Margaret O’Connor

Dedicated orthogeriatric service reduces hip fracture mortality

BackgroundHip fracture is a common serious injury afflicting the geriatric population and is associated with poor clinical outcomes, functional and walking disabilities and high 1-year mortality rates. A multidisciplinary approach has been shown to improve outcomes of geriatric patients with fragility fracture.AimsWe piloted a dedicated orthogeriatric service for hip fracture patients to determine if the service facilitated a change in major patient outcomes, such as mortality, length of stay and dependency.MethodsA dedicated orthogeriatrics service for hip fracture was established as a collaborative project between the Department of Geriatric Medicine and Department of Orthopaedic Surgery at a university teaching hospital. Orthogeriatrics service data were collected prospectively on an orthogeriatric filemaker database from July 2011 to July 2012 (Nxa0=xa0206). Data were compared to previously recorded data (Irish Hip Fracture Database) on a cohort of hip fracture patients admitted to the same orthopaedic trauma unit from July 2009 to July 2010 (Nxa0=xa0248).ResultsPatients in the orthogeriatric service group experienced significant reductions in 1-year mortality (χ2xa0=xa013.34, Pxa0<xa00.001), length of acute hospital stay (Uxa0=xa0−3.77, Pxa0<xa00.001) and requirements for further rehabilitation (χ2xa0=xa026.59, Pxa0<xa00.001). Patients in the pre-service establishment group were significantly more dependent following their fracture than the patients in the orthogeriatric service group (χ2xa0=xa05.34, Pxa0=xa00.021).ConclusionsA multidisciplinary management approach to fragility fracture of the femoral neck that involves comprehensive geriatric assessment, daily medical involvement of a geriatric team and specialised follow-up assessment leads to a significant reduction in mortality and improved outcomes.

Older patient hospital admissions following primary care referral: the truth is in the referring

BackgroundHealth information has a major role in the planning of future healthcare provision. With current reconfiguration and cost saving measures, further demands are being placed on acute hospitals.AimTo examine the elderly admissions and the referral documentation of older patients admitted to a tertiary level hospital.MethodsA retrospective analysis of primary care referral documentation for all acute admissions of patients over 75xa0years to University Hospital Limerick (UHL) over a 2-month period. Documentation was analysed on the basis of patient demographics, presenting complaint and referral source. Primary care referral documentation was then analysed on the basis of presenting complaint, patient demographics, referrer details, and the clinical information provided.ResultsOver the 2-month period there were a total of 381 elderly admissions through the Emergency department. The most common presenting complaint was with shortness of breath (21.5xa0%). 42.5xa0% of admissions were from a primary care setting. 31.1xa0% of referrals were typed and 47.0xa0% handwritten. Over 90xa0% of referrals contained the patient’s name, date of birth and address. 98.7xa0% of referrals included a presenting complaint and 54xa0% included a past medical history. 20xa0% of referrals listed known drug allergies, while 9.3xa0% documented social history or baseline functional status. Referral letters from general practice and after-hour services were largely similar.ConclusionsAlmost all primary care referrals included the required details as per recent HIQA guidelines. The further inclusion of optional information relating to patient social or functional status, which are of particular relevance to the older population may help patient management.

Giant Cell Arteritis Presenting with Bilateral Subdural Haematomas of Arterial Origin

Giant cell arteritis or temporal arteritis is an inflammatory condition affecting medium to large sized vessels, particularly the cranial arteries. A 76-year-old man with no significant past medical history presented to the emergency department with a 3-week history of diffuse headaches associated with fever, loss of appetite, weight loss and general malaise. A CT scan of the brain showed bilateral shallow chronic low density subdural haematomas. A complete laboratory panel was unremarkable except for a raised erythrocyte sedimentation rate and elevated C-reactive protein. A transthoracic echocardiogram and CT scan of the body were unremarkable. MRI of the brain confirmed bilateral old subdural collections and showed marked vessel wall enhancement in the frontal branches of the left superficial temporal artery. A left temporal artery biopsy confirmed giant cell temporal arteritis. We speculate that a vasculitic process in the small subdural arteries may have contributed to our patient’s spontaneous subdural haematomas. LEARNING POINTS A contrast-enhanced T1 axial fat-suppressed MRI of the brain is a non-invasive modality of diagnostic value in giant cell arteritis (GCA); increased access to high resolution MRI technology may reduce the requirement for invasive temporal artery biopsy in the future. Subdural hematomas may be of arterial origin; GCA has been reported in association with subdural hematomas but causation is not proven. GCA must be suspected in patients presenting with headaches and raised inflammatory markers even in the absence of classic features or dual pathology as failure to recognize and treat promptly could lead to permanent visual loss.