89 Improving Pain Assessment and Management for Patients with Cognitive Impairment on the Care of the Older Person (COOP) Wards

Introduction

Patients with cognitive impairment are at risk of underassessment and inadequate management of pain. Self-reporting is unlikely to be a reliable indicator of pain and numerical scales have reduced validity, hence an alternative assessment tool must be used. The Abbey Pain Scale is widely regarded to be user friendly. Regular analgesia should be used for these patients where possible instead of “as required” (PRN). Using QIP methodology, we aimed to improve the use of the Abbey Pain Scale for assessment of patients with cognitive impairment and better analgesia prescribing.

Methods

Audit of patient records on COOP wards (computer and physical notes, n = 48 first cycle, n = 32 second cycle) before and after staff training, assessing patients with cognitive impairment for: use of Abbey Pain Scale; use of regular paracetamol; pain assessments documented by different healthcare professionals.

Results

In the first cycle, 16 patients had cognitive impairment: only 1 of these patients (6%) was assessed using the Abbey Pain Scale. Group teaching for the multidisciplinary team on pain assessments was undertaken with practice development nurses. In the re-audit, 13 patients had cognitive impairment and 6 of these (46%) were assessed using the Abbey Pain Scale, showing a clear improvement following staff training. The second cycle showed a 50% increase in the prescription of regular paracetamol for patients with cognitive impairment. There was also a 2.5-fold improvement in therapy staff documenting pain assessments between the two audits.

Conclusions

Staff training in the use of the Abbey Pain Scale led to an almost 8-fold increase in its use for patients with cognitive impairment. Training on the use of the Abbey Pain Scale should be regularly provided to nurses, physiotherapists and doctors on the care of the older person wards.

Vaccine-Preventable Infections Among Solid Organ Transplant Recipients: A Data-Linked Cohort Study, Australia, 2000-2015

IntroductionRecipients of solid organ transplants are at risk of serious infection due to immunosuppression. Some infections are preventable with vaccination; infection rates vary with immunosuppression, vaccination rates and baseline disease prevalence. Both adherence with and response to vaccination in this population are variable, and optimum vaccination strategies continue to be refined. Objectives and ApproachWe aimed to characterise the incidence and complications of vaccine-preventable infections in transplant recipients. Eligible participants received an organ transplant in New South Wales, Australia, in 2000-2015. Linkage was undertaken between transplant registries and the notifiable conditions information management system. Vaccine-preventable infections were diphtheria, Haemophilus influenzae type b, influenza, invasive pneumococcal disease, measles, mumps, pertussis, poliovirus, rubella and tetanus. Standardized incidence ratios (SIR) were calculated relative to Australian population notification rates, standardizing for gender, age and calendar year. ResultsAmong 3,394 recipients, 399 vaccine-preventable infections affected 339 (10%) recipients. Influenza was the most common vaccine-preventable infection with 352 notifications among 305 recipients. Influenza cases were 8.9 times more common among transplant recipients than the general population (95%CI: 8.0-10.0). In 36 cases (10%), hospitalization was required, and 2 deaths due to influenza were reported. There were 20 notifications of invasive pneumococcal disease (IPD) for 18 recipients. IPD occurred 10.2 times more often among transplant recipients than the general population (95%CI: 6.4-16.2). Most (n=13, 65%) cases were hospitalized, and one patient died from IPD. Cases of pertussis occurred only slightly more often than in the general population (SIR 1.5, 95%CI: 1.0-2.3). Of 26 cases, there was one reported hospitalization and no deaths due to pertussis. Only one case of mumps, and no other vaccine-preventable infections, were reported. ConclusionTransplant recipients have excess cases of influenza and IPD compared to the general population, although this has improved over time. The need for appropriate recipient vaccination is emphasized.

Nurse-led advance care planning with older people who have end-stage kidney disease: feasibility of a deferred entry randomised controlled trial incorporating an economic evaluation and mixed methods process evaluation (ACReDiT)

BACKGROUND

Advance Care Planning is recommended for people with end-stage kidney disease but evidence is limited. Robust clinical trials are needed to investigate the impact of advance care planning in this population. There is little available data on cost-effectiveness to guide decision makers in allocating resources for advance care planning. Therefore we sought to determine the feasibility of a randomised controlled trial and to test methods for assessing cost-effectiveness.

METHODS

A deferred entry, randomised controlled feasibility trial, incorporating economic and process evaluations, with people with end-stage kidney disease, aged 65 years or older, receiving haemodialysis, in two renal haemodialysis units in Northern Ireland, UK. A nurse facilitator helped the patient make an advance care plan identifying: a surrogate decision-maker; what the participant would like to happen in the future; any advance decision to refuse treatment; preferred place of care at end-of-life.

RESULTS

Recruitment lasted 189 days; intervention and data collection 443 days. Of the 67 patients invited to participate 30 (45%) declined and 36 were randomised to immediate or deferred advance care plan groups. Twenty-two (61%) made an advance care plan and completed data collection at 12 weeks; 17 (47.2%) were able to identify a surrogate willing to be named in the advance care plan document. The intervention was well-received and encouraged end-of-life conversations, but did not succeed in helping patients to fully clarify their values or consider specific treatment choices. There was no significant difference in health system costs between the immediate and deferred groups.

CONCLUSIONS

A trial of advance care planning with participants receiving haemodialysis is feasible and acceptable to patients, but challenging. A full trial would require a pool of potential participants five times larger than the number required to complete data collection at 3 months. Widening eligibility criteria to include younger (under 65 years of age) and less frail patients, together with special efforts to engage and retain surrogates may improve recruitment and retention. Traditional advance care planning outcomes may need to be supplemented with those that are defined by patients, helping them to participate with clinicians in making medical decisions.

TRIAL REGISTRATION

Registered December 16, 2015. ClinicalTrials.gov Identifier: NCT02631200 .

Fuzzy fractional-order model of the novel coronavirus

In this paper, a novel coronavirus infection system with a fuzzy fractional differential equation defined in Caputo's sense is developed. By using the fuzzy Laplace method coupled with Adomian decomposition transform, numerical results are obtained for better understanding of the dynamical structures of the physical behavior of COVID-19. Such behavior on the general properties of RNA in COVID-19 is also investigated for the governing model. The results demonstrate the efficiency of the proposed approach to address the uncertainty condition in the pandemic situation.

Development of Bioadhesive Buccal Tablets of Nicorandil Using a Factorial Approach

OBJECTIVES

In the present investigation, bioadhesive buccal tablets were prepared using the sustained-release polymer hydroxypropyl methylcellulose (HPMC) K100M, bioadhesive polymer neem gum, and an impervious backing layer of ethyl cellulose. Nicorandil is sensitive to the first-pass effect; therefore, a buccal-adhesive dosage form can avoid this effect.

MATERIALS AND METHODS

We used the direct compression technique to prepare the tablet formulation. A 3² full factorial design was composed in which the amounts of HPMC K100M (X1) and neem gum (X2) were chosen as the independent variables and the dependent variables were the percentage drug release at 6 h (Y1) and mucoadhesive strength in grams (Y2). Various in vitro parameters, i.e. thickness, friability, hardness, weight variation, surface pH, moisture absorption ratio, dissolution studies, and drug release kinetics, and ex vivo parameters like mucoadhesive strength and mucoadhesion time were determined for the prepared tablets. We subjected the optimized batch to a comparison with the marketed formulation and stability studies were performed.

RESULTS

The formulation containing a 50:50 ratio of neem gum and HPMC K100M (F5) was considered optimum. The zero-order release kinetics model best fitted the optimized batch release profile, suggesting the system would release the drug at a constant rate.

CONCLUSION

The release by the optimized formulation of the drug at a sustained rate along with its bioadhesive nature showed that the buccal route can be an option for the administration of nicorandil.

0869 Slow Wave Sleep Is Associated With Decreased Risk Of Gestational Diabetes Mellitus

Introduction

Pregnancy is associated with disrupted slow-wave sleep (SWS) and a high prevalence of sleep disordered breathing (SDB), which may further exacerbate the decrease of deep sleep. Reduced slow wave sleep may impair glucose homeostasis, contributing to Gestational Diabetes Mellitus (GDM). Studies investigating EEG markers of deep and light sleep, and their associations with SDB and GDM are lacking. In this study, we measured associations of EEG Delta-power with objective SDB measures assessed in late-pregnancy to determine if changes in these bands are associated with GDM risk.

Methods

74 women (24-36 weeks pregnancy) underwent overnight polysomnography. Spectral profiles for Delta relative power were created for NREM and REM sleep after removing epochs with movements or muscle artifacts. The association of Delta power with SDB, assessed by the Apnea Hypopnea-Index (AHI) and AHI-based SDB severity (none, mild, moderate, severe) was tested by multivariate linear regression including demographic variables with bivariate correlations (p<0.2) versus Delta-power. Conditional-regression was used to explore relationships between Delta-power and GDM, controlling for covariates.

Results

Obstructive Sleep Apnea (OSA, AHI>5) was present in 14% of subjects (8 GDM-cases and 3 controls). In bivariate analyses, AHI, AHI-severity categories and OSA were associated with Delta-power in NREM (all p<0.2) and AHI was associated with Delta relative-power in REM (p=0.18). However, these associations did not remain significant after adjusting for covariates. Delta relative-power in NREM was significantly associated with decreased risk of GDM (OR:0.50, 95%CI-0.25,0.91), but, in REM sleep, was not associated with GDM risk (OR:1.25, 95%CI-0.79,1.97).

Conclusion

These analyses failed to demonstrate an association between OSA or OSA severity and EEG Delta power. However, lower levels of SWS, characterized by low Delta power were associated with increased GDM risk.

Support

NIH-R00-NR013187

Abstract P1-20-22: Evaluating the use of targeted axillary dissection and comprehensive physical therapy to reduce the risk of lymphedema in node-positive breast cancer patients

Background: Before the advent of neoadjuvant chemotherapy (NC), the standard of care for node-positive breast cancer patients was to undergo complete axillary lymph node dissection (ALND). These patients also generally receive adjuvant radiation (AR), including axillary lymph node radiation. However, ALND and AR have been shown to increase the risk of secondary lymphedema to 20-30%. When treated with NC, resolution of all nodal metastasis to pathologically confirmed node-negative disease occurs in approximately 40% of patients. Such patients are eligible for targeted axillary dissection (TAD), which involves removal of clipped biopsy-positive node and sentinel nodes. TAD patients also receive AR, and their lymphedema rate has been reported at 10-12%. There is considerable variability on recommended protocols for lymphedema prevention in these patients. The goal of this study was to investigate whether TAD in combination with comprehensive physical therapy can further reduce the risk of lymphedema in node-positive breast cancer patients receiving NC.

Methods: An IRB-approved retrospective review was conducted of 29 consecutive patients undergoing NC and localization of axillary nodes for their breast cancer surgery between Aug 2016 and Dec 2018. Patients with negative nodes intra-operatively underwent TAD only whereas those with positive nodes underwent ALND. Comprehensive physical therapy program included deep myofascial release, range of motion exercises, and stretching. Patients with ALND were provided prophylactic compression sleeve for 3 months. The main outcome measures were Lymphedema Index (L-DEX) scores (normal range -10 to +10) and range of motion at 1 month post-surgery. Lymphedema was also monitored clinically for a median duration of 7 months post-surgery. Baseline characteristics and outcomes between the TAD and ALND groups were compared.

Results: A total of 16 patients underwent TAD whereas 13 underwent ALND (Table 1). Post-NC stages were 11 Stage 0, 3 Stage I, 9 Stage IIB, 5 Stage III A, 1 Stage IIIC. 10 patients completed breast conservation surgery, 13 had mastectomy with implant-based reconstruction (9 nipple-sparing mastectomy, 4 skin-sparing mastectomy), and 6 had mastectomy without immediate reconstruction. The clipped node was localized at a median of 1 day (range 1-35) before surgery, and 100% of the clipped nodes were retrieved. 28/29 (97%) patients underwent AR (1 patient refused). There were no statistically significant differences in pre-op L-DEX and 1-month post-op L-DEX between TAD and ALND groups. At 1-month post-op, 22 patients had full and 7 had limited range of motion. Two ALND patients with BMI of 25.8 and 32.2 kg/m2 developed lymphedema at 9.2 and 16 months respectively after surgery and were successfully managed with physical therapy. None of the 29 patients experienced tumor recurrence after a median follow-up of 7 months.

Conclusion: This preliminary study found no evidence of lymphedema in TAD and ALND patients at one month following surgery. After a median follow-up of 7 months, 15% of ALND patients but no TAD patients experienced lymphedema. Prospective studies with large sample sizes are needed to further investigate the role of TAD combined with physical therapy in reducing the risk of lymphedema.

Table 1: Comparison of patient characteristics and outcomes between TAD and ALND (N=29)CharacteristicTAD (n=16)ALND (n=13)P-valueMedian age in years49.654.50.28Median BMI in kg/m226.432.20.16Response to NCComplete response10 (62.5)1 (7.7)0.01*Partial response6 (37.5)9 (69.2)No response0 (0)3 (23.1)Median sentinel nodes removed320.02*Median size of clipped node (mm)15200.04*Median follow-up duration in months7.75.80.37Median number of PT visits380.20Median L-DEX score pre-op-1.5-1.30.73Median L-DEX score 1 month post-op-2.72.10.55Median L-DEX score difference (post-op minus pre-op)0.4-0.10.98Range of motion 1 month post-opFull14 (87.5)8 (61.5)0.10Limited2 (12.5)5 (38.5)Deep myofascial release to axilla and breast 1 month post-opYes12 (75)11 (84.6)0.53No4 (25)2 (15.4)Lymphedema during long-term follow-upYes0 (0)2 (15.4)No16 (100)11 (84.6)0.10Values in parentheses are column percentages*P <= 0.05

Citation Format: Miral Amin, Karan Shah. Evaluating the use of targeted axillary dissection and comprehensive physical therapy to reduce the risk of lymphedema in node-positive breast cancer patients [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-20-22.

62 Geriatric Surgical Liaison Staff Perspectives of Geriatric Care Before and After Introduction of An Embedded Service

Introduction

National evidence demonstrates that older people having surgery, both in the elective and emergency setting, have more adverse outcomes postoperatively when compared with their younger counterparts (1). National reports have recommended daily input from a geriatric team for older patients having surgery (2). At our hospital we have introduced a geriatric surgical liaison consultant as a formal post to ensure daily geriatric input or review for patients over the age of 70 or comorbid younger patients as requested. The aim of this study was to review perspectives across the multi-disciplinary team on care provided to these patients before and after introduction of the surgical liaison team.

Methods

We created a 10 part questionnaire, which was distributed amongst all members of the multi-disciplinary team, asking them to rate confidence out of 10 in management of comorbidity, polypharmacy, discharge planning, pain assessments and nutrition. These data were then analysed to produce median scores for each category before and after the introduction of the service. We compared the change in scores between the foundation year 1 (FY1) doctors and the remainder of the respondents.

Results

The below table demonstrates the median scores across all 36 respondents in their confidence with the assessment and management of the 10 key domains before and after the liaison service was introduced:

Conclusions

Universally within our survey, staff reported improvement in all 10 key indicators of care of older patients on surgery with the introduction of a geriatric surgical liaison team. Greatest benefit was seen within the FY1 group.

References

1. McVeigh TP, Al-Azawi D, O'Donoghue GT, Kerin MJ. Assessing the impact of an ageing population on complication rates and in-patient length of stay, Int J Surg, 2013, vol. 11 (pg. 872–5).

2. Wilkinson K. An age old Problem: A Review of the Care Received by Elderly Patients Undergoing Surgery: A Report by the National Confidential Enquiry Into Patient Outcome and Death. London, 2010.

Influence of pyrolysis parameters on phosphorus fractions of biosolids derived biochar

Transforming biosolids into biochar, through pyrolysis, could result in more sustainable waste management. Influence of pyrolysis conditions (temperature, heating rate and residence time) on physico-chemical properties of biosolids (collected at Mount Martha Water Recycling Plant, Melbourne), phosphorus fractions and phosphorus forms was investigated. Twelve different biochar samples were produced at 400, 500 and 600 °C, at two heating rates (5 and 20 °C/min) and at two residence times (30 and 120 min). Biochar yield, pH, electrical conductivity (EC), elements (C, H and N) and BET surface area were analysed. Sequential extraction of P in biosolids and resultant biochars was done using Hedley method. Characterization was completed with SEM images and results from ³¹P liquid state NMR. Increased temperatures would not only increase the alkalinity, decrease EC and increase the adsorption capacity by increasing the surface area but also convert the readily available P to a less available pool. Therefore, this nutrient might be released to soil slowly over a longer period of time. The results showed that temperature, along with residence time and heating rate, had a significant effect on the characteristics observed. Therefore, all these factors need to be carefully considered when preparing biochar for use as a soil amendment.

Woodhouse-Sakati syndrome in a family is associated with a homozygous start loss mutation in the DCAF17 gene

BACKGROUND

Woodhouse-Sakati syndrome (WSS) is a rare neuroendocrine and ectodermal disorder inherited in an autosomal recessive pattern. The syndrome presents prominent clinical features, including alopecia, neuroendocrine defects, neurological findings and progressive hearing loss. The condition results from mutations in the DCAF17 gene.

AIMS

To search for the underlying genetic defect in a Pakistani family with WSS phenotypes.

METHODOLOGY

Whole exome sequencing was used to search for the disease-causing variant.

RESULTS

Analysis of the exome data revealed a start loss sequence variant (c.1A>G, p.M1?) in DCAF17.

CONCLUSION

This variant is predicted to abolish translation of the DCAF17 polypeptide. To our knowledge, this is the first start loss variant identified in the DCAF17.

Peripheral retinal avascularity and capillary leakage in central serous chorioretinopathy

Purpose

To report a novel finding of peripheral retinal avascularity (PRA) and peripheral capillary leakage (PCL) on wide-field fluorescein angiography (WFA) in non-dependent quadrants, in eyes with bilateral chronic central serous chorioretinopathy (CSCR).

Methods

Forty six patients with bilateral CSCR were studied. Four patients had PRA and PCL, and 42 patients did not. The demographic profile, clinical findings, and imaging characteristics of the two groups were compared.

Results

There was no significant difference between those patients with and without PRA and PCL with respect to the demographic profile, clinical findings, and imaging characteristics. Laser photocoagulation to extrafoveal points of leakage seen on fluorescein angiography (FA) was sufficient to cause complete resolution of CSCR in these 4 patients. PRA areas were not treated.

Conclusion

The PRA and PCL in CSCR are novel findings, which have not been previously described.