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Background: In emergency care settings, screening for disease or risk factors for poor health outcomes among older adults can identify those in need of specialist and early intervention. The aim of this study was to identify barriers and facilitators to implementing older person-centred screening in emergency care settings in the Mid-West of Ireland., Methods: This study employed a qualitative descriptive design underpinned by the theoretical domains framework (TDF). This design informs implementation strategy by establishing a theoretical foundation for focused objectives. One on one semi-structured interviews were conducted with a purposive sample of healthcare workers (HCWs) to explore their screening experiences with older adults in emergency care settings. Information power guided sample size calculation. In data analysis, verbatim interview transcripts were deductively mapped to TDF constructs forming meta-themes that revealed specific barriers and facilitators to person-centred screening for older individuals. These findings will directly inform implementation strategies., Results: Three themes were identified; Preconditions to Implementing Older Person-Centred Screening; Knowledge and Skills Required to Implement Older Person-centred Screening and Motivation to Deliver Older Person-Centred Screening. Overall, screening in emergency care settings is a complicated process which is ideally undertaken by knowledgeable and skilled practitioners with a keen awareness of team dynamics and environmental challenges in acute care settings. These practitioners serve as champions and sources of specialist knowledge and practice. Less experienced clinicians seek supervision and support to undertake screening competently and confidently. Education on frailty and aged related syndromes facilitates screening uptake. Recognition of the value of screening is a clear motivator and leadership is vital to sustain screening practices., Conclusions: Screening serves as an entry point for specialist intervention, necessitating a specialist multidisciplinary team (MDT) approach for effective implementation in emergency care settings. Strengthening screening practices for older adults who attend emergency care settings involves employing audit, supervision and tailored supports. Skilled and experienced practitioners play a key role in mentoring and supporting the broader MDT in screening engagement. Long-term and sustainable implementation relies on utilising existing managerial, practice development and educational resources to underpin screening practices. Communication between Emergency Department (ED) staff, the specialist team and wider geriatric team is vital to ensure a cohesive approach to delivering older person-centred care in the ED., (© 2024. The Author(s).)

This paper is a personal reflection on involvement in the development of the first voluntary assisted dying legislation in Australia. Points of contention are discussed, where plural values were evident, as the legislation progressed towards implementation. Finally, ongoing areas of difficulty with the legislation are listed, where further thought is required to ensure ease of access for those in need., (© 2024. The Author(s).)

Background: There is a paucity of research reporting the long-term outcomes of older adults who have completed geriatric rehabilitation following COVID-19., Aim: The primary aim of this study is to describe the long-term functional outcomes of a cohort of older adults with acute COVID-19 who have completed inpatient geriatric rehabilitation., Methods: This is a subgroup analysis of Irish data from a pan-European prospective cohort study. Functional ability, patient reported symptoms, and quality of life were measured using the Barthel index, the COVID-19 Yorkshire Rehabilitation Screen, and the EQ-5D-5L, respectively., Results: Thirty patients enrolled in the study. The rate of mortality was 23.3% at 6 months after discharge from rehabilitation. Patients achieved a return to pre-admission functional ability but reported a significant increase in patient reported symptoms and their quality of life did not return to pre-admission levels when assessed at 6 months after discharge from rehabilitation., Conclusions: Multidisciplinary rehabilitation for older adults with acute COVID-19 infection can assist patients to return to their premorbid functional ability. On discharge from rehabilitation, ongoing follow-up of older adults is recommended to assist them to negotiate and manage ongoing symptomatology such as breathlessness or fatigue., (© 2024. The Author(s).)

Objectives: There is conflicting evidence regarding the outcomes of acute stroke patients who present to hospital within normal working hours ('in-hours') compared with the 'out-of-hours' period. This study aimed to assess the effect of time of stroke presentation on outcomes within the Irish context, to inform national stroke service delivery., Materials and Methods: A secondary analysis of data from the Irish National Audit of Stroke (INAS) from Jan 2016 to Dec 2019 was carried out. Patient and process outcomes were assessed for patients presenting 'in-hours' (8:00-17:00 Monday-Friday) compared with 'out-of-hours' (all other times)., Results: Data on arrival time were available for 13,996 patients (male 56.2%; mean age 72.5 years), of which 55.7% presented 'out-of-hours'. In hospital mortality was significantly lower among those admitted 'in-hours' (11.3%, n = 534) compared with 'out-of-hours' (12.8%, n = 749); (adjusted Odds Ratio (OR) 0.82; 95% Confidence Interval CI [95% CI] 0.72-0.89). Poor functional outcome at discharge (Modified Rankin Scale ≥ 3) was also significantly lower in those presenting 'in-hours' (adjusted OR 0.79; 95% CI 0.68-0.91). In patients receiving thrombolysis, mean door to needle time was shorter for 'in-hours' presentation at 55.8 mins (n = 562; SD 35.43 mins), compared with 'out-of-hours' presentation at 80.5 mins (n = 736; SD 38.55 mins, p < .001)., Conclusion: More than half of stroke patients in Ireland present 'out-of-hours' and these presentations are associated with a higher mortality and a lower odds of functional independence at discharge. It is imperative that stroke pathways consider the 24 hour period to ensure the delivery of effective stroke care, and modification of 'out-of-hours' stroke care is required to improve overall outcomes., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Loughlin et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Traditional models of palliative care have been tested by the challenges of caring for increasing numbers of people at the end stages of a chronic non-malignant illness. The COVID-19 pandemic and consequent reliance on telehealth services, has enabled the development of creative models of care., Aims: To improve home-based palliative care for people with chronic illness using telehealth, and this was demonstrated using quality-of-life measures., Methods: A total of 35 non-cancer referrals to a community palliative care service were recommended for the pilot project, with one specialist palliative care nurse as their contact. All were offered a telehealth service with a specially designed app to self-monitor their symptoms, a session on advance care directives, and self-rated quality-of-life measures using the RAND 36-Item Health Survey (Version 1.0), consisting of 36 items that cover nine domains. Statistical analysis was performed using SPSS software., Findings: Over the 21 months of the pilot study, 13 people chose to participate in the pilot. For participants, telehealth meant more control over their symptoms, fewer emergency presentations and appointment travel time was alleviated. Quality-of-life surveys highlighted physical impairments, which did not change over time., Conclusion: This pilot programme demonstrated an innovative approach to addressing the demands of people dying of chronic illness, with further work required to explore the place of telehealth consultations in the overall healthcare system.

Background: There is growing momentum worldwide for assisted dying. In Australia, voluntary assisted dying may occur in any setting, including an intensive care unit (ICU). As the subject of much debate worldwide, exploring ICU clinicians' perceptions of assisted dying is essential., Aim: The aim of this study was to explore clinicians' perceptions of and preparedness for voluntary assisted dying in the ICU., Method: An exploratory qualitative descriptive design using individual interviews was used. Medical, nursing, and allied health clinicians from three ICUs were recruited. Interviews were conducted between Nov 2022 and Jan 2023, with a hypothetical scenario about voluntary assisted dying used to prompt discussion. Interviews were recorded, professionally transcribed, and analysed using inductive content analysis., Findings: ICU registered nurses (n = 20), physicians (n = 2), and allied health clinicians (n = 4) participated with interviews lasting 18-45 min (mean: 28 min). Analysis revealed four themes: (i) purpose of ICU reflected that ICU care was not all about saving lives, yet recognising dying and changing priorities was challenging; (ii) dying in the ICU is complex due to difficulties in talking about dying, accepting death as the outcome and evaluating care efficacy; (iii) voluntary assisted dying is a lot of grey because of perceived clinical and ethicolegal challenges; and finally, (iv) respecting choice was about respecting patients' values, beliefs, and autonomy, as well as clinicians' beliefs and right to exercise autonomy through conscientious objection., Conclusion: Dying and death are inevitable, and views and perspectives about assisted dying will continue to evolve. Respecting patient choice is at the core of assisted dying, but respecting clinicians' perspectives and choice is equally important. With voluntary assisted dying now legal in all Australian states, ensuring ICU team and individual clinician preparedness through access to education, resources, and specialist support services is key to raising awareness and easing uncertainty about deaths through voluntary assisted dying., (Copyright © 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Objectives: This pilot project replicated a self-compassion program to support health-care professionals in palliative care settings. We anticipated that undertaking this program would enhance participants' psychological well-being., Methods: Participants were recruited by convenience sampling from palliative care services in an area of Melbourne, Australia. Because of the COVID-19 pandemic, the program was offered online and comprised six once-weekly gatherings. Three survey rounds with identical questions were conducted prior to, immediately after, and 3 months after the training. The surveys consisted of 6 scales: the Self-Compassion Scale, the Santa Clara Brief Compassion Scale, the Cognitive and Affective Mindfulness Scale, the Depression Anxiety Stress Scale, the Professional Quality of Life Scale, and the Interpersonal Reactivity Index Scale. Paired-sample t-test and repeated measures analysis of variance analyses were used to compare participant responses., Results: Nine participants working in palliative care completed the training and 3 surveys and included qualitative responses. The experience was overwhelmingly positive. Self-compassion ( F  = 14.44; p  < 0.05) and mindfulness ( F  = 18.44; p  < 0.05) scores significantly increased post-training, were picked up in a short time and endured. The emotional state improved by compassion satisfaction, showing a positive improvement 3 months post-training, along with there being no changes in compassion satisfaction, burnout, and dispositional empathy., Significance of Results: Participants all worked in a supportive environment, which encouraged self-care. Even against the pandemic difficulties, a short online program was effective, assisting participants to cultivate their inner resources in mindfulness and self-compassion. While a small sample size, expansion of the training may benefit the wider palliative care workforce.

Aim: Older adults comprise a growing proportion of Emergency Department (ED) attendees and are vulnerable to adverse outcomes following an ED visit including ED reattendance within 30 days. Interventions to reduce older adults' risk of adverse outcomes following an ED attendance are proliferating and often focus on improving the transition from the ED to the community. To optimise the effectiveness of interventions it is important to determine how older adults experience the transition from the ED to the community. This study aims to systematically review and synthesise qualitative studies reporting older adults' experiences of transition to the community from the ED., Methods: Six databases (Academic Search Complete, CINAHL, MEDLINE, PsycARTICLES, PsycINFO, and Social Science Full Text) were searched in March 2022 and 2023. A seven-step approach to meta-ethnography, as described by Noblit and Hare, was used to synthesise findings across included studies. The methodological quality of the included studies was appraised using the 10-item Critical Appraisal Skills Programme (CASP) checklist for qualitative research. A study protocol was registered on PROSPERO (Registration: CRD42022287990)., Findings: Ten studies were included, and synthesis led to the development of five themes. Unresolved symptoms reported by older adults on discharge impact their ability to manage at home (theme 1). Limited community services and unresolved symptoms drive early ED reattendance for some older adults (theme 2). Although older adults value practical support and assistance transporting home from the ED this is infrequently provided (theme 3). Accessible health information and interactions are important for understanding and self-managing health conditions on discharge from the ED (theme 4). Fragmented Care between ED and community is common, stressful and impacts on older adult's ability to manage health conditions (theme 5). A line of argument synthesis integrated these themes into one overarching concept; after an ED visit older adults often struggle to manage changed, complex, health and care needs at home, in the absence of comprehensive support and guidance., Discussion/ Conclusion: Key areas for consideration in future service and intervention development are identified in this study; ED healthcare providers should adapt their communication to the needs of older adults, provide accessible information and explicitly address expectations about symptom resolution during discharge planning. Concurrently, community health services need to be responsive to older adults' changed health and care needs after an ED visit to achieve care integration. Those developing transitional care interventions should consider older adults needs for integration of care, symptom management, clear communication and information from providers and desire to return to daily life., (© 2024. The Author(s).)

Background: This study aimed to explore the process, clinical, and patient-reported outcomes of older adults who received an interdisciplinary Comprehensive Geriatric Assessment (CGA) in the emergency department (ED) over a six-month period after their initial ED attendance., Patients and Methods: A prospective cohort study recruited older adults aged ≥65 years who presented to the ED of a university teaching hospital in Ireland. Baseline assessment data comprising a battery of demographic variables and validated indices were obtained at the index ED attendance. Telephone interviews were completed with participants at 30- and 180-day follow-up. The primary outcome was incidence of hospital admission following the index ED attendance. Secondary outcomes included participant satisfaction, incidence of functional decline, health-related quality of life, incidence of unscheduled ED re-attendance(s), hospital (re)admission(s), nursing home admission, and death., Results: A total of 133 participants (mean age 82.43 years, standard deviation = 6.89 years; 71.4% female) were recruited; 21.8% of the cohort were admitted to hospital following the index ED attendance with a significant decline in function reported at hospital discharge (Z = 2.97, p = 0.003). Incidence of 30- and 180-day unscheduled ED re-attendance was 10.5% and 24.8%, respectively. The outcome at the index ED attendance was a significant predictor of adverse outcomes whereby those who were discharged home had significantly lower odds of multiple adverse process outcomes at 30- and 180-day follow-up, and significantly higher function and health-related quality of life at 30-day follow-up., Conclusion: While this study was observational in nature, findings suggest CGA in the ED may improve outcomes by mitigating against the adverse effects of potentially avoidable hospital admissions and focusing on a longitudinal approach to healthcare delivery at the primary-secondary care interface. Future research should be underpinned by an experimental study design to address key limitations in this study., Competing Interests: The authors report no conflicts of interest in this work., (© 2024 O’Shaughnessy et al.)

Northern Plains American Indians (AIs) have some of the highest smoking and lung cancer mortality rates in the USA. They are a high-risk population in which many are eligible for low-dose computed tomography (LDCT) screening, but such screening is rarely used. This study investigated methods to increase LDCT utilization through both a provider and community intervention to lower lung cancer mortality rates. This study used the Precaution Adoption Model for provider and community interventions implemented in four study regions in western South Dakota. The goal was to increase LDCT screening for eligible participants. Intake surveys and LDCT screenings were compared at baseline and 6 months following the education programs for both interventions. A total of 131 providers participated in the provider intervention. At the 6-month follow-up survey, 31 (63%) referred at least one patient for LDCT (p < 0.05). Forty (32.3%) community participants reported their provider recommended an LDCT and of those, 30(75%) reported getting an LDCT (p < 0.05). A total of 2829 patient surveys were completed at the imaging sites and most (88%, n = 962) cited provider recommendation as their reason for obtaining an LDCT. Almost half (46%; n = 131) of the referring providers attended a provider education workshop, and 73% of the providers worked at a clinic that hosted at least one community education session. Over the study period, LDCT utilization increased from 640 to 1706, a 90.9% increase. The provider intervention had the strongest impact on LDCT utilization. This study demonstrated increased LDCT utilization through the provider intervention but increases also were documented for the other intervention combinations. The community-based education program increased both community and provider awareness on the value of LDCTs to lower lung cancer mortality rates., (© 2023. The Author(s) under exclusive licence to American Association for Cancer Education.)

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with a strong genetic basis. ASDs are commonly characterized by impairments in language, restrictive and repetitive behaviors, and deficits in social interactions. Although ASD is a highly heterogeneous disease with many different genes implicated in its etiology, many ASD-associated genes converge on common cellular defects, such as aberrant neuronal morphology and synapse dysregulation. Our previous work revealed that, in mice, complete loss of the ASD-associated X-linked gene NEXMIF results in a reduction in dendritic complexity, a decrease in spine and synapse density, altered synaptic transmission, and ASD-like behaviors. Interestingly, human females of NEXMIF haploinsufficiency have recently been reported to demonstrate autistic features; however, the cellular and molecular basis for this haploinsufficiency-caused ASD remains unclear. Here we report that in the brains of Nexmif ± female mice, NEXMIF shows a mosaic pattern in its expression in neurons. Heterozygous female mice demonstrate behavioral impairments similar to those of knockout male mice. In the mosaic mixture of neurons from Nexmif ± mice, cells that lack NEXMIF have impairments in dendritic arborization and spine development. Remarkably, the NEXMIF-expressing neurons from Nexmif ± mice also demonstrate similar defects in dendritic growth and spine formation. These findings establish a novel mouse model of NEXMIF haploinsufficiency and provide new insights into the pathogenesis of NEXMIF -dependent ASD., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Background: Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary process that addresses an older adult's biopsychosocial capabilities to create an integrated and co-ordinated plan of care. While quantitative evidence that demonstrates the positive impacts of CGA on clinical and process outcomes has been synthesised, to date qualitative research reporting how older adults and service providers experience CGA has not been synthesised. This study aimed to systematically review and synthesise qualitative studies reporting community-dwelling older adults', caregivers' and healthcare professionals' (HCP) experiences of CGA in the primary care and out-patient (OPD) setting., Method: We systematically searched five electronic databases including MEDLINE, CINAHL, PsycINFO, PsycARTICLES and Social Sciences Full Text targeting qualitative or mixed methods studies that reported qualitative findings on older adults', caregivers' and HCPs' experiences of CGA in primary care or out-patient settings. There were no language or date restrictions applied to the search. The protocol was registered with the PROSPERO database (Registration: CRD42021283167). The methodological quality of the included studies was appraised using the Critical Appraisal Skills Programme checklist for qualitative research. Results were synthesised according to Noblit and Hare's seven-step approach to meta-ethnography, which involves an iterative and inductive process of data synthesis., Results: Fourteen studies were included where CGA was completed in the home, general practice, out-patient setting in acute hospitals and in hybrid models across the community and hospital-based OPD settings. Synthesis generated four key themes: (1) CGA is experienced as a holistic process, (2) The home environment enhances CGA, (3) CGA in the community is enabled by a collaborative approach to care, and (4) Divergent experiences of the meaningful involvement of older adults, caregivers and family in the CGA process., Conclusion: Findings demonstrate that CGA in a home-based or OPD setting allows for a holistic and integrated approach to care for community-dwelling older adults while increasing patient satisfaction and accessibility of healthcare. Healthcare professionals in the community should ensure meaningful involvement of older adults and their families or caregivers in the CGA process. Further robustly designed and well reported trials of different models of community-based CGA informed by the findings of this synthesis are warranted., (© 2023. The Author(s).)

Background: Comprehensive geriatric assessment (CGA) is considered the gold standard approach to improving a range of outcomes for older adults living with frailty admitted to hospital. To date, research has predominantly focused on quantitative syntheses of the international evidence with limited focus on qualitative synthesis of stakeholder perspectives. This review aims to resolve this research gap by identifying and synthesising qualitative studies reporting multiple stakeholders' experiences of inpatient CGA., Methods: A systematic search of five electronic databases was conducted. Qualitative or mixed methods studies that included qualitative findings on the experiences of CGA in an inpatient hospital setting from the perspective of healthcare professionals (HCP), older adults, and those important to them were included. The protocol was registered on PROSPERO (Registration: CRD42021283167) and the 10-item Critical Appraisal Skills Programme checklist was used to appraise the methodological quality of included studies. Results were synthesised as a meta-ethnography., Results: Eleven studies, which reported on the experiences of 153 HCPs, 91 older adults and 57 caregivers were included. The studies dated from 2011 to 2021 and three key themes were identified: (1) HCPs, older adults and caregivers report conflicting views on CGA as a holistic process, (2) most HCPs, but only some older adults and caregivers view CGA goalsetting and care planning as collaborative, and (3) all stakeholders value care continuity during the transition from hospital to home but often fail to achieve it., Conclusion: While HCPs, older adults, and caregivers' values and ambitions related to CGA broadly align, their experiences often differ. The identified themes highlight organisational and relational factors, which positively and negatively influence CGA practices and processes in an inpatient hospital setting., (© 2023. The Author(s).)

Mutations in autism spectrum disorder (ASD) risk genes disrupt neural network dynamics that ultimately lead to abnormal behavior. To understand how ASD-risk genes influence neural circuit computation during behavior, we analyzed the hippocampal network by performing large-scale cellular calcium imaging from hundreds of individual CA1 neurons simultaneously in transgenic mice with total knockout of the X-linked ASD-risk gene NEXMIF (neurite extension and migration factor). As NEXMIF knockout in mice led to profound learning and memory deficits, we examined the CA1 network during voluntary locomotion, a fundamental component of spatial memory. We found that NEXMIF knockout does not alter the overall excitability of individual neurons but exaggerates movement-related neuronal responses. To quantify network functional connectivity changes, we applied closeness centrality analysis from graph theory to our large-scale calcium imaging datasets, in addition to using the conventional pairwise correlation analysis. Closeness centrality analysis considers both the number of connections and the connection strength between neurons within a network. We found that in wild-type mice the CA1 network desynchronizes during locomotion, consistent with increased network information coding during active behavior. Upon NEXMIF knockout, CA1 network is over-synchronized regardless of behavioral state and fails to desynchronize during locomotion, highlighting how perturbations in ASD-implicated genes create abnormal network synchronization that could contribute to ASD-related behaviors., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2023 Mount, Athif, O’Connor, Saligrama, Tseng, Sridhar, Zhou, Bortz, San Antonio, Kramer, Man and Han.)

Background: Older adults frequently attend the emergency department (ED) and experience high rates of subsequent adverse outcomes including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. Our aim was to evaluate the feasibility of a physiotherapy-led integrated care intervention for older adults discharged from the ED (ED PLUS)., Patients and Methods: Older adults presenting to the ED of a university teaching hospital with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED PLUS. ED PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient's home. Feasibility and acceptability were assessed quantitatively and qualitatively. All clinical and process outcomes were assessed by a research nurse blinded to group allocation. Data analyses were primarily descriptive., Results: Twenty-nine participants were recruited indicating a 67% recruitment rate. At 6 months, there was 100% retention in the usual care group, 88% in the CGA group and 90% in the ED PLUS group. ED PLUS participants expressed positive feedback, and there was a trend towards improved function and quality of life and less ED revisits and unscheduled hospitalisations in the ED PLUS group., Conclusion: ED PLUS bridges the transition of care between the index visit to the ED and the community and is feasible using systematic recruitment strategies. Despite recruitment challenges in the context of COVID-19, the intervention was successfully delivered and well received by participants. There was a lower incidence of functional decline and improved quality of life in the ED PLUS group., Trial Registration: The trial was registered in Clinical Trials Protocols and Results System as of 21st July 2021, with registration number NCT04983602., Competing Interests: The authors report no conflicts of interest in this work., (© 2023 Conneely et al.)

Background: Innovations in models of care for older adults living with frailty presenting to the emergency department (ED) have become a key priority for clinicians, researchers and policymakers due to the deleterious outcomes older adults experience due to prolonged exposure to such an environment. This study aimed to develop a set of expert consensus-based statements underpinning operational design, outcome measurement and evaluation of a Frailty at the Front Door (FFD) model of care for older adults within an Irish context., Methods: A modified real-time Delphi method was used. Facilitation of World Café focus groups with an expert panel of 86 members and seperate advisory groups with a Public and Patient Involvement panel of older adults and members of the Irish Association of Emergency Medicine generated a series of statements on the core elements of the FFD model of care. Statements were analysed thematically and incorporated into a real-time Delphi survey, which was emailed to members of the expert panel. Members were asked to rank 70 statements across nine domains using a 9-point Likert scale. Consensus criteria were defined a priori and guided by previous research using 9-point rating scales., Results: Fifty members responded to the survey representing an overall response rate of 58%. Following analyses of the survey responses, the research team reviewed statements for content overlap and refined a final list of statements across the following domains: aims and objectives of the FFD model of care; target population; screening and assessment; interventions; technology; integration of care; evaluation and metrics; and research., Conclusion: Development of a consensus derived FFD model of care represents an important step in generating national standards, implementation of a service model as intended and enhances opportunities for scientific impact. Future research should focus on the development of a core outcome set for studies involving older adults in the ED., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Palliative care is limited in Ethiopia, particularly in rural areas, where more than 78% of the population live. Current initiatives and research are focused on urban settings and are primarily donor dependent. This study aims to explore the status of palliative care, enabling factors and implementation challenges in Ethiopia's rural and regional health care settings., Methods: A qualitative regional case study was conducted with health professionals drawn from different health care settings, academic institutions and included health planners and practitioners. Focus groups were conducted with rural community members and face- to face- individual interviews were conducted with health professionals working in numerous roles as well as academic leaders., Results: Participants indicated that despite a few leaders being aware of the inclusion of palliative care in the Ethiopia national policies and guidelines, palliative care is not, integrated into the existing health care system. Other participants responded that palliative care is not well integrated into the undergraduate and postgraduate courses except for limited content in the diploma and a few postgraduate courses. Participants described the challenges for palliative care implementation as follows: many lacked awareness about palliative care; and chronically ill patients other than those with HIV received inadequate care, limited to physical care, some pain management, and psychosocial support rather than comprehensive palliative care. In addition, some participants perceived that palliative care was not within the remit of their service, so families and patients were forced to seek alternative or informal care, including from traditional healers., Conclusions: Enablers for the improvement of palliative care access in rural and regional health care were identified, including better integration of palliative care into the national health care plan and guidelines; palliative care content in university and college courses; and use of mobile phone technology to facilitate care. And policy makers and responsible stakeholders could consider the palliative care implementation in rural and regional health care settings through a combination of home, community and facility-based models., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Validated screening tools can be utilised to detect early disease processes and risk factors for disease and adverse outcomes. Consequently, identifying individuals in need of early intervention and targeted assessment can be achieved through the implementation of screening in the ED. Successful implementation can be impacted by a lack of resources and ineffective integration of screening into the clinical workflow. Tailored implementation processes and staff training, which are contextually specific to the ED setting, are facilitators to effective implementation. This review will assist in the identification of barriers and facilitators to screening in the ED using a QES to underpin implementation processes. Healthcare workers engage in screening in the ED routinely. Consequently, this review focused on synthesizing the experience of healthcare workers (HCWs) who are involved in this process. This synthesis is informed by a QES protocol published by the lead author in 2021 (Barry et al., HRB Open Res 3:50, 2021)., Methodology: A comprehensive literature search, inclusive of grey literature sources, was undertaken. Initially, an a priori framework of themes was formed to facilitate the interpretation and organisation of search results. A context specific conceptual model was then formulated using "Best fit" framework synthesis which further assisted in the interpretation of data that was extracted from relevant studies. Dual blind screening of search results was undertaken using RAYYAN as a platform. Thirty studies were identified that met the inclusion criteria. Dual appraisal of full text articles was undertaken using CASP, GRADE CERQual assessed confidence of findings and data extraction was performed by two reviewers collaboratively., Findings: This is the first known synthesis of qualitative research on HCW's experiences of screening in the ED. Predominantly, the findings illustrate that staff experience screening in the ED as a complex challenging process. The barriers and facilitators identified can be broadly categorised under preconditions to screen, motivations to screen and knowledge and skills to screen. Competing interests in the ED, environmental stressors such as overcrowding and an organisational culture that resists screening were clear barriers. Adequate resources and tailored education to underpin the screening process were clear facilitators., Trial Registration: PROSPERO: CRD42020188712 05/07/20., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Adopting preventive strategies in individuals with subclinical Alzheimer's disease (AD) has the potential to delay dementia onset and reduce healthcare costs. Thus, it is extremely important to identify inexpensive, scalable, sensitive, and specific markers to track disease progression. The electroencephalography spectral power ratio (SPR: the fast to slow spectral power ratio), a measure of the shift in power distribution from higher to lower frequencies, holds potential for aiding clinical practice. The SPR is altered in patients with AD, correlates with cognitive functions, and can be easily implemented in clinical settings. However, whether the SPR is sensitive to pathophysiological changes in the prodromal stage of AD is unclear. We explored the SPR of individuals diagnosed with amyloid-positive amnestic mild cognitive impairment (Aβ+aMCI) and its association with both cognitive function and amyloid load. The SPR was lower in Aβ+aMCI than in the cognitively unimpaired individuals and correlated with executive function scores but not with amyloid load. Hypothesis-generating analyses suggested that aMCI participants with a lower SPR had an increased probability of a positive amyloid positron emission tomography. Future research may explore the potential of this measure to classify aMCI individuals according to their AD biomarker status., Competing Interests: Declaration of Competing Interest SSB serves as a consultant for Kinto Care. APL is a co-founder of Linus Health and TI Solutions AG; serves on the scientific advisory boards for Starlab Neuroscience, Magstim Inc., TetraNeuron, Skin2Neuron, Hearts Radiant, and MedRhythms; and is listed as an inventor on several issued and pending patents on the real-time integration of noninvasive brain stimulation with electroencephalography and magnetic resonance imaging. AAFS, PDP, MO, MMS, CSYB, and PJF declare that they have no competing interests., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The COVID-19 pandemic created a complex high-risk clinical research environment with clinical research activities significantly impacted. Clinical research stakeholders adapted rapidly to new clinical practices; PPE, infection control policies, all while engaging with a more unwell patient demographic. The aim of this study is to explore the experiences of conducting clinical research during COVID-19 with clinical research stakeholders., Methods: This qualitative study of semi-structured interviews conducted with clinical research stakeholders in an acute Hospital setting across a variety of disciplines; Consultant Geriatrician, Clinical Research Nurse, Occupational Therapy, Physiotherapy. Interviews were fully transcribed prior to reflexive thematic analysis. NVivo software was used to support data management and analysis., Results: Three main themes were produced; (1) The challenging COVID-19 clinical research landscape, (2) COVID-19 clinical research communication barriers, and (3) Adaptations and learnings from clinical research during COVID-19., Conclusions: This study explored the experiences of conducting clinical research during COVID-19 with clinical research stakeholders examining challenges faced and adaptations required. The findings inform, equip and support clinical research stakeholders in the event of future adverse public health events., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Ethiopia has a national palliative care guideline, and palliative care is explicitly recognised in the country's healthcare policy and health sector transformation plans. However, palliative care is not fully delivered in the regional public hospitals and primary health care units., Objective: This study explores perceived policy barriers to deliver palliative care services in rural and regional healthcare settings, which primary healthcare units largely serve., Design: Face-to-face interviews were conducted in a rural region of Ethiopia., Methods: Forty-two participants were recruited from a variety of health settings including primary, secondary and tertiary levels across the region. Interviews were conducted with policymakers from the regional health bureau, pharmacists, medical doctors, health officers (clinical officers) and nurses, including chief nursing officers in leadership roles at all levels of healthcare institutions. Data analysed using thematic analysis., Results: Participants described several barriers related to healthcare policy, including lack of government priority and focus on palliative care; lack of health professionals' awareness of the national palliative care plans and guidelines; and lack of palliative care integration into the existing healthcare system and the national budget. Participants remarked that palliative care services in the region were mainly limited to HIV patients, often managed with external support and, hence unsustainable., Conclusions: Policy priority and focus is a fundamental component for the provision of palliative care because lack of focus and support from the government have led to inadequate access to palliative care for all in need. Hence, as participants suggested, palliative care should be integrated into all healthcare levels, particularly into the primary health care units and the health extension programme, to facilitate health extension workers to support millions living in rural areas., Competing Interests: The authors declare that there is no conflict of interest., (© The Author(s), 2023.)

Background: Availability and accessibility of opioids are a worldwide problem. In low-resource settings, such as Ethiopia, access to opioids is either limited or nonexistent and legally restricted in health care settings. This study aimed to identify barriers for the availability and accessibility of opioids in Ethiopian rural and regional health care settings., Methods: A mixed-method case study design was used. A total of 220 nurses from primary, secondary, and tertiary health care settings were invited to participate in a survey of knowledge and practice. For the qualitative interview, 38 participants were recruited from educational facilities, health services, and the community across a region., Results: Barriers in availability and accessibility of opioid analgesics were expressing pain considered as a sign of weakness, lack of knowledge, side effect concerns about prescribing morphine, only doctors being authorized to prescribe morphine, lack of foreign currency to import morphine ingredients, and inequity in accessing morphine in hospitals and none in rural health care settings., Conclusion: The findings of this study indicate that opioids, particularly morphine, were not consistently available and accessible to all patients in need. Health professionals lacked knowledge about opioids. Strengthening the existing pain-free initiatives and improving the type, dose, and supply of morphine could help reduce needless suffering and enhance access to essential pain medicines for those in need., Competing Interests: No competing financial interests exist., (© Atsede Aregay et al., 2023; Published by Mary Ann Liebert, Inc.)

Objectives: Assessment of frailty prior to aortic valve intervention is recommended in European and North American valvular heart disease guidelines. However, there is a lack of consensus on how it is best measured. The Clinical Frailty Scale (CFS) is a well-validated measure of frailty that is relatively quick to calculate. This meta-analysis sought to examine whether the CFS predicts mortality and morbidity following either transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR)., Methods: Nine electronic databases were searched systematically for data on clinical outcomes post-TAVI/SAVR, where patients had undergone preoperative frailty assessment using the CFS. The primary endpoint was 12-month mortality. TAVI and SAVR data were assessed and reported separately. For each individual study, the incidence of adverse outcomes was extracted according to a CFS score of 5-9 (ie, frail) versus 1-4 (ie, non-frail), with meta-analysis performed using a random effects model., Results: Of 2612 records screened, nine were included in the review (five TAVI, three SAVR and one which included both interventions). Among 4923 TAVI patients, meta-analysis showed 12-month mortality rates of 19.1% for the frail cohort versus 9.8% for the non-frail cohort (RR 2.53 (1.63 to 3.95), p<0.001, I 2 =83%). For the smaller cohort of SAVR patients (n=454), mortality rates were 20.3% versus 3.9% for the frail and non-frail cohorts, respectively (RR 5.08 (2.31 to 11.15), p<0.001, I 2 =5%)., Conclusions: Frailty, as determined by the CFS, was associated with an increased mortality risk in the 12 months following either TAVI or SAVR. These data would support its use in the preoperative assessment of elderly patients undergoing aortic valve interventions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: frailty screening facilitates the stratification of older adults at most risk of adverse events for urgent assessment and subsequent intervention. We assessed the validity of the Identification of Seniors at Risk (ISAR), Clinical Frailty Scale (CFS), Programme on Research for Integrating Services for the Maintenance of Autonomy seven item questionnaire (PRISMA-7) and InterRAI-ED at predicting adverse outcomes at 30 days and 6 months amongst older adults presenting to the Emergency Department (ED)., Methods: a prospective cohort study of adults ≥65 years who presented to the ED was conducted. The ISAR, CFS, PRISMA-7 and InterRAI-ED were assessed. Blinded follow-up telephone interviews were completed at 30 days and 6 months to assess the incidence of mortality, ED re-attendance, hospital readmission, functional decline and nursing home admission. The sensitivity, specificity, negative predictive value and positive predictive value of the screening tools were calculated using 2 × 2 tables., Results: a total of 419 patients were recruited; 47% female with a mean age of 76.9 (Standard deviation = 7.2). The prevalence of frailty varied across the tools (CFS 57% versus InterRAI-ED 70%). At 30 days, the mortality rate was 5.1%, ED re-attendance 18.1%, hospital readmission 14%, functional decline 47.6% and nursing home admission 7.1%. All tools had a high sensitivity and positive predictive value for predicting adverse outcomes., Conclusion: older adults who screened positive for frailty were at significantly increased risk of experiencing an adverse outcome at 30 days with the ISAR being the most sensitive tool. We would recommend the implementation of the ISAR in the ED setting to support clinicians in identifying older adults most likely to benefit from specialised geriatric assessment and intervention., (© The Author(s) 2023. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objectives: This study aims to measure and explore the barriers to translating theoretical knowledge of palliative care into clinical practice., Methods: A mixed-method study, combining a cross-sectional survey and key interviews was conducted. The quantitative data were obtained from 173 nurses and the key interviews were conducted with 42 health professionals drawn from multiple settings. For quantitative data analysis, Statistical Package for the Social Sciences software were conducted, and a thematic analysis supported with NVivo software were used for analyzing qualitative data., Results: Of the 220 nurses invited, 173 completed the survey (79%). Most (78%) had a bachelor's degree in nursing. Fewer than half, 69 (40%) scored 75% or more for the knowledge test; 173 (100%) scored 50% or greater for attitude; and only 32 (18.5%) scored 75% or greater for self-reported practice. While there was a small, positive correlation between palliative care attitudes and self-reported practice ( r  = 0.22, p  = 0.003), the qualitative findings indicated that nurses had significant challenges in translating their theoretical knowledge into clinical practice. Limited clinical practice was linked to inadequate knowledge resulting from insufficient integration of palliative care content in undergraduate curricula and a lack of follow-up training. This was further exacerbated by shortages of medicine, staff, and financial resources and was linked to limited attention accorded to palliative care by the government., Significance of Results: While the results showed the majority held positive views toward palliative care, improving palliative care practices requires, and enhancing nurses' knowledge of palliative care. This requires changing teaching methods and engaging policymakers.

Background: Older adults are at increased risk for disease severity and poorer prognosis following COVID-19 infection. The aim of this systematic review and meta-analysis is to explore the impact of multidisciplinary rehabilitation in the acute or post-acute hospital setting for older adults with COVID-19., Methods: The Cochrane library, EMBASE, Cinahl and Medline (via EBSCO), PubMed, and Web of Science were systematically searched in June 2022 and a repeat search was completed in March 2023. Screening, data extraction and quality appraisal were conducted independently by two reviewers. Studies reporting outcomes for older adults following multidisciplinary rehabilitation (provided by two or more Health and Social Care Professionals) were included. Both observational and experimental study designs were included. The primary outcome was functional ability. Secondary outcomes included discharge disposition, acute hospital and rehabilitation unit length of stay, mortality, primary and secondary healthcare utilisation, and long-term effects of COVID-19., Results: Twelve studies met the inclusion criteria, comprising a total of 570 older adults. Where reported, older adults stayed in the acute hospital for a mean of 18 days (95%CI, 13.35- 23.13 days) and in rehabilitation units for 19 days (95%CI, 15.88-21.79 days). There was a significant improvement in functional ability among older adults with COVID-19 who received multidisciplinary rehabilitation (REM, SMD = 1.46, 95% CI 0.94 to 1.98). The proportion of older adults who were discharged directly home following rehabilitation ranged from 62 to 97%. Two studies reported a 2% inpatient mortality rate of older persons during rehabilitative care. No study followed up patients after the point of discharge and no study reported on long term effects of COVID-19., Conclusions: Multidisciplinary rehabilitation may result in improved functional outcomes on discharge from rehabilitation units/centres for older adults with COVID-19. Findings also highlight the need for further research into the long-term effect of rehabilitation for older adults following COVID-19. Future research should comprehensively describe multidisciplinary rehabilitation in terms of disciplines involved and the intervention provided., (© 2023. The Author(s).)

Background: Health providers frequently probe patients' recall of current and/or remote news events to determine the extent of memory loss. Impaired memory for transient events (ie, in the news for a circumscribed time) may provide information regarding the onset of cognitive impairment., Objective: To use the Transient News Events Test (TNET) to explore how memory changes over time in both older adults with cognitive impairment (CI) and noncognitively impaired (NCI) older adults. We also investigated the role of episodic and semantic memory on TNET performance., Method: Sixty-seven older adults completed the TNET as part of a comprehensive neuropsychological assessment. Analyses included t tests to evaluate group differences for TNET score and correlations between TNET and neuropsychological measures, including episodic and semantic memory tests., Results: NCI adults demonstrated better memory for TNET items than adults with CI. The NCI and CI groups did not differ regarding memory for remote events; however, the CI group exhibited worse memory for recent events. There was a significant association between TNET score and the capacity for episodic and semantic memory in the CI group. In the NCI group, TNET score was significantly associated with episodic memory., Conclusion: Findings support the use of transient news events to assess remote memories in older adults. Novel remote memory measures broaden the scope of memory assessment far beyond what is feasible with traditional neuropsychological assessment and may provide insight into the onset of memory changes., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Recruitment and retention of doctors is a priority for the Irish healthcare service, with many leaving to work in regions with more favourable conditions. Aligning flexible training options with other jurisdictions may be an effective means of improving working conditions. We sought to assess possible improvements to the existing system and to review barriers to flexible training. We carried out a survey using 'Survey Monkey' and disseminated it to 1557 basic specialist (BST) and higher specialist trainee (HST) doctors of the Institute of Medicine, 3500 members of the Irish Medical Organisation (IMO), and across social media. There were 854 respondents; 303 (35.5%) BST, 352 (41.2%) HST, 125 (14.6%) non-training doctors, unknown, n = 74. The response rate was approximately 15-23%. Non-consultant doctors identified a preference for access to flexible training (n = 849, 99.4%), with 82.2 of doctors reporting that they would consider applying (n = 702). Most (92.4%) considered the current provision of 16 whole-time equivalent positions as inadequate (n = 789). Of doctors who would not apply for flexible training, themes identified included a perceived negative impact on their career, not meeting eligibility criteria, prolonged training, and salary implications. Suggestions for improving the system included expanding the number of places available, removing eligibility criteria, job sharing options, and the provision of regional training schemes. Access to flexible training should be a priority for the healthcare service, which may enhance recruitment and retention. A majority of our sample of non-consultant doctors identified a preference for access to flexible training options., (© 2022. The Author(s), under exclusive licence to Royal Academy of Medicine in Ireland.)

A major barrier to Victorians with a terminal illness accessing voluntary assisted dying is the Commonwealth Criminal Code Amendment (Suicide Related Material Offences ) 2005 (the Code), which prohibits the use of any electronic forms of communication when discussing suicide. The proliferation of telehealth as a means of access to medical practitioners as a result of the COVID-19 pandemic has heightened the anachronistic prohibition of such communication in relation to voluntary assisted dying, particularly in Victoria, as the federal law arguably prohibits its use. In this paper we explore the definition of suicide and its application to voluntary assisted dying and argue for a revision of the Code, to enable equitable and timely access to voluntary assisted dying for people of Victoria.

Introduction: Older adults frequently attend the emergency department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. Our aim was to evaluate the feasibility of a physiotherapy-led integrated care intervention for older adults discharged from the ED (ED-PLUS)., Methods: Older adults presenting to the ED with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED-PLUS (trial registration: NCT04983602). ED-PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a 6-week, multi-component, self-management programme in the patient's own home. Feasibility (recruitment and retention rates) and acceptability of the programme were assessed quantitatively and qualitatively. Functional decline was examined post-intervention using the Barthel Index. All outcomes were assessed by a research nurse blinded to group allocation., Results: Twenty-nine participants were recruited, indicating 97% of our recruitment target; 90% of participants completed the ED-PLUS intervention. All participants expressed positive feedback about the intervention. The incidence of functional decline at 6 weeks was 10% in the ED-PLUS group versus 70%-89% in the usual care and CGA-only groups., Discussion: High adherence and retention rates were observed among participants and preliminary findings indicate a lower incidence of functional decline in the ED-PLUS group. Recruitment challenges existed in the context of COVID-19. Data collection is ongoing for 6-month outcomes.

Introduction: Early supported discharge (ESD) aims to link acute and community care, allowing hospital inpatients to return home and continue to receive the necessary input from healthcare professionals that they would otherwise receive in hospital. It has been researched extensively in the stroke population, showing reduced length of stay for patients and improved functional outcomes. This systematic review aims to explore the totality of evidence for the use of ESD in an older adult population who have been hospitalised with medical complaints., Methods: Systematic searches were conducted in MEDLINE, CINAHL, Ebsco, Cochrane Library and EMBASE. Randomised controlled trials (RCTs) and quasi-RCTs were included if they provided an ESD intervention to older adults admitted to hospital for medical complaints compared with usual inpatient care. Patient and process outcomes were explored. The Cochrane Risk of Bias Tool was used to assess methodological quality. A meta-analysis was conducted using RevMan 5.4.1., Results: Five RCTs met the inclusion criteria. The quality of the trials was mixed overall, with high levels of heterogeneity. ESD demonstrated a statistically significant reduction in length of stay (MD -6.04 days, 95% CI -9.76 to -2.32) and improvements in function, cognition, and health-related quality of life, with no increased risk of long-term care admission, hospital re-admission or mortality in the ESD interventions versus usual care groups., Discussion: This review demonstrates that ESD positively impacts patient and process outcomes for older adults. Further consideration should be given to exploring the experiences of those involved in ESD including older adults, family members/caregivers as well as healthcare professionals.

Introduction: Early supported discharge (ESD) is well established as a model of health service delivery for people with stroke. Emerging evidence indicates that ESD also reduces the length of stay for older medical inpatients. There is a dearth of evidence exploring the views of stakeholders on ESD as a model of care for older medical inpatients. The overall aim of this study is to explore the views and perceptions of older adults, family carers and healthcare professionals on the potential role of ESD for older adults admitted to hospital with medical complaints., Methods: Purposeful sampling was used to recruit older adults and family carers for interview. For Healthcare Professionals (HCPs), snowball purposeful sampling was used. Phone interviews took place following a semi-structured interview guide. Focus groups were moderated by A-MM. Braun and Clarke's approach to thematic analysis was used. Ethical approval was granted by the HSE Mid-Western Area Regional Ethics Committee in November 2021 (REC Ref. 096/2021)., Results: Fifteen HCPs took part across three focus groups, with six older adults and two family members participating in one-to-one interviews. Three themes were identified: 1. Pre-ESD experiences of providing and receiving older adult inpatient care, 2. Navigating discharge procedures from acute hospital services, 3. A vision for more integrated model of care and a medical ESD team., Discussion: This study provided insight into the current discharge experiences of older adult care in the acute setting, the potential role for ESD in this population and the key factors that would need to be considered for the running of an ESD service for older adults admitted to hospital with medical complaints., Conclusion: This research highlights the barriers and facilitators to ESD for older medical inpatients from the perspectives of key stakeholders. Given the adverse outcomes associated with prolonged hospital stay, these findings will help inform the development of a feasibility trial, examining patient and process outcomes for older adults admitted to hospital with medical complaints who receive an ESD intervention., Competing Interests: The authors declare that they have no competing interest in this work., (© 2022 Williams et al.)

Introduction: The increasing number of older adults with multiple complex care needs has placed increased pressure on healthcare systems internationally to reorientate healthcare delivery. For many older adults, their first point of contact with the health service is with their general practitioner (GP) and GP participation with integrated care models is the foundation of a population-based approach. A knowledge gap remains in relation to the effectiveness of GP participation in community-based integrated health and social care approaches for older adults. This systematic review aims to examine the effectiveness of multidisciplinary-integrated care for community-dwelling older adults with GP participation., Methods and Analysis: This systematic review will include randomised controlled trials (RCTs), quasi and cluster RCTs focusing on integrated care interventions for community-dwelling older adults by multidisciplinary teams including health and social care professionals and GPs. The databases PUBMED, EMBASE, CINAHL, Central Register of Controlled Trials in the Cochrane Library and MEDLINE will be searched. The primary outcome measure will be functional status. Secondary outcomes will include: primary healthcare utilisation, secondary healthcare utilisation, participant satisfaction with care, health-related quality of life, nursing home admission and mortality. The methodological quality of the studies will be assessed using the Cochrane Risk of Bias Tool V.2. The elements of care integration will be mapped in the individual studies using the Rainbow Model of Integrated Care taxonomy. A meta-analysis will be completed, depending on the uniformity of the data. Grading of Recommendations, Assessment, Development and Evaluation will be used to assess the certainty of evidence., Ethics and Dissemination: Formal ethical approval is not required as all data included are anonymous secondary data. Scientific outputs will be presented at relevant conferences and in collaboration with our public and patient involvement stakeholder panel of older adults at the Ageing Research Centre at the University of Limerick., Prospero Registration Number: CRD42022309744., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The presence of lymph node metastases is a well-studied prognostic factor for cutaneous melanoma. Characterization of melanoma lymph node metastases and their association with survival in multiple, large observational studies has led to recognition of the following high-risk features: quantity of lymph node metastases (number of nodes), size of the nodal tumor deposit (in mm), and extracapsular extension. Despite increasing utilization of these features in the design of randomized clinical trials, in addition to their role in contemporary clinical decision-making, current staging systems lag behind, only accounting for the quantity of lymph nodes with metastases. Herein, we review the prognostic role of melanoma lymph node metastases and their high-risk features, current reporting standards, how such features have been utilized in practice-changing trials, and best practices for future clinical trial design and clinical decision-making., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Rhodin, Fimbres, Burner, Hollander, O’Connor and Beasley.)

Background: Comprehensive geriatric assessment (CGA) has been shown to improve outcomes in hospitalised older adults; however, there is currently no compelling evidence to support CGA interventions within the Emergency Department (ED). The aim of this study is  to explore the clinical and process outcomes of older adults who receive ED-CGA over a period of six months after their initial ED attendance. Design: Prospective cohort study. Methods: The STrengthening the Reporting of the OBservational studies in Epidemiology (STROBE) standardised reporting guidelines will be adhered to. Older adults aged ≥65 years who score ≥2 on the Identification of Seniors at Risk (ISAR) tool and present to the ED with a medical complaint during the operational hours of the dedicated interdisciplinary team, will be considered eligible for recruitment. Demographic and health assessment information will be obtained at the ED index attendance followed by completion of an interdisciplinary CGA. A dedicated research nurse will complete follow-up telephone interviews with participants at 30 days and six months. The primary outcome will be incidence of hospital admission from the ED index attendance. Secondary outcomes will include functional decline, patient satisfaction with the ED index attendance, unscheduled ED reattendance(s), unscheduled hospital (re)admission(s), nursing home admission(s), healthcare utilisation, and death. Descriptive statistics will be used to profile the characteristics of the study participants and multivariate logistic and linear regression analysis will be used to analyse risk of adverse outcomes. Ethics and dissemination: Ethical approval was granted by the University of Limerick Hospital Group Research Ethics Committee (107/2021). The authors will disseminate study findings through publication in a peer-reviewed journal and presentation at national and international conferences. Patient and public involvement will be sought from a panel of older adults at the Ageing Research Centre in the University of Limerick. Clinicaltrials.gov Identifier: NCT05252182., Competing Interests: No competing interests were disclosed., (Copyright: © 2022 O'Shaughnessy Í et al.)

Background: There is encouraging evidence that interdisciplinary teams of Health and Social Care Professionals (HSCPs) can enhance patient care in the Emergency Department (ED), especially for older adults with complex needs. However, no formal process evaluations of implementations of ED-based HSCP interventions are available. The study aimed to evaluate the development and delivery of a HSCP team intervention for older adults in the ED of a large Irish teaching hospital., Methods: Using the Medical Research Council (MRC) Framework for process evaluations, we investigated implementation and delivery, mechanisms of impact, and contextual influences on implementation by analysing the HSCP team's activity notes and participant recruitment logs, and by carrying out six interviews and four focus groups with 26 participants (HSCP team members, ED doctors and nurses, hospital staff). Qualitative insights were analysed thematically., Results: The implementation process had three phases (pre-implementation, piloting, and delivery), with the first two described as pivotal to optimise care procedures and build positive stakeholders' involvement. The team's motivation and proactive communication were key to promote acceptability and integration in the ED (Theme 1); also, their specialised skills and interdisciplinary approach enhanced patient and staff's ED experience (Theme 2). The investment and collaboration of multiple stakeholders were described as essential contextual enablers of implementation (Theme 4). Delivering the intervention within a randomised controlled trial fostered credibility but caused frustration among patients and staff (Theme 3)., Discussion: This process evaluation is the first to provide in-depth and practical insights on the complexities of developing and delivering an ED-based HSCP team intervention for older adults. Our findings highlight the importance of establishing a team of HSCPs with a strong interdisciplinary ethos to ensure buy-in and integration in the ED processes. Also, actively involving relevant stakeholders is key to facilitate implementation., Trial Registration: ClinicalTrials.gov, NCT03739515; registered on 12th November 2018., Competing Interests: The authors declare that they have no competing interests

Introduction: Early supported discharge (ESD) aims to link acute and community care, allowing hospital inpatients to return home and continue to receive the necessary input from healthcare professionals that they would otherwise receive in hospital. The concept has shown reduced length of stay and improved functional outcomes in stroke patients. This systematic review aims to explore the totality of evidence for the use of early supported discharge in older adults hospitalised with medical complaints., Methods: A literature search of CINAHL in EBSCO, Cochrane Central Register of Controlled Trials in the Cochrane Library (CENTRAL), EMBASE and MEDLINE in EBSCO was carried out. Randomised controlled trials or quasi-randomised controlled trials were included. The Cochrane Risk of Bias Tool 2.0 was used for quality assessment. The primary outcome measure was hospital length of stay. Secondary outcomes included mortality, function, health related quality of life, hospital readmissions, long-term care admissions and cognition. A pooled meta-analysis was conducted using RevMan software 5.4.1., Results: Five studies met the inclusion criteria. All studies were of some concern in terms of their risk of bias. Statistically significant effects favouring ESD interventions were only seen in terms of length of stay (REM, MD = -6.04, 95% CI -9.76 to -2.32, I 2  = 90%, P = 0.001). No statistically significant effects favouring ESD interventions were established in secondary outcomes., Conclusion: ESD interventions can have a statistically significant impact on the length of stay of older adults admitted to hospital for medical reasons. There is a need for further higher quality research in the area, with standardised interventions and outcome measures used., (© 2022. The Author(s).)

Background: Comprehensive geriatric assessment (CGA) has been shown to improve outcomes in hospitalised older adults; however, there is currently no compelling evidence to support CGA interventions within the Emergency Department (ED). The aim of this study is  to explore the clinical and process outcomes of older adults who receive ED-CGA over a period of six months after their initial ED attendance. Design: Prospective cohort study. Methods: The STrengthening the Reporting of the OBservational studies in Epidemiology (STROBE) standardised reporting guidelines will be adhered to. Older adults aged ≥65 years who score ≥2 on the Identification of Seniors at Risk (ISAR) tool and present to the ED with a medical complaint during the operational hours of the dedicated interdisciplinary team, will be considered eligible for recruitment. Demographic and health assessment information will be obtained at the ED index attendance followed by completion of an interdisciplinary CGA. A dedicated research nurse will complete follow-up telephone interviews with participants at 30 days and six months. The primary outcome will be incidence of hospital admission from the ED index attendance. Secondary outcomes will include functional decline, patient satisfaction with the ED index attendance, unscheduled ED reattendance(s), unscheduled hospital (re)admission(s), nursing home admission(s), healthcare utilisation, and death. Descriptive statistics will be used to profile the characteristics of the study participants and multivariate logistic and linear regression analysis will be used to analyse risk of adverse outcomes. Ethics and dissemination: Ethical approval was granted by the University of Limerick Hospital Group Hospital Research Ethics Committee (107/2021). The authors will disseminate study findings through publication in a peer-reviewed journal and presentation at national and international conferences. Patient and public involvement will be sought from a panel of older adults at the Ageing Research Centre in the University of Limerick. Clinicaltrials.gov Identifier: NCT05252182., Competing Interests: No competing interests were disclosed., (Copyright: © 2022 O'Shaughnessy Í et al.)

Background: the aim of this systematic review and meta-analysis was to update and synthesise the totality of research evidence on the effectiveness of acute geriatric unit (AGU) care for older adults admitted to hospital with acute medical complaints., Methods: MEDLINE, CINAHL, CENTRAL and Embase databases were systematically searched from 2008 to February 2022. Screening, data extraction and quality grading were undertaken by two reviewers. Only trials with a randomised design comparing AGU care and conventional care units were included. Meta-analyses were performed in Review Manager 5.4 and the Grading of Recommendations, Assessment, Development and Evaluations framework was used to assess the certainty of evidence. The primary outcome was incidence of functional decline between baseline 2-week prehospital admission status and discharge and at follow-up., Results: 11 trials recruiting 7,496 participants across three countries were included. AGU care resulted in a reduction in functional decline at 6-month follow-up (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.66-0.93; moderate certainty evidence) and an increased probability of living at home at 3-month follow-up (RR 1.06, 95% CI 0.99-1.13; high certainty evidence). AGU care resulted in little or no difference in functional decline at hospital discharge or at 3-month follow-up, length of hospital stay, costs, the probability of living at home at discharge, mortality, hospital readmission, cognitive function or patient satisfaction., Conclusions: AGU care improves clinical and process outcomes for hospitalised older adults with acute medical complaints. Future research should focus on greater inclusion of clinical and patient reported outcome measures., (© The Author(s) 2022. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

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., (© 2021. Royal Academy of Medicine in Ireland.)

Background: Providing palliative care for individuals who use alcohol and/or drugs poses a multi-faceted challenge. In addition to clinical and social needs, individuals may endure mental health problems, co-morbidities and homelessness, thus requiring a multi-disciplinary, flexible approach to care., Aim: To identify the palliative care needs and models of care for people who use drugs and/or alcohol., Design: A mixed-methods systematic review was conducted using the JBI Manual for Evidence Synthesis., Data Sources: Six databases were searched to identify relevant studies. Full text review and quality appraisal were completed independently and in-duplicate by two reviewers with conflicts resolved by a third reviewer. Qualitative and quantitative data were tabulated together using narrative synthesis, then categorised according to outcomes of interest, with similar and divergent findings reported accordingly., Results: Thirteen studies were included, nine qualitative and four quantitative, using a range of data collection methods, across various settings. The difficulties for individuals who use alcohol and/or drugs as well as their formal and informal carers, in relation to end-of-life care were examined, revealing access, care and skills issues. Three themes emerged which could underpin the development of a model of care: interpersonal/organisational relationships; holistic care; and collaborating with other services and training., Conclusion: Despite end-of-life needs of this population being different to others, challenges include creating inclusive policies, sensitising staff to distinctive individual needs and training exchanges for staff working in both drug and alcohol services and palliative care.

Introduction: Frailty is associated with adverse outcomes relating to cardiac procedures. It has been proposed that frailty scoring should be included in the preoperative assessment of patients undergoing aortic valve replacement. We aim to examine the Rockwood Clinical Frailty Scale (CFS), as a predictor of adverse outcomes following aortic valve replacement., Methods and Analysis: Prospective and retrospective cohort studies and randomised controlled trials assessing both the preoperative frailty status (as per the CFS) and incidence of adverse outcomes among older adults undergoing either surgical aortic valve replacement or transcatheter aortic valve replacement will be included. Adverse outcomes will include mortality and periprocedural complications, as well as a composite of 30-day complications. A search will be conducted from 2005 to present using a prespecified search strategy. Studies will be screened for inclusion by two reviewers, with methodological quality assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Relative risk ratios with 95% CIs will be generated for each outcome of interest, comparing frail with non-frail groups. Data will be plotted on forest plots where applicable. The quality of the evidence will be determined using the Grading of Recommendations, Assessment, Development and Evaluation tool., Ethics and Dissemination: Ethical approval is not required for this study as no primary data will be collected. We will publish the review in a peer-reviewed journal on completion., Prospero Registration Number: CRD42020213757., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Older adults frequently attend the emergency department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. This paper reports a protocol designed to evaluate the feasibility of conducting a three arm randomised controlled trial (RCT) within the ED setting and in the patient's home. The interventions are comprehensive geriatric assessment (CGA), ED PLUS and usual care., Methods: The ED PLUS pilot trial is designed as a feasibility RCT conducted in the ED and Acute Medical Assessment Unit of a university teaching hospital in the mid-west region of Ireland. We aim to recruit 30 patients, aged 65 years and over presenting to the ED with undifferentiated medical complaints and discharged within 72 h of index visit. Patients will be randomised by a computer in a ratio of 1:1:1 to deliver usual care, CGA or ED PLUS during a 6-month study period. A randomised algorithm is used to perform randomization. CGA will include a medical assessment, medication review, nursing assessment, falls assessment, assessment of mobility and stairs, transfers, personal care, activities of daily living (ADLs), social supports and baseline cognition. ED PLUS, a physiotherapist led, multidisciplinary intervention, aims to bridge the transition of care between the index visit to the ED and the community by initiating a CGA intervention in the ED and implementing a 6-week follow-up self-management programme in the patient's own home following discharge from the ED. The outcomes will be parameters of the feasibility of the intervention and trial methods and will be assessed quantitatively and qualitatively., Discussion: Rising ED visits and an ageing population with chronic health issues render ED interventions to reduce adverse outcomes in older adults a research priority. This feasibility RCT will generate data and experience to inform the conduct and delivery of a definite RCT., Trial Registration: The trial was registered in Clinical Trials Protocols and Results System as of 21 st July 2021, with registration number NCT049836020 ., (© 2021. The Author(s).)

Individuals with Fanconi anemia (FA), a rare genetic bone marrow failure syndrome, have an increased risk of young-onset head and neck squamous cell carcinomas (SCCs) and esophageal SCC. The FA DNA repair pathway is activated upon DNA damage induced by acetaldehyde, a chief alcohol metabolite and one of the major carcinogens in humans. However, the molecular basis of acetaldehyde-induced genomic instability in SCCs of the head and neck and of the esophagus in FA remains elusive. Here, we report the effects of acetaldehyde on replication stress response in esophageal epithelial cells (keratinocytes). Acetaldehyde-exposed esophageal keratinocytes displayed accumulation of DNA damage foci consisting of 53BP1 and BRCA1. At physiologically relevant concentrations, acetaldehyde activated the ATR-Chk1 pathway, leading to S- and G2/M-phase delay with accumulation of the FA complementation group D2 protein (FANCD2) at the sites of DNA synthesis, suggesting that acetaldehyde impedes replication fork progression. Consistently, depletion of the replication fork protection protein Timeless led to elevated DNA damage upon acetaldehyde exposure. Furthermore, FANCD2 depletion exacerbated replication abnormalities, elevated DNA damage, and led to apoptotic cell death, indicating that FANCD2 prevents acetaldehyde-induced genomic instability in esophageal keratinocytes. These observations contribute to our understanding of the mechanisms that drive genomic instability in FA patients and alcohol-related carcinogenesis, thereby providing a translational implication in the development of more effective therapies for SCCs., (© 2021 The Authors. Molecular Oncology published by John Wiley & Sons Ltd on behalf of Federation of European Biochemical Societies.)

Introduction: Early supported discharge (ESD) aims to link acute and community care, allowing hospital inpatients to return home and continue to receive the necessary input from healthcare professionals that they would otherwise receive in hospital. The concept has been researched extensively in the stroke population, showing reduced length of stay for patients and improved functional outcomes. This systematic review aims to explore the totality of evidence for the use of ESD in an older adult population who have been hospitalised with medical complaints., Methods: A systematic review of randomised controlled trials and quasi randomised controlled trials will be carried out in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies will be included if they provide an ESD intervention to older adults admitted to hospital for medical complaints compared with continuing inpatient care. MEDLINE, CINAHL, CENTRAL and EMBASE databases will be searched. The primary outcome measure will be length of hospital stay, secondary outcomes will include functional abilities, falls, quality of life, carer and patient satisfaction, unplanned emergency department re-presentation, unscheduled hospital readmission, nursing home admission or mortality. Titles and abstracts of studies will be screened independently by two authors. The Cochrane Risk of Bias Tool will be used independently by two reviewers to assess the methodological quality of the included studies. GRADE will be used to assess the quality of the body of evidence. A pooled meta-analysis will be conducted using RevMan software V.5.4.1, depending on the uniformity of the data., Ethics and Dissemination: The authors will present the findings of the review to a patient and public involvement stakeholder panel of older people that has been established at the Ageing Research Centre in the University of Limerick. Formal ethical approval is not required for the review as all data collected will be secondary data and will be analysed anonymously., Prospero Registration Number: CRD42021223112., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Older adults are clinically heterogeneous and are at increased risk of adverse outcomes during hospitalisation due to the presence of multiple comorbid conditions and reduced homoeostatic reserves. Acute geriatric units (AGUs) are units designed with their own physical location and structure, which provide care to older adults during the acute phase of illness and are underpinned by an interdisciplinary comprehensive geriatric assessment model of care. This review aims to update and synthesise the totality of evidence related to the effectiveness of AGU care on clinical and process outcomes among older adults admitted to hospital with acute medical complaints., Design: Updated systematic review and meta-analysis METHODS AND ANALYSIS: MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Controlled Trials in the Cochrane Library and Embase electronic databases will be systematically searched from 2008 to February 2021. Trials with a randomised design that deliver an AGU intervention to older adults admitted to hospital for acute medical complaints will be included. The primary outcome measure will be functional decline at discharge from hospital and at follow-up. Secondary outcomes will include length of stay, cost of index admission, incidence of unscheduled hospital readmission, living at home (the inverse of death or institutionalisation combined; used to describe someone who is in their own home at follow-up), mortality, cognitive function and patient satisfaction with index admission. Title and abstract screening of studies for full-text extraction will be conducted independently by two authors. The Cochrane risk of bias 2 tool will be used to assess the methodological quality of the included trials. The quality of evidence for outcomes reported will be assessed using the Grading of Recommendations Assessment, Development and Evaluations framework. A pooled meta-analysis will be conducted using Review Manager, depending on the uniformity of the data., Ethics and Dissemination: Formal ethical approval is not required as all data collected will be secondary data and will be analysed anonymously. The authors will present the findings of the review to a patient and public involvement stakeholder panel of older adults that has been established at the Ageing Research Centre in the University of Limerick. This will enable the views and opinions of older adults to be integrated into the discussion section of the paper., Prospero Registration Number: CRD42021237633., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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 (r s  = 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., (Copyright © 2021 Elsevier Inc. All rights reserved.)