132 GERIATRIC REHABILITATION IN THE COVID-19 ERA: SERVICE INNOVATION AND PATIENT OUTCOMES

Background

Methods

Results

Conclusion

222 OLDER ADULT INPATIENTS’ PERCEPTIONS OF PROGRESSIVE RESISTANCE TRAINING IN A SPECIALIST GERIATRIC REHABILITATION SETTING

Background

Progressive resistance training (PRT) has the potential to reduce age-related disability and has been proven to benefit the older adult in a variety of ways. PRT is prescribed routinely by physiotherapists for frail older adults in an inpatient setting. To date little is known of their experiences engaging in PRT. This study aimed to explore older adult inpatients’ perceptions and experience of PRT as part of their overall physiotherapy program in a Specialised Geriatric Rehabilitation Unit.

Methods

The study had a qualitative design. Semi-structured interviews explored experiences and perceptions of PRT along with motivators and barriers to participation. Interviews were face to face and conducted in the unit. Data was analysed using thematic analysis. 11 frail older inpatients with orthogeriatric (n = 5), neurological (n = 2), general surgical (n = 2) and general medical (n = 2) diagnoses were interviewed.

Results

The study identified three overarching themes: Acceptability, Facilitators and Barriers. In the category of Acceptability participants identified the subthemes: (1) PRT is challenging, (2) PRT is Rewarding and (3) PRT is Enjoyable. In the category of Facilitators, the following subthemes emerged: (4) Positive outcomes as motivators and (5) Supervision is necessary for engagement. In the category of Barriers, (6) Low self-efficacy beliefs and (7) the Negative effects of PRT, such as pain and fatigue affected participation.

Conclusion

Frail older inpatients find PRT to be an acceptable form of exercise. It is perceived to be challenging, but rewarding and enjoyable for most. Participants were motivated to participate in PRT by the positive outcomes (improved strength, general health, function, independence, confidence) they experienced. They felt supervision from professionals with medical expertise was essential to participation; and had low self-efficacy beliefs surrounding independent practice; fearing falling and causing harm. Pain and fatigue also impacted participation.

Dissolved methane in Indian freshwater reservoirs

Emission of methane (CH4), a potent greenhouse gas, from tropical reservoirs is of interest because such reservoirs experience conducive conditions for CH4 production through anaerobic microbial activities. It has been suggested that Indian reservoirs have the potential to emit as much as 33.5 MT of CH4 per annum to the atmosphere. However, this estimate is based on assumptions rather than actual measurements. We present here the first data on dissolved CH4 concentrations from eight freshwater reservoirs in India, most of which experience seasonal anaerobic conditions and CH4 buildup in the hypolimnia. However, strong stratification prevents the CH4-rich subsurface layers to ventilate CH4 directly to the atmosphere, and surface water CH4 concentrations in these reservoirs are generally quite low (0.0028-0.305 μM). Moreover, only in two small reservoirs substantial CH4 accumulation occurred at depths shallower than the level where water is used for power generation and irrigation, and in the only case where measurements were made in the outflowing water, CH4 concentrations were quite low. In conjunction with short periods of CH4 accumulation and generally lower concentrations than previously assumed, our study implies that CH4 emission from Indian reservoirs has been greatly overestimated.

Post-partum depression in the community: a qualitative study from rural South India

BACKGROUND

Post-partum depression, although heterogeneous, is often considered a medical disease when viewed from the biomedical perspective. However, recent reports from the Indian subcontinent have documented psychosocial causal factors.

METHOD

This study employed qualitative methodology in a representative sample of women in rural South India. Women in the post-partum period were assessed using the Tamil versions of the Short Explanatory Model Interview, the Edinburgh Postnatal Depression Scale and a semi-structured interview to diagnose ICD 10 depression. Socio-demographic and clinical details were also recorded.

RESULTS

Some 137 women were recruited and assessed, of these, 26.3% were diagnosed to have post-partum depression. The following factors were associated with post-partum depression after adjusting for age and education: age less than 20 or over 30 years, schooling less than five years, thoughts of aborting current pregnancy, unhappy marriage, physical abuse during current pregnancy and after childbirth, husband's use of alcohol, girl child delivered in the absence of living boys and a preference for a boy, low birth weight, and a family history of depression. Post-partum depression was also associated with an increased number of causal models of illness, a number of non-medical models, treatment models and non-medical treatment models.

CONCLUSION

Many social and cultural factors have a major impact on post-partum depression. Post-partum depression, when viewed from a biomedical framework, fails to acknowledge the role of context in the production of emotional distress in the post-partum period.

Predominance of Brain and Lung Metastases in Triple-Negative Breast Cancer Patients

Background: Patients with triple-negative breast cancer have an increased likelihood of recurrence compared to other types of breast cancer, however, little is known about their pattern of metastatic spread. Our object was to evaluate the metastatic patterns of women diagnosed with triple-negative breast cancer compared to other subtypes. Methods: We studied a cohort of 572 white patients diagnosed with invasive breast cancer at West Virginia University Hospital between 1999 and 2004. Hospital registry, charts, and pathology records provided clinical data including tumor receptor status and biopsy-proven metastatic spread to bone, brain, liver and lung. Breast cancers that were negative for estrogen, progesterone, and HER2neu, otherwise known as triple-negative were compared with HER2neu-postive and HER2neu-negative (endocrine receptor positive) disease. Body mass index was calculated and a value of ≥30 considered indicative of obesity. Specimens of primary carcinoma were available for analysis of Ki67 mitotic index and expression of p53. Results: 134/572 (23.4%) had triple-negative breast cancer, while the frequencies were 108/572 (18.9%) and 330/572 (57.7%) in HER2neu-positive and HER2neu-negative (endocrine receptor positive) groups. Women with triple-negative disease were more likely to have brain-metastasizing breast cancer; 10.5% versus 4.6% for HER2neu-positive and 3.3% for HER2neu-negative (P<0.05). They were also more likely to have metastasis to the lung; 10.5% versus 2.8% for HER2neu-positive and 7.0% for HER2neu-negative (P<0.05). Triple-negative breast cancer patients who developed brain and lung metastases were younger <50 years and significantly more obese (P=0.0236). High Ki67 labeling index and p53 expression were associated with more advanced disease indicating an aggressive phenotype for this group.Patterns of metastasis in breast cancer subtypesSite of metastasisTriple-negativeHER2-positiveHER2-negativeP valueBone20/134 (14.9)7/108 (6.5)38/330 (11.5)0.1037Brain14/134 (10.5)5/108 (4.6)11/330 (3.3)0.0136*Liver11/134 (8.2)4/108 (3.7)22/330 (6.7)0.3261Lung14/134 (10.5)3/108 (2.8)23/330 (6.9)0.0507*Other5/134 (3.7)3/108 (2.8)3/330 (0.91)0.1093 Conclusion: The excess risk of brain and lung metastasis in women with triple-negative breast cancers versus other subtypes needs further validation. The unique biology of triple-negative tumors may explain this pattern of metastatic spread.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6159.

Challenges for retrospective cohort studies: A profile of patients who refuse participation or are lost to follow-up

6615

Background: As hematopoietic cell transplantation (HCT) has increasingly become a curative option for many diseases, studying long-term complications has assumed critical importance. A major issue in conducting scientifically rigorous long-term follow up studies with large cohorts is the ability to track patients, and obtain informed consents. High participation rates are critical to avoid selection bias and ensure generalizability. Methods: A mass consenting process was implemented to obtain informed consents from 1056 City of Hope HCT patients transplanted during 1976–2006 who were one+ year survivors and alive in June 2007. This process involved mailing consent forms followed by phone calls. Patients were classified as consented, refused, or lost-to-follow-up (LTFU). Sociodemographic and clinical characteristics indicative of higher risks for refusal or LTFU were identified. Results: Study patients comprised 58% males, and 53% Caucasians. Median age at HCT was 34 years (0.6–73); median age at study initiation was 47 years (6–81); and median time from HCT to study initiation was 10 years (1–30). Primary diagnoses included acute/chronic leukemia (43%), Hodgkin/non-Hodgkin lymphoma (36%), multiple myeloma (9%), and other miscellaneous diagnoses (12%). Fifty percent received allogeneic HCT. At the end of the process, 46% consented, 17% refused, and 37% were LTFU. Compared to consented patients, males, Asians, and younger patients were more likely to refuse consent. Patients LTFU were more likely to have lower SES, a longer time since HCT, in addition to being males, Asians and younger at HCT (Table). Conclusions: This study demonstrates the critical need for maintaining up-to-date contact information on patients after HCT in order to obtain valid long-term follow-up data. It also describes the characteristics of the sub-population that are more likely to refuse or be LTFU, information necessary for planning targeted interventions in long-term follow-up initiatives.

[Table: see text]

No significant financial relationships to disclose.

Prognostic significance of the “surprise” question in cancer patients

9588

Background: In patients with advanced cancer, failure to accurately estimate and communicate prognoses can lead to overly aggressive care at the end of life with less attention to important palliative care issues such as pain and symptom management and patients’ values and goals for care. The “surprise” question—would I be surprised if this patient died in the next year?—has been recognized as an innovation to improve end-of-life care in the primary care population by identifying patients with a poor prognosis who are appropriate for palliative care. It has not been previously tested in cancer patients. The purposes of this study were to determine the feasibility and outcomes of the use of the “surprise” question in a cancer center population. Methods: Between July and November 2007, oncologists prospectively classified consecutive breast, lung, and colon cancer patients being seen at the Mary Babb Randolph Cancer Center of West Virginia University into “Yes” and “No” groups based on the surprise question. Patients were followed and their status at the end of one year-alive or dead-was determined along with patient demographics, type of cancer, and stage at presentation. A multivariate Cox proportional hazards regression analysis was used to identify variables associated with patient death. Results: Oncologists classified 826 of 853 prospective patients (97%), with 131 (16%) classified into the “No” group and 695 (84%) into the “Yes” group. At the end of the year, 71 patients had died; 41% of the “No” patients compared to 3% of the “Yes” patients (P <.001). The surprise question ‘No‘ response was more predictive of patient death than stage of cancer, cancer type, or age (hazard ratio 7.53, P value <.001). The “Yes” patients lived longer than the “No” patients (359.8±32.8 days versus 270±131.5 days, P <.001). The sensitivity of the surprise question “No” response was 75% and the specificity was 90%. Conclusions: We conclude that the surprise question is a simple, feasible, and effective tool to identify cancer patients with the worst prognoses who should receive the highest priority for palliative care interventions, particularly advance care planning.

No significant financial relationships to disclose.

Differential survival after prostate cancer by race: Role of NCI-designated comprehensive cancer centers

6520

Background: A significant gap exists between Caucasians and African-Americans (AAs) in prostate cancer mortality, possibly due to sociodemographics, disease biology, or treatment. Furthermore, differential access to care at NCI-designated Comprehensive Cancer Centers (NCICCCs) conceivably contributes to this difference. Methods: Using data from the Los Angeles Cancer Surveillance Program, we studied the underlying causes of differences in mortality in 18,790 men (AAs: 4,211; Caucasians: 14,579) diagnosed with prostate cancer between 1998 and 2003, and followed until 2006. Three NCICCCs serve this area: USC-Norris, UCLA-Jonsson, and City of Hope. Results: Median age at diagnosis was 67.5 yrs; AAs were significantly more likely to have lower SES; carry no insurance; have distant disease; and be managed with “watchful waiting.” The overall and prostate-specific survival was significantly superior for patients treated at NCICCCs, and for Caucasians (Table). Multivariate analysis, after adjustment for sociodemographics, race, insurance, tumor-related factors, and treatment-modality, revealed that treatment at NCICCCs was associated with lower overall (HR=0.74, 95% CI=0.6–0.9) and prostate-specific mortality (HR=0.69, 95% CI=0.5–0.97). AAs were less likely to utilize NCICCCs (OR=0.42, 95%CI=0.4–0.5). Finally, adjustment for sociodemographic, tumor/treatment-related factors, and treatment site abrogated the racial difference in overall (HR=1.08, 95%CI=0.99–1.2) and prostate-specific (HR=1.11, 95%CI=0.9–1.3) mortality. Conclusions: Patients treated at NCICCCs have lower mortality compared with other facilities. AAs are less likely to utilize NCICCCs for prostate cancer. AAs and Caucasians have comparable overall and prostate-specific survival, after adjustment for sociodemographic, tumor/treatment-related factors, and treatment site. Future studies are needed to understand barriers and facilitators to utilization of NCICCCs for management of prostate cancer.

[Table: see text]

No significant financial relationships to disclose.

Endogenous excess cortisol production and diabetes mellitus as predisposing factors for pulmonary cryptococcosis: a case report and literature review

Pulmonary cryptococcosis usually occurs as an opportunistic infection in immunocompromised patients. Endogenous Cushing's syndrome is associated with cortisol excess and can predispose to development of cryptococcal infections. We report a case of diabetic patient with ACTH secreting pituitary tumour who developed a cavitating lung mass. Computed tomography-guided biopsy of the lesion revealed mucicarminophilic budding forms of cryptococcus. Broncheoalveolar lavage culture grew Cryptococcus neoformans. There was radiological response to treatment with liposomal Amphotericin, but patient ultimately succumbed to septicemia and multiorgan failure. Opportunistic infections with organisms like Cryptococcus neoformans, should be considered in patients with endogenous Cushing's syndrome and a pulmonary infiltrate.

Multiple cavitating masses in an immunocompromised host with rheumatoid arthritis-related interstitial lung disease: an unusual expression of cytomegalovirus pneumonitis

Cytomegalovirus is a known opportunistic infection in immunocompromised individuals. We document multiple cavitating lung masses caused by cytomegalovirus in a patient with rheumatoid arthritis-induced interstitial lung disease on immunosuppressant medication, an unusual expression of CMV pneumonitis. With increasing use of immunosuppressive therapy and increase in AIDS, pulmonary cytomegalovirus infection is expected to be a more frequently encountered disease and familiarity with its uncommon radiological manifestations will be advantageous.

Epidemiologic characteristics of colon cancer in Asian Indian and Pakistani population living in the USA compared to US White population in SEER database from 1988 to 2002

20112

Background: About 1.5% of the US population is South East Asian in origin and it is one of the rapidly growing groups. Colon cancer is the second most common in male and third most common cancer in females in Asian Indian and Pakistani population living in the USA. This is the first study examining the epidemiologic characteristics of colon cancer in this group. Methods: SEER cancer incidence public use database have reported cancer incidence in 13 SEER registries from 1973 to 2002. Since 1988, Indian/Pakistani populations were reported separately under race and ethnicity. Frequency sessions were performed and descriptive parameters were calculated regarding age, sex, stage, grade, tumor location and diagnostic methods used. Results: A total of 4,229 cases of cancer were reported from 1988 to 2002 in this group and 352 (9%) were colon cancers. The reported incidence of colon cancer in SEER database is increasing (11 in 1988 vs. 53 in 2002). Table shows the comparative studies of different variables of colon cancer between Indian/Pakistani and US White population reported in SEER database. Conclusions: Our study shows that the incidence of colon cancer in Asian Indian and Pakistani population under age 50 is substantially higher than the US White population and the predilection is towards the male sex. Our results suggest that this ethnic group warrants close screening and risk factor stratification for earlier detection of colon cancer as well as awareness and counseling in high-risk families.

[Table: see text]

No significant financial relationships to disclose.

A stepped approach for prediction of obstructive sleep apnea in overtly asymptomatic obese subjects: a hospital based study

BACKGROUND AND PURPOSE

Prevalence of obstructive sleep apnea (OSA) is high in obese subjects, many of whom may not be overtly symptomatic. Polysomnography (PSG) is a costly and time-consuming investigation. Since it is not feasible to subject all obese individuals to PSG, it is useful to define predictors of OSA among these subjects.

PATIENTS AND METHODS

One hundred and eighteen obese subjects [body mass index (BMI)> or =25 kg/m(2)] presenting to the hospital with non-sleep related complaints were included, of which 53 subjects with PSG evidence of OSA [apnea-hypopnea index (AHI)> or =15/h] were defined as cases and 65 subjects without any evidence of OSA (AHI<15/h) were defined as controls. Anthropometry, biochemical investigations, blood gas analysis, pulmonary function tests, and PSG were performed for all subjects.

RESULTS

Waist hip ratio (WHR) (as percentage of a standard) [odds ratio (95% CI): 1.07 (1.00-1.14); P = 0.049] male gender [odds ratio (95% CI): 3.97 (0.99-15.81); P = 0.046] and neck circumference (NC) [odds ratio (95% CI): 1.23 (1.03-1.47); P = 0.023] were found to be independent predictors of OSA. Overnight oxygen desaturation data were evaluated in patients selected as having OSA on the basis of these clinical markers, and the best cut-off for level of desaturation (10%) was defined. The stepped approach had a specificity, sensitivity, positive and negative predictive value of 89.2, 88.5, 86.8 and 90.6%, respectively, for the diagnosis of OSA.

CONCLUSIONS

Male gender, WHR and NC are independent predictors of OSA in overtly asymptomatic obese subjects. A stepped approach to diagnose OSA should be used, as it is accurate and cost-effective.

Modulatory effect of Cyclea peltata Lam. on stone formation induced by ethylene glycol treatment in rats

The inhibitory effect of the root of Cyclea peltata Lam. on nephrolithiasis induced in rats by feeding with ethylene glycolated water (1%) for 35 days was summarized. Ethylene glycol administration led to oxalate stone formation, as indicated by its high level in urine. Complementary to this anion, the cation calcium level in urine was elevated. These two ions may have contributed to the formation of calcium oxalate stones. In addition to high serum potassium, a low serum magnesium level contributed to stone formation. Simultaneous administration of the powdered root of Cyclea peltata resulted in decreased urinary oxalate and calcium. Likewise, serum potassium was lowered and magnesium was elevated. These observations provided the basis for the conclusion that this plant inhibits the stone formation induced by ethylene glycol treatment.

Reliability of epigastric auscultation to detect gastric insufflation

BACKGROUND

We studied the reliability of epigastric auscultation to detect gastric insufflation in 30 anaesthetized, paralysed intubated patients.

METHODS

A 16FG gastric tube was positioned with the tip in the mid-oesophagus with the proximal end attached to an injection port with a one-way valve. Four observers participated in the study. Observers were paired and each pair studied 15 patients. Each patient underwent four test sequences in random order, two by each observer. Each test sequence comprised one observer injecting different volumes of air (0.25 ml, 0.5 ml, 1 ml, 2 ml, 3 ml, 4 ml, 5 ml, 10 ml, 15 ml and 0 ml as a control) in random order whilst the second blinded observer listened with a stethoscope over the epigastrium. Each randomized volume was injected rapidly at 5 s intervals for 1 min. The number of injections required to detect air entering the stomach was recorded. The stomach was deflated between each test sequence.

RESULTS

To detect air entering the stomach with 95% confidence, 11 injections were required for 0.25 ml; 7 for 0.5 ml; 3 for 1 ml; 2 for 2 ml and 3 ml, and I for > or =4 ml. The mean (range) inter- and intraobserver reliability was 0.73 (0.71-0.75) and 0.76 (0.76-0.89), respectively. The incidence of false positives was 21% (25/120) and the incidence of false negatives was 10% (103/1080), making the specificity and sensitivity 79% and 91%, respectively.

CONCLUSIONS

We conclude that epigastric auscultation can detect gastric insufflation of 0.25 ml air after 11 breaths and > or = 4 ml air after one breath with 95% confidence. Inter- and intraobserver reliability is moderate to excellent. Epigastric auscultation should be repeated to reduce the risk of false positives.

Tumor necrosis factor activates a nuclear inhibitor of vitamin D and retinoid-X receptors

Tumor necrosis factor-alpha (TNF) is an important contributor to the pathophysiology of bone loss in osteoporosis. Previous work has revealed that TNF inhibits 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) action. We have shown that TNF decreases binding of the vitamin D receptor (VDR) and its heterodimeric partner, the retinoid-x receptor (RXR), to the vitamin D response element (VDRE) of the osteocalcin gene. Here we test the hypothesis that TNF induces a nuclear inhibitor of RXR/VDR binding to DNA and that this inhibitor can have independent effects on RXR. The effect of TNF on RXR and VDR binding to their cognate response elements and stimulation of transcription was studied in VDR deficient CV-1 and COS-7 cells. In CV-1 cells transfected with VDR and RXR expression vectors, TNF-alpha inhibited 1,25(OH)2D3 stimulated transcription of a VDRE-CAT reporter and 9-cis-retinoic acid (9cRA) stimulated transcription of an RXRE-CAT reporter. Inhibition of transcription was associated with decreased binding of VDR and RXR to their cognate response elements. To determine if TNF-alpha induced a nuclear inhibitor of VDR and RXR binding to DNA, nuclear extract was isolated from TNF treated receptor deficient COS cells and mixed with nuclear extract from ligand treated receptor replete COS cells. Receptor binding to DNA was inhibited by the extract from TNF treated COS-7 cells. The inhibitory activity rapidly appeared in nuclear extracts following TNF stimulation. We conclude that TNF activates a nuclear inhibitor of VDR and RXR.

Linear IgA bullous dermatosis in south India

BACKGROUND

A study of five cases of linear IgA dermatosis (LABD) in a referral hospital in South India is presented.

METHODS

A dermatologic examination, skin biopsy, and direct immunofluorescence were carried out on all patients. Patients were then followed up.

RESULTS

All five cases showed linear IgA deposits at the dermo-epidermal junction. One case in addition showed IgG and C3 deposits. All cases responded to treatment with dapsone. The treatment duration varied from 14 to 16 months and the fifth patient is still on treatment after 37 months.

CONCLUSIONS

Linear IgA bullous dermatosis is a self-limiting bullous disorder. To the best of our knowledge this is the first report of LABD from India.

Breast metastases from primary leiomyosarcoma

Two cases of metastatic leiomyosarcoma of the breast are presented. The reasons why they are considered as secondary tumours and not primary tumours are also discussed.

Diagnostic evaluation of the lupus band test in discoid and systemic lupus erythematosus

BACKGROUND

The usefulness of the lupus band test (LBT) in the diagnosis of cutaneous lupus erythematosus remains controversial. The study was done to determine the sensitivity, specificity, and predictive value of the LBT in discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE).

METHODS

During the study period, 32 patients with SLE and 28 patients with DLE were included. The final classification of cases was based on the American Rheumatism Association Criteria (ARA) for SLE, histopathology, and consensus of the clinical staff. Thirty controls, 15 each for DLE and SLE, were chosen from a group of patients, who had lesions clinically simulating DLE and SLE, but could be excluded by histopathology, laboratory tests, and follow-up. Histopathologic examinations and direct immunofluorescence (DIF) tests were done on lesional skin.

RESULTS

In DLE, the sensitivity of the LE band test was 58% and the specificity 87%. The positive predictive value was 95% and negative predictive value was 32%. In SLE the sensitivity was 93% and specificity 87%. The positive predictive value was 64% and negative predictive value 98%.

CONCLUSIONS

The high negative predictive value of LBT in SLE suggests that it is valuable in excluding diseases clinically similar to SLE.

Cutaneous lupus erythematosus in India: immunofluorescence profile

The clinical profile and cutaneous lesions of 65 patients with lupus erythematosus (LE) are described. This included 28 discoid LE (13 disseminated, 15 localized), five subacute cutaneous LE, and 32 systemic LE. The need to recognize a pigmented macular form constituting 25% of discoid LE is emphasized. Increased incidence of involvement of the lower lip in discoid LE and pigmentation in systemic LE is noted. Lupus band test was found to be highly sensitive; it was positive for lesional skin of all untreated patients with subacute cutaneous LE and systemic LE, it was, however, not useful on nonlesional skin.

Complete recovery of spinal cord compression following parathyroidectomy

A case is reported of spinal cord compression at T₂ level caused by a brown tumour of primary hyperparathyroidism involving the posterior arch of the vertebra. The spontaneous regression of cord compression following parathyroidectomy is documented clinically and radiologically.