102 A REVIEW OF THE REFERRAL PATHWAYS & OUTCOMES TO RAPID ACCESS FRAILTY ASSESSMENT UNIT (RAFAU)IN A REGIONAL HOSPITAL

Background

The RAFAU is a Multidisciplinary Team including Medical, Physiotherapy and Occupational Therapy, incorporating a fulltime team of OT and PT based in the Emergency Department called RAFT (Rapid Access Frailty Team). It aims to prevent hospital admissions and social crises. There are three main referral pathways, via community (GP, Public Health Nurses, Allied Health Professionals), RAFT-ED, and general medical follow up.

Methods

The data used was from RAFAU attendances between May 2021 and March 2022. Inclusion criteria was age greater than 65 and attendance in person. Exclusion criteria was incomplete data. Data was manually recorded after each attendance using data entry points including age range, methods of and reason for referral, etc. This gave us the raw data to develop information on our cohort. Data analysis was completed using Excel.

Results

A total of 569 patients were seen. The most populous age brackets were 81-85 (28%), 70-75 (25%) and 75-80 (26%) respectively. The vast majority of referrals were from GPs (57%), followed by RAFT-ED (30%). The most common reasons for referral were Medical (34%), Cognitive (27%) and Falls (26%).

Conclusion

A significant number of patients were seen for the first time by the RAFAU MDT. GPs were the major source of referrals which is to be expected as GPs are in more frequent contact with patients and act as gatekeepers to specialist hospital services. The primary referral reasons were also to be expected as these are three issues that are at the core of Gerontology. 173 hospital admissions were prevented in the ED by a combination of the RAFT and Emergency Doctors. There is good rationale for keeping the RAFAU and RAFT-ED team, and where possible expanding their services. This model could easily be expanded to other hospitals.

The presentation, treatment and outcome of renal cell carcinoma in old age

OBJECTIVE

To review clinical presentation and outcome of patients with a diagnosis of renal cell carcinoma at a district general hospital and assess whether older patients were more likely to present in a non-specific manner or receive more conservative management and whether their survival was less favourable.

SUBJECTS AND METHODS

39 patients presenting with a diagnosis of renal cell carcinoma between 1987 and 1995 were identified from hospital activity analysis data and histopathology records. We divided the subjects into young patients (< 69 years: n = 27) and elderly patients (>70 years: n = 10), and made a retrospective analysis of clinical features, laboratory results, pathology, staging, treatment and survival from hospital records.

RESULTS

Anaemia, hypertension and weight loss were common clinical features in both young and elderly groups. The prevalence of non-urological symptoms did not differ between study groups. Anaemia was frequently microcytic and hypochromic. Hypertension was present in 46% of patients and one-third of these were newly diagnosed. In 19% of patients with renal cell carcinoma, the diagnosis was made incidentally while imaging for other indications. Elderly patients were as likely to receive surgical treatment as younger patients. Survival differed with stage but not age.

CONCLUSIONS

Neither clinical presentation, management nor survival differed between the young and elderly subjects. Renal cell carcinoma should be considered in elderly patients with systemic features such as malaise or weight loss associated with anaemia, hypertension and raised erythrocyte sedimentation rate.

Miliary tuberculosis presenting as infection of a pacemaker pulse-generator pocket

A seventy year old woman had a permanent VVI pacemaker inserted in 1983 for complete heart block and presented ten years later with purulent discharge from the generator pocket. During a prolonged pyrexial illness, she developed renal and respiratory failure and her illness was complicated by recurrent ventricular fibrillation. The patient died on her 31st hospital day. Subsequent histological and microbiological investigation revealed widespread miliary tuberculosis which included involvement of myocardial tissue, great vessels and the pacemaker pocket. To our knowledge, this is the first reported occurrence of miliary tuberculosis involving a permanent pacemaker system. Furthermore, the granulomatous myocarditis which occurred as part of the miliary picture is a rare occurrence and possibly explains the recurrent ventricular fibrillation.

Permanent pacemaker practice at a Scottish district general hospital between 1987 and 1993

BACKGROUND

Raigmore is a district general hospital offering a permanent pacemaker service to its catchment population of 233,500. It has been argued that the British public would be better served by a less centralised pacing service. There also exists the view, however, that a lower rate of complications and best follow up practice are achieved by specialised centres. The pacemaker practice over a 79 month period (January 1987 to July 1993) was thus reviewed with these issues in mind.

METHODS

The pacemaker records of all new implantations for the period under observation were reviewed retrospectively. Data were acquired under the headings age, sex, symptoms, electrocardiographic (ECG) indications, and complications (early and late). Comparison was made with United Kingdom national data, a previous audit from Raigmore, and two recently published large series from specialist centres (one British and the other French).

RESULTS

The mean age of patients who underwent implantation was 74 years and 47.5% were male. The most common presenting symptoms were syncope (46%), dizzy spells (24.5%), and heart failure (11.5%). The most common ECG indications for pacing were complete heart block (wide QRS) (28%), atrial flutter/fibrillation with bradycardia (21.6%) and complete heart block (narrow QRS) (9.6%). The implantation rate was 184/million population/year in 1993. The early and late complication rates were low (2.48%).

CONCLUSIONS

The presence of a pacing centre in a remote part of the United Kingdom fulfils a necessary service and has low complication rates, with implantation rates and patterns that are comparable with those in other parts of the country.

Myopathy in the nyala

Between January 1973 and June 1981, a total of 21 nyalas (Tragelaphus angasi) died with clinical and/or pathologic evidence of myopathy. The main clinical signs were stiffness, inability to rise, and failure to suckle in newborn fawns. Death usually occurred without premonitory signs of disease. Gross lesions were characterized by white or pale patches of skeletal or cardiac muscle. Histologically, acute degeneration or necrosis and mineralization were commonly observed in skeletal muscle. Acute necrosis of the myocardium with or without arteriolar fibrinoid necrosis was usually found in juvenile animals. Interstitial fibrosis of the myocardium with arteriosclerosis was commonly observed in adults. The plasma alpha tocopherol values of 3 affected nyalas ranged from 0.03 to 0.08 mg/dl (mean, 0.05 mg/dl). Unaffected nyalas from the same herd had a range of 0.09 to 0.24 mg/dl (mean, 0.13 mg/dl), which is low enough to be considered clinically deficient. The blood selenium values of the affected nyalas and other nyalas from the same herd ranged from 0.30 to 0.33 ppm (mean, 0.32 ppm), and were considered normal.