTRODUCTION: The purposes of the study were to carry out a trend analyses of the total number of osteoporotic-type fractures in males and females aged 50 years and over in Ireland between 2000 and 2009 and to project the number of osteoporotic-type fractures in the Republic of Ireland expected by 2025. METHODS: Age- and gender-specific trends in the absolute numbers and direct age-standardised rates of hospitalisations for all osteoporotic-type fractures in men and women ≥ 50 years were analysed, along with the associated hospitalisation costs and length of stay using the Hospital In-Patient Enquiry system database. Future projections of absolute numbers of osteoporotic-type fractures in years 2015, 2020 and 2025 were computed based on the 2009 incidence rates applied to the projected populations. RESULTS: Between 2000 and 2009, the absolute numbers of all osteoporotic-type fractures increased by 12 % in females and by 15 % in males while the absolute numbers of hip fractures increased by 7 % in women and by 20 % in men. The age-specific rates for hip fractures decreased in all age groups with the exception of the 55-59-year age group which showed an increase of 4.1 % (p = 0.023) within the study period. The associated hospitalisation costs and length of stay increased. Assuming stable age-standardised incidence rates from 2009 over the next 20 years, the number of all types of osteoporotic-type fractures is projected to increase by 79 % and the number of hip fractures is expected to increase by 88 % by 2025. CONCLUSIONS: Hospitalisations for osteoporotic-type fractures continued to increase in Ireland. Hip fractures increased by 7 % in women and 20 % in men.

SU-E-J-179: Requirements for the Accuracy of Electron Density Data Planning for MRI Based Cervix Cancer Treatment Planning.

PURPOSE: A sensitivity analysis of the effect of variations in electron density data (ED) on dose calculation accuracy for MRI based cervical cancer treatment planning. METHODS: Five cervical cancer patients were analysed in this work. Planning CT scans represented gold standard ED data. Standard four field 3DCRT plans (prescription 45Gy) were designed on these CT scans. The CT data was then manipulated to simulate the following methods of assigning ED to MRI; (1) homogenous bulk density corrections, (2) Bulk density correction to bones, (3) rigid image registration of CT to MR, and (4) regression analysis based pseudo CT. Plans were then generated on the manipulated data sets, and compared to the plans generated on the original. Dose was analysed using Chi analysis and equivalent uniform dose (EUD). Data was analysed to quantify (A) the effect on plan design (called optimisation error), and (B) the effect on dose calculation accuracy (systematic error). RESULTS: Analysis of the averaged patient results showed that for 3DCRT, the use of imperfect electron density data had minimal impact on plan design for all tested data sets. Analysis of systematic error showed minimal errors for cases (1), (2) and (3), where average errors of less than 0.3 Gy in EUD were recorded and Chi analysis showed that over 95% of points within the high dose region (D>36Gy) were within 2% or 2mm of the original dose. For case (4), errors greater than .5 Gy in EUD were recorded; these were not considered acceptable errors. CONCLUSIONS: Using imperfect electron density data for 3DCRT treatment planning for cervical cancer patients is feasible for appropriately considered choices of electron density assignment. Further analysis is needed to test this result for IMRT, and is ongoing.

Improved language performance subsequent to low-frequency rTMS in patients with chronic non-fluent aphasia post-stroke.

BACKGROUND: Low-frequency repetitive transcranial magnetic stimulation (rTMS) has emerged as a potential tool for neurorehabilitation and remediation of language in chronic non-fluent aphasia post-stroke. Inhibitory (1 Hz) rTMS has been applied to homologous language sites to facilitate behavioural language changes. Improvements in picture-naming performance and speech output over time have been reported. METHODS: Low-frequency (1 Hz) rTMS was applied to six real stimulation and six sham placebo patients for 20 min per day, for 10 days, and behavioural language outcome measures were taken at baseline (pre-stimulation) and 2 months post-stimulation. RESULTS: The findings demonstrate treatment-related changes observed in the stimulation group when compared to the placebo control group at 2 months post-stimulation on naming performance as well as other aspects of expressive language and auditory comprehension. CONCLUSIONS: These findings provide considerable evidence to support the theory of rTMS modulating mechanisms of transcallosal disinhibition in the aphasic brain and highlight the potential clinical applications for language rehabilitation post-stroke.

Sport and recreation-related injuries and fracture occurrence among emergency department attendees: implications for exercise prescription and injury prevention.

OBJECTIVE: To investigate the epidemiology of sports and recreation-related injury (SRI) among emergency department (ED) attendees. DESIGN: Descriptive epidemiology study. SETTING: An Irish university hospital ED. PARTICIPANTS: All patients aged over 4 years attending a large regional ED, during a 6-month period, for the treatment of SRI were prospectively surveyed. ASSESSMENT OF RISK FACTORS: In all cases identified as SRI the attending physician completed a specifically designed questionnaire. It was postulated that recreation-related injury is a significant proportion of reported SRI. RESULTS: Fracture rate was highest in the 4-9-year age group (44%). On multivariate logistic regression the adjusted odds ratio (OR; 95% CI) of fracture was higher for children (vs adults) at 1.21 (1.0 to 1.45). The adjusted OR was higher for upper-limb 5.8 (4.5 to 7.6) and lower-limb injuries 1.87 (1.4 to 2.5) versus axial site of injury and for falls 2.2 (1.6 to 2.9) and external force 1.59 (1.2 to 2.1) versus an overextension mechanism of injury. In the same model, "play" was independently associated with fracture risk, adjusted OR 1.98 (1.2 to 3.0; p = 0.001) versus low-risk ball sports 1.0 (reference); an effect size similar to that seen for combat sports 1.96 (1.2 to 3.3; p = 0.01) and greater than that seen for presumed high-risk field sports 1.4 (0.9 to 2.0) CONCLUSION: Fall and subsequent upper-limb injury was the commonest mechanism underlying SRI fracture. Domestic "play" in all age groups at the time of injury accorded a higher fracture risk than field sports. Patient education regarding the dangers of unsupervised play and recreation represents a means of reducing the burden of SRI.

Serum sodium as a risk factor for in-hospital mortality in acute unselected general medical patients.

BACKGROUND: Serum sodium has been shown to predict mortality in heart and liver failure. AIM: To determine whether serum sodium independently predicts in-hospital mortality during any emergency medical admission. DESIGN: An analysis was performed of all emergency medical patients admitted to St James's Hospital (SJH), Dublin between 1 January 2002 and 31 December 2006, using the hospital inpatient enquiry (HIPE) system, linked to the patient administration system and laboratory datasets. Hospital mortality was obtained from a database of 20 deaths occurring during the same period under physicians participating in the 'on call' roster. METHODS: The serum sodium was determined at admission in all cases where it was deemed clinically necessary. Logistic regression was used to calculate crude and 25 adjusted odds ratios (ORs). Factors adjusted for included age, illness severity score (Modified Apache II score), major disease category, ICU stay, year effect, blood transfusion, gender and sepsis. RESULTS: A total of 14 239 patients (47.5% male) were included in the analysis. Mortality had a U-shaped distribution and was highest in patients whose sodium level was <125 or >140 mmol/l. The unadjusted OR of death within 30 days of admission was 3.36 (95% CI 2.59-4.36) and 4.07 (95% CI 2.95-5.63) with sodium level <125 and >140 mmol/l, respectively. Adjustment for all of the factors above reduced the mortality odds in all hyponatraemia groups but all remained significant predictors of mortality. After adjustment for illness severity score the OR ratio for death in the >140 mmol/l group fell to 1.41 (95% CI 0.97-2.07). DISCUSSION: The serum sodium is a powerful initial marker of likely mortality in unselected general medical patients. The increased death rate in hyponatraemic patients is independent of other clinical variables, whereas mortality in the hypernatraemic group is primarily a factor of illness severity.

A survey of the management of gout in primary care.

There is no information available regarding current practice and standards in management of gout in Irish general practice. This study aims to assess current practice in the context of the 2006 EULAR evidence based recommendations for diagnosis and management of gout. A 20 point questionnaire was circulated to all 170 general practitioners in the North Dublin GP Partnership assessing frequency of diagnostic and therapeutic interventions undertaken. 91% of practitioners manage gout exclusively in primary care. 89% make a diagnosis on clinical grounds and 77% routinely measure serum urate. Diagnostic joint aspiration is rarely performed (3%). 86% routinely assess and manage risk factors for gout. 66% initiate urate-lowering therapy. Only 32% routinely monitor urate levels in patients receiving urate-lowering therapy. Thus, although management of gout in primary care in Ireland is generally in line with the EULAR recommendations some aspects of care remain suboptimal.

DREEM and beyond; studies of the educational environment as a means for its enhancement.

CONTEXT: Educational environment makes an important contribution to student learning. The DREEM (Dundee Ready Educational Environment Measure) questionnaire is a validated instrument for assessing educational environment, but used alone it has little value for identifying means of remediation of poor aspects of environment. AIMS: This study used qualitative analysis, in association with the DREEM questionnaire, to evaluate the educational environment across all five years of a large undergraduate medical school, and identify areas for change to enhance student experience. METHOD: The DREEM questionnaire was administered to 968 undergraduate students, together with an open question asking for suggested changes to current medical school practices. Items of concern highlighted by this study were further defined through qualitative analysis, using focus groups, email questionnaires and introduction of Stressful Incident reporting. RESULTS: Through responses to the open question, two items with low scores on the DREEM questionnaire were identified as requiring remediation. Focus groups and email questionnaires were used to define the underlying causes of poor scores, which varied by student year group. Stress resulting from experiences on clinical placement was highlighted by some students, but on closer investigation found to be rare. Remedial steps to improve student support are described. CONCLUSIONS: The qualitative data have substantially enhanced questionnaire interpretation, and allowed actions to address common causes for student dissatisfaction to be undertaken. This combined methodology is recommended to other institutions wishing to improve the educational environment, and thus the overall quality of educational provision.

Defining a role for the subthalamic nucleus within operative theoretical models of subcortical participation in language.

OBJECTIVE: To investigate the effects of bilateral, surgically induced functional inhibition of the subthalamic nucleus (STN) on general language, high level linguistic abilities, and semantic processing skills in a group of patients with Parkinson's disease. METHODS: Comprehensive linguistic profiles were obtained up to one month before and three months after bilateral implantation of electrodes in the STN during active deep brain stimulation (DBS) in five subjects with Parkinson's disease (mean age, 63.2 years). Equivalent linguistic profiles were generated over a three month period for a non-surgical control cohort of 16 subjects with Parkinson's disease (NSPD) (mean age, 64.4 years). Education and disease duration were similar in the two groups. Initial assessment and three month follow up performance profiles were compared within subjects by paired t tests. Reliability change indices (RCI), representing clinically significant alterations in performance over time, were calculated for each of the assessment scores achieved by the five STN-DBS cases and the 16 NSPD controls, relative to performance variability within a group of 16 non-neurologically impaired adults (mean age, 61.9 years). Proportions of reliable change were then compared between the STN-DBS and NSPD groups. RESULTS: Paired comparisons within the STN-DBS group showed prolonged postoperative semantic processing reaction times for a range of word types coded for meanings and meaning relatedness. Case by case analyses of reliable change across language assessments and groups revealed differences in proportions of change over time within the STN-DBS and NSPD groups in the domains of high level linguistics and semantic processing. Specifically, when compared with the NSPD group, the STN-DBS group showed a proportionally significant (p<0.05) reliable improvement in postoperative scores achieved on the word test-revised (TWT-R), as well as a reliable decline (p<0.01) in the accuracy of lexical decisions about words with many meanings and a high degree of relatedness between meanings. CONCLUSIONS: Bilateral STN-DBS affects certain aspects of linguistic functioning, supporting a potential role for the STN in the mediation of language processes.