Background: In Singapore, the clinical pathway for total knee replacement was introduced in 1997 to streamline multidisciplinary care and reduce length of stay for patients in acute hospitals. However, patients who chose to be discharged to a community hospital for rehabilitation currently have a longer length of stay due to the higher demand and longer waiting time for beds in these step-down care facilities. To our knowledge, no qualitative studies have been done in Singapore to investigate the post-discharge issues faced by these patients. This study aims to understand how decisions about discharge were being made among elderly patients post-discharge. Design: Grounded theory qualitative methodology was applied. Method: Data was collected from nine inpatients who recently underwent total knee replacement or total hip replacement surgery in a tertiary hospital in Singapore by in-depth interviews conducted between October 2012 and July 2013. Data was analyzed using thematic analysis. Findings: Three major themes emerged from the interviews when participants were asked about the reasons for choosing a community hospital instead of going home after discharge. The themes were: perceived lack of caregiver; lack of confidence; and services provided in the community hospitals. Conclusion: This study showed that factors related to perceived unavailability of caregivers, low level of confidence and accessibility of comprehensive community rehabilitation services were important considerations among elderly patients when choosing their discharge destinations and care. Relevant stakeholders can then explore solutions to these problems so as to correctly site patients.

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People with peripheral neuropathy (PN) secondary to diabetes have higher risks of falls due to loss of the somatosensation of the feet. The purpose of this study was to investigate the cutoff values of the vibration threshold and the monofilament test to predict postural instability. Ten healthy younger adults, ten healthy older adults and ten people with PN secondary to diabetes were recruited in this study. A handheld bio-thesiometer and a set of monofilaments were used to measure the vibration threshold (VT) and tactile sensitivity (TS), respectively. VT and TS were measured at six different sites on the plantar surface, including big toe, 1st metatarsus, little toe, 5th metatarsus, middle arch, and calcaneus (heel), plus the lateral and medial malleoli. Subjects also underwent a Sensory Organization Test (SOT) to identify postural instability, defined as equilibrium scores less than age matched norms. Linear regression was used to determine which site(s) was able to predict the balance test performance. Receiver operating characteristic curves were used to compute the VT and TS cutoff values associated with postural instability. A cutoff value of 10V for lateral malleolus VT was able to predict postural abnormality with 100% Sensitivity and 54.5% Specificity. A cutoff value of 3.61 for middle arch TS was able to predict postural abnormality with 100% Sensitivity and 86.4% Specificity. Postural instability appears earlier than the current recommended clinical cutoff values for peripheral neuropathy (25V for VT and 5.07 for TS). Although current cutoff values of the vibration threshold and the monofilament test are useful for detecting a propensity for neuropathic foot ulcer, they may not be adequate for detecting early postural instability. Fall prevention strategies may be needed early in the progression of PN. Disclosure N. Aung: None. S.A. Meardon: None. C. Lin: None. R.J. Tanenberg: None.

We present the case of a 70-year-old Caucasian female who presented to the emergency department with acute pancreatitis and ketoacidosis. An extensive workup for ketoacidosis showed that the patient had hyperglycemic ketoacidosis with findings similar to diabetic ketoacidosis (DKA). However, the patient did not have a history of diabetes, and no diagnosis of diabetes could be made on the current admission as well. Ketoacidosis was determined to be induced by acute hyperglycemia secondary to pancreatitis, which suppresses insulin secretion transiently. It is important to note that DKA can be seen in patients with different types of diabetes and is not just limited to type 1 diabetes.