Scientific Research

Introduction

Dopamine transporter scan (DaT scan) nuclear imaging can be a useful tool in the diagnostic work up of conditions such as Parkinson’s disease (PD) where the underlying physiology of the disease involves striatal dopamine transporter loss. Selective serotonin reuptake inhibitors (SSRIs) bind with high affinity to the dopamine transporter, competing with test compound, ioflupane. There is inconsistent guidance on stopping SSRIs prior to DAT scan due to lack of robust evidence. However, case studies suggest the interaction may result in false positive results. We investigated potential SSRI related false positive DaT scan results in view of developing a local guideline.

Methods

DaT Scan reports of patients attending two district general hospitals in South Wales over a one year period were retrospectively analysed and cross-referenced with their diagnosis and drug history on Welsh Clinical Portal (WCP).

Results

Seventy two patient records were analysed. Mean age was 73 and 64% were male. Eight patients (11%) were taking an SSRI at the time of their DaT scan. Patients taking SSRIs were not more likely to have a positive DaT scan result than patients not on SSRIs (7/8 and 40/64 respectively, p = 0.598). Those taking SSRIs were also not more likely to have a clinical diagnosis of PD than those not taking SSRIs (5/8 and 27/64 respectively, p=0.451).

Conclusion

In our evaluation SSRIs did not increase the likelihood of false positive DaT scan results. As absence of evidence is due to few and small number studies, we employ a pragmatic approach of considering stopping or continuing SSRIs prior to DaT on a case-by-case basis and interpreting results in context, with consideration of repeat scan off SSRI if appropriate.

Introduction

On graduation medical students need to be equipped to recognise and manage acute stroke and TIA (Transient Ischemic Attack). Despite inclusion of acute stroke and TIA in our local curriculum less than 10% of students (2/30) reported directly observing stroke thrombolysis during their placement. Due to COVID restrictions no student had been able to attend TIA clinic. To improve students practical understanding of the assessment and management of acute stroke and TIA a simulation-based teaching session was designed.

Method

The simulation session consisted of a hyperacute stroke assessment and management simulation (2 scenarios) and a simulated TIA clinic (3 scenarios). Students were asked to complete a pre-course and post-course questionnaire regarding their confidence in 8 domains, on a continuous scale 0 to 5.

Results

There were 23 participants over 2 sessions. 18/23 completed the pre-course questionnaire and 16/23 the post-course questionnaire. The mean confidence reported by students increased in all domains: recognition of acute stroke from 3.3 to 4.8; identifying candidates for thrombolysis from 3.1 to 4.6; discussing thrombolysis with a patient or carer from 2.3 to 4.1; knowing when to call for senior support from 3.1 to 4.3; asking for a patient to be transferred to facilitate acute stroke care from 2.2 to 4.2; recognising a TIA from 2.8 to 4.9; requesting investigations for TIA from 2.5 to 4.6; and discussing anticoagulation with a patient from 2.9 to 4.4.

Conclusion

Improvements in the confidence of medical students in assessing and managing acute stroke (including thrombolysis) and TIA can be achieved through a stroke medicine themed simulation session.

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is associated with poor health outcomes (1) and few people aged >70 years likely benefit from HbA1c <53mmol/mol(2) with ≤64mmol/mol generally accepted in people with moderate-severe frailty. We analysed fallers with T2DM to evaluate their outcomes and frailty status.

METHODS

Older Persons Assessment Service (OPAS) is an Emergency Department service which accepts patients on frailty criteria (aged >70 years, falls, confusion, care dependence, polypharmacy and poor mobility). OPAS databank was retrospectively analysed for people with T2DM admitted with a fall June 2020 to April 2022. Interactions between clinical outcomes with therapeutic agents used, age, Charlson Co-morbidity index (CCMI) and Clinical Frailty Score (CFS) were evaluated.

RESULTS

Six-hundred and seventy-nine patients were assessed; 191 (28.1%) had diabetes with a mean HbA1c 56.7 (IQR: 43.0 – 61.5) mmol/mol, 245 (36.1%) were male. Patients with diabetes had a similar mean CFS (5.3 vs 5.3, p=0.52) and age (83.8 vs 83.2 years, p=0.28) as those without diabetes, but had a higher mean CCMI (5.0 vs 7.0, p<0.001). People with diabetes were more likely to die within 12 months (31.4% vs 25%, p<0.05), and there was a trend to greater mortality in patients with diabetes who used insulin and/or gliclazide compared to those who used other agents (49.6% vs 30.9%, p=0.12).

CONCLUSIONS

Falls are a significant burden, and hypoglycaemic agents may contribute to the greater mortality observed in people with diabetes. Clinician awareness of the poorer prognosis associated with diabetes to support de-prescribing diabetes therapies (2) for patients with significant frailty and HbA1c <64mmol/mol. A frailty assessment should be part of any interaction(3) in the older T2DM patient. We are currently writing a local guideline on Diabetes management in Older Adults in Swansea Bay UHB.

Introduction

People receiving haemodialysis, have the highest medicine burden of all chronically ill populations. This high medicine burden, exposes people to medication related problems impacting on quality of life and healthcare experience. Medicines optimisation, reviewing medicines to manage polypharmacy and improve outcomes, in the general population, is associated with decreased risk of death, decreased referral to nursing home, lower drug costs and improvements in patient’s perception of health.

Method

A literature review searching, Cochrane, Google scholar, Delphi, CINAHL, Medline and via OVID, Embase, Amed and Ovid Emcare To answer PICO: Population - Adult patients (Adults, frail older adults, elderly) receiving haemodialysis (dialysis; dialysis, renal; hemodialysis; renal dialysis; chronic renal failure) Intervention - Medicines Optimisation (Individualized medicine, medication management, polypharmacy, medication adherence, inappropriate medication) Comparison - No comparison (usual care) Outcome - Healthcare experience (Health related quality of life, quality of life)

Results

Medicines optimisation for patients receiving haemodialysis identifies high numbers of potentially inappropriate medications and high numbers of omitted indicated medicines. All three identified studies significantly reduce polypharmacy, using different refined deprescribing tools. George, J. S, 2021 reports a significant improvement in patient reported Living with Medicines Score following deprescribing together with a (non-significant) improvement in adherence. McIntyre, C. 2017 describe no negative impact on self-reported patient satisfaction but did not capture impact upon quality of life. Parker, K. 2019 using the criteria from Screening Tool for Older Persons’ Prescriptions (STOPP) and Screening Tool to Alert Doctors to the Right Treatment (START), identified significant numbers of medicines for review but did not improve medication adherence or the healthcare experience for people receiving haemodialysis.

Conclusion(s)

Medicines optimisation can improve the healthcare experience for people receiving haemodialysis. This may lessen the health-related consequences of polypharmacy and the negative impact on quality of life.