320 IDENTIFYING OUTCOMES FOR PATIENTS LEAVING REHABILITATION WITHOUT THE MULTI-DISCIPLINARY TEAM (MDT) RECOMMENDED HOME CARE PACKAGE (HCP) HOURS IN PLACE

Background

Home-Care Packages (HCPs) aim to support older people to remain in their homes. The community care system in Ireland has a small range of services with inconsistent availability. This study aims to identify outcomes for patients leaving rehabilitation without the MDT recommended HCP.

Methods

Demographics of patients discharged from rehab January 2021 to December 2021 were collected. Patients were classified into those with and without recommended HCP at time of discharge. Telephone consultations were held and data collected including; number of falls since discharge and EQ-ED-5L quality of life questionnaires were completed.

Results

Of 30 patients included (aged 66-94), 9 did not have full HCP hours on discharge. The range of Length of Stay (LoS) was 2-120 days in the correct HCP group and 7-59 in the incorrect HCP group. There was 7 readmissions to hospital, 5 from full HCP group. Three patients had a fall since discharge. In the correct HCP group, 42% had a mobility score of 3 or greater and 38% had a self-care score of 3 or greater. This was 11% and 33% respectfully in the incorrect HCP group.

Conclusion

Those who were discharged with full HCP had larger range of LoS. All patients who suffered falls were in the full HCP group. Incorrect HCP group had better scores in mobility and self-care. There were low rates of readmission to hospital in this group of patients discharged following a period of rehabilitation.

164 OLDER PATIENTS AT THE PREOPERATIVE ASSESSMENT CLINIC: CHANGING THE FOCUS FROM FIT FOR SURGERY TO OPTIMISATION FOR SURGERY

Background

The Pre-operative Assessment Clinic (PAC) is run by the Anaesthetic Department and assesses older patients undergoing elective orthopaedic surgery. The aim of this study was to examine how PAC currently assesses older patients and how effective it is in assessing for likelihood of postoperative complications and requirement for rehabilitation.

Methods

A single-centre, retrospective study that received approval from the local ethics committee. Data were collected on all patients post elective orthopaedic surgery admitted to the on-site specialist rehabilitation unit for older persons, between 1st May 2020 and 31st December 2021. Data were collected from hospital Information Technology platform, Bluespiers.

Results

Seventy-six patients (58 female; median age: 80 years) were included. Median time from PAC to surgery was 95 days. Functional assessment was completed in 63.16% of cases, formal cognitive assessment was done in 13% of cases. Number of falls in the preceding year was recorded in 31% of patients. Baseline mobility was recorded in 93% of cases. Whilst smoking and alcohol history was recorded in 96% of cases, number of units was not calculated. 45% (n=34) of patients were correctly identified as likely to require post-operative inpatient rehabilitation. PAC did not record sarcopaenia, polypharmacy or delirium risk factors. From our dataset, at least 13% had sarcopaenia, 80% had polypharmacy and 23% required opiate medications. Post-operatively, 16% of patients developed a delirium and 12% had an acute kidney injury.

Conclusion

In its current format, PAC fails to optimally risk stratify frail, older patients. Attention concentrates on fitness for surgery rather than optimisation of patients. Failure to record frailty, sarcopenia, cognitive impairment and risk factors for delirium is leading to missed opportunities in terms of delirium prevention, and peri-operative optimisation of older patients as well as discharge planning before surgery. Collaboration with specialist geriatric services at PAC should improve patient outcomes.

248 BENEFITS OF POST-OPERATIVE SPECIALIST GERIATRIC CARE FOR OLDER PATIENTS UNDERGOING ELECTIVE ORTHOPAEDIC SURGERY

Background

The Covid-19 pandemic changed work practices across many different healthcare institutions. The difficulties with cross-site transfers created an opportunity in our institution to provide on-site post-operative rehabilitation for older patients undergoing elective orthopaedic surgery. The aim of this study is to assess the impact of post-operative specialist geriatric care on older patients.

Methods

This is a single-centre, retrospective study that received approval from the local hospital ethics committee. Data were collected on all patients admitted to the on-site specialist rehabilitation unit post-elective orthopaedic surgery between 1st May 2020 and 31st December 2021. Two patients in this group were excluded as they had not attended a pre-operative assessment clinic. Data were collected from hospital Information Technology platform, Bluespiers.

Results

76 patients, 18 males and 58 females, were included in this study. The median age was 80 years. In the specialist rehabilitation unit, evidence of cognitive impairment was established in 40.79% of cases, there were 3 cases of newly diagnosed dementia, a history of falls was identified in 32.89% of patients and 13.16% of patients were found to have sarcopaenia. The median length of stay in the rehabilitation unit was 25 days. 51.32% of patients were discharged home independently, 23.68% of patients went home with a new Home-Care Package (HCP), 15.79% of patients were discharged home with an existing HCP, 6.58% of patients were transferred for further treatment and 2.63% patients were discharged to residential care units.

Conclusion

This data demonstrates a clear role for specialist geriatric care in elective rehabilitation, with a significant proportion of patients being discharged home independently. The benefits of a comprehensive geriatric assessment in the peri-operative setting include increased identification of cognitive impairment allowing appropriate implementation of brain health as well as identification of a history of falls, enabling falls risk assessment and management including bone health assessment.

P338Dystrophin deficient cardiomyopathy: predictors associated with the cardiac phenotype in a Duchenne registry population - A guide for device therapy

Background

Patients with Duchenne muscular dystrophy (DMD) typically exhibit cardiac dysfunction. With increasing life expectancy due to advances in respiratory support, cardiomyopathy and associated dsyrhythmia are fast becoming the primary cause of morbidity and mortality in this patient group. Despite advances, the correlation between genotype and cardiac phenotype remains poorly understood and individual registries small, with implementation of device therapy often delayed due to poor diagnostic imaging. 

Methods and Aims: A single-center registry for DMD patients was established and data including genotyping, medical therapy and investigations such as cardiac MRI, nt-Pro BNP levels, echocardiogram were analysed. The aim was to potentially identify predictors associated with a more severe cardiac phenotype and thus help to guide provision of device therapy.  

Results

A total of 19 patients (age 17 - 31) with DMD were reviewed (demographics table 1). All patients were evaluated with echocardiography on at least one occasion (mean EF 46.5%). Cardiac MRI was attempted in 6 patients however only completed in 2 due to contractures preventing access to scanning. 11 of 19 patients (58%) demonstrated an impaired left ventricular ejection fraction (EF) <50% (mean EF 42%). Proximal "hot spot" mutations/deletions (exon 2-19) were associated with a more pronounced reduction in EF, all patients with proximal mutations demonstrating an EF < 45% (mean 41%). 5 of 6 (83%) of those with >1 exon deletion mutations demonstrated more severely impaired EF (mean EF 41%) compared to those with single exon deletions (mean EF 52%). Interestingly, one patient with a proximal mutation (exon 3-6 deletion) remains mobilising to distances of 70 meters, however cardiac MRI revealed a moderate degree of fibrosis with an EF of 43%. Correlation between nt-Pro BNP levels with reduced EF was not uniform, however a level < 100 was associated with an EF >55% in 89% of patients studied. of those on steroid regimes, 6 (54%) had impaired LVEF compared to 5 (83%) of those not on steroid therapy. All patients were on at least one class of heart failure modification, with 79% on two and 37% on three agents. Only one patient in the registry has had an ICD implanted. He has had a device for 10 years in and in this time there have been no therapies delivered however runs of non-sustained ventricular tachycardia have been noted. 

Conclusions

Correlation between predictors and cardiac phenotype in a Duchenne population remains unreliable. Location and size of exon alteration appears to be indicative of more markedly impaired LV function, however larger studies are required to characterise this further and challenges remain with regard to accurate assessment of EF. The use of predictors in future may help to guide appropriate provision of device therapy.

'Everything was just getting worse and worse': deteriorating job quality as a driver of doctor emigration from Ireland

BACKGROUND

Medicine is a high-status, high-skill occupation which has traditionally provided access to good quality jobs and relatively high salaries. In Ireland, historic underfunding combined with austerity-related cutbacks has negatively impacted job quality to the extent that hospital medical jobs have begun to resemble extreme jobs. Extreme jobs combine components of a good quality job-high pay, high job control, challenging demands, with those of a low-quality job-long working hours, heavy workloads. Deteriorating job quality and the normalisation of extreme working is driving doctor emigration from Ireland and deterring return.

METHODS

Semi-structured qualitative interviews were conducted with 40 Irish emigrant doctors in Australia who had emigrated from Ireland since 2008. Interviews were held in July-August 2018.

RESULTS

Respondents reflected on their experiences of working in the Irish health system, describing hospital workplaces that were understaffed, overstretched and within which extreme working had become normalised, particularly in relation to long working hours, fast working pace, doing more with less and fighting a climate of negativity. Drawing on Hirschman's work on exit, voice and loyalty (1970), the authors consider doctor emigration as exit and present respondent experiences of voice prior to emigration. Only 14/40 respondent emigrant doctors intend to return to work in Ireland.

DISCUSSION

The deterioration in medical job quality and the normalisation of extreme working is a key driver of doctor emigration from Ireland, and deterring return. Irish trained hospital doctors emigrate to access good quality jobs in Australia and are increasingly likely to remain abroad once they have secured them. To improve doctor retention, health systems and employers must mitigate a gainst the emergence of extreme work in healthcare. Employee voice (about working conditions, about patient safety, etc.) should be encouraged and used to inform health system improvement and to mitigate exit.

Prevalence of myeloma precursor state monoclonal gammopathy of undetermined significance in 12372 individuals 10-49 years old: a population-based study from the National Health and Nutrition Examination Survey

We studied the prevalence of monoclonal gammopathy of undetermined significance (MGUS) in younger individuals, age 10–49 years, using samples from the National Health and Nutritional Examination Survey (NHANES) III. NHANES prevalence rates were standardized to the 2000 US total population. Among 12 372 individuals (4073 blacks, 4146 Mexican-Americans, 3595 whites, and 558 others), MGUS was identified in 63 persons (0.34%, 95% CI 0.23–0.50). The prevalence of MGUS was significantly higher in blacks (0.88%, 95% CI 0.62–1.26) compared with whites (0.22%, 95% CI 0.11–0.45), P=0.001. The prevalence of MGUS in Mexican-Americans was at an intermediate level (0.41%, 95% CI 0.23–0.73). The disparity in prevalence of MGUS between blacks and whites was most striking in the 40–49 age-group; 3.26% (95% CI 2.04–5.18) versus 0.53% (95% CI 0.20–1.37), P=0.0013. There was a trend to earlier age of onset of MGUS in blacks compared with whites. MGUS was seen in only two persons in the 10–19 age-group (both Mexican-American), and in three persons in the 20–29-year age-group (all of whom were black). In persons less than 50 years of age, MGUS is significantly more prevalent, with up to 10 years earlier age of onset, in blacks compared with whites.

ALDH1A3 is epigenetically regulated during melanocyte transformation and is a target for melanoma treatment

Despite the promising targeted and immune-based interventions in melanoma treatment, long-lasting responses are limited. Melanoma cells present an aberrant redox state that leads to the production of toxic aldehydes that must be converted into less reactive molecules. Targeting the detoxification machinery constitutes a novel therapeutic avenue for melanoma. Here, using 56 cell lines representing nine different tumor types, we demonstrate that melanoma cells exhibit a strong correlation between reactive oxygen species amounts and aldehyde dehydrogenase 1 (ALDH1) activity. We found that ALDH1A3 is upregulated by epigenetic mechanisms in melanoma cells compared with normal melanocytes. Furthermore, it is highly expressed in a large percentage of human nevi and melanomas during melanocyte transformation, which is consistent with the data from the TCGA, CCLE and protein atlas databases. Melanoma treatment with the novel irreversible isoform-specific ALDH1 inhibitor [4-dimethylamino-4-methyl-pent-2-ynthioic acid-S methylester] di-methyl-ampal-thio-ester (DIMATE) or depletion of ALDH1A1 and/or ALDH1A3, promoted the accumulation of apoptogenic aldehydes leading to apoptosis and tumor growth inhibition in immunocompetent, immunosuppressed and patient-derived xenograft mouse models. Interestingly, DIMATE also targeted the slow cycling label-retaining tumor cell population containing the tumorigenic and chemoresistant cells. Our findings suggest that aldehyde detoxification is relevant metabolic mechanism in melanoma cells, which can be used as a novel approach for melanoma treatment.

Micafungin as primary antifungal prophylaxis in patients presenting with acute myeloid leukemia

OBJECTIVE

To study the efficacy and safety of micafungin for prophylaxis of invasive fungal infections in patients undergoing induction chemotherapy for acute myeloid leukemia.

PATIENTS AND METHODS

A prospective observational single-center study of 41 patients from the hematology department between May 2012 and April 2015. Micafungin was administered once daily from the first day of induction chemotherapy to the end of the neutropenic phase.

RESULTS

Neither Candida nor Aspergillus infection was documented in our 41 patients from the first day of micafungin infusion to the end of the neutropenic phase. Patients were followed for three months after discontinuation of micafungin and none of them contracted an invasive fungal infection. Only one patient presented with grade III-IV hepatic and ionic toxicities.

CONCLUSION

Micafungin is associated with a good safety profile and is an interesting option for preventing invasive fungal infections in the high-risk population of patients presenting with hematological disorders.

Venous thromboembolism risk and prophylaxis in the acute hospital care setting: the Irish results of the ENDORSE study

ENDORSE (Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting), is a multinational, cross-sectional survey of venous thromboembolism (VTE) risk prevalence and effective prophylaxis in the acute hospital care setting. Three Irish hospitals enrolled in the study. The American College of Chest Physicians (ACCP) guidelines were employed to evaluate VTE risk and prophylaxis. Of 552 patients, 297 (53.8%) and 255 (46.2%) were categorised as surgical or medical, respectively, with 175 (59%) surgical and 109 (43%) medical patients deemed to be at risk for VTE. Of these, only 112 (64%) and 51 (47%) received recommended VTE prophylaxis, respectively. The results are consistent with those observed in other countries and demonstrate a high prevalence of risk for VTE and a low rate of prophylaxis use, particularly in medical patients. Awareness of VTE guidelines should be an integral component of health policy.

[Automated screening for transfusionnal hemochromatosis]

Post-transfusion hemochromatosis is a major concern in patients with chronic transfusion (i.e. more than 20 red blood cell concentrates). While the monitoring of infectious complications and transfusion accidents is clearly one of the missions of haemovigilance, hemochromatosis is not yet subject to such a systematic monitoring. We therefore wanted to assess the incidence of this complication in the context of a general hospital (hospital of Aix) and propose the establishment of a screening and a comprehensive monitoring of post transfusion hemochromatosis.

Dosimetry study of a phase II multiple-dose intracavitary administration of 131I-TM601 in adult patients with recurrent high-grade glioma

e13006

Background: Postoperative radiotherapy for glioma has been shown to improve survival with increased radiation doses. Dose escalation of external beam radiotherapy or brachytherapy is limited by normal brain radionecrosis. Radiolabeled targeting molecules can deliver localized radiation to tumor and reduce normal brain radionecrosis. TM601, or synthetic Chlorotoxin, is a peptide derived from scorpion venom that specifically binds to tumor cells. Here we report dosimetry results of an imaging sub-study of a phase II trial, in which weekly doses of 131I-TM601 were infused into surgically created tumor resection cavities for 3 or 6 weeks. Methods: Five out of 76 patients treated in a phase II trial were imaged after receiving 1, 3, or 6 doses of 40 mCi/0.8 mg 131I-TM601 intracavitarily. For each imaging study, 5 sequential SPECT images (1–168 hour) were registered with MRI to determine the 131I-TM601 radiation dose to the 2-cm tumor cavity margin. Five sequential body scans were also acquired to determine 131I-TM601 radiation dose to extra-cranial organs. Results: 131I-TM601 is a rapidly penetrating and clearing radiolabeled peptide. The median residual activity in the cavity at 7 days post injection was 8.4%. Median radiation dose to the cavity margin was 121 cGy/mCi and ranged 52- 338 cGy/mCi in 5 subjects. The median coefficient of variation (intra-patient inter-fraction) for the 2-cm margin dose was 14.7% and ranged 7.1–18.9%. Median tumor cavity volume was 11.4 mL, and ranged 5.2 - 35.5 mL. There was no observed correlation between the 2-cm margin dose and the cavity volume. Median radiation dose to thyroid, kidneys, red marrow, and body was 8.3, 1.3, 0.4, and 0.6 cGy/mCi, respectively. Conclusions: Radiation dose ratio for 2-cm cavity margin-to-normal tissues was quite high. While intra-patient reproducibility was relatively good, cumulative effect of the residual activity was only meaningful within a week. These results support the multi-dose fractionation scheme for 131I-TM601 to minimize normal tissue toxicity, including radiation necrosis, and extend continuous irradiation to clinical or sub-clinical residual tumor cells after surgery.

[Table: see text]

Relapsing polychondritis: reversible airway obstruction or asthma

We describe a patient who presented with poorly controlled asthma. Bronchoscopy showed collapsing airways, characteristic of RP (relapsing polychondritis).

Rasmussen’s Aneurysm: A Forgotten Entity?

We present the case of a rare entity which is a complication of a disease process that had almost disappeared from the Western World. With the recent resurgence in reported cases of Mycobacterium tuberculosis (TB) in Western communities, it is important to recognize complications and sequelae. A young alcoholic male with confirmed active TB suffered a cardiac arrest following massive haemoptysis. Multidetector computed tomography angiography diagnosed a Rasmussen's aneurysm, confirmed by digital subtraction angiography and then successfully embolized with glue. We outline this rare case and the embolization technique and review previously documented reports.

Impact of chemoradiotherapy for locally advanced head and neck cancer on swallowing function

6054

Background: We examined the impact of chemoradiotherapy (CRT) on swallowing function in a group of patients treated for locally advanced head and neck cancer in an ongoing randomized phase II study with concurrent CRT, with or without Ethyol. Methods: Chemotherapy consisted of weekly carboplatin AUC 1.5 and paclitaxel at 45 /m2 for 4 weeks. Radiation was delivered using a 3 field technique with a concomitant boost schedule to a total dose of 72 Gy. Patients were randomized to receive or not receive daily subcutaneous Ethyol. Patients had video swallow studies at the start of radiation and 8, 12, 24 and 52 weeks post chemoradiotherapy. Dysphagia and weight loss were monitored. Video swallow study reports were collected and the incidence of penetration, aspiration, pharyngeal residue and upper esophageal narrowing analyzed. Results: Baseline data were available for 31 patients out of 43 enrolled. 29% of the patients penetrated, 6.4% aspirated and 29% had pharyngeal residue. Patients on both arms of the study had a steady decline in swallowing function from onset until 24 weeks post radiation. Penetration, aspiration and pharyngeal residue were consistently noted at all time points and improvements in deglutition were seen on the 52-week post radiation video swallow. Forty percent of the patients (17/43) had narrowing in the upper esophagus. On average, a third of the patients examined required dilations. The remaining patients with esophageal narrowing were able to advance their diet and have their feeding tubes removed without dilations. The average time from the end of the treatment to PEG removal was 219 days. Conclusion: Based on the video swallow studies that were conducted, patients had a gradual decline in swallowing function from initiation of CRT until 24 weeks post. Esophageal narrowing was common, often requiring dilation. Given that it takes 7 months on average for the feeding tubes to come out, we recommend that these patients undergo intensive swallowing therapy and continuous long term follow up and assessment at two and possibly three years post CRT. Study is ongoing.

No significant financial relationships to disclose.

[Necrotic myocarditis in acute eosinophilic lymphoblastic leukaemia]

INTRODUCTION

Hypereosinophilia can cause severe cardiac complications. The association between an acute lymphoblastic leukemia and hypereosinophilia was rare. We report a case of a 29-year-old man who presented a heart failure secondary to necrotic myocarditis related to an acute eosinophilic lymphoblastic leukaemia.

EXEGESIS

The patient developed a heart failure and secondary a cardio-embolic stroke, due to a large mobile left ventricle thrombosis. His peripheral blood showed a total white count of 28,500 leucocytes/mm3 with 18,800 eosinophils/mm3. The myelogram cytology showed precursor B-cell acute lymphoblastic leukaemia with hypereosinophilia.

CONCLUSION

The possibility of the rapid emergence of cardiac lesions in hypereosinophilic syndromes warrants very close physician vigilance. An Echocardiography and MRI performed at the early stage and in the follow-up allow to detect and to manage these cardiac disorders.