Middlesex Hospital

Abstract Geriatric Outreach and Training with Care (GOT Care!) was created as a model for interprofessional geriatric education and practice. An interprofessional team of geriatric expert clinical faculty guided students from seven health professions in learning about and caring for chronically ill homebound older adults experiencing high emergency department (ED) use. The GOT Care! project was evaluated using the IHI Quadruple AIM framework and positive outcomes supported development of this model within a health system, however, gaps and need for further inquiry were also identified. GOT Care! 2.0, a secondary analysis of GOT Care! program data, was conducted with the aim of better understanding medical expenditures, healthcare utilization risk factors, and the observed reduction in ED visits for GOT Care! participants. Electronic health records, billing records and medical expenditures were extracted and analyzed for a 6 month pre- and post-program period. Direct costs were reduced significantly in the post-period (mean=$1,264.85) compared to the pre-period (mean=$4,457.44) (p < 0.001) and at 12 months (p < 0.001). Multiple factors associated with the likelihood of increased or decreased medical expenditures at 6 and 12 months were identified. With the support of the findings of the secondary analysis, an in-home interprofessional geriatric service pilot was launched. This pilot was based on the GOT Care! model and integrates the IHI Age-Friendly health system criteria focused on improving the IHI Quadruple AIM for a health system’s vulnerable older adult population.

Non-ketotic hyperglycemic hemichorea-hemiballismus syndrome is a rare neurological condition associated with hyperglycemia from uncontrolled diabetes mellitus. We present a case of a male patient in his late 80s with a background of T2DM who presented with a new onset of progressive involuntary movements involving the left side of his body. Imaging revealed hyperdensity in the right basal ganglia, suggestive of non-ketotic hyperglycemic hemichorea. Management included glycemic control and neuroleptic treatment, with resolution of symptoms in most cases. This case highlights the importance of considering metabolic causes of hemichorea-hemiballismus in elderly patients, glycemic control, and the correlation of these factors with quality of life.

HISTORY:34 year old classical guitarist with a history of bilateral De Quervain’s Tenosynovitis who presented with new onset pain in the right lateral forearm which worsened with ulnar deviation. She presented with a similar complaint 1 year ago where she underwent ultrasound-guided corticosteroid injection on the right side which resolved the pain at that time. Of note, she recently increased her level of activity for an upcoming performance, started using bell weights, and had to carry her 30 pound newborn son. She initially tried a thumb spica splint and brace, topical NSAIDs, and physical therapy with mild benefit. After failing 3 weeks of physical therapy, she returned for a steroid injection. Earlier that week, she felt a sharp pain along radial styloid as if something "popped". Limited diagnostic US showed hypoechoic fluid surrounding the 1st compartment and a small hyperechoic disruption along tendon sheath. Patient decided to forgo steroid injection until further MRI imaging given the risk of tearing or worsening of the acute disruption. PHYSICAL EXAMINATION: No gross deformity, upper and lower extremity strength and range of motion grossly intact. Tenderness to palpation along the right lateral wrist. Positive finkelstein test. DIFFERENTIAL DIAGNOSIS: 1) Osteoarthritis of the first carpometacarpal joint 2) De Quervain's Tenosynovitis 3) Intersection Syndrome TEST AND RESULTS: X-ray Right Wrist: Mild bony changes and chronic traction at the radial styloid. No fracture or dislocation. Joint spaces, articular surfaces, and carpal alignment are normal. MRI Right Wrist: Tenosynovitis in the first dorsal compartment. Enlarged abductor pollicis longus tendon at the radial styloid. Other tendons intact. Flexor tendons and carpal tunnel normal. FINAL WORKING DIAGNOSIS: De Quervain’s Tenosynovitis TREATMENT AND OUTCOMES: Following the MRI, the patient was referred to orthopedic surgery for possible surgical intervention, as she had previously tried corticosteroid injections, occupational therapy, and other conservative treatments. She underwent a debridement and release of the right wrist’s first dorsal extensor compartment tendon sheath. Since the procedure, her pain and activity levels have significantly improved, and she has returned to her normal health.

ObjectivesTo alert the paediatric community of this unusual presentation of electrolyte abnormalities, the most differentials, and management steps.MethodsProspective and retrospective data collection during the admission of this patient to the neonatal unit.ResultsSecondary pseudohypoaldosteronism is a condition characterized by aldosterone resistance in renal tubules. It is highly associated in the literature with urinary tract infections and malformations, especially in male infants. A three day old term male infant was admitted in the neonatal unit with jaundice. Apart from hyper- bilirubinaemia, his laboratory test results revealed hyponatremia and hyperkalaemia, and pyuria. He was treated with intravenous fluids, calcium gluconate, enteral feeding, and antimicrobial therapy. Electrolyte disorders were addressed and he was discharged on the 7th day of hospitalization without any sequelae. His urine culture showed mixed growth and his renal ultrasonography showed no abnormalities.ConclusionTransient pseudohypoaldosteronism is an important consideration in the differential diagnosis in infants with hyponatremia and hyperkalaemia, even when investigations show no abnormality. It should be considered in cases presenting for a different primary reason and where such electrolyte imbalances are an incidental finding.ReferencesFountain JH, Kaur J, Lappin SL. Physiology, Renin Angiotensin System. [Updated 2023 Mar 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470410/.Watanabe T. Reversible secondary pseudohypoaldosteronism. Pediatr Nephrol 2003;18:486. https://doi.org/10.1007/s00467-003-1104-6.Llana I, Sanchez-Redondo M, Benedit M, et al. 960 Secondary Pseudohypoaldosteronism Due to Pyelonephritis: Two Cases Report. Archives of Disease in Childhood 2012;97:A274.Rodríguez-Soriano J, Vallo A, Oliveros R, Castillo G. Transient pseudohypoaldosteronism secondary to obstructive uropathy in infancy. J Pediatr. 1983;103:375–80. 10.1016/s0022–3476(83)80406–5.Delforge X, Kongolo G, Cauliez A, Braun K, Haraux E, Buisson P. Transient pseudohypoaldosteronism: a potentially severe condition affecting infants with urinary tract malformation. J Pediatr Urol. 2019;15:265.e1–7. 10.1016/j.jpurol.2019.03.002.

Abstract Background North Middlesex University Hospital runs an outpatient frailty service where patients are referred for a Comprehensive Geriatric Assessment. There is a daily ‘hot slot’ for patients who otherwise would have required hospital admission if not seen within seven days. We aimed to improve utilisation of hot slots from 50% to 100%. Empty hot slots result in the under-utilisation of pre-allocated resources and increase the workload of healthcare professionals in other departments. Methods Author ESK audited hot slot usage in November and December 2022, marking slots as ‘filled’ or ‘unfilled’. In January 2023 we established a clear referral process for the hot slots and implemented an education program targeted at referrers to increase awareness of the availability of hot slots and referral criteria. Authors ESK, NS and FM re-audited the hot slot usage from February to April 2023. Author FM analysed the data and conducted statistical testing of the results. Authors NS and FM produced visual representation of the data collected. Results After exclusion of periods where the hot slots were closed (n=13) including strike days, bank holidays and times with below minimum staffing; 82 hot slots were audited, pre-intervention (n=39) and post-intervention (n=43). The utilisation of hot slots increased from 51% pre-intervention to 86% post-intervention. Fisher's exact test shows this is statistically significant (p<0.0007). Conclusions The education program increased utilisation of hot slots but fell short of the targeted 100% utilisation rate. We made the hot slot available exclusively to the Geriatric Emergency Medicine (GEM) team for one week in August 2023 to assess whether this increases GEM utilisation of the hot slot. We intend to further analyse the data to review the appropriateness of referrals and try to improve this. A larger project could assess impact of hot slot usage on patient outcomes.

COVID-19 also known as severe acute respiratory syndrome coronavirus 2 is the result of a highly transmissible coronavirus which can result in severe infection of the respiratory tract. The global pandemic which began in early 2020 has created a number of challenges for the medical community to contain the rate of transmission, especially to health care workers. A minority of the infected population will progress toward severe respiratory distress ultimately requiring mechanical ventilator assistance. Although preliminary data suggest a poor prognosis for those requiring ventilation support, there is a subgroup who will eventually be weaned off. As the pandemic evolves, this cohort of infected, chronically intubated and ventilated individuals will become more prevalent and may require tracheostomy to aid in recovery. Unfortunately, tracheostomy is an aerosol-generating procedure which poses high risks to all members within the operating room, as described by previous authors. There is an urgent need to explore and develop methods to maximize the safety of tracheostomy and other aerosol-generating procedures in order to reduce intraoperative transmission. In the present article, we present a modified technique for negative pressure enclosure in patients with COVID-19 who underwent tracheostomy.