Number Of Medical Comorbidities Research Articles

Cognitive status is a determinant of health resource utilization among individuals with a history of falls: a 12-month prospective cohort study.

Falls are a costly public health problem worldwide. The literature is devoid of prospective data that identifies factors among fallers that significantly drive health care resource utilization. We found that cognitive function--specifically, executive functions--and cognitive status are significant determinants of health resource utilization among older fallers. Although falls are costly, there are no prospective data examining factors among fallers that drive health care resource utilization. We identified key determinants of health resource utilization (HRU) at 6 and 12 months among older adults with a history of falls. Specifically, with the increasing recognition that cognitive impairment is associated with increased falls risk, we investigated cognition as a potential driver of health resource utilization. This 12-month prospective cohort study at the Vancouver Falls Prevention Clinic (n = 319) included participants with a history of at least one fall in the previous 12 months. Based on their cognitive status, participants were divided into two groups: (1) no mild cognitive impairment (MCI) and (2) MCI. We constructed two linear regression models with HRU at 6 and 12 months as the dependent variables for each model, respectively. Predictors relating to mobility, global cognition, executive functions, and cognitive status (MCI versus no MCI) were examined. Age, sex, comorbidities, depression status, and activities of daily living were included regardless of statistical significance. Global cognition, comorbidities, working memory, and cognitive status (MCI versus no MCI ascertained using the Montreal Cognitive Assessment (MoCA)) were significant determinants of total HRU at 6 months. The number of medical comorbidities and global cognition were significant determinants of total HRU at 12 months. MCI status was a determinant of HRU at 6 months among older adults with a history of falls. As such, efforts to minimize health care resource use related to falls, it is important to tailor future interventions to be effective for people with MCI who fall. ClinicalTrials.gov Identifier: NCT01022866.

Pre-operative Waterlow score: Predicts risk of post-operative infection in patients with neck of femur fractures.

Nursing staff prospectively collect Waterlow scores (Ws) on all inpatients across most NHS hospitals, identifying patients at risk of pressure ulcers. This bedside score has not been applied in predicting other negative outcomes in patients with neck of femur (NOF) fractures. To investigate the relationship between increasing Waterlow score and 30-day post-operative infection in patients with NOF fracture. Pre-operative Ws and 30-day clinical outcome data were collected on 97 consecutive operatively treated NOF fracture patients at our institution (level one trauma centre). 30-day infection rate was 36%, which manifested as hospital acquired pneumonia (66%) and urinary tract infection (34%). For every one point increase in Ws, the odds of having an infection increased by 1.68 times (95% CI 1.37-2.08). The relationship between Ws and 30-day infection was similar when adjusted for potential confounders: patient demographics (age and gender), number of medical comorbidities, ASA grade, and days to surgery. For our data, the Ws predictive of infection was ≥17. This has a sensitivity of 84.9% (95% CI 68.1-94.9%) and a specificity of 84.1% (95% CI 74.7-92.1%). The area under the curve was 0.89 (95% CI 0.82-0.96). Our study demonstrates a strong relationship between increasing Ws and post-operative infection risk. This raises the interesting yet controversial question of using Ws to identify patients at high-risk of developing post-operative infections and the potential benefit of an extended period of antibiotic prophylaxis.

Association between number of comorbid medical conditions and depression among individuals with diabetes; race and ethnic variations.

BackgroundMedical and psychiatric comorbidities are commonly comorbid with diabetes. Race and ethnicity may, however, modify the link between medical and psychiatric comorbidities in individuals with diabetes. In this study we compared Non-Hispanic Whites, African Americans, and Caribbean Blacks with diabetes for the association between number of comorbid medical conditions and lifetime and 12-month major depressive disorder (MDD) in individuals with diabetes.MethodsData came from the National Survey of American Life (NSAL), 2001–2003. We included 603 patients with diabetes (75 non-Hispanic Whites, 396 African Americans, and 131 Caribbean Blacks). Number of comorbid medical conditions was the independent variable, lifetime and 12-month MDD were dependent variables, and age, gender, education, marital status, employment, and body mass index were covariates. Race- and ethnic- specific logistic regressions were used to determine race and ethnic differences in the associations between number of chronic medical conditions and lifetime and 12-month MDD, while the effect of all covariates were controlled.ResultsNumber of chronic medical conditions was positively associated with lifetime MDD among non-Hispanic Whites (OR = 1.719, 95 % CI = 1.018 – 2.902) and African Americans (OR = 1.235, 95 % CI = 1.056– 1.445) but not Caribbean Blacks (P > .05). Number of chronic medical conditions was also associated with 12-month MDD among non-Hispanic Whites (OR = 1.757, 95 % CI = 1.119 – 2.759) and African Americans (OR = 1.381, 95 % CI = 1.175 - 1.623) but not Caribbean Blacks (P > .05).ConclusionsThis study shows race- and ethnic- differences in the association between number of medical comorbidities and MDD among patients with diabetes. These findings invite researchers to study the mechanisms behind race- and ethnic- differences in vulnerability and resilience to the mental health effects of chronic medical conditions.

Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures.

PurposeTo introduce the concept of fracture reduction with positive medial cortical support and its clinical and radiological correlation in geriatric unstable pertrochanteric fractures.MethodsA retrospective analysis of 127 patients (32 men and 95 women, with mean age 78.7 years) with AO/OTA 31A2.2 and 2.3 hip fractures treated with cephalomedullary nail (PFNA-II or Gamma-3) between July 2010 and June 2013 was performed. They were classified into three groups according the grade of medial cortical support in postoperative fracture reduction (positive, neutral, and negative). The positive cortex support was defined that the medial cortex of the head–neck fragment displaced and located a little bit superomedially to the medial cortex of the shaft. If the neck cortex is located laterally to the shaft, it is negative with no cortical buttress, and if the two cortices contact smoothly, it is in neutral position. The demographic baseline, postoperative radiographic femoral neck–shaft angle and neck length, rehabilitation progress and functional recovery scores of each group were recorded and compared.ResultsThere were 89 cases (70 %) in positive, 26 in neutral, and 12 in negative support. No statistical differences were found between the three groups among patient age, sex ratio, prefracture score of activity of daily living, walking ability score, ASA physical risk score, number of medical comorbidities, osteoporosis Singh index, fracture reduction quality (Garden alignments), and the position of lag screw or helical blade in femoral head (TAD). In follow-up, patients in positive medial cortical support reduction group had the least loss in neck–shaft angle and neck length, and got ground-walking much earlier than negative reduction group, with good functional outcomes and less hip–thigh pain presence.ConclusionFracture reduction with nonanatomic positive medial cortical support allows limited sliding of the head–neck fragment to contact with the femur shaft and achieve secondary stability, providing a good mechanical environment for fracture healing.

Cardiovascular and cerebrovascular risk factors and events associated with second-generation antipsychotic compared to antidepressant use in a non-elderly adult sample: results from a claims-based inception cohort study.

This is a study of the metabolic and distal cardiovascular/cerebrovascular outcomes associated with the use of second-generation antipsychotics (SGAs) compared to antidepressants (ADs) in adults aged 18-65 years, based on data from Thomson Reuters MarketScan® Research Databases 2006-2010, a commercial U.S. claims database. Interventions included clinicians' choice treatment with SGAs (allowing any comedications) versus ADs (not allowing SGAs). The primary outcomes of interest were time to inpatient or outpatient claims for the following diagnoses within one year of SGA or AD discontinuation: hypertension, ischemic and hypertensive heart disease, cerebrovascular disease, diabetes mellitus, hyperlipidemia, and obesity. Secondary outcomes included the same diagnoses at last follow-up time point, i.e., not censoring observations at 365 days after SGA or AD discontinuation. Cox regression models, adjusted for age, gender, diagnosis of schizophrenia and mood disorders, and number of medical comorbidities, were run. Among 284,234 individuals, those within one year of exposure to SGAs versus ADs showed a higher risk of essential hypertension (adjusted hazard ratio, AHR=1.16, 95% CI: 1.12-1.21, p<0.0001), diabetes mellitus (AHR=1.43, CI: 1.33-1.53, p<0.0001), hypertensive heart disease (AHR=1.34, CI: 1.10-1.63, p<0.01), stroke (AHR=1.46, CI: 1.22-1.75, p<0.0001), coronary artery disease (AHR=1.17, CI: 1.05-1.30, p<0.01), and hyperlipidemia (AHR=1.12, CI: 1.07-1.17, p<0.0001). Unrestricted follow-up results were consistent with within one-year post-exposure results. Increased risk for stroke with SGAs has previously only been demonstrated in elderly patients, usually with dementia. This study documents, for the first time, a significantly increased risk for stroke and coronary artery disease in a non-elderly adult sample with SGA use. We also confirm a significant risk for adverse metabolic outcomes. These findings raise concerns about the longer-term safety of SGAs, given their widespread and chronic use.

Every reason to discontinue lithium.

Lithium as a gold standard therapy for bipolar disorder is well known to have a number of medical comorbidities that impact renal, parathyroid, and thyroid function. Despite these medical comorbidities, there remains a group of lithium-responsive lithium-treated patients who have maintained mood stability for decades. The risk/benefit ratio of end organ toxicity/mood stability must be evaluated in each individual case.

Mortality, complication risk, and total charges after the treatment of epidural abscess

Background contextThe treatment of epidural abscess is known to have a high rate of morbidity. Little is known regarding the risk factors for postoperative complications, mortality, and costs of care. PurposeTo identify predictors of postsurgical morbidity and mortality, and total charges, associated with epidural abscess. Study designNationwide Inpatient Sample (NIS) from the year 2006 to 2011. Patient sampleAll patients who had epidural abscess and underwent surgery in the NIS were included. Weighting was used to derive a representative sample. Outcome measuresThey included in-hospital mortality, the development of complications, and total charges. A utility for failure to rescue (FTR) was also developed. Failure to rescue was defined as occurring when patients died after sustaining a complication. MethodsAll patients identified as having epidural abscess and receiving surgical intervention were included. Risk factors were assessed in a bivariate fashion with those maintaining p values less than .2 included in the final multivariable models. Independent predictors of outcome were those that maintained significance after inclusion in multivariable regression. Predictors for total charges were evaluated using generalized linear modeling. ResultsThe population consisted of 30, 274 individuals. The mean age was 57.4 years (±14.7 years). Sixty-three percent of the population was white and 27% was underinsured. Diabetes was present in 30% and 19% had some degree of paralysis. Three percent of patients died during hospitalization and 26% sustained one or more complications. Mean total charges were $159,782 (range: $4,008–$3,373,410). Significant independent predictors for mortality included age, insurance status, liver disease, paralysis, and renal failure, with age (80 years or more) having the greatest effect (odds ratio 4.0 [95% confidence interval 2.0, 7.9]). Many of these same variables were found to be influential in the development of postoperative complications, major morbidity, and FTR. The number of medical comorbidities, underinsured status, paralysis, and renal failure were factors that influenced charges to an extent greater than 20% of the population mean. ConclusionsAge, insurance status, paralysis, and medical comorbidities appear to be the predictors of morbidity, mortality, and expense of care. The results of this work highlight the characteristics that may be targeted to reduce charges and improve care for epidural abscess.

Endoscopic Thyroidectomy is Safe in Patients with a High Body Mass Index

Obesity is associated with a number of medical comorbidities and is considered a risk factor for surgical complications. However, the impact of obesity on the safety of minimally invasive video-assisted thyroidectomy (MIVAT) has not been well defined. We sought to determine the relationship between obesity and the risk of complications in patients undergoing MIVAT. A prospectively maintained database of all thyroid surgeries performed from January 2006 through June 2012 was searched and all cases of MIVAT were identified. Patients were stratified into three body mass index (BMI) groups according to the National Institutes of Health classification for obesity: normal (BMI ≤ 24.9 kg/m(2)), overweight (BMI 25-29.9 kg/m(2)) and obese (BMI ≥ 30 kg/m(2)). The total number of complications was compared among the three groups, and MIVAT patients were also compared to a cohort of patients undergoing conventional thyroid surgery. There were 233 MIVATs performed on 223 patients. The mean overall BMI for the study population was 25.4 kg/m(2). There were 123 procedures (52.8%) in the normal group, 76 procedures (32.6%) in the overweight group, and 34 procedures (14.6%) in the obese group. Complications included 1 case of cellulitis (0.4%), 6 cases of temporary hypocalcemia (2.6%), and 6 cases of transient vocal fold paresis (2.6%). No patients suffered permanent hypocalcemia or a permanent recurrent laryngeal nerve injury. There were 9 complications in the normal group (7.3%), 4 complications in the overweight group (5.3%), and no complications in the obese group. Due to the low number of complications in this series, the overweight and obese groups were combined into a high BMI group for further analysis. Statistical analysis using simple logistic regression models revealed that there was no significant difference in the number of complications in patients with a high BMI compared with patients with a normal BMI (odds ratio [OR] 0.48 [confidence interval (CI) 0.14-1.63], p=0.2). The MIVAT group had fewer overall complications than the conventional thyroidectomy group. Overweight and obese patients undergoing MIVAT in this series were not at an increased risk for surgical complications. The MIVAT procedure may be considered safe in patients with a high BMI, who may derive particular benefit from a minimally invasive approach.

Abstract T P3: The Impact of Mechanical Thrombectomy in Patients Over 80 Years of Age

Many physicians debate the efficacy of mechanical thrombectomy (MT) for acute ischemic stroke (AIS), but most agree that to establish the true benefit there needs to be improved patient selection. The elderly are the fastest growing age group in the USA and present a growing population of AIS patients. The benefit of MT for these patients may be greatly reduced due to diminishing neuroplasticity and a larger number of medical co-morbidities at the time of intervention. The paucity of data on this intervention in the elderly limits the physician’s ability to adequately counsel patients and their families regarding any potential benefit from this emergent intervention. To address this knowledge gap, our objective was to examine clinical and economic outcomes after MT in the AIS population from the Nationwide Inpatient Sample (2008-2010). Our hypothesis was that patients &gt; 80 years of age would fare worse at discharge in comparison to their younger counterpart. Independent samples t-tests and chi-squared tests were used to make comparisons. Multivariable models, adjusted for confounding factors, investigated outcomes. Less than 1% of all AIS cases were treated with MT. Of these, 18% (9300 cases) involved patients &gt; 80 years. The odds of mortality in elderly patients treated with MT were more than double that of younger patients (OR:2.11, P&lt;.001) and there was a significant reduction in the odds of being discharged home (OR:0.30, P&lt;.001). Although univariate analysis depicted a significant difference in hospital charges and length of stay, multivariate analysis revealed no significant differences. In conclusion, patients &gt; 80 years experienced worse clinical outcomes than their younger counterpart. Studies to better identify specific subpopulations of patients, in all age groups, that would benefit from mechanical thrombectomy are needed urgently.

Combined Coronary Artery Bypass and Open Repair of Abdominal Aortic Aneurysm

The coexistence of symptomatic abdominal aortic aneurysm (AAA) and coronary artery disease (CAD) is not uncommon. In most cases, coronary revascularization with angioplasty or bypass (CABG) is performed before AAA repair to reduce the risk of cardiac morbidity. The purpose of this was to review the management of patients with symptomatic large AAA and coronary artery disease. A retrospective chart review of two patients with symptomatic coronary artery disease and >9 cm AAA managed using a combined approach. A 60-year-old man presented with a 9.2 centimeter AAA and severe CAD and a 73-year-old man with a 9.0-centimeter AAA. Both patients underwent combined CABG and open AAA repair. Operative times were 400 and 373 minutes, respectively. Neither experienced any postoperative complications, such as renal failure, respiratory failure, bleeding, or infection, despite a number of medical comorbidities and decades of tobacco use. Both men are alive and well at 8 and 9 years respectively. In special circumstances, patients with large AAA and severe CAD can be considered for combined repair. We report two such cases treated successfully with excellent long-term results.

The cholinergic system may play a role in the pathophysiology of residual excessive sleepiness in patients with obstructive sleep apnea

Obstructive sleep apnea (OSA) is a prevalent condition characterized by momentary cessations in breathing during sleep due to intermittent obstruction of the upper airway. OSA has been frequently associated with a number of medical comorbidities. CPAP (continuous positive airway pressure) is the gold standard treatment and is known to improve OSA symptoms, including excessive sleepiness. However, 12–14% of CPAP-treated patients continue to complain of sleepiness despite normalization of ventilation during sleep, and 6% after exclusion of other causes of EDS. This is of great concern because EDS is strongly associated with systemic health disorders, lower work performance, and a high risk of accidents. We hypothesized that decreased central cholinergic activity plays a role in the pathophysiology of residual excessive sleepiness in patients with OSA treated with CPAP. Acetylcholine (Ach) plays a large role in wakefulness physiology, and its levels are reduced in sleepiness. Herein, we discuss the potential role of the cholinergic system in this new clinical condition.

Acute complications of movement disorders surgery: Effects of age and comorbidities

The most common indication for movement disorder surgery is Parkinson's disease (PD), and the incidence of PD increases with age. The analysis reported here was undertaken with the primary goal of examining whether there is a relationship between peri-operative complications and age. The Nationwide Inpatient Sample (Agency for Healthcare Research and Quality, Rockville, MD, USA) was queried for 10 years beginning in 1999 for patients undergoing deep brain stimulator insertion, pallidotomy, and thalamotomy for treatment of PD, essential tremor, and dystonia. Inpatient complications, including death, stroke (both ischemic and hemorrhagic), and other overall complications were examined. The relative risks associated with advanced age; primary diagnosis; treatment modality; the diagnoses of hypertension, diabetes, and nicotinism; and the cumulative number of comorbidities were examined. There were 5464 patients who met inclusion criteria, including 4145 patients treated for PD and 4961 patients treated with deep brain stimulation (DBS). Overall in-hospital mortality was 0.26%, with 0.15% related to surgical factors. There was a correlation between in-hospital mortality, increasing age, and number of medical comorbidities. After multivariate regression no factor remained predictive of mortality. Having more than 1 medical comorbidity or PD increased the risk of in-hospital complications. Patients with PD were more likely to suffer hemorrhage or stroke. Hypertension, diabetes, nicotinism, and modality of treatment were not associated with increased mortality, hemorrhage or stroke risk, or in-hospital mortality in univariate or multivariate analysis. Both age and medical comorbidity are correlated with in-hospital complications, but age appears to serve as a surrogate for comorbidity. Surgery for PD appears to carry an increased risk of hemorrhage or stroke and in-hospital complications.

Identifying patient characteristics associated with high schizophrenia-related direct medical costs in community-dwelling patients.

Schizophrenia is a chronic, debilitating disease that affects approximately 1% of the U.S. population and has disproportionately high costs. Several factors, including age, gender, insurance status, and comorbid conditions, have been hypothesized to be associated with schizophrenia- related costs. To identify demographic and clinical characteristics of community-dwelling schizophrenia patients experiencing high schizophrenia-related direct medical costs. Community-dwelling patients with a diagnosis for schizophrenic disorder (ICD-9-CM code 295) and other nonorganic psychoses (ICD-9-CM code 298) were identified from the 2005-2008 Medical Expenditure Panel Survey (MEPS). Schizophrenia-related direct medical costs were calculated for (a) inpatient hospitalizations; (b) prescription medications; and (c) outpatient, office-based physician, emergency room, and home health care visits. Using Andersen's Behavorial Model of Health Services Use and the literature, factors that could potentially affect schizophrenia-related direct medical costs were identified. Based on the distribution of their mean annual costs, patients were classified into high- and low-cost groups. Logistic regression was used to determine the likelihood of high-cost group membership based on age, sex, race, insurance status, marital status, region of residence, family income as a percentage of poverty line, number of medical comorbidities, number of mental health-related comorbidities, patient-perceived general health status, patient-perceived mental health status, and year of inclusion in MEPS. In addition, a generalized linear model (GLM) regression (gamma distribution with a log-link function) was used to evaluate the relationships between the independent variables and total schizophrenia-related direct medical costs as a continuous variable. From the MEPS database, we identified 317 patients with schizophrenia who represented 2.75 million noninstitutionalized, community-dwelling schizophrenia patients in the United States between 2005 and 2008. The logistic regression procedure showed that older patients (OR=0.933, 95% CI=0.902-0.966) and patients with a spouse (OR=0.150, 95% CI=0.041-0.555) were less likely to be in the high-cost group, while those who reported having "poor" perceived general health status (OR=15.548, 95% CI=1.278-189.127) were more likely to be in the high-cost group. The GLM regression procedure showed that younger patients (compared with older patients), African Americans (compared with Caucasions), patients with private insurance (compared with the uninsured), and those living in the northeastern United States (compared with those living in the southern United States) had higher schizophrenia-related direct medical costs. Identification of factors associated with a high-cost population may help decision makers in managed care, government, and other organizations allocate resources more efficiently and health care providers manage patients more effectively through assignment of these patients to case managers and appropriate monitoring and treatment.

Tuberculous Pyomyositis Masquerading as Pyogenic Infection: A Case Report.

Tuberculous pyomyositis is a rare entity, with nonspecific presentation that often leads to a delay in diagnosis. It is caused by a small aerophilic bacillus organism and spreads by exhaled respiratory droplets from affected individuals. When tuberculous pyomyositis presents as the initial and only manifestation of the disease, there is a diagnostic dilemma. Even with readily available advanced imaging studies, there are no pathognomonic findings indicative of the disease. Early and accurate recognition is essential to avoid additional morbidity, mortality, and public health risk. Tuberculous pyomyositis has been reported as an opportunistic infection in patients with immunosuppression. Modern manifestations have been unmasked following medical therapy for respiratory infections treated with quinolone antibiotics1. It may present as painful soft-tissue swelling with conditions such as ankylosing spondylitis2, rheumatoid arthritis3, and polymyositis4. There is an increased incidence in individuals who are being treated with corticosteroids and disease-modifying antirheumatic drugs (DMARDS)5, and, paradoxically, in individuals with human immunodeficiency virus (HIV)6 that is being brought into remission with medication therapy7. There is an increased incidence in people who may be immunocompromised or who have a number of medical comorbidities, including diabetes mellitus, congestive heart failure, renal failure, drug addiction, systemic lupus erythematosis, nephrotic syndrome, and renal transplant. To the best of our knowledge, much of the literature pertaining to these conditions has been published from areas where tuberculosis (TB) is endemic. However, the defined patient population at risk is not necessarily defined by the pulmonary TB population, but rather by a population that is common in most hospitals in the United States. The reported outcomes of tuberculous pyomyositis have varied widely, from complete disease remission to death. Early accurate diagnostic consideration is important in optimizing outcomes. With this report, …

The Role of Preoperative Self‐Efficacy in Predicting Outcome after Total Knee Replacement

The aim of the present study was to determine if self-efficacy is a significant and independent preoperative predictor of patient-reported pain and function at one year after total knee replacement (TKR). Patients listed for a primary TKR because of osteoarthritis were recruited from preoperative assessment clinics at one regional orthopaedic centre. Before surgery, patients completed the Western Ontario and McMasters Osteoarthritis Index (WOMAC) Pain and Function Scale, Pain Self-Efficacy Scale, the Hospital Anxiety and Depression Scale, the Self-Administered Co-morbidity Questionnaire and questions about other painful joints. Patients then completed the WOMAC Pain and Function Scales at one year postoperatively. Regression analysis was performed to determine if self-efficacy was a significant predictor of outcome after TKR. Overall, 251 patients were recruited into this study, and one-year questionnaire data were available for 220 patients. At one year postoperatively, 7% of patients reported severe pain in their replaced knee and 9% reported severe functional limitations. Self-efficacy was found to be a significant preoperative predictor of functional ability, but not pain, at one year postoperatively, after controlling for age, gender, depression, anxiety, number of medical co-morbidities, preoperative knee status and painful joints elsewhere. Significant predictors of postoperative pain were greater anxiety and higher pain severity. Other significant predictors of postoperative disability were greater anxiety, worse functional disability and a greater number of painful joints elsewhere. The present study demonstrated that self-efficacy is a significant preoperative predictor of patient-reported functional ability at one year after TKR. Future research is needed to assess the impact of interventions for enhancing self-efficacy on patient-reported outcomes after TKR.

Dihydrotestosterone—a culprit in left ventricular hypertrophy

and signs of heart failure, whereas the coexistence of medical comorbidities were not fully considered. The complexity and time constraints of Charlson comorbidity index might limit its use in AMI stratification. Besides, the Charlson index counts myocardial infarction as comorbid conditions [4]. The numberofmedical comorbidities for the early risk stratification of patients with AMI was objective, economical, simple to perform, and based entirely on information at admission, especially for primary care physicians. This informationmight be easy to obtain, and not time-consuming. Based on the number of medical comorbidities at admission, the risk of in-hospital mortality could be further evaluated. Those with more comorbidities were more likely to have higher in-hospital mortality, and merit intensive in-hospital managementandnursing care. For thosewithout comorbidity, relatively lessmedical andnursing services couldbeprovided,whichmight lead to reduced burden of medical expenses. It was hopeful that medical comorbidities at admission could be included in future risk scoring system or combined with other risk index for more precise early risk stratification of patients hospitalized with AMI. This study had limitations. First, it was not a randomized trial. Second, the effect of comorbidities at admission on in-hospital mortality were gaged by counting the number of comorbidities. A better method would be to construct an index that weighed medical comorbidities according to their impact on in-hospital mortality, which might be of more help in clinical practice. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology (Shewan and Coats 2010;144:1–2).

Predisposing Factors for Postoperative Delirium After Hip Fracture Repair in Individuals with and without Dementia

Based on a multifactorial model of delirium, to compare the types and magnitude of pre- and intraoperative predisposing factors for incident delirium in a stratified sample of individuals with and without preoperative dementia undergoing acute hip fracture repair. Prospective cohort study. Academic medical center. Four hundred twenty-five individuals with acute hip fracture and without delirium (mean age 80.2±6.8, 73.2% female, 33.1% with probable dementia) admitted to a multidisciplinary hip fracture repair service. A research nurse assessed each participant for delirium based on the Confusion Assessment Method (CAM) before study enrollment and from the second postoperative day until hospital discharge. The incidence of delirium was higher in the group with probable dementia (56%) than in the group without dementia (26%) (P<.001). In the group without dementia (n=284), age (odds ratio (OR)=1.07, 95% CI=1.02-1.13), male sex (OR=2.81, 95% CI=1.40-5.64), body mass index (OR=0.92, 95% CI=0.86-0.99), number of medical comorbidities (OR=1.15, 95% CI=1.01-1.32), and duration of surgery longer than 2hours (OR=2.53, 95% CI=1.20-4.88) were independently associated with postoperative delirium. In the group with probable dementia, only the lag time from the emergency department to operating room was significantly associated (OR=2.83, 95% CI=1.24-2.25) with delirium. Preoperative determination of dementia status is important for risk stratification for incident delirium after acute hip fracture repair surgery because types and magnitude of predisposing risk factors for postoperative delirium substantially differ based on preoperative dementia status.

Low risk prostate cancer in men &gt; 70 years old: to treat or not to treat

Abstract Objectives Prostate cancer (CaP) in the aging male will become an increasingly important and controversial health care issue. We evaluated the outcomes between a variety of treatments for low-risk CaP in patients 70 years of age and older. Methods and materials A total of 3,650 men diagnosed with CaP between 1989 and 2009 were identified in the Center for Prostate Disease Research database to be 70 years of age or older at time of diagnosis. Of these patients, 770 men met the D'Amico criteria [13] for low-risk disease and were treated with radical prostatectomy, external beam radiation therapy, or watchful waiting. Cox proportional hazard models were used to compare clinicopathologic features across treatment groups. Kaplan-Meier analysis was used to compare biochemical recurrence-free, progression-free, and overall survival. Results Of the 770 patient cohort, 194 (25%) chose radical prostatectomy, 252 (33%) chose external beam radiation therapy, and 324 (42%) were initially managed by watchful waiting with 110 (34%) of this subset ultimately undergoing secondary treatment. The median follow-up was 6.4 years. There were no significant differences in distributions of race/ethnicity, number of medical comorbidities, or clinical stage across the treatment groups. Patients managed on watchful waiting without secondary treatment had the poorest overall survival on Kaplan-Meier analysis ( P = 0.0001). Additionally, multivariate analysis confirmed this result for watchful waiting without secondary treatment as being a statistically significant predictor of overall mortality (HR 1.938, P = 0.0084).

Patient and Systems Factors that Predict Coordination of a Repeat Colonoscopy in a Diverse Academic General Medicine clinic

Purpose: As screening colonoscopy (SC) continues to be used for CRC screening in an aging population, the process of following up these results becomes more critical. Unlike Pap smears and mammography, follow-up for a positive finding on colonoscopy occurs in years, not months. Patients who are in public insurance programs, do not speak English, and receive care in clinics with poor continuity are at greatest risk of being lost to follow-up. The purpose of this retrospective review was to identify patient and systems factors that predict repeat colonoscopy (RC) coordination after an adenomatous polyp was found on SC.Table: Table. Patient factorsMethods: From a cohort of 353 patients who underwent SC (2003-2006), 58 patients with adenomatous polyps were identified who required follow-up between 2008-2010. Our Electronic Medical Record (EMR) was implemented in 2008. A chart review including demographic characteristics, medical comorbidities, colonoscopy findings, pathology reports and gastroenterology (GI) follow-up notes were abstracted in 2010-2011. Systems factors abstracted from the EMR included ongoing follow-up with a primary care physician (PCP), referral for SC by a PCP, chart documentation after the initial procedure and inclusion of SC in either the “Problem List” (PL) or the “Health Maintenance” (HM) sections in EMR. The primary outcome, RC coordination was defined as contact with the GI office (office visit or telephone encounter) to schedule the RC. Chi-square analysis was performed to analyze the collected variables as predictors of RC coordination. Results: Of the 58 patients, 46.5% (n=27) had RCs coordinated, for which 81.5% (n=22/27) underwent the repeat exams over an average of 5.09 years of follow-up. Patient factors that significantly predicted coordination of a RC were insurance status at time of follow-up, number of medical co-morbidities, identified PCP, and number and size of the polyps found on SC. Systems factors correlating with RC coordination were SC referral by the PCP, follow-up recommendations in the colonoscopy report, and presence of SC information in the EMR-PL. Surprisingly, the HM section was not used by many providers and inclusion of SC information in the EMR-HM did not correlate with RC coordination. Conclusion: Beyond highlighting patient factors related to RC, this study underscores the importance of having a PCP to facilitate RC. Moreover, in an academic setting, where 3 year training programs may not permit long term longitudinal care, we found that both entering the SC information in the EMR-PL and GI follow-up plans in the colonoscopy report independently increased the chance of a RC in a population vulnerable to loss of follow-up.Table: Systems factors

Anxiety and depression, chronic physical conditions, and quality of life in an urban population sample study

No previous studies have empirically demonstrated a multiplicative interactive effect of anxiety disorders and/or depression (ADD) and chronic medical conditions on quality of life (QOL). We hypothesized that QOL impairment was worsened by the presence of ADD and medical co-morbidity, more than when it was with either medical co-morbidity alone or ADD alone. Complete data of 2,801 participants from the National Mental Health Survey of Adults in Singapore were analyzed, using SCAN diagnoses of anxiety disorders and depression, self-reports of chronic medical conditions, and SF-12 measures of QOL (Mental Component Summary, MCS, and Physical Component Summary, PCS). Persons diagnosed with ADD (compared to those without) had considerably more medical co-morbidities (59 vs. 33%, p < 0.001). In multiple regression analyses, ADD (vs. no ADD) was associated with lower PCS (b = -1.013, p = 0.045) and MCS scores (b = -9.912, p < 0.001), as was number of medical co-morbidities (0, 1-2, 3 +), PCS scores (b = -2.058, p < 0.001) and MCS scores (b = -1.138, p < 0.001). There were significant interactive effects of medical co-morbidities and ADD on PCS (p < 0.001), and MCS (p = 0.086), suggesting that the negative effects of medical conditions on quality of life was aggravated non-additively by the co-morbid presence of ADD, and vice versa. The individual effects of medical and psychiatric morbidity on functional status and quality of life were considerably worse when both were present in the same individual. Future studies should examine the impact of identifying and treating anxiety and depressive disorders in patients with medical problems for better outcomes.