82 THE IMPACT OF THE COVID-19 PANDEMIC ON THE ACTIVITY OF A RAPID-ACCESS GERIATRIC DAY HOSPITAL SERVICE

Background

In the 1970s, Jack Flanagan developed the first Geriatric Day Hospital (GDH) in Ireland. Since, the GDH model of care has evolved to accommodate for the growing demands of our ageing population. Before the COVID-19 pandemic, the operational scope of our GDH was extended to allow for the rapid medical and multidisciplinary assessment and follow-up of older patients. During the pandemic, the GDH did not suspend operations and remained open as a COVID-negative ambulatory pathway. We evaluated the activity of this GDH service.

Methods

Retrospective Service Evaluation Approval was granted by our Research & Innovation Office (Reference: 7419). Pseudonymised data corresponding to all GDH attendances between January 2017 and December 2021 were retrieved from the hospital electronic records. Yearly trends in proportions were tested with the Chi-square for trend statistic. Trends in monthly attendances were assessed via Statistical Process Control (SPC) charts with three-sigma limits. Statistical significance was set at p<0.05.

Results

There were 27,278 attendances of patients aged 65 and over to the GDH over the 5-year period (6,362, 5,978, 6,115, 4,306, and 4,517, respectively). Mean age was 82 every year. Of the 7,813 new episodes, yearly proportions referred directly by primary care teams were 10.4%, 29.5%, 38.6%, 24.5%, and 16.3% (p<0.001). SPC charts showed that Apr-May 2020 and Jan-Feb 2021 had significantly lower numbers of review attendances (50-59 and 146-142, respectively, average 324 p/m). However, new appointments did not significantly decline (average 130 p/m). Of the 7,813 new episodes, 2,595 (33.2%) were seen by Physiotherapy, and 1,860 (23.8%) by Occupational Therapy.

Conclusion

Our GDH saw a sustained number of new attendances and demonstrated increased community availability during the unprecedented COVID-19 crisis, especially during the first wave of the pandemic when hospital access was most affected. A rapid access GDH model can facilitate integrated care at times of crisis to promote ageing in place.

184 ‘THROUGH THE LENS OF A CAMERA’—USING PHOTOVOICE TO EXPLORE OLDER ADULTS PERCEPTIONS AND EXPERIENCES OF COMMUNITY AMBULATION

Background

The ability of an older adult to walk independently outdoors in their community assists with maintaining independence, a healthy lifestyle and a good quality of life. The study qualitatively explored older persons’ perceptions and experiences of the variables associated with their ability to walk outdoors in their community, through the use of photographs and discussion.

Methods

This qualitative study employed Photovoice Methodology (Wang and Burris, 1997). Inclusion criteria were community dwelling older adults over 65 years old, attending a day hospital, able to ambulate at least 10 metres with/without an assistive device and no visual or fine motor limitations that would preclude using a camera. Participants attended an information session and received and practiced with a single use camera. Over one week they took photographs of perceived barriers or facilitators to community ambulation. The developed photographs formed the basis for focus group discussions. Focus groups were recorded; transcribed and thematic analysis was used to identify key themes.

Results

Eight participants, mean age of 78.8 years completed the Photovoice substudy. Five of the participants were female and six lived alone. One participant had experienced a fall in the past six months. Three key themes were identified; personal, environmental and strategic factors, all associated with an older adults’ ability to ambulate in the community. Each of these themes had a number of subthemes highlighting barriers and facilitators to community ambulation in this population.

Conclusion

This novel study design was well received. It provided real life experiences, insights and rich valuable data that may not be captured by other means. The findings demonstrate the multifactorial nature of independent community ambulation, both the personal and environmental factors associated with independent community ambulation in older adults. Physiotherapists should adopt a broader, holistic approach to the assessment and treatment of older adults, to promote the achievement of independent community ambulation.

Does the shoe really fit? Characterising ill-fitting footwear among community-dwelling older adults attending geriatric services: an observational cross-sectional study

Background

Falls in older people are common and can result in loss of confidence, fear of falling, restriction in activity and loss of independence. Causes of falls are multi-factorial. There is a paucity of research assessing the footwear characteristics among older people who are at high risk of falls, internationally and in the Irish setting. The aim of this study was to examine the proportion of older adults attending a geriatric day hospital in Ireland who were wearing incorrectly sized shoes.

Methods

A consecutive sample of 111 older adults aged 60 years and over attending a geriatric day hospital in a large Irish teaching hospital was recruited. Demographic data including age, mobility, medications, co-habitation status, footwear worn at home and falls history were recorded. Shoe size and foot length were measured in millimetres using an internal shoe gauge and SATRA shoe size stick, respectively. Participants’ self-reported shoe size was recorded. Footwear was assessed using the Footwear Assessment Form (FAF). A Timed Up and Go (TUG) score was recorded. Functional independence was assessed using the Nottingham Extended Activities of Daily Living (NEADL) Scale. The primary outcome of interest in this study was selected as having footwear within the suggested range (10 to 15 mm) on at least one foot. Participants who met this definition were compared to those with ill-fitting footwear on both feet using Chi-square tests, T-tests or Mann–Whitney U tests.

Results

The mean difference between shoe length and foot length was 18.6 mm (SD: 9.6 mm). Overall, 72% of participants were wearing footwear that did not fit correctly on both feet, 90% had shoes with smooth, partly worn or fully worn sole treading and 67% reported wearing slippers at home. Participant age, TUG score and NEADL score were not associated with ill-fitting footwear.

Conclusions

Wearing incorrectly fitting shoes and shoes with unsafe features was common among older adults attending geriatric day services in this study. A large number of participants reported wearing slippers at home.

Condyloma acuminatum‐like lesion of the urinary bladder progressing to invasive spindle cell carcinoma

Condyloma acuminata of the urinary bladder is a rare finding, particularly in the absence of similar lesions of the external genitalia. We present a case in which an isolated condyloma acuminatum-like lesion rapidly progressed to a poorly differentiated spindle cell carcinoma, underlying the need for careful endoscopic follow-up of patients with such lesions.

Parotid neoplasms in children: experience of diagnosis and management in a district general hospital

Parotid neoplasms are uncommon in children and the available literature is predominantly from specialized centres. This paper highlights our experience at a district general hospital, in the diagnosis and management of parotid neoplasms in children. The case records of all parotidectomies performed in a 26-year period between 1974-1999 were scrutinized and patients aged 18 years and below identified. The demographic data, histology, presentation, investigations, treatment, outcomes and complications were analysed. 545 parotidectomies were performed in 536 patients, in whom 569 neoplasms were diagnosed. Only 12 patients aged 18 and under were identified (2.2%). The relative frequency of individual tumours differed markedly from that in adults. 75% of the tumours were benign. Pleomorphic adenoma and mucoepidermoid carcinoma were the most common tumours. A painless mass was the most frequent clinical presentation and CT sialogram was the most common investigation. Parotidectomy with preservation of the facial nerve was performed in all cases, and adjuvant radiotherapy employed in the case of malignant tumours. All patients were alive and well at the time of last follow up. Transient facial nerve palsy and hypertrophic scars were the most common complications.

A right-sided renal carcinoma uniquely presenting as a mass in the spermatic cord

Renal cell carcinoma presenting as a mass in the left testis or spermatic cord has previously been described with retrograde venous spread along the gonadal artery as the suggested mechanism. However a right-sided presenting lesion has not been described and suggests an alternative method of spread.

Nitric oxide synthase expression is downregulated in basal cell carcinoma of the head and neck

The small molecule nitric oxide (NO) has many actions, most of which are poorly understood. Recently, NO and related compounds have been implicated in skin damage caused by ultraviolet light although their exact role is not clear. We undertook an immuno histochemical study to assess the expression of type II NO synthase (NOS2) and type III (NOS3) in basal cell carcinomas (BCCs) of the head and neck. In all 48 cases studied, NOS2 was found in the basal cell layer of the skin at the tumour margin but it w as significantly reduced in the tumour epithelial cells (P=0.001). NOS3 was localized to the endothelium of the blood vessels in both skin and tumour in all cases, and it was not seen in the tumour epithelial cells. The results suggest that expression of NOS is down-regulated in basal cell carcinomas.

Expression of inducible nitric oxide synthase and p53 in oral epithelial dysplasia

AIM

Nitric oxide (NO) has been studied in a variety of human cancers and is implicated in both tumor promotion and inhibition. Downregulation of the enzyme iNOS by wild-type p53 (but not mutant) protein has been shown to occur in normal cells and some tumors, but the relationship has not been reported in oral epithelial dysplasia.

METHODS AND RESULTS

An immunohistochemical study was conducted with antibodies to iNOS and p53 (clone DO-7) in 36 cases of oral dysplasia of varying severity. Statistical analysis showed a significant correlation between iNOS staining and grade of dysplasia (P <.001) and between p53 and iNOS staining (P <.001).

CONCLUSIONS

This preliminary study has shown that iNOS expression correlates with severity of dysplasia, and it is also increased in those cases showing positive staining for p53. Further research is required to fully establish the relationship between iNOS and p53 in both dysplasia and oral squamous cell carcinoma.

Cerebral blood flow during experimental endotoxemia in volunteers

OBJECTIVE

To measure cerebral blood flow, cerebral metabolic rate for oxygen, cerebral oxygen delivery, and cerebral vascular resistance during experimental endotoxemia in volunteers.

DESIGN

Experimental, prospective study.

SETTING

University general clinical research center.

SUBJECTS

Healthy volunteers (six male, four female, 30.1 +/- 1.9 yrs of age).

INTERVENTIONS

Volunteers had radial, pulmonary arterial, and jugular venous bulb catheters inserted. All volunteers received a bolus of Escherichia coli endotoxin (4 ng/kg). Cerebral blood flow was measured, using the Kety-Schmidt technique.

MEASUREMENTS AND MAIN RESULTS

Cerebral and systemic hemodynamics and oxygenation variables were measured at baseline and hourly for 5 hrs after endotoxin administration. A systemic hyperdynamic response characterized by an increase in body temperature (97.9 +/- 0.02, 100.2 +/- 0.02, and 99.7 +/- 0.02 degrees F [36.6 +/- 0.01, 37.9 +/- 0.1, and 37.6 +/- 0.1 degrees C] at baseline, 3, and 5 hrs, respectively), cardiac index (3.7 +/- 0.2, 6.2 +/- 0.2, and 5.7 +/- 0.2 L/min/m2 at baseline, 3, and 5 hrs), and heart rate (70 +/- 2.6, 96 +/- 2.6, and 93 +/- 2.9 beats/min at baseline, 3, and 5 hrs), and a decrease in mean arterial pressure (99.3 +/- 2.2, 84.4 +/- 2.8, and 84 +/- 3.4 mm Hg at baseline, 3, and 5 hrs) and systemic vascular resistance (1498 +/- 53, 788 +/- 37, 849 +/- 36 dyne.sec/cm5.m2 at baseline, 3, and 5 hrs) followed the endotoxin bolus. Cerebral blood flow (65.4 +/- 4.3, 57.7 +/- 3.1, and 58.6 +/- 3.0 mL/100 g/min at baseline, 3, and 5 hrs), cerebral oxygen delivery (11.6 +/- 0.7, 9.8 +/- 0.6, and 9.5 +/- 0.6 mL/100 g/min at baseline, 3, and 5 hrs), cerebral metabolic rate for oxygen (3.8 +/- 0.4, 3.3 +/- 0.3, and 3.0 +/- 0.3 mL/100 g/min at baseline, 3, and 5 hrs), and cerebral vascular resistance (1.4 +/- 0.2, 1.4 +/- 0.2, and 1.3 +/- 0.2 mm Hg/mL/100 g/min at baseline, 3, and 5 hrs) were unchanged throughout the 5-hr study period. Signs of cerebral dysfunction were not apparent, although the volunteers appeared drowsy during the latter part of the study.

CONCLUSION

A dose of endotoxin sufficient to induce systemic vasodilation in healthy subjects does not influence cerebral blood flow or the cerebral metabolic rate for oxygen.

The effects of propofol on hemodynamics and renal blood flow in healthy and in septic sheep, and combined with fentanyl in septic sheep

Sepsis is characterized by myocardial depression and systemic vasodilation, both of which are most likely mediated by nitric oxide. Propofol inhibits nitric oxide synthase and may therefore be beneficial in sepsis. On the other hand, renal blood flow, known to be only minimally affected by propofol in healthy subjects, may be drastically reduced in septic individuals, because the renal microvasculature is known to be very sensitive to nitric oxide. In this study, the effects of propofol in healthy and in septic sheep, and in combination with fentanyl, were analyzed and compared with nonanesthetized septic sheep. In healthy sheep, propofol caused only minor hemodynamic changes. In septic sheep, however, hemodynamics deteriorated. Renal blood flow was reduced to 60% +/- 10% of the preseptic baseline and to 39% +/- 4% of the septic value. This reduction was selective, since the cardiac output decreased significantly less. These adverse effects of propofol on hemodynamics and renal blood flow were reduced when propofol was combined with fentanyl.

The determination of volume of right ventricular casts using a conductance catheter

Conductance catheters were used to assess the volume of right ventricular models made from post-mortem casts. Models were made from silastic rubber and filled with saline. The correlation between volume assessed by conductance catheter and real volume was investigated as saline was withdrawn from, and injected into, five models. The mean regression between real and conductance-derived volume was 1.05 (SE 0.04 mean R2 0.94 SE 0.02) with Y-intercept -0.25 ml SE 1.72. Parallel wall conductance was assessed through the tricuspid orifice sealed with human tricuspid tissue, or left open, and found to be negligible. There was no difference between volumes measured by a catheter through either the pulmonary or tricuspid orifice. We conclude that conductance catheters are suitable for the assessment of right ventricular volume, despite the complex geometry.

Electromyographic and cinematographic analysis of elbow function in tennis players using single- and double-handed backhand strokes

It is generally believed that tennis players using a double-handed backhand rarely develop lateral epicondylitis since the helping arm appears to absorb more energy and changes the mechanics of the swing. The purpose of this paper was to compare muscle activity about the elbow in single- and double-handed backhand strokes in competitive tennis players. Muscle activity in 3 elbow extensors, a wrist flexor, and a forearm pronator of the dominant arm was compared during the single-handed (N = 14) and double-handed (N = 13) backhand ground strokes using indwelling electromyography and high-speed cinematography. Significantly higher activity was seen in the double-handed technique in the flexor carpi radialis muscle in the preparation phase and in the pronator teres muscle in the acceleration phase. Higher flexor carpi radialis muscle activity in preparation of the double-handed stroke appeared to be a function of the double-handed grip used on the racquet, and the increased pronator teres muscle activity in acceleration indicated maintenance of greater pronation provided by the grip of the non-dominant hand. The decreased occurrence of lateral epicondylitis in players using a double-handed backhand may not be caused by decreased extensor activity, but rather by factors associated with flawed stroke mechanics more often seen in the single-handed technique.

Tennis: a physiological profile during match play

Heart rate (HR), hematocrit, hemoglobin, blood glucose, and plasma concentrations of lactate, cortisol, and testosterone were monitored in 10 male subjects (Division I, 20.3 +/- 2.5 yrs, VO2max: 58.5 +/- 9.4 ml.kg-1.min-1) during singles tennis and a treadmill test. During the on-court session, HR was 144.6 +/- 13.2 beats.min-1 for the 85 min of play. Plasma lactate rose 50% from a post-warmup value of 1.6 +/- 0.6 mmol.l-1 to 2.3 +/- 1.2 mmol.l-1 during play (p greater than 0.05). Blood glucose slightly decreased (8%, p greater than 0.05) from a pre-exercise value of 4.6 +/- 0.8 mmol.l-1 as a result of the 10-min warmup. This was followed by a 23% rise (p less than 0.05) from 4.2 +/- 1.0 mmol.l-1 to 5.2 +/- 0.6 mmol.l-1, measured after the first 30 min of play. Blood glucose subsequently remained steady at slightly above the pre-exercise value. Plasma cortisol rose (9%, p greater than 0.05) during the warmup and subsequently decreased (p less than 0.05) from a post-warmup value of 558.2 +/- 285.2 nmol.l-1 to 337.1 +/- 173.3 nmol.l-1 (a 40% decrease), and remained decreased during recovery. Plasma testosterone rose 22% (p less than 0.05) from pre-exercise to recovery (13.5 +/- 3.8 nmol.l-1 and 16.5 +/- 2.6 nmol.l-1, respectively). Although tennis is characterized by periods of high-intensity exercise, the overall metabolic response resembles prolonged moderate-intensity exercise.

Phaeochromocytoma--a presentation mimicking malignant hyperthermia

A 52-year-old apparently healthy, normotensive woman who presented for elective cholecystectomy experienced intra-operative hypertension and tachycardia, which were controlled by propranolol. Oesophageal temperature increased, there was a metabolic and respiratory acidosis with hypoxaemia, and malignant hyperthermia was diagnosed. Severe cardiogenic pulmonary oedema ensued, and was treated with intravenous glyceryl trinitrate. Ventricular fibrillation caused cardiac arrest, and this was treated successfully. Postoperatively a phaeochromocytoma was discovered, and removed at a subsequent operation. The case illustrates the similarities in presentation of malignant hyperthermia and phaeochromocytoma, and the possibility that misdiagnosis may exacerbate the crisis.

Pseudolymphoma of the tongue mimicking Hodgkin's disease. (A case report)

We have presented a case of what we believe to be pseudolymphoma arising on the dorsal aspect of the anterior part of the tongue in a middle-aged male with histological features initially suggestive of Hodgkin's disease. The nature and significance of pseudolymphoma have been discussed, together with a critical review of the relevant literature and a suggested outline of management for patients with this type of lesion.

Transient ground glass hepatocellular change following a period of glue sniffing in a patient with underlying benign recurrent cholestatic jaundice

This report describes the liver biopsy findings in an obese adolescent male suffering from benign recurrent intrahepatic cholestatic jaundice who developed transient focal feathery swelling and ground glass hepatocellular change within several weeks of indulging in glue sniffing. Clinically the situation provided a rare opportunity to observe the nature and progress of morphological features by means of sequential liver biopsies taken for the investigation of the patient's underlying jaundice. The temporal relationship between the confessed period of glue sniffing and appearance of the hepatocellular abnormality provides, in our opinion, strong supportive evidence of a definite link between the two.

Endocardial fibroelastosis associated with fatal adriamycin (doxorubicin) cardiomyopathy during treatment of Ewing's sarcoma

We report a case of fatal adriamycin cardiomyopathy in a 12-year-old boy treated for Ewing's sarcoma. At necropsy, in addition to the typical changes of advanced cardiotoxicity in the myocardium there was endocardial fibroelastosis, mainly affecting the left ventricle.