Vulnerability to Food Insecurity among Older People: The Role of Social Capital

Food insecurity is a public health issue in Western countries, including the UK. Being food-insecure means older adults may not access sufficient nutritious, safe, and socially acceptable food, leading to a higher risk of malnutrition. We conducted a qualitative study of 25 households with men and women aged 60-95 years to investigate how older adults access food and to explore social capital, which might contribute to food security or prevent malnutrition. We conducted participant-led kitchen tours, interviews, photo, and video elicitation across multiple household visits. In addition, we brought stakeholders together from a range of sectors in a workshop to explore how they might respond to our empirical findings, through playing a serious game based on scenarios drawn from our data. This was a successful way to engage a diverse audience to identify possible solutions to threats to food security in later life. Analysis of the data showed that older people's physical and mental health status and the local food environment often had a negative impact on food security. Older people leveraged social capital through reciprocal bonding and bridging social networks which supported the maintenance of food security. Data were collected before COVID-19, but the pandemic amplifies the utility of our study findings. Many social elements associated with food practices as well as how people shop have changed because of COVID-19 and other global and national events, including a cost-of-living crisis. To prevent ongoing adverse impacts on food security, focus and funding should be directed to re-establishment of social opportunities and rebuilding bridging social capital.

THE USE OF SPINAL ANAESTHESIA FOR RETROGRADE URETERO-RENOSCOPY DURING THE COVID-19 PANDEMIC

Background The use of spinal anaesthesia (SA) for retrograde uretero-renoscopic surgery is considered to be not as effective as a general anaesthetic (GA) by urologists. However, there were significant concerns associated with GA both for the patient and the anaesthetic team at the height of the COVID-19 pandemic. Our unit was able to successfully transfer surgery to a purpose-built day facility that had extensive experience in delivering SA. This created the opportunity to assess the SA technique in uretero-renoscopy in a cohort of unselected patients. Objective To assess the feasibility of SA as a primary form of anaesthetic for retrograde endoluminal renal and ure-teric surgery. Results Over 4 months, 41 ureteroscopic procedures were performed. The conversion rate to GA (for inadequate analgesia) was 9.8%. Surgical outcome data were compared with an equivalent cohort of patients’ who underwent GA before the pandemic. Both groups had similar outcomes: day-case discharge rate (SA 84%, GA 86%) and surgical completion rate (SA 94%, GA 90%). However, there was a difference in postoperative readmission rate (SA 8%, GA 22%) favouring SA. Conclusions This observational study demonstrated that SA is a safe and effective form of anaesthesia for uretero-renoscopic surgery, delivering non-inferior outcomes to GA. This has implications for the immediate provision of care as COVID-19 continues and as an alternative anaesthetic option to suit patients post pandemic. A larger prospective observational study would be appropriate to clearly define the benefits of SA for ureteroscopy.

A sustainable outpatient transformation project for metabolic stone assessment: A specialist stone nurse led non-face-to-face (F2F) clinic

Introduction: Recent NHSEI policy and the COVID-19 pandemic are increasing the proportions of consultations occurring non-face-to-face (F2F). Here we describe a nurse-led non-F2F clinic for the metabolic assessment of kidney stone patients. Method: A metabolic assessment may be indicated in patients forming urate stones, CaPO4 stones, or recurrent stones or with clinical features suggesting a metabolic cause. In otherwise uncomplicated clinical scenarios, these patients are reviewed in a non-F2F clinic run by an endo-urological specialist nurse. A stone history is taken by telephone. Blood tests are arranged in primary care. A collapsible 24-hour urine collection container is posted to the patient and returned via the primary care sample collection service. The cases are reviewed at the Metabolic Stone MDT by the nurse, nephrologist and urologist. Results: A total of 145 patients were eligible with six DNAs, leaving 139 patients reviewed through the non-F2F clinic between March 2020 and June 2021. Demographics were 81 males: 58 females, age range 17-83. About 126 of 139 (91%) patients completed the tests, which is a significantly higher rate than completion rates typically reported. Stone analysis was also available in 97 patients (28 CaOx;54 CaPO4;15 urate). Around 102 patients (81%) were discharged with dietary advice, while 24 patients (19%) were referred for consultant review. Two patients had primary hyperparathyroidism. Nineteen patients had hypercalciuria, all requiring consultant review. Conclusion: Nurse-led non-F2F review streamlines the metabolic assessment of stone-formers, reducing the need for hospital attendances and reducing consultant workload.

Initial experiences of starting a new regional extracorporeal shockwave lithotripsy (ESWL) service during a global pandemic

Introduction: The 2018 GIRFT report and 2019 NICE renal and ureteric stone guidelines recommended regional, fixed-site lithotripsy units to provide elective and emergency extracorporeal shockwave lithotripsy (ESWL) for urinary tract calculus <20 mm. In our region, Trusts were serviced by a mobile lithotripter, which was unable to provide adequate emergency treatment, as such a new fixedsite regional service was developed. Methods: The ongoing pandemic resulted in many challenges in the service development, including a reduction in urological operating by 25% during the COVID-19 pandemic, with additional loss of capacity as only patients ASA 2 or below was able to be treated in peripheral centres. A new pathway was introduced aiming to reduce admissions to surgical wards, instead moving directly to treatment and pain relief at home, in line with the 2019 NHS long-term plan. After 6 weeks of treating local patients, the service was opened to Trusts across the region to enable equal access for all patients' for both emergency and elective ESWL. Results: In the first 6 months, 144 local stones were treated with ESWL (38 ureteric and 106 renal), of which 118 (81.9%) were successfully cleared, with the NICE guidelines quoting success rates between 72.4% and 83.8%. Across that period, this would have required 40 additional operating sessions (160 operative hours) to treat these stones ureteroscopically. With ureteroscopy £2347 more expensive than ESWL to get stone clearance (Constanti et al. BJUI 2020;125: 457-466), the treatment cost saving in the first 6 months is £281,666. In addition, 53 stones were treated as an emergency from the region, with a stone clearance rate of 81% and 53% treated within 48 hours. Conclusion: The new ESWL service has resulted in regional stone treatments with success rates in line with published data, in addition to providing economic and operative capacity benefits during a global pandemic.

Observational study of the use of spinal anaesthesia as an alternative to general anaesthetic for ureteroscopy during the CIVID-19 pandemic

Introduction: General anaesthetic has traditionally been felt to be more appropriate than spinal anaesthesia for patients undergoing ureteroscopy as it is difficult to achieve a suitably high block. During the COVID-19 pandemic, our centre moved elective operating to an alternative day-case surgical environment where the anaesthetic team performed predominantly spinal anaesthesia and were therefore very experienced with this modality. In view of concerns of COVID-19 transmission by aerosolisation during the intubation and extubation phases of general anaesthetic, spinal anaesthesia as an alternative first line modality was trialled with the option of converting to general anaesthesia if surgery could not be achieved safely and comfortably for the patient. Method: During a three-month period, unless contraindicated, spinal anaesthesia was used as the first line anaesthetic for ureteroscopy cases. A retrospective study of outcomes was then undertaken. Results: 44 patients were treated with a conversion rate to general anaesthetic of 9% (n=4). There was a complication rate of 20% (n=9);4 partial procedures, 4 readmissions with symptomatic residual fragments or sepsis and 1 patient required post-operative overnight stay due to anaesthetic. Spinal anaesthetic time averaged 25minutes. Conclusions: The global COVID-19 pandemic has led to change in practice and we have demonstrated that spinal anaesthesia is a valuable alternative to general anaesthetic in the majority of ureteroscopy cases. When undertaken by an experienced anaesthetic team, using this method does not significantly add to procedure time.

Change of practice due to COVID-19. Is Flexible and Rigid Ureteroscopy for renal and ureteric surgery achievable under spinal anaesthesia?

Introduction: During the COVID-19 pandemic our center moved elective operating to an alternative day-case facility where the team performed predominantly spinal anaesthesia (SA). General anaesthetic (GA) is traditionally preferred to SA for patients undergoing flexible and rigid ureteroscopy as it is difficult to achieve a suitably high block. SA was deemed a safer form of anaesthetic under COVID conditions due to the risk of aerosol transmission. The anaesthetic team was confident their technique could achieve adequate analgesia. We trialed SA for all ureteroscopic procedures with the option of converting to GA if surgery could not be achieved safely and comfortably for the patient. Methods: Over a 3 month period, SA was used as the 1st line anaesthetic option for ureteroscopy cases. We carried out a retrospective observational study of outcomes. Results: • 41 patients were treated with a conversion rate to GA of 10%(n=4);• Reasons for conversion - 2 anatomical/ patient factors, 2 inadequate patient analgesia. • Procedures: Renal Stones 34%(n=14), Upper/ Mid- Ureteric Stones 17%(n= 7), Distal-Ureteric Stones 41%(n=17);Diagnostic 7%(n=3). • Postoperative complication rate of 22%(n=9) ;• 4 partial procedures, 4 readmission for sepsis/ residual fragments, 1 overnight admission. • Average anaesthetic time was 25 minutes (9-44mins) Conclusion: The global COVID-19 pandemic has led to changes in practice and we have demonstrated that SA is a valuable alternative to GA in the majority of ureteroscopy cases. It does not add significantly to procedure time and the complication rate is comparable to our previous practice.

COVID-19 EXPOSING GLUCOSE-6-PHOSPHATE DEHYDROGENASE DEFICIENCY WITH METHEMOGLOBINEMIA: A CASE REPORT

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Glucose-6-phosphate dehydrogenase deficiency (G6PD-D) is one of the most common enzyme deficiencies in humans. Oxidative injuries often precipitate acute hemolytic anemia (AHA) in G6PD-D patients [1]. Furthermore, severe AHA in G6PD-D patients has been rarely associated with methemoglobinemia [2]. In this case report, we present a COVID-19 patient treated with hydroxychloroquine (HCQ) who subsequently developed AHA and methemoglobinemia. CASE PRESENTATION: A 60-year-old African American (AA) male with hypertension and type 2 diabetes mellitus presented to the hospital with fever and shortness of breath. COVID-19 testing was positive. The patient developed refractory hypoxia and tachypnea, requiring intubation and admission to the intensive care unit. On day 2, 800mg of hydroxychloroquine (HCQ) was administered and on day 3, HCQ 400mg was given. On day 5, pulse oximetry readings (SpO2) decreased despite increase in fraction of inspired oxygen. Arterial blood gas analysis revealed an appropriate partial pressure of oxygen (PaO2) suggesting discordance between SpO2 and PaO2. As a result, a methemoglobin level was ordered and was elevated to 12% (normal range 0-3%). Concurrently, hemoglobin (Hb) levels had decreased from 12.0 g/dL to 6.8 g/dL. Additional lab work suggested hemolysis, with elevated lactate dehydrogenase (2060 IU/L, normal 98-192IU/L), decreased haptoglobin (<3 mg/dL, normal 41-203mg/dL), elevated bilirubin (6.3mg/dL, normal 0.3-1.2mg/dL), and schistocytes and spherocytes on peripheral smear. The development of methemoglobinemia along with AHA raised suspicion for underlying G6PD-D. A G6PD level was obtained and was within normal range (19.8units/g, normal 7-20.5units/g). Family history revealed that the patient's three children and one grandchild carried the disease, raising the patient’s likelihood of having the trait due to its x-linked inheritance pattern. The patient was given IV ascorbic acid, as methylene blue is contraindicated in G6PD-D. Despite this, Hb levels continued to decrease, requiring multiple blood transfusions. Unfortunately, the patient developed refractory shock with progression of multiorgan system failure and expired on day 10 of hospitalization. DISCUSSION: This patient presented with severe and rapid progression of COVID-19 infection. The use of HCQ was chosen in an attempt to treat the patient, possibly triggering AHA and methemoglobinemia in the setting of a likely underlying G6PD-D. Although the patient's G6PD level was normal, this can often be falsely elevated in the midst of a severe hemolytic episode and thus needs to be checked 3 months after event to confirm diagnosis [3]. Given that about 10% of AA's carry mutations in G6PD, this reaction may be more common than reported. CONCLUSIONS: Physicians should proceed with caution when prescribing HCQ as a treatment option for COVID-19 in populations at high risk for the mutation. Reference #1: Cappellini MD, Fiorelli G. Glucose-6-phosphate dehydrogenase deficiency. Lancet. 2008;371(9606):64-74. doi:10.1016/S0140-6736(08)60073-2 Reference #2: Alzaki AA, Alalawi NH. Diabetic Ketoacidosis Revealing Severe Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD-D) Deficiency with Methemoglobinemia: A Case Report. Am J Case Rep. 2019;20:726-729. doi:10.12659/AJCR.915007 Reference #3: van den Broek L, Heylen E, van den Akker M. Glucose-6-phosphate dehydrogenase deficiency: not exclusively in males. Clin Case Rep. 2016;4(12):1135-1137. doi:10.1002/ccr3.714 DISCLOSURES: No relevant relationships by Aaron Dickinson, source=Web Response No relevant relationships by Margarita Gianniosis, source=Web Response No relevant relationships by Leah Lande, source=Web Response No relevant relationships by Rashid Riaz, source=Web Response