Poster Abstracts / JAMDA 15 (2014) B3eB28 B7

appropriate based on his background as pilot. His right hand contracturehas significantly decreased after spending 20�30 minutes playing the“Microsoft Flight Simulator” computer game. Currently, he is able to self-feed with his right hand with nursing supervision. We are working withhim on the left hand.Discussion: The etiology of hand contractures in Parkinson’s disease ispoorly understood. It may be caused by multiple factors. It is thought thatover activity of the small muscles of the hand is an important contributingfactor in producing hand deformities in Parkinson’s disease. It has beenshown that blocking the ulnar nerve at the elbowwith local anesthetic canreverse finger flexion deformities. However, the nerve block is an invasiveintervention which may not be practical in frail patients with co- mor-bidities. It is never too late to explore the non-invasive measures toimprove hand contractures in advanced Parkinson’s disease. The individ-ualized computer based exercise game in this case resulted in significantimprovement of the hand contracture. More studies are needed to explorethe etiology and management of this poorly understood complication ofParkinson’s disease.Author Disclosures: All authors have stated there are no financial dis-closures to be made that are pertinent to this abstract.

Marjolin Ulcers: Transformation of Chronic Venous Ulcers toSquamous Cell Carcinoma

Presenting Author: Jowairiyya Ahmad, MD, Montefiore Medical CentreAuthor(s): JowairiyyaAhmad,MD,NahunGaleas,MD;andOscarAlvarez,PhD

Introduction: The Incidence of malignant tumors in chronic ulcer is 2%, andthe incidence of squamous cell carcinoma (SCC) as the cause of themalignanttumor is 0.4% which is greater than the general population. The progressionof SCC to invasive disease depends upon age of the lesion and the immunestatus of the patient. We describe 4 cases of patients with chronic venousulcers which were transformed to squamous cell carcinoma (SCC).Case Description: The average age of the four patients in this series were78.0 years. All hadmultiple co-morbidities, altered immune status, and a longhistory of chronic non-healing venous ulcers. The patients were referred forbiopsy and were eventually diagnosed with late stages of squamous cellcarcinoma. One of the patients had a first biopsy which was negative, butrepeat serial biopsies were performed due to a high clinical suspicion. Therepeat biopsy was positive for squamous cell carcinoma with deep margins.All patients in the series had a poor prognosis and were not deemed to begood candidates for a Mohs procedure. All patients were ultimately referredfor palliative wound care.Discussion: The case series highlights the importance of obtaining biopsiesin long standing ulcers upon initial presentation inwound clinic. Subsequentbiopsies must be done to exclude malignancy, especially in atypical pre-sentations or when the ulcer fails to heal. Biopsies should be repeatedfrequently even if the first biopsy is negative. MRIs help stage malignantulcers. Undiagnosed Marjolin ulcers can be fatal. Geriatricians should bemore aware of the management and prognosis. From the above case serieswe conclude: 1) If a chronic ulcer fails to heal, there should be a low thresholdfor biopsy in a patient with a compromised immune system; 2) Biopsiesshould be repeated after the first biopsy is negative in the setting of highsuspicion; and 3) MRIs can help stage these malignancies so that treatmentcan be initiated early.Author Disclosures: All authors have stated there are no financial disclosuresto be made that are pertinent to this abstract.

Medical Foster Home: Experience With 16 Veterans

Presenting Author: Grace Cordts, MD, MPH, MS, VA Maryland HealthCare SystemAuthor(s): Grace Cordts, MD, MPH, MS, Nicole Trimble, LCSW; andCrystal Taylor, LCSW

Introduction: Medical Foster Home (MFH) is a unique partnership ofadult foster home and a VA interdisciplinary home care team, providinglong term care in a personal home as a non-institutional extended careoption. Many veterans live alone, independently for years through thesupport of assistive devices and home care services. Eventually the vet-eran may decline to the point that it is no longer safe to remain livingalone. Traditionally, this situation is resolved by nursing home placement.However, the veteran may refuse nursing home care, instead acceptingserious risks. MFH offers a safe, favorable, and less costly alternative. TheVA Maryland Health Care System (VAMHCS) has a unique partnershipwith privately owned adult foster homes to provide an alternative tonursing home care. The VAMHCS has had a sanctioned MFH programsince July 2012. Sixteen Veterans have been enrolled in the program withan average daily census of 5. This case series presents this experience withlessons learned.Case Description: Sixteen Veterans have been enrolled in the program.The Veterans range from 56-75 years old. The length of stay in the pro-gram ranges from 1-3 years. Caregivers range in age from 45-55. Seventy-five percent of the veterans reside in a private room. Veterans report 100%improvement in quality of life (QOL), privacy and feeling safe. They reportthey feel like the caregivers really care about them as people. Veterans feellike the MFH Coordinator was able to find them a home that fit them. TheVeterans in the MFH program are followed by the Home Based PrimaryCare (HBPC) Team for their medical care. The MFH Coordinator goes to theHBPC teammeetings. The process of identifying and certifying homes willbe presented. Homes need to be licensed by the state of Maryland. Thecaregiver must own or rent. The expectation is that the caregiver providesthe majority of care eliminating multiple staff cycling in and out inkeeping with the mission of the program to make the Veteran feel likethey are at home.Discussion: The VAMHCS experience with MFH shows that MFH is anexcellent alternative to nursing home placement. It is a comprehensiveapproach to the care of the elderly which includes medical care of theVeteran through the HBPC. Veterans in the program report an improve-ment in their QOL. A good deal of thought goes into pairing the Veteranwith the caregiver and home to ensure the success of the situation. Thisalso includes looking at the other residents in the home. Some barriers toidentifying homes include that they have to be licensed by the state ofMaryland which is lengthy and costly; they cannot have more than 3residents in the home and some are licensed for more and do not want totake just three residents secondary to profit margins; and caregiver mustlive in the home. The program is cost effective for the VAMHCS. Theprogram pays for itself if two service connected Veterans are in MFHhome.Author Disclosures: All authors have stated there are no financial dis-closures to be made that are pertinent to this abstract.

One-and-a-Half Syndrome: An Unusual Cause of Dizziness

Presenting Author: Daniel Haimowitz, MD, CMD, Lehigh ValleyAuthor(s): Daniel Haimowitz, MD, CMD, Catherine Glew, CMD; andYelena Shpigel

Introduction: This is a rare cause of dizziness, which can be seen inyounger patients with multiple sclerosis. Uncommon in the elderly, it isusually a result of a brainstem infarct.Case Description: An 80 year old CCRC resident developed the suddenonset of imbalance. When she tried to turn her eyes she developeddouble vision, associated with nausea and gait dysfunction. She feltextremely dizzy, especially when she turned her eyes. Neurologic examwas remarkable for complete paralysis of horizontal gaze in the right eyeand preserved abduction of the left eye. Brain imaging was initially readas negative; however, after review was felt to support a subacute punc-tate pontine infarct potentially involving the region of the right mediallongitudinal fasciculus and/or the right VI nerve nucleus region. Aspirintherapy was initiated and an eye patch used for the right eye. The patient

Poster Abstracts / JAMDA 15 (2014) B3eB28B8

required a short-stay rehab admission and was discharged back to theCCRC.Discussion: One and a half syndrome is an unusual Internuclear Oph-thalmoplegia. This syndrome consists of a gaze palsy in one direction withan INO on horizontal gaze in the opposite direction. With attemptedhorizontal gaze, only abduction of the contralateral eye remains. Conver-gence is also spared. This syndrome is produced by damage to the para-median reticular formation (PPRF) and/or abducens nucleus and MLF onthe same side.Author Disclosures: Financial support for the poster will be requestedfrom the Lehigh Valley Health Network.

Thyroid Storm in an Elderly Patient

Presenting Author: Wajahat A. Lodhi, MD, Fairview HospitalAuthor: Wajahat A. Lodhi, MD

Introduction: Thyroid disease is not uncommon in elderly population;Hypothyroidism is more common than hyperthyroidism. Thyroid stormthough rare is not an unusual presentation. It has a mortality of 15-20% ifuntreated; it becomes a challenge in geriatric population where there aremultiple other causes which mimic this presentation. Thyroid stormusually presents with fever, confusion and agitation which can lead tocoma and death without urgent identification and treatment. A goodhistory, physical exam and appropriate blood tests and imaging areessential as in any case.Case Description: 73 year old white male presented from home toemergency department via EMS after the wife noticed her husband wasconfused and lethargic. Patient had history of dementia, hypertension,and diabetes; he was admitted recently in the same institution fordysphagia and the primary care physician (PCP) started him on flu-conazole 2 weeks prior to presentation. The wife reported that thepatient complained of sore throat, low grade fever (T 100 F), weaknessfor 3 days and the next day became confused, agitated and lethargic.Wife called his PCP who advised her to take him to Emergencydepartment. On evaluation by EMS, patient had T 38 C, Pulse 75, RR 16,BP 100/60 and Oxygen saturation 97% on ambient air. Patient waslethargic, confused and mumbling unintelligible words. According tohis wife this was a new change, his baseline was minimal dependenceon his wife. His home medications were Solifenacin 5 mg daily, Hy-drochlorothiazide 12.5 mg daily, Amlodipine 2.5 mg daily, Benazepril40 mg daily, Nebivolol 10 mg daily, vitamin D 50,000 IU every month,Atorvastatin 80 mg daily, Finasteride 5 mg daily, Aspirin 81 mg daily,Donepezil 10 mg daily, Sitagliptin/Metformin 1 tablet daily. In theEmergency department examination was significant for slight rightsided weakness and urine analysis (UA), complete blood count, com-plete metabolic panel, cardiac enzymes, blood cultures, CXR and brainCT (computed tomography) was ordered which were unremarkableexcept for a slight rise in bun and creatinine from base line and whiteblood count (WBC) 7000. UA showed some bacteria WBC 10 and nitritenegative. EKG showed NSR with HR 75 with no ST and T changes. Hewas started on normal saline (NS) infusion, broad spectrum antibioticsand admitted to telemetry. Next day patient remained Lethargic anddeveloped new onset Atrial fibrillation with rapid ventricular rate.Cardiology and Neurology was consulted. Patient was started on Car-dizem drip and Neurology did not find any focal weakness exceptchange in mental status and ordered magnetic resonance imaging(MRI)/magnetic resonance angiography (MRA), ESR, CRP and TSH andgave initial impression of possible left Middle cerebral artery CVA. TSHcame back as 0.009 and FT3 (free T3) of 16.5 ng/dL and FT4 (free T4) asvery high (not recordable). Endocrinology was consulted and theyrecommended adding Metoprolol and patient was started on pro-pylthiouracil (PTU) and Hydrocortisone IV. His blood and urine culturescame back positive for coagulase negative staphylococcus and patientwas started on Nitrofurantoin. Patient had prolonged stay due to hisAtrial fibrillation with rapid ventricular rate resistant to treatment. He

was continued on Diltiazem, Sotalol was added. Chemical cardioversionwith Ibutilide failed. After one week his FT3 and FT4 normalized and hehad electrical cardioversion which converted him back to normal sinusrhythm. Patient started to feel better and his confusion startedresolving. Antibiotic were given for 5 days and stopped. Steroid weretapered and patient was discharged to Nursing facility for rehabilita-tion.Discussion: Again it is not uncommon to see the knee jerk reflex ofredundant blood work and imaging. It is all the more important toevaluate patient’s condition, look for signs and symptoms but most ofthe time this is challenging as patients are confused, uncooperativeand an evaluation is difficult. In this case there was imaging andcertain blood tests were done which probably were not required. Assoon as the patient is diagnosed, he/she should be started on Pro-pylthiouracil which is fast acting and blocks the conversion from T4 toT3 and normalizes the T3 in few days. Hydrocortisone again helps inblocking the conversion to active form but also helpful in cases ofthyroiditis. In this case thyroid-stimulating immunoglobulin wasnegative and most probable cause was Thyroiditis due to viral infec-tion. This patient had many reasons to have confusion; his medication,and recent use of fluconazole (inhibitor of CYP450 system), infection,dehydration which made this case all the more challenging. He wasdiagnosed with urinary tract infection which most probably wasasymptomatic bacteriuria and contamination due to Foley catheterinsertion and he was started on Nitrofurantoin which is not the drug ofchoice in a geriatric patient.Author Disclosures: All authors have stated there are no financial dis-closures to be made that are pertinent to this abstract.

Transitions in Care: Salient Scenarios

Presenting Author: Hardeep Gill, MD, The MetroHealth SystemAuthor(s): Hardeep Gill, MD; and Mary Corrigan, MD

Introduction: 20% of Medicare patients discharged from the hospital arereadmitted within 30 days, and 33% within 90 days. 20% of dischargedpatients will have adverse events after discharge. Reimbursement deter-mined by care quality and patient satisfaction. Medicare Patient AdvisoryCommission “MedPac”;estimates $12 billion in savings could be achievedby better discharge planning to prevent avoidable readmissions.Case Description: Case 1, 55 year old male with Stage 4 esophageal cancer,and spinal cord compression due to T7 fracture was transferred to SNF latein the evening for rehabilitation and radiation. Patient was determined tobe stable medically. His vitals were within normal limits. His labs revealedrenal insufficiency and mild anemia. Patient had a 5.7 X 7.1 cm neck mass,stent placement for dysphagia, and was started on palliative radiation.Patient was receiving Dilaudid 2 mg every hour for pain. Day 1 of SNF,patient was hypoxic, in excruciating pain, and was transferred toMICU anddied within 1 day. Of note, patient was a Full Code. Case 2, 31 year old malepatient was transferred to SNF for rehabilitation after sustaining a righttibial plateau fracture, with closed reduction and external fixator and laterORIF. Patient’s medications were resumed per the Golden Rod. There wereno IV medications listed. 48 hours later, patient noted to be lethargic andfebrile with increased drainage from the surgical site. He was transferredback to operating room for debridement. Patient missed 48 hours of an-tibiotics not mentioned in the discharge orders. Case 3, 86 year old femalewith non small cell lung CA, plan for transfer to SNF. Updated vitals reveal:BP 104/66, T 100.4 F, P 110, RR 24, Pulse Ox 92% on 4L. Per medical floor,patient was stable to be transferred. Transfer was questioned based onvitals. Notified that extensive workup had been done which was unre-markable. One hour later, updated that x-ray showed white out of thepatient’s lung.Discussion: Case 1 Pitfalls: No end of life care discussionwith emphasis ongoals of care in light of patients’ condition and disease trajectory. Case 2Pitfalls: Essential medication omitted from the Golden Rod contributing tosignificant morbidity and mortality. Case 3 Pitfalls: Hand off information