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Marjolin Ulcers: Transformation of Chronic Venous Ulcers to Squamous Cell Carcinoma
Poster Abstracts / JAMDA 15 (2014) B3eB28
appropriate based on his background as pilot. His right hand contracture has significantly decreased after spending 20 30 minutes playing the “Microsoft Flight Simulator” computer game. Currently, he is able to selffeed with his right hand with nursing supervision. We are working with him on the left hand. Discussion: The etiology of hand contractures in Parkinson’s disease is poorly understood. It may be caused by multiple factors. It is thought that over activity of the small muscles of the hand is an important contributing factor in producing hand deformities in Parkinson’s disease. It has been shown that blocking the ulnar nerve at the elbow with local anesthetic can reverse finger flexion deformities. However, the nerve block is an invasive intervention which may not be practical in frail patients with co- morbidities. It is never too late to explore the non-invasive measures to improve hand contractures in advanced Parkinson’s disease. The individualized computer based exercise game in this case resulted in significant improvement of the hand contracture. More studies are needed to explore the etiology and management of this poorly understood complication of Parkinson’s disease. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
Marjolin Ulcers: Transformation of Chronic Venous Ulcers to Squamous Cell Carcinoma Presenting Author: Jowairiyya Ahmad, MD, Montefiore Medical Centre Author(s): Jowairiyya Ahmad, MD, Nahun Galeas, MD; and Oscar Alvarez, PhD
Introduction: The Incidence of malignant tumors in chronic ulcer is 2%, and the incidence of squamous cell carcinoma (SCC) as the cause of the malignant tumor is 0.4% which is greater than the general population. The progression of SCC to invasive disease depends upon age of the lesion and the immune status of the patient. We describe 4 cases of patients with chronic venous ulcers which were transformed to squamous cell carcinoma (SCC). Case Description: The average age of the four patients in this series were 78.0 years. All had multiple co-morbidities, altered immune status, and a long history of chronic non-healing venous ulcers. The patients were referred for biopsy and were eventually diagnosed with late stages of squamous cell carcinoma. One of the patients had a first biopsy which was negative, but repeat serial biopsies were performed due to a high clinical suspicion. The repeat biopsy was positive for squamous cell carcinoma with deep margins. All patients in the series had a poor prognosis and were not deemed to be good candidates for a Mohs procedure. All patients were ultimately referred for palliative wound care. Discussion: The case series highlights the importance of obtaining biopsies in long standing ulcers upon initial presentation in wound clinic. Subsequent biopsies must be done to exclude malignancy, especially in atypical presentations or when the ulcer fails to heal. Biopsies should be repeated frequently even if the first biopsy is negative. MRIs help stage malignant ulcers. Undiagnosed Marjolin ulcers can be fatal. Geriatricians should be more aware of the management and prognosis. From the above case series we conclude: 1) If a chronic ulcer fails to heal, there should be a low threshold for biopsy in a patient with a compromised immune system; 2) Biopsies should be repeated after the first biopsy is negative in the setting of high suspicion; and 3) MRIs can help stage these malignancies so that treatment can be initiated early. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
Medical Foster Home: Experience With 16 Veterans Presenting Author: Grace Cordts, MD, MPH, MS, VA Maryland Health Care System Author(s): Grace Cordts, MD, MPH, MS, Nicole Trimble, LCSW; and Crystal Taylor, LCSW
B7
Introduction: Medical Foster Home (MFH) is a unique partnership of adult foster home and a VA interdisciplinary home care team, providing long term care in a personal home as a non-institutional extended care option. Many veterans live alone, independently for years through the support of assistive devices and home care services. Eventually the veteran may decline to the point that it is no longer safe to remain living alone. Traditionally, this situation is resolved by nursing home placement. However, the veteran may refuse nursing home care, instead accepting serious risks. MFH offers a safe, favorable, and less costly alternative. The VA Maryland Health Care System (VAMHCS) has a unique partnership with privately owned adult foster homes to provide an alternative to nursing home care. The VAMHCS has had a sanctioned MFH program since July 2012. Sixteen Veterans have been enrolled in the program with an average daily census of 5. This case series presents this experience with lessons 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 program ranges from 1-3 years. Caregivers range in age from 45-55. Seventyfive percent of the veterans reside in a private room. Veterans report 100% improvement in quality of life (QOL), privacy and feeling safe. They report they feel like the caregivers really care about them as people. Veterans feel like the MFH Coordinator was able to find them a home that fit them. The Veterans in the MFH program are followed by the Home Based Primary Care (HBPC) Team for their medical care. The MFH Coordinator goes to the HBPC team meetings. The process of identifying and certifying homes will be presented. Homes need to be licensed by the state of Maryland. The caregiver must own or rent. The expectation is that the caregiver provides the majority of care eliminating multiple staff cycling in and out in keeping with the mission of the program to make the Veteran feel like they are at home. Discussion: The VAMHCS experience with MFH shows that MFH is an excellent alternative to nursing home placement. It is a comprehensive approach to the care of the elderly which includes medical care of the Veteran through the HBPC. Veterans in the program report an improvement in their QOL. A good deal of thought goes into pairing the Veteran with the caregiver and home to ensure the success of the situation. This also includes looking at the other residents in the home. Some barriers to identifying homes include that they have to be licensed by the state of Maryland which is lengthy and costly; they cannot have more than 3 residents in the home and some are licensed for more and do not want to take just three residents secondary to profit margins; and caregiver must live in the home. The program is cost effective for the VAMHCS. The program pays for itself if two service connected Veterans are in MFH home. Author Disclosures: All authors have stated there are no financial disclosures 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 Valley Author(s): Daniel Haimowitz, MD, CMD, Catherine Glew, CMD; and Yelena Shpigel
Introduction: This is a rare cause of dizziness, which can be seen in younger patients with multiple sclerosis. Uncommon in the elderly, it is usually a result of a brainstem infarct. Case Description: An 80 year old CCRC resident developed the sudden onset of imbalance. When she tried to turn her eyes she developed double vision, associated with nausea and gait dysfunction. She felt extremely dizzy, especially when she turned her eyes. Neurologic exam was remarkable for complete paralysis of horizontal gaze in the right eye and preserved abduction of the left eye. Brain imaging was initially read as negative; however, after review was felt to support a subacute punctate pontine infarct potentially involving the region of the right medial longitudinal fasciculus and/or the right VI nerve nucleus region. Aspirin therapy was initiated and an eye patch used for the right eye. The patient
appropriate based on his background as pilot. His right hand contracture has significantly decreased after spending 20 30 minutes playing the “Microsoft Flight Simulator” computer game. Currently, he is able to selffeed with his right hand with nursing supervision. We are working with him on the left hand. Discussion: The etiology of hand contractures in Parkinson’s disease is poorly understood. It may be caused by multiple factors. It is thought that over activity of the small muscles of the hand is an important contributing factor in producing hand deformities in Parkinson’s disease. It has been shown that blocking the ulnar nerve at the elbow with local anesthetic can reverse finger flexion deformities. However, the nerve block is an invasive intervention which may not be practical in frail patients with co- morbidities. It is never too late to explore the non-invasive measures to improve hand contractures in advanced Parkinson’s disease. The individualized computer based exercise game in this case resulted in significant improvement of the hand contracture. More studies are needed to explore the etiology and management of this poorly understood complication of Parkinson’s disease. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
Marjolin Ulcers: Transformation of Chronic Venous Ulcers to Squamous Cell Carcinoma Presenting Author: Jowairiyya Ahmad, MD, Montefiore Medical Centre Author(s): Jowairiyya Ahmad, MD, Nahun Galeas, MD; and Oscar Alvarez, PhD
Introduction: The Incidence of malignant tumors in chronic ulcer is 2%, and the incidence of squamous cell carcinoma (SCC) as the cause of the malignant tumor is 0.4% which is greater than the general population. The progression of SCC to invasive disease depends upon age of the lesion and the immune status of the patient. We describe 4 cases of patients with chronic venous ulcers which were transformed to squamous cell carcinoma (SCC). Case Description: The average age of the four patients in this series were 78.0 years. All had multiple co-morbidities, altered immune status, and a long history of chronic non-healing venous ulcers. The patients were referred for biopsy and were eventually diagnosed with late stages of squamous cell carcinoma. One of the patients had a first biopsy which was negative, but repeat serial biopsies were performed due to a high clinical suspicion. The repeat biopsy was positive for squamous cell carcinoma with deep margins. All patients in the series had a poor prognosis and were not deemed to be good candidates for a Mohs procedure. All patients were ultimately referred for palliative wound care. Discussion: The case series highlights the importance of obtaining biopsies in long standing ulcers upon initial presentation in wound clinic. Subsequent biopsies must be done to exclude malignancy, especially in atypical presentations or when the ulcer fails to heal. Biopsies should be repeated frequently even if the first biopsy is negative. MRIs help stage malignant ulcers. Undiagnosed Marjolin ulcers can be fatal. Geriatricians should be more aware of the management and prognosis. From the above case series we conclude: 1) If a chronic ulcer fails to heal, there should be a low threshold for biopsy in a patient with a compromised immune system; 2) Biopsies should be repeated after the first biopsy is negative in the setting of high suspicion; and 3) MRIs can help stage these malignancies so that treatment can be initiated early. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
Medical Foster Home: Experience With 16 Veterans Presenting Author: Grace Cordts, MD, MPH, MS, VA Maryland Health Care System Author(s): Grace Cordts, MD, MPH, MS, Nicole Trimble, LCSW; and Crystal Taylor, LCSW
B7
Introduction: Medical Foster Home (MFH) is a unique partnership of adult foster home and a VA interdisciplinary home care team, providing long term care in a personal home as a non-institutional extended care option. Many veterans live alone, independently for years through the support of assistive devices and home care services. Eventually the veteran may decline to the point that it is no longer safe to remain living alone. Traditionally, this situation is resolved by nursing home placement. However, the veteran may refuse nursing home care, instead accepting serious risks. MFH offers a safe, favorable, and less costly alternative. The VA Maryland Health Care System (VAMHCS) has a unique partnership with privately owned adult foster homes to provide an alternative to nursing home care. The VAMHCS has had a sanctioned MFH program since July 2012. Sixteen Veterans have been enrolled in the program with an average daily census of 5. This case series presents this experience with lessons 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 program ranges from 1-3 years. Caregivers range in age from 45-55. Seventyfive percent of the veterans reside in a private room. Veterans report 100% improvement in quality of life (QOL), privacy and feeling safe. They report they feel like the caregivers really care about them as people. Veterans feel like the MFH Coordinator was able to find them a home that fit them. The Veterans in the MFH program are followed by the Home Based Primary Care (HBPC) Team for their medical care. The MFH Coordinator goes to the HBPC team meetings. The process of identifying and certifying homes will be presented. Homes need to be licensed by the state of Maryland. The caregiver must own or rent. The expectation is that the caregiver provides the majority of care eliminating multiple staff cycling in and out in keeping with the mission of the program to make the Veteran feel like they are at home. Discussion: The VAMHCS experience with MFH shows that MFH is an excellent alternative to nursing home placement. It is a comprehensive approach to the care of the elderly which includes medical care of the Veteran through the HBPC. Veterans in the program report an improvement in their QOL. A good deal of thought goes into pairing the Veteran with the caregiver and home to ensure the success of the situation. This also includes looking at the other residents in the home. Some barriers to identifying homes include that they have to be licensed by the state of Maryland which is lengthy and costly; they cannot have more than 3 residents in the home and some are licensed for more and do not want to take just three residents secondary to profit margins; and caregiver must live in the home. The program is cost effective for the VAMHCS. The program pays for itself if two service connected Veterans are in MFH home. Author Disclosures: All authors have stated there are no financial disclosures 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 Valley Author(s): Daniel Haimowitz, MD, CMD, Catherine Glew, CMD; and Yelena Shpigel
Introduction: This is a rare cause of dizziness, which can be seen in younger patients with multiple sclerosis. Uncommon in the elderly, it is usually a result of a brainstem infarct. Case Description: An 80 year old CCRC resident developed the sudden onset of imbalance. When she tried to turn her eyes she developed double vision, associated with nausea and gait dysfunction. She felt extremely dizzy, especially when she turned her eyes. Neurologic exam was remarkable for complete paralysis of horizontal gaze in the right eye and preserved abduction of the left eye. Brain imaging was initially read as negative; however, after review was felt to support a subacute punctate pontine infarct potentially involving the region of the right medial longitudinal fasciculus and/or the right VI nerve nucleus region. Aspirin therapy was initiated and an eye patch used for the right eye. The patient