Protocol for the Tallaght University Hospital Institute for Memory and Cognition-Biobank for Research in Ageing and Neurodegeneration.

INTRODUCTION: Alzheimer's disease and other dementias affect >50 million individuals globally and are characterised by broad clinical and biological heterogeneity. Cohort and biobank studies have played a critical role in advancing the understanding of disease pathophysiology and in identifying novel diagnostic and treatment approaches. However, further discovery and validation cohorts are required to clarify the real-world utility of new biomarkers, facilitate research into the development of novel therapies and advance our understanding of the clinical heterogeneity and pathobiology of neurodegenerative diseases. METHODS AND ANALYSIS: The Tallaght University Hospital Institute for Memory and Cognition Biobank for Research in Ageing and Neurodegeneration (TIMC-BRAiN) will recruit 1000 individuals over 5 years. Participants, who are undergoing diagnostic workup in the TIMC Memory Assessment and Support Service (TIMC-MASS), will opt to donate clinical data and biological samples to a biobank. All participants will complete a detailed clinical, neuropsychological and dementia severity assessment (including Addenbrooke's Cognitive Assessment, Repeatable Battery for Assessment of Neuropsychological Status, Clinical Dementia Rating Scale). Participants undergoing venepuncture/lumbar puncture as part of the clinical workup will be offered the opportunity to donate additional blood (serum/plasma/whole blood) and cerebrospinal fluid samples for longitudinal storage in the TIMC-BRAiN biobank. Participants are followed at 18-month intervals for repeat clinical and cognitive assessments. Anonymised clinical data and biological samples will be stored securely in a central repository and used to facilitate future studies concerned with advancing the diagnosis and treatment of neurodegenerative diseases. ETHICS AND DISSEMINATION: Ethical approval has been granted by the St. James's Hospital/Tallaght University Hospital Joint Research Ethics Committee (Project ID: 2159), which operates in compliance with the European Communities (Clinical Trials on Medicinal Products for Human Use) Regulations 2004 and ICH Good Clinical Practice Guidelines. Findings using TIMC-BRAiN will be published in a timely and open-access fashion.

What factors are associated with advance care planning in community-dwelling older people? Data from TILDA.

PURPOSE: To assess advance care planning (ACP) in a large population-representative sample of older people. METHODS: At Wave 4 of the Irish Longitudinal Study on Ageing, participants were asked: Have you made your wishes/preferences known about the kind of care that you would like to receive in the event of serious illness? RESULTS: One quarter (1153/4831) had discussed ACP. Of those, 90% had discussed with family/friends, 10% documented ACP in writing, while 2% had discussed with a healthcare professional. Age ≥ 80 years [OR 1.63 (1.31-2.02)], female sex [OR 1.58 (1.37-1.83)], higher educational attainment [OR 1.42 (1.18-1.71)], poorer self-rated health [OR 1.67 (1.06-2.62)] and lower levels of religiosity [OR 1.50 (1.02-2.19)] were independently associated with ACP. CONCLUSION: Only one in four older people had discussed ACP informally, while less than 3% have ACP documented in writing. Further work is required to educate the public and healthcare professionals regarding treatment choices at end-of-life.

Trends in emergency department use by older people during the COVID-19 pandemic.

PURPOSE: Reports suggest that many older people deferred seeking healthcare during the COVID-19 pandemic due to fear of contracting COVID-19. The aim of this study was to examine trends of emergency department (ED) use by older people during the first wave of the COVID-19 pandemic compared to previous years. METHODS: The study site is a 1000-bed university teaching hospital with annual ED new-patient attendance of > 50,000. All ED presentations of patients aged ≥ 70 years from March to August 2020, 2019 and 2018 inclusive (n = 13,989) were reviewed and compared for presenting complaint, Manchester Triage Score, and admission/discharge decision. RESULTS: There was a 16% reduction in presentations across the 6 months in 2020 compared to the average of 2018/2019. On average, 4 fewer people aged ≥ 70 years presented to the ED per day in 2020. Much of this was concentrated in March (33% fewer presentations) and April (31% fewer presentations), when the country was in 'lockdown', i.e. non-essential journeys were banned. There was a 20% reduction in patients presenting with stroke and cardiac complaints. In the 3 months following easing of restrictions, there was a 25% increase in falls and orthopaedic injuries when compared to 2018/2019. CONCLUSION: This study demonstrates a significant decline in the number of older people presenting to the ED for unscheduled care, including for potentially time-dependent illnesses such as stroke or cardiac complaints. Given the possibility of further lockdowns, it is imperative that we consider enabling strategies to ensure older people access unscheduled care in a timely manner when necessary.

Lower gastrointestinal symptoms and symptoms-based triaging systems are poor predictors of clinical significant disease on colonoscopy.

Introduction: Lower gastrointestinal symptoms (LGS) are a common cause of referral to the gastroenterology service. International guidelines are available to prioritise referrals. Some studies have reported that symptoms alone are a poor marker of clinically significant disease (CSD) but symptoms remain the main way to prioritise referrals in routine clinical practice. Aims/background: To correlate LGS with colonoscopy findings in an unselected patient cohort and to investigate whether using National Institute for Health and Care Excellence (NICE) guidelines improve risk stratification. Method: Colonoscopy data over a 2-year period were obtained from our endoscopy database. Only patients with assessment of symptoms as their primary indication for colonoscopy were included. Patient records were retrospectively reviewed. Exclusion criteria: known inflammatory bowel disease (IBD), familial cancer syndromes, polyp and colorectal cancer (CRC) surveillance, and prior colonoscopy within 5 years. Demographics, symptoms and colonoscopy findings were recorded and analysed. Results: 1116 cases were reviewed; 493 (44%) males, age 54.3 years (16-91). CSD occurred in only 162 (14.5%); CRC 19 (1.7%), high-risk adenoma 40 (3.6%), inflammation 97 (8.7%) (IBD 65 (5.8%), microscopic colitis 9 (0.8%) and indeterminate-inflammation 23 (2%)), angiodysplasia 6 (0.5%). Diarrhoea gave the highest diagnostic yield for CSD of 5.3% (OR 3.15, 95% CI 2.2 to 4.7, p<0.001), followed by PR bleeding, 2.9% (OR 1.9, 95% CI 1.24 to 2.9, p=0.003). Weight loss gave the lowest diagnostic yield of 0.4%; (OR 0.79, 95% CI 0.28 to 2.24, p=0.65). 592 (53%) and 517 (46%) fitted the NICE guidelines for CRC and IBD, respectively. Using NICE positivity improved detection but overall yield remained low 3% vs 0.4% (OR 7.71, 95% CI 1.77 to 33.56, p=0.0064) for CRC, and 9% vs 2.8% (OR 3.5, 95% CI 1.99 to 6.17, p<0.0001) for IBD. Conclusions: The overall prevalence of CSD in our unselected symptomatic patients is low (14.5%). A holistic approach including combining symptoms and demographics with novel tools including stool biomarkers and minimally invasive colonoscopy alternatives should be applied to avoid unnecessary colonoscopy.

The Patient-Held Active Record of Medication Status (PHARMS) study: a mixed-methods feasibility analysis.

BACKGROUND: Medication errors frequently occur as patients transition between hospital and the community, and may result in patient harm. Novel methods are required to address this issue. AIM: To assess the feasibility of introducing an electronic patient-held active record of medication status device (PHARMS) at the primary-secondary care interface at the time of hospital discharge. DESIGN AND SETTING: A mixed-methods study (non-randomised controlled intervention, and a process evaluation of qualitative interviews and non-participant observation) among patients >60 years in an urban hospital and general practices in Cork, Ireland. METHOD: The number and clinical significance of errors were compared between discharge prescriptions of the intervention (issued with a PHARMS device) and control (usual care, handwritten discharge prescription) groups. Semi-structured interviews were conducted with patients, junior doctors, GPs, and IT professionals, in addition to direct observation of the implementation process. RESULTS: In all, 102 patients were included in the final analysis (intervention n = 41, control n = 61). Total error number was lower in the intervention group (median 1, interquartile range [IQR] 0-3) than in the control group (median 8, IQR (4-13.5, P<0.001), with the clinical significance score in the intervention group also being lower than the control group (median 2, IQR 0-4 versus median 11, IQR 5-20, P<0.001). The PHARMS device was found to be technically implementable using existing information technology infrastructure, and acceptable to all key stakeholders. CONCLUSION: The results suggest that using PHARMS devices within existing systems in general practice and hospitals is feasible and acceptable to both patients and doctors, and may reduce medication error.

The PHARMS (Patient Held Active Record of Medication Status) feasibility study: a research proposal.

OBJECTIVE: Medication errors are a major source of preventable morbidity, mortality and cost and many occur at the times of hospital admission and discharge. Novel interventions (such as new methods of recording medication information and conducting medication reconciliation) are required to facilitate accurate transfer of medication information. With existing evidence supporting the use of information technology and the patient representing the one constant in the care process, an electronic patient held medication record may provide a solution. This study will assess the feasibility of introducing a patient held electronic medication record in primary and secondary care using the Consolidated Framework for Implementation Research (CFIR).This feasibility study is a mixed method study of community dwelling older adult patients admitted to an urban secondary care facility comprising a non-randomised intervention and qualitative interviews with key stakeholders. Outcomes of interest include clinical outcomes and process evaluation.This study will yield insights pertaining to feasibility, acceptability and participation for a more definitive evaluation of the intervention. The study also has the potential to contribute to knowledge of implementation of technology in a healthcare context and to the broader area of implementation science.

An in vivo comparison of internal bacterial colonization in two dental implant systems: identification of a pathogenic reservoir.

OBJECTIVES: The aim of this study was to compare internal bacterial colonization in two implant systems, one screw root form (SRF) with an external hexagon connection and one plateau root form (PRF) with a Morse taper internal connection. MATERIALS AND METHODS: Thirty-two implants; 12 SRF and 20 PRF, were sampled in 15 patients. All implants had been in function for at least 6 months prior to sampling. The implant restoration was removed and 10 µl of sterile saline was introduced into the implant well via a sterile glass syringe. The saline was drawn back up and transferred to the laboratory for microbiological analysis. The number of aerobic and anaerobic colony forming units per millilitre was determined and the dominant micro-organism in each sample was identified by 16s rRNA gene amplicon sequencing. RESULTS: There was a significant difference between bleeding on probing around the SRF implants (3%) and the PRF implants (28%) (p = 0.0496). Bacterial colonization was identified at 11 SRF and 19 PRF implants. The numbers of anaerobic bacteria recovered from PRF implants was significantly higher than that from SRF implants (p = 0.0002). Streptococcus species and Enterococcus faecalis were found to dominate. CONCLUSIONS: This in vivo study demonstrated bacterial colonization in both types of implant systems, irrespective of the type of connection. Significantly greater anaerobic counts were found in the Morse taper internal connection implants.