Decreasing Length of Stay in Opioid Withdrawal

INTRODUCTION

In 2017, more than 1,200 opioid-related deaths were reported in Virginia, with slightly fewer in 2018, at 1,193 deaths. The current opioid crisis has placed a strain on an already limited number of mental health (MH) inpatient beds. The industry standard for assessment and treatment of opioid withdrawal symptoms, in the inpatient setting, is the Clinical Opiate Withdrawal Scale (COWS), and yet some units continue to utilize the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) for this population.

AIM

The purpose of this nurse-led performance improvement project was to implement COWS in the inpatient MH setting and improve length of stay (LOS) by 1 day.

METHOD

In 2018, in a large federal teaching facility in the mid-Atlantic region, the COWS was implemented to replace the CIWA-Ar for opioid withdrawal, with the focus on decreasing LOS. Prior to implementation of COWS, LOS on the inpatient MH unit for opioid withdrawal was 8.6 days, which was higher than the ~6- to 7-day LOS for surrounding private sector hospitals. Individual electronic medical records were reviewed for LOS and completion of COWS and pertinent details were discussed daily with nursing staff and monthly with the interdisciplinary team. Baseline data were collected from April 2017 to March 2018, with data collection continuing through the project implementation, April to September 2018.

RESULTS

Completion of COWS on 100% of patients admitted with opioid withdrawal and a decrease in LOS from 8.6 to 4.7 days was found, a 45% reduction.

CONCLUSION

The nurse-driven performance improvement project affected business acumen, through decreased LOS, as well as quality of care, through better symptom management.

1080 NURSES’ PREFERENCE FOR TOOLS TO IDENTIFY FRAILTY IN MAJOR TRAUMA PATIENTS: FINDINGS FROM THE FRAIL-T IN MAJOR TRAUMA STUDY

Introduction

Early assessment of frailty in older major trauma patients is important to providing appropriate care that goes beyond chronological age. Guidance exists that this assessment should be completed as early as possible in the Emergency Department (ED). To increase rates of frailty screening in this group the measurement tool needs to be quick to complete and easy to use. This study aimed to ascertain the preference of nursing staff completing frailty assessment in older major trauma patients in the ED.

Method

This prospective multi-centre study recruited from five UK MTCs between June 2019 and March 2020. Eligible patients were aged 65 or over requiring ‘trauma team activation’ and admitted to hospital. Patients were assessed for frailty by nurses trained to use three different frailty screening tools—the Clinical Frailty Scale (CFS), the PRISMA-7 tool, and the Trauma Specific Frailty Index (TSFI). Completion rates for each of the tools were calculated and nurses were asked to rate their preference for each of the tools and the reasons for non-completion if relevant.

Results

Data were analysed from 370 patients. Completion rates for each of the tools varied with highest degree of compliance using the CFS (98.9%). TSFI was least likely to be completed with ‘lack of available information to complete questions’ as the most cited reason. Nurses showed a clear preference for the CFS with 57.3% ranking this as first choice (PRISMA-7 32.16%; TSFI 10.54%). Both PRISMA-7 and CFS were both rated highly as ‘extremely easy to complete’ (PRISMA-7 58.5%, CFS 59.61%).

Conclusion

User acceptability is an important consideration in the selection of a frailty measurement tool for use in major trauma patients. Our study shows the Clinical Frailty Scale has high rates of completion and acceptability and can be implemented in practice for assessment of frailty in major trauma.

Biomarkers of systemic inflammation predict survival with first-line immune checkpoint inhibitors in non-small-cell lung cancer

INTRODUCTION

Pembrolizumab is an established first-line option for patients with advanced non-small-cell lung cancer (NSCLC) expressing programmed death-ligand 1 ≥50%. Durable responses are seen in a subset of patients; however, many derive little clinical benefit. Biomarkers of the systemic inflammatory response predict survival in NSCLC. We evaluated their prognostic significance in patients receiving first-line pembrolizumab for advanced NSCLC.

METHODS

Patients treated with first-line pembrolizumab for advanced NSCLC with programmed death-ligand 1 expression ≥50% at two regional Scottish cancer centres were identified. Pretreatment inflammatory biomarkers (white cell count, neutrophil count, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, albumin, prognostic nutritional index) were recorded. The relationship between these and progression-free survival (PFS) and overall survival (OS) were examined.

RESULTS

Data were available for 219 patients. On multivariate analysis, albumin and neutrophil count were independently associated with PFS (P < 0.001, P = 0.002, respectively) and OS (both P < 0.001). A simple score combining these biomarkers was explored. The Scottish Inflammatory Prognostic Score (SIPS) assigned 1 point each for albumin <35 g/l and neutrophil count >7.5 × 10⁹/l to give a three-tier categorical score. SIPS predicted PFS [hazard ratio 2.06, 95% confidence interval (CI) 1.68-2.52 (P < 0.001)] and OS [hazard ratio 2.33, 95% CI 1.86-2.92 (P < 0.001)]. It stratified PFS from 2.5 (SIPS2), to 8.7 (SIPS1) to 17.9 months (SIPS0) (P < 0.001) and OS from 5.1 (SIPS2), to 12.4 (SIPS1) to 28.7 months (SIPS0) (P < 0.001). The relative risk of death before 6 months was 2.96 (95% CI 1.98-4.42) in patients with SIPS2 compared with those with SIPS0-1 (P < 0.001).

CONCLUSIONS

SIPS, a simple score combining albumin and neutrophil count, predicts survival in patients with NSCLC receiving first-line pembrolizumab. Unlike many proposed prognostic scores, SIPS uses only routinely collected pretreatment test results and provides a categorical score. It stratifies survival across clinically meaningful time periods that may assist clinicians and patients with treatment decisions. We advocate validation of the prognostic utility of SIPS in this and other immune checkpoint inhibitor treatment settings.

803 QUALITY OF LIFE IN OLDER TRAUMA PATIENTS AFTER INJURY: FINDINGS FROM THE FRAILTY IN MAJOR TRAUMA STUDY (FRAIL-T)

Introduction

Major trauma is a substantial health burden for older patients with a significant proportion having ongoing functional and psychological difficulties long after their injury. Frailty impacts adversely on outcome after trauma but the longer term effects are unknown. This study aimed to determine differences in health related quality of life (HRQoL) and change in dependence for frail and non-frail patients aged 65 or over discharged from Major Trauma Centres (MTCs) following injury.

Methods

This prospective multi-centre study recruited from five UK MTCs between June 2019 and March 2020. Eligible patients were aged 65 or over requiring ‘trauma team activation’ and admitted to hospital. Follow-up data was collected via questionnaire at two time points: on day of hospital discharge and at 6 months. Primary outcome at follow-up was patient reported health-related quality of life (HRQoL) using the EQ-5D-5L measure.

Results

Data were analysed from 181 patients. 54 died in the follow-up period and HRQoL data was available for 127 patients. Of these 16% were identified as frail during the trauma hospital admission using the Clinical Frailty Scale. On average, frail patients were older (82 years) compared to non-frail (77 years). HRQoL was rated similarly at discharge in both groups (Non-Frail: 60, Frail: 65, p = 0.137), but at follow-up non-frail patients reported improvement whilst those who were frail had deteriorated from the discharge base-line (Non-Frail: 70, Frail: 50, p = 0.01). At 6 months post injury, half of the frail cohort (49%) were more dependent on care than pre-trauma compared to less than a third of non-frail patients (29%).

Conclusion

Patients who were frail in-hospital had worse HQRoL than non-frail patients 6 months after discharge from hospital, with increased dependence. Understanding the impact of injury on quality of life is important in planning for, and supporting, the ongoing care of frail older trauma patients.

Pathophysiology and treatment of osteoporosis: challenges for clinical practice in older people

Osteoporosis, a common chronic metabolic bone disease is associated with considerable morbidity and mortality. As the prevalence of osteoporosis increases with age, a paralleled elevation in the rate of incident fragility fractures will be observed. This narrative review explores the origins of bone and considers physiological mechanisms involved in bone homeostasis relevant to management and treatment. Secondary causes of osteoporosis, as well as osteosarcopenia are discussed followed by an overview of the commonly used pharmacological treatments for osteoporosis in older people.

20 Comparison of Six Frailty Screening Tools in Patients Aged 65+ with An Arm Fragility Fracture

Introduction

Frailty is associated with an increased risk of falling and fracture, but not routinely assessed in fracture clinic. Early identification and management of frailty among older people with arm fragility fracture could help avoid further falls and fractures, especially of the hip. We evaluated the feasibility of assessing frailty in a busy fracture clinic.

Methods

People aged 65+ years with an arm fracture in one acute trust were recruited. Frailty was assessed in fracture clinics using six tools: Fried Frailty Phenotype (FFP), FRAIL scale, PRISMA-7, electronic Frailty Index (e-FI), Clinical Frailty Score (CFS), and Study of Osteoporotic Fracture (SOF). The sensitivity and specificity of each tool was compared against FFP as a reference. Participants identified as frail by 2+ tools were referred for Comprehensive Geriatric Assessment (CGA).

Results

100 patients (mean age 75 years±7.2; 20 men) were recruited. Frailty prevalence was 9% (FRAIL scale), 13% (SOF), 14% (CFS &gt; 6), 15% (FFP; e-FI &gt; 0.25), and 25% (PRISMA-7). Men were more likely to be frail than women. Data were complete for all assessments and completion time ranged from one minute (PRISMA-7; CFS) to six minutes for the FFP which required most equipment. Comparing with FFP, the most accurate instrument for stratifying frail from non-frail was the PRISMA-7 (sensitivity = 93%, specificity = 87%) while the remaining tools had good specificity (range 93%–100%) but average sensitivity (range 40%–60%). Twenty patients were eligible for CGA. Five had recently had CGA and 11/15 referred were assessed. CGA led to 3–6 interventions per participant including medication changes, life-style advice, investigations, and onward referrals.

Conclusion

It was feasible to assess frailty in fracture clinic and to identify patients who benefitted from CGA. Frailty prevalence was 9%—25% depending on the tool used and was higher among men. PRISMA-7 could be a practical tool for routine use in fracture clinics.

154 The Feasibility of Assessing Sarcopenia Among Older People with Arm Fracture Using Different Criteria

Introduction

Osteoporosis and sarcopenia often co-exist (osteo-sarcopenia) and both are associated with increased risk of falls and fractures. Early identification and treatment of sarcopenia among older people with fragility arm fractures could prevent further fractures. This study evaluated the feasibility of assessing sarcopenia in a fracture clinic.

Methods

People aged 65+ years with arm fracture attending fracture clinics in one acute trust were recruited. Sarcopenia was assessed using gait speed, grip strength with unfractured arm (hand dynamometer using appropriate cut off adjusted for age and gender), skeletal muscle mass index SMI (Bioimpedance BIA), SARC-F questionnaire, the European Working Group on Sarcopenia in Older People (EWGSOP) I and II criteria. The sensitivity and specificity of each measure was calculated against the EWGSOP II criteria as the standard reference.

Results

100 patients (Mean age 75 years±7.2; 80 female) were recruited. Sarcopenia was identified among 4% (EWGSOP I), 5% (SMI), 13% (EWGSOP II), 16% (gait speed test), 18% (SARC-F) and 39% (grip strength) and was more prevalent among men. SARC-F had the best sensitivity and specificity (100% and 96% respectively) when compared to the EWGSOP II criteria. Sensitivity and specificity for the remaining measures were respectively (100%, 71%) for grip strength, (75%, 94%) for gait speed, (25%, 97%) with SMI and (25%, 99%) for EWGSOP I. Time needed to complete the assessments was 1–2 minutes for gait speed, grip strength and SARC-F; five minutes for BIA test, and nine minutes when EWGSOP I and II criteria were applied. Data were complete for grip strength and SARC-F. Missing data was reported among 2% for gait speed, 8% for BIA test, 8% for EWGSOP II and 10% for EWGSOP I.

Conclusion

It was feasible to assess sarcopenia in fracture clinics and SARC-F was a quick, simple and sensitive tool suitable for routine use.

Longitudinal characterisation of haematological and biochemical parameters in cancer patients prior to and during COVID-19 reveals features associated with outcome

BACKGROUND

Cancer patients are at increased risk of death from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Cancer and its treatment affect many haematological and biochemical parameters, therefore we analysed these prior to and during coronavirus disease 2019 (COVID-19) and correlated them with outcome.

PATIENTS AND METHODS

Consecutive patients with cancer testing positive for SARS-CoV-2 in centres throughout the United Kingdom were identified and entered into a database following local governance approval. Clinical and longitudinal laboratory data were extracted from patient records. Data were analysed using Mann-Whitney U test, Fisher's exact test, Wilcoxon signed rank test, logistic regression, or linear regression for outcomes. Hierarchical clustering of heatmaps was performed using Ward's method.

RESULTS

In total, 302 patients were included in three cohorts: Manchester (n = 67), Liverpool (n = 62), and UK (n = 173). In the entire cohort (N = 302), median age was 69 (range 19-93 years), including 163 males and 139 females; of these, 216 were diagnosed with a solid tumour and 86 with a haematological cancer. Preinfection lymphopaenia, neutropaenia and lactate dehydrogenase (LDH) were not associated with oxygen requirement (O2) or death. Lymphocyte count (P < 0.001), platelet count (P = 0.03), LDH (P < 0.0001) and albumin (P < 0.0001) significantly changed from preinfection to during infection. High rather than low neutrophils at day 0 (P = 0.007), higher maximal neutrophils during COVID-19 (P = 0.026) and higher neutrophil-to-lymphocyte ratio (NLR; P = 0.01) were associated with death. In multivariable analysis, age (P = 0.002), haematological cancer (P = 0.034), C-reactive protein (P = 0.004), NLR (P = 0.036) and albumin (P = 0.02) at day 0 were significant predictors of death. In the Manchester/Liverpool cohort 30 patients have restarted therapy following COVID-19, with no additional complications requiring readmission.

CONCLUSION

Preinfection biochemical/haematological parameters were not associated with worse outcome in cancer patients. Restarting treatment following COVID-19 was not associated with additional complications. Neutropaenia due to cancer/treatment is not associated with COVID-19 mortality. Cancer therapy, particularly in patients with solid tumours, need not be delayed or omitted due to concerns that treatment itself increases COVID-19 severity.

A review of the NG17 recommendations for the use of basal insulin in type 1 diabetes

AIMS

To revisit the data analysis used to inform National Institute of Health and Care Excellence (NICE) NG17 guidance for initiating basal insulin in adults with type 1 diabetes mellitus (diabetes).

METHODS

We replicated the data, methodology and analysis used by NICE diabetes in the NG17 network meta-analysis (NMA). We expanded this data cohort to a more contemporary data set (extended 2017 NMA) and restricted the studies included to improve the robustness of the data set (restricted 2017 NMA) and in a post hoc analysis, changed the index comparator from neutral protamine Hagedorn (NPH) insulin twice daily to insulin detemir twice daily.

RESULTS

The absolute changes in HbA_1c were similar to those reported in the NG17. However, all 95% credible intervals for change in HbA_1c point estimates crossed the line of null effect, except for detemir twice daily (in the NICE and extended 2017 NMAs) and NPH four times daily. In the detemir twice-daily centred post hoc analysis, the 95% credible intervals for change in HbA_1c crossed the line of null effect for all basal therapies, except NPH.

CONCLUSIONS

In NG17, comparisons of basal insulins were based solely on efficacy of glycaemic control. Many of the trials used in this analysis were treat-to-target, which minimize differences in HbA_1c . In the NMAs, statistical significance was severely undermined by the wide credible intervals. Despite these limitations, point estimates of HbA_1c were used to rank the insulins and formed the basis of NG17 guidance. This study queries whether such analyses should be used to make specific clinical recommendations.

P87 Spinal fractures incurred by a fall from standing height

Objectives

Falls from standing are an important cause of vertebral fractures, particularly in the elderly. They are associated with significant morbidity and long-term mortality. The aim of this study was to determine the treatment and outcomes, in a single centre, of managing spinal fractures due to falls from standing height.

Design

Retrospective case note review of patients with a fracture sustained due to a fall from standing (2011–2016 inclusive).

Subjects

229 patients with average age 76.6±14.5 years; 134 (58.5%) female.

Methods

Patients were identified from the Trauma Audit and Research Network database. Case notes were reviewed for demographics, treatment details and outcome at 6 months post-admission.

Results

1408 patients were admitted with spinal fractures of which 229 (16.3%) sustained a fall from standing height. Two hundred and eighty-three fractures were identified in the 229 patients, which were distributed in the cervical (n=140), thoracic (n=65) and lumbar (n=78) spine. The average ISS score was 9.7±5.4. Twenty-three (10.0%) patients had either incomplete or complete spinal cord injury. Fifty-six (24.5%) patients underwent surgical intervention. Forty-three patients (18.7%) died within 6 months and increasing age and Charlson co-morbidity score were associated with higher mortality.

Conclusions

Falls from standing comprise a large portion of the spinal service emergency workload. They are associated with a high 6 month mortality similar to other fragility fractures experienced by the elderly.

A multicentre, UK, retrospective, observational study to assess the effectiveness of insulin glargine 300 units/ml in treating people with Type 1 diabetes mellitus in routine clinical practice (SPARTA)

AIM

To conduct an open-label study to provide UK real-world evidence regarding the use of insulin glargine 300 units/ml (U300) in people with Type 1 diabetes mellitus.

METHODS

People with Type 1 diabetes who had been prescribed U300 ≥6 months before data collection and had HbA_1c levels recorded within 3 months prior to U300 (baseline) were included. The primary endpoint was change in HbA_1c from baseline to month 6 after U300 initiation. Other endpoints included number of documented hypoglycaemic and diabetic ketoacidosis episodes, and change in daily basal insulin dose.

RESULTS

A total of 298 people with Type 1 diabetes were included [mean age 42.1 years, mean HbA_1c 79 mmol/mol (9.4%)]. After U300 initiation, the mean reduction in HbA_1c from baseline to month 6 was -4 mmol/mol (-0.4%; P<0.001; n=188). The total daily basal insulin dose at 6 months was 1.3 units higher than at the time of U300 initiation (P<0.001; n=275) but was not significantly different from the prior basal insulin dose. There was no clinically significant difference in weight between baseline and month 6 [mean difference +0.7 kg, 95% CI -0.1, 1.5; P=0.084; n=115). During the 6 months before and after U300 initiation, severe hypoglycaemic episodes were documented for 6/298 and 4/298 participants. Diabetic ketoacidosis episodes requiring Accident and Emergency department visits or hospitalization were documented for 4/298 and 6/298 participants, before and after U300 initiation, respectively.

CONCLUSIONS

In people with Type 1 diabetes, a change in basal insulin to U300 was associated with clinically and statistically significant HbA_1c improvements, without significant changes in basal insulin dose and weight. Documented severe hypoglycaemia episodes and diabetic ketoacidosis requiring Accident and Emergency department visits or hospitalization were low and similar before and after U300 initiation.

A retrospective observational study of people with Type 1 diabetes with self-reported severe hypoglycaemia reveals high level of ambulance attendance but low levels of therapy change and specialist intervention

AIM

To evaluate the impact of severe hypoglycaemia on NHS resources and overall glycaemic control in adults with Type 1 diabetes.

METHODS

An observational, retrospective study of adults (aged ≥ 18 years) with Type 1 diabetes reporting one or more episodes of severe hypoglycaemia during the preceding 24 months in 10 NHS hospital diabetes centres in England and Wales. The primary outcome was healthcare resource utilization associated with severe hypoglycaemia. Secondary outcomes included demographic and clinical characteristics, diabetes control and pathway of care.

RESULTS

Some 140 episodes of severe hypoglycaemia were reported by 85 people during the 2-year observation period. Ambulances were called in 99 of 140 (71%) episodes and Accident and Emergency attendance occurred in 26 of 140 (19%) episodes, whereas 29 of 140 (21%) episode required no immediate help from healthcare providers. Participants attended a median of 5 (range 0-58) diabetes clinic consultations during the observation period; 13% (70 of 552) of all consultations were severe hypoglycaemia-related. Of the HbA1c measurements recorded closest prior to severe hypoglycaemia (n = 119), only 7 of 119 measurements were < 48 mmol/mol (< 6.5%) and mean HbA1c was 70 (sd 19) mmol/mol (8.5%, sd 1.7%). Some 119 changes to diabetes treatment were recorded during the observation period (median/person 0;, range 0-11), of which 52 of 119 changes (44%) followed severe hypoglycaemic events.

CONCLUSIONS

We observed a high level of ambulance service intervention but surprisingly low levels of hypoglycaemia follow-up, therapy change and specialist intervention in people self-reporting severe hypoglycaemia. These results suggest there may be important gaps in care pathways for people with Type 1 diabetes self-reporting severe hypoglycaemia.

Atlantoaxial Instability in down Syndrome-Guidelines for Screening and Detection

A community survey was conducted in all adults with Down syndrome living in three health districts to see if there was any correlation between radiological and neurological abnormalities which could indicate the presence of atlantoaxial instability. There was no difference in the proportion of individuals with neurological abnormalities in the group with radiological abnormalities suggestive of atlantoaxial instability (6/14) compared with individuals with normal X-rays (50/123) as determined by the chi square test (0.01463: not significant). The clinical and ethical implications for screening of people with Down syndrome living in the community are discussed in view of these findings.

Estimating the impact of better management of glycaemic control in adults with Type 1 and Type 2 diabetes on the number of clinical complications and the associated financial benefit

AIM

To estimate potential cost avoidance through modest and achievable improvements in glycaemic control in adults with Type 1 or Type 2 diabetes mellitus in the UK healthcare system.

METHODS

The IMS Core Diabetes Model was used to examine the impact of improved glycaemic control (indicated by reduction in HbA_1c level), in a representative cohort of adults with Type 1 or Type 2 diabetes. The cumulative incidence of microvascular and macrovascular complications was modelled across 5-year periods to a 25-year time horizon. Complication costs were applied to the data to estimate potential accrued cost avoidance.

RESULTS

Significant cost avoidance of ~£340 m is apparent in the first 5 years, increasing to ~£5.5bn after 25 years of sustained improvement in control. The overwhelming majority of cost avoidance arises from reductions in microvascular complications. In people with Type 1 diabetes the greatest cost avoidance comes from a reduction in renal disease (74% of cost avoidance), while in people with Type 2 diabetes it is generated by a reduction in foot ulcers, amputations and neuropathy: 57% cost avoidance). Greater cost reduction is accrued more rapidly in people with higher starting HbA_1c levels.

CONCLUSION

Modest improvements in glycaemic control generate significant reductions in the incidence and, therefore, cost of microvascular complications in people with Type 1 or Type 2 diabetes. This study provides clear support for the premise that prioritized and sustained investment in early and better intervention can provide concrete financial benefits in both the short and longer term.

The Diagnosis of Affective and Psychotic Disorders in Adults with Autism: Seven Case Reports

Seven men with autistic disorders developed mood disorders or psychotic illnesses during adult life. This association has also been described in several previous reports. Although no firm conclusions can be drawn on the basis of case reports alone, it appears that autistic disorders may increase vulnerability to such psychoses. Possible reasons for the association are discussed, as is treatment.

Transient receptor potential (TRP) channels in the airway: role in airway disease

Over the last few decades, there has been an explosion of scientific publications reporting the many and varied roles of transient receptor potential (TRP) ion channels in physiological and pathological systems throughout the body. The aim of this review is to summarize the existing literature on the role of TRP channels in the lungs and discuss what is known about their function under normal and diseased conditions. The review will focus mainly on the pathogenesis and symptoms of asthma and chronic obstructive pulmonary disease and the role of four members of the TRP family: TRPA1, TRPV1, TRPV4 and TRPM8. We hope that the article will help the reader understand the role of TRP channels in the normal airway and how their function may be changed in the context of respiratory disease.

Transfer parameters for ICRP reference animals and plants collected from a forest ecosystem

The International Commission on Radiological Protection (ICRP) have suggested the identification of a series of terrestrial, marine and freshwater sites from which samples of each Reference animal and plant (RAP) could be systematically collected and analysed. We describe the first such study in which six of the eight terrestrial RAPs, and associated soil samples, were collected from a site located in a managed coniferous forestry plantation in north-west England. Adult life stages of species representing six of the terrestrial RAPs (Wild grass, Pine tree, Deer, Rat, Earthworm and Bee) were sampled and analysed to determine concentrations of 60 elements and gamma-emitting radionuclides. The resultant data have been used to derive concentration ratios (CR(wo-soil)) relating element/radionuclide concentrations in the RAPs to those in soil. This paper presents the first-reported transfer parameters for a number of the RAP-element combinations. Where possible, the derived CR(wo-soil) values are compared with the ICRPs-recommended values and any appreciable differences discussed.

Recovery of adrenal function in a patient with confirmed Addison's disease

Addison's disease is a condition characterised by immune-mediated destruction of the adrenal glands leading to a requirement of lifelong replacement therapy with mineralocorticoid and glucocorticoid. We present a case of a 53-year-old man who presented at the age of 37 years with nausea, fatigue and dizziness. He was found to have postural hypotension and buccal pigmentation. His presenting cortisol level was 43 nmol/l with no response to Synacthen testing. He made an excellent response to conventional replacement therapy with hydrocortisone and fludrocortisone and then remained well for 16 years. On registering with a new endocrinologist, his hydrocortisone dose was revised downwards and pre- and post-dose serum cortisol levels were assessed. His pre-dose cortisol was surprisingly elevated, and so his dose was further reduced. Subsequent Synacthen testing was normal and has remained so for further 12 months. He is now asymptomatic without glucocorticoid therapy, although he continues on fludrocortisone 50 μg daily. His adrenal antibodies are positive, although his ACTH and renin levels remain elevated after treatment. Addison's disease is generally deemed to lead to irreversible cell-mediated immune destruction of the adrenal glands. For this reason, patients receive detailed counselling and education on the need for lifelong replacement therapy. To our knowledge, this is the third reported case of spontaneous recovery of the adrenal axis in Addison's disease. Recovery may therefore be more common than previously appreciated, which may have major implications for the treatment and monitoring of this condition, and for the education given to patients at diagnosis.

Sacred healing stories told at the end of life

INTRODUCTION

Cancer is a challenging disease to diagnose and treat, and oftentimes even with the best medical intervention, it spreads and is deemed incurable, requiring a shift from cure to end-of-life care. This study used a spirituality measure and the PATS© storytelling intervention developed by the principal investigator to better understand the experience of being diagnosed with cancer and being told no further curative treatments are warranted.

PURPOSE

The purpose of this exploratory study was to implement a storytelling approach to explore the experience of living with terminal cancer. Second, the study documented the presence of spirituality and healing in the narratives.

METHOD

The qualitative data were analyzed by narrative analysis developed by Riessman.

FINDINGS

Seven synoptic stories were written and later sorted into healing categories. The narrative analysis yielded three themes. There were instances of religion and spirituality found in the transcribed stories. The participants' scores on the Spiritual Health Inventory indicated the presence of spirituality.

CONCLUSION

Storytelling allowed the seven study participants to share personal experiences and achieve a sense of connectedness and intimacy. The use of the PATS© intervention is a way to facilitate physical, emotional, and spiritual healing and provide holistic end-of-life care.