Washington University Medical Center Research Articles

An Inpatient Rehabilitation Service for Deconditioned Older Adults

Objective: To determine whether deconditioned older adults referred from internal medicine units in an acute hospital setting benefited from inpatient rehabilitation services. Design: The design of this study was a retrospective review of consecutive admissions to a rehabilitation hospital. Setting: The rehabilitation setting was an 80-bed HealthSouth acute medical rehabilitation center adjacent to the Washington University Medical Center in mid-town St Louis, Mo, and affiliated with Barnes-Jewish Hospital. Patients: Participants were 88 patients aged 55 years and older, having a primary diagnosis of deconditioning or weakness admitted to an inpatient rehabilitation unit from February 2004 to February 2005. Main Outcome Measures: Medical diagnoses, laboratory data, medications prescribed, nutritional status, physical, occupational, and speech therapy interventions, and documentation of geriatric syndromes were obtained from the rehabilitation medical records. Outcomes measured were discharge disposition, the change in functional status as assessed by the Functional Independence Measure (FIM), and the FIM efficiency rating. Results: The majority of patients were referred from the hospital after an average length of stay of 9 days and stayed for an average of 12 days in the acute inpatient rehabilitation unit. The average FIM scores dramatically improved during inpatient rehabilitation (29.4 ± 16.2), the FIM efficiency rating was 3.0 ± 1.9, and 71% of patients were discharged home. Common geriatric syndromes in this sample included depression, cognitive impairment, pain, falls, and polypharmacy. When assessed, vitamin D deficiency/insufficiency was also common in this sample. Conclusions: An inpatient rehabilitation service, focused on the deconditioned older adult, was able to demonstrate significant improvement in FIM scores during an inpatient rehabilitation stay and the majority of these patients were discharged home. These outcomes occurred despite the presence of geriatric syndromes, comorbid illnesses, and a recent hospitalization for an acute medical illness. Further pilot studies on deconditioned patients who are admitted to inpatient rehabilitation service may confirm the need for trials that compare outcomes across other settings such as home and long-term care. Key words: deconditioned, older adults, rehabilitation

Arachnoid Cyst Resulting in Sixth Nerve Palsy in a Child

A 2 year old presented with incomitant esotropia and abduction deficit consistent with sixth nerve palsy. Neuroimaging revealed an arachnoid cyst on the left. Neurosurgical shunting followed by strabismus surgery relieved the abduction deficit and esotropia. An arachnoid cyst may be a rare cause of acquired sixth nerve palsy and strabismus in children.

Minimally invasive management of pancreatic disease

1 Department of Surgery, University of Washington, Seattle, WA, USA 2 Department of Surgery, University of Louisville, Louisville, KY, USA 3 Department of Gastroenterology, McGill University, Montreal, Quebec, Canada 4 Department of Surgery, The Beth Israel Deaconess Medical Center, Boston, MA, USA 5 Department of Surgery, The George Washington University Medical Center, 2150 Pennsylvania Avenue NW, Suite 6B, Washington, DC, 20037, USA

Guidelines for the treatment of diabetic ulcers

1. Chaired this panel2. University of Pittsburgh/UPMC, Pittsburgh, PA3. Georgetown University Hospital, Washington, DC4. Colaizzi Pedorthic Center, Pittsburgh, PA5. HCA Richmond Retreat Hospital, Richmond, VA6. University of Michigan Hospital, Ann Arbor, MI7. University of Texas Health Science Center, San Antonio, TX8. Covance, Princeton, NJ9. St Joseph’s Hospital, Belleville, IL10. University of South Florida, Tampa, FL11. Penn North Centers for Advanced Wound Care, Warren, PA12. Cabrini Medical Center, NY, NY13. Beth Israel Deaconess Medical Center, Boston, MA, and14. Barnes-Jewish Hospital at Washington University Medical Center, St Louis, MO

C. Bob Basu, M.D., M.P.H. and Gustavo A. Colon, M.D.

I wish to thank Drs. Basu and Colon for serving as guest editors of this edition of Seminars in Plastic Surgery on the topic of “Optimization of Patient Safety in Cosmetic Surgery” and the contributors whose aid and counsel produced the issue that follows. Dr. Basu is an Assistant Professor in the Plastic Surgery Division of the Michael E. DeBakey Department of Surgery at Baylor College of Medicine, where his specialty is breast reconstruction and aesthetic and reconstructive plastic surgery. After graduating magna cum laude from Princeton University, Dr. Basu earned his M.D. and Master of Public Health (M.P.H) degrees from Tufts University School of Medicine in Boston. He completed his residency training in general surgery at The George Washington University Medical Center in Washington, D.C. and his training in plastic and reconstructive plastic surgery at Baylor College of Medicine. Dr. Basu's commitment to patient safety and improving surgical outcomes is reflected in his research, which focuses on outcomes analysis in aesthetic and reconstructive plastic surgery. Dr. Colon has a long and highly respected history in the plastic surgery community. He is an enormously successful plastic surgeon in the New Orleans community, where he is a Clinical Professor at Louisiana State University School of Medicine. He also has an established private practice in New Orleans, where he specializes in aesthetic surgery. Dr. Colon obtained his B.A. from Johns Hopkins University and received his medical degree from the University of Maryland. He subsequently completed 7 years of postgraduate training at the following institutions: United States Public Health University, Baltimore; United States Public Health Services, New Orleans; and Tulane University School of Medicine, New Orleans. Dr. Colon is board certified by the American Board of Plastic Surgery. Dr. Colon has served on the American Board of Plastic Surgery and numerous plastic surgery societies.

Shigellosis and Cryptosporidiosis, Baltimore, Maryland

To the Editor: Floret et al. argue convincingly that natural disasters, including severe floods and windstorms, tend not to result in epidemics of infectious disease (1). This conclusion is consistent with the lack of epidemics of shigellosis and cryptosporidiosis after hurricane rains in Baltimore, Maryland. Shigellosis and cryptosporidiosis are associated with waterborne and foodborne transmission (2,3). We examined Baltimore shigellosis and cryptosporidiosis incidence to assess whether disease risk was related to temperature or rainfall from January 1, 1998, to December 31, 2004. Maryland FoodNet supplied case data; population estimates were acquired from the Maryland Department of Planning State Data Center; and meteorologic data for Baltimore Washington International airport (≈10 miles from the city center) were obtained from the National Atmospheric and Oceanic Administration (4). During the study period, 38 cases of cryptosporidiosis and 943 cases of shigellosis were reported in Baltimore. Temperature was strongly seasonal; precipitation was not. A dry period during 1999 was observed. No seasonal cryptosporidiosis patterns were identifiable. Two outbreaks of shigellosis occurred; in 2000 (≈50 cases) and 2002–2004 (≈870 cases). Sporadic cases of shigellosis were not seasonal. Two hurricanes resulted in heavy rainfall in Baltimore during the study period (5). Hurricane Floyd inundated the city with rain on September 16, 1999, and on September 19, 2003, Hurricane Isabel produced heavy rains and storm surge in Baltimore (which is located near the northern end of Chesapeake Bay). Approximately 4 other named tropical storms or depressions directly affected Baltimore rainfall during the study. However, collectively, none of these events had distinguishable signatures in the incidence of shigellosis or cryptosporidiosis in this urban environment. The institutional review boards of the University of Maryland School of Medicine, The George Washington University Medical Center, and the Maryland Department of Health and Mental Hygiene approved this study. Dr Hartley is supported by a National Institutes of Health Career Development Award (K25 AI-58956).

Future shock?

Pulmonary and Critical Care Medicine Division, Department of Medicine, The George Washington University Medical Center, Washington, DC

Treatment of asymptomatic carotid artery disease: Similar early outcomes after carotid stenting for high-risk patients and endarterectomy for standard-risk patients

The role of carotid angioplasty and stenting (CAS) in the treatment of asymptomatic patients with carotid disease remains controversial. The purpose of this report is to compare outcomes in asymptomatic patients treated with CAS and carotid endarterectomy (CEA). This was the initial experience performing CAS for most of the surgeons. For comparison, we also report our outcomes in standard-risk patients treated concurrently with CEA during the same period of time. A retrospective, nonrandomized review of asymptomatic patients undergoing CEA or CAS at Washington University Medical Center in St. Louis was done. Patients with >70% asymptomatic carotid stenosis treated between September 2003 and April 2005 were identified. CEA was the first therapeutic consideration in all patients. CAS was reserved for high-risk patients. Thirty-day outcomes of stroke or death were recorded. During this time interval, 248 patients were treated including with 93 CAS and with 145 CEA. Symptomatic or clinically detected adverse outcomes such as myocardial infarction (MI), arrhythmia, renal failure, or pulmonary complications were noted but were not the primary end points of this review. This study addresses only the periprocedural outcomes of CEA and CAS in asymptomatic patients. No data >30-day follow-up are included. During this period, 93 CAS and 145 CEA procedures were done in asymptomatic patients. Patient characteristics in both groups were similar. Carotid protection devices were used in 91.4% of CAS patients. The results in the CAS group showed one death (1.1%) and one stroke (1.1%). In the CEA group, three strokes occurred (2.1%, P = 0.9999), one associated with death (0.7%, P = 0.9999). The CAS group had 1.34 +/- 0.83 risk factors vs 0.39 +/- 0.58 in the CEA group (P < .0001). Median CAS and CEA length of stay was 1 day. CAS for asymptomatic carotid stenosis demonstrated equivalent outcomes compared with CEA, despite CAS being reserved for use in a disadvantaged subset of high-risk patients owing to anatomic risk factors or medical comorbidities. These results suggest CAS should be considered a reasonable treatment option in the high-risk but asymptomatic patient. Enthusiasm for CAS should be tempered by the recognition that long-term outcomes in CAS-treated asymptomatic patients remain unknown.

Letters

Back to table of contents Previous article Next article LettersFull AccessLettersLarry H. Pastor M.D.Larry H. Pastor M.D.Search for more papers by this authorPublished Online:1 Apr 2006https://doi.org/10.1176/ps.2006.57.4.580aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: I was delighted to read Griffeth and Bally's timely article in the February issue. Last year I was called to active duty as chief psychiatrist of Task Force 344 Med, whose mission at Forward Operating Base Abu Ghraib, Iraq, included care of thousands of foreign detainees in U.S. custody. Indeed, the problem of unreliability of assessment information is significant and due not only to linguistic and cultural barriers but also to socioeconomic differences and to the distortion of information unique to wartime circumstances. Detainees are a heterogeneous group, including terrorist masterminds, lower-level street thugs, innocents caught in the wrong place at the wrong time, and medically ill opportunists incarcerating themselves to obtain U.S. medical care. Reports of hopelessness and suicidality were not uncommon. Some developed symptoms at the onset of incarceration; others presented later, after long family separation and mounting frustration at the pace of the Iraqi justice system. One phenomenon seen repeatedly was that a single intervention with detainees who reported suicidal ideation was often sufficient to relieve such ideation and restore adaptive thinking and behavior. The pattern of symptoms and response seems to validate the "social integration" theories of Okasha that are cited by the Griffeth and Bally ( 1 ). Intervention often took the form of a heated discussion on a variety of topics ranging from hope versus despair, to the current affairs and future of Iraq, to questions of God's benevolence, to the feelings of the American people toward Iraqis and Arabs. Interventions were held out of earshot of other prisoners but, typically, within their line of sight. To give a prisoner in a yellow jumpsuit and sandals an audience with a field-grade U.S. Army officer in "full battle rattle," with a military entourage of other officers and enlisted team members, likely conferred a sense of respect for the individual's opinions and elevated the detainee's self-esteem, even if only temporarily. I found it useful to acknowledge that I could not accelerate the resolution of their legal situation, but as a U.S. Army officer, I could assure them respect for their rights and dignity, safety while in U.S. custody, opportunity to redress grievances, and access to medical care. Detainees often expressed gratitude and affirmed a restoration of their will to live and to cope with life in the camps.We do not know what individual patients told their tent-mates after these intense interlocutory sessions; patients could have offered any explanation, including one that further enhanced their esteem in the eyes of other detainees. In line with the theories of Okasha, it is plausible that an audience with "the American Army officers" altered the patient's status and role within his immediate social group and thereby played a therapeutic role in altering his mental status.Regarding language barriers: over the course of a tour of duty, one can learn dozens of Arabic words and phrases. To begin and end conversations directly with patients in their native language and to communicate such thoughts as, "Kulna Ichwan?" ("Are not all men brothers?") or "Inshallah, t'kon zien" ("With God's help, may you be well") helps break down barriers and advance a therapeutic alliance.Dr. Pastor, who is a lieutenant colonel in the U.S. Army Reserve, is associate clinical professor of psychiatry and human behavior at George Washington University Medical Center in Washington, D.C., and assistant adjunct professor at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.Reference1. Okasha A: Mental health in the Middle East: an Egyptian perspective. Clinical Psychology Review 19:917-933, 1999Google Scholar FiguresReferencesCited byDetailsCited byNone Volume 57Issue 4 April, 2006Pages 580-581PSYCHIATRIC SERVICES April 2006 Volume 57 Number 4 Metrics PDF download History Published online 1 April 2006 Published in print 1 April 2006

Precancer: A conceptual working definition: Results of a Consensus Conference

Background: Precancers are lesions that precede the appearance of invasive cancers. The successful prevention or treatment of precancers has the potential to eliminate deaths due to cancer. Methods: A National Cancer Institute-sponsored Conference on Precancer was convened on November 8–9, 2004, at The George Washington University Medical Center, Washington, DC. A definition of precancers was developed over 2 days of Conference discussions. Results: The following five criteria define a precancer: (1) evidence must exist that the precancer is associated with an increased risk of cancer; (2) when a precancer progresses to cancer, the resulting cancer arises from cells within the precancer; (3) a precancer differs from the normal tissue from which it arises; (4) a precancer differs from the cancer into which it develops, although it has some, but not all, of the molecular and phenotypic properties that characterize the cancer; (5) there is a method by which the precancer can be diagnosed. Conclusions: The Conference participants developed a general definition for precancers that would provide a consistent and clinically useful way of distinguishing precancers from all other types of lesions. It was recognized that many precancerous lesions may not meet this strict definition, but the group felt it was necessary to define criteria that will help standardize clinical and biological studies. Furthermore, a set of defining criteria for putative precancer lesions will permit pathologists to build a diagnostically useful taxonomy of precancers based on specified clinical and biological properties. Precancers thus characterized can be classified into clinically relevant sub-groups based on shared properties (i.e. biomarkers, oncogenes, common metabolic pathways, responses to therapy, etc.). Publications that introduce newly described precancer entities should describe how each of the five defining criteria apply. This manuscript reviews the proposed definition of precancers and suggests how pathologists, oncologists and cancer researchers may determine when these criteria are satisfied.

UROTHELIAL NEOPLASMS IN PATIENTS 20 YEARS OR YOUNGER: A CLINICOPATHOLOGICAL ANALYSIS USING THE WORLD HEALTH ORGANIZATION 2004 BLADDER CONSENSUS CLASSIFICATION

Urothelial neoplasms in patients younger than 20 years are rare, with conflicting data regarding clinical outcomes. We identified 23 patients 4 to 20 years old with urothelial neoplasms, reclassified the microscopic diagnoses using the 2004 WHO/International Society of Urologic Pathology grading classification and collected data on presentation, risk factors and outcomes. Pathological grading revealed 2 urothelial papillomas, 10 papillary urothelial neoplasms of low malignant potential (PUNLMPs), and 8 low grade and 3 high grade papillary urothelial cancers, all without invasion. Mean patient age was 13.2 years (range 4 to 20), 19 patients were male and 19 presented with gross hematuria. All lesions were solitary and measured 0.1 to 6 cm. One patient had a history of smoking and 1 had parents who smoked. Three patients (13%) had recurrences classified as either urothelial papilloma (1) or PUNLMP (2). All patients were alive with no evidence of disease after a mean followup of 4.5 years (range 6 months to 13 years). Urothelial neoplasms in individuals younger than 20 years more commonly occur in males and are predominantly low grade with a favorable clinical outcome. Before the current classification system the 10 patients with a diagnosis of PUNLMP would have been classified as having papillary carcinoma. Thus, the diagnostic category of PUNLMP allowed 43.5% of patients in this series to avoid being labeled with "cancer" at a young age.

Animal Models of Melanoma

Linan Ha, Frances P. Noonan,w Edward C. De Fabo,w and Glenn Merlino Laboratory of Cell Regulation and Carcinogenesis, National Cancer Institute, Bethesda, Maryland, USA; wLaboratory of Photobiology and Photoimmunology, Department of Environmental and Occupational Health, School of Public Health and Health Services, The George Washington University Medical Center, Washington, District of Columbia, USA

Experience with laparoscopic gastric resection: results and outcomes for 37 cases

This study aimed to review the authors' technique, results, and outcomes for laparoscopic gastric wedge and segmental resections in patients with benign gastric diseases. A retrospective clinical chart review was performed for all the patients who underwent laparoscopic gastric resection at the Washington University Medical Center from 1997 through March 2004. The surgical approach, operative results, complications, and subsequent clinical course were analyzed. Data are expressed as mean +/- standard deviation. Laparoscopic gastric resection was attempted in 37 cases involving 21 women and 16 men with a mean age of 61 +/- 13 years. The indications for surgery included suspected gastric stromal tumor (GIST) or carcinoid (n = 22), other benign gastric lesions (n = 6), benign gastric outlet obstruction (n = 4), and nonhealing peptic ulcer (n = 5). Segmental resection using gastroenteric anastomosis, with or without vagotomy, was performed in 14 patients, wedge resection in 22 patients, and laparoscopic enucleation in 1 patient. Resection was totally laparoscopic in 25 cases and laparoscopically assisted (with an accessory incision) in 12 cases. The mean operative time was 165 +/- 58 min, and the blood loss was 84 +/- 77 ml. Two patients (5.4%) underwent conversion to open resection. Intraoperative gastroscopy was performed in 16 cases (44%) as an aid to the resection. Regular diet was resumed at a mean of 3.0 +/- 1.7 days, and the mean length of hospital stay was 3.9 +/- 2.1 days. Four patients (10.8%) experienced major complications including subphrenic abscess (n = 1), pneumonia with respiratory failure (n = 1), splenic vein injury requiring splenectomy (n = 1), and gastric outlet obstruction (n = 1) that required reoperation 1 year later. Minor complications included intraabdominal fluid collection (n = 1), postoperative gastroparesis (n = 1), urinary retention (n = 1), and incisional hernia (n = 1). Laparoscopic gastric resections can be performed safely in patients with a variety of benign gastric disorders. The use of an accessory incision for reanastomosis and specimen extraction facilitates the procedure in difficult cases.

Lactic acidosis in sepsis: Another commentary*

Pulmonary and Critical Care Medicine Division, Department of Medicine, The George Washington University Medical Center, Washington, DC(Gutierrez) Department of Obstetrics and Gynecology, Georgetown University Hospital, Washington, DC(Wulf) The authors have no financial interests to disclose.

The unpretentious role of 2,3-diphosphoglycerate in critical illness*

Pulmonary and Critical Care Medicine Division, Department of Medicine, The George Washington University Medical Center, Washington, DC The author has no financial interests to disclose.

Employers Start to Recognize Cost of Untreated Illness

Employers Start to Recognize Cost of Untreated Illness

F2-isoprostanes: Potential markers of oxidative stress during resuscitation*

Pulmonary and Critical Care Medicine Division, Department of Medicine, George Washington University Medical Center, Washington, DC

The Efficacy of Radiation Therapy in the Management of Grade I Astrocytomas

The purpose of this study was to analyze the outcome of patients with grade I astrocytomas treated with radiation therapy, specifically looking at the prognostic significance of age, timing of radiation therapy (immediately after surgery or delayed until progression) and tumor location. The records of patients with grade I astrocytomas treated at Washington University Medical Center between 1982 and 2002 were reviewed. Twenty patients with grade I pilocytic astrocytoma (n=19) or subependymal giant cell astrocytoma (n=1) were treated with radiation therapy with curative intent. The median follow-up was 6.4 years. The 5-year overall survival for all patients was 100%. The 5-year progression-free survival (PFS) following radiation therapy for all patients was 68%. Patients who received radiation therapy immediately after biopsy or surgery had a 5-year PFS of 77% versus 50% for patients who received radiation therapy after initial disease progression (P=0.013). Patients with infratentorial tumors had an improved outcome with a 5-year PFS of 80% versus 59% for those with supratentorial tumors (P=0.0076). Patient age did not significantly influence outcome. All tumor recurrences were local. While this study reports an excellent overall survival, approximately one third of patients with grade I astrocytomas had progressive disease following radiation therapy. In particular, patients with supratentorial tumors and delayed radiation therapy had a worse PFS. Additional investigation is needed to improve the outcome in these patients.

Interventions Can Alleviate Demoralization

Back to table of contents Previous article Next article Professional NewsFull AccessInterventions Can Alleviate DemoralizationJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:3 Jun 2005https://doi.org/10.1176/pn.40.11.00400010aSome evidence from American studies buttresses that from Italian research that demoralization is common among persons who have heart disease, cancer, or other kinds of medical conditions (see story above).The American evidence comes from James Griffith, M.D., and Lynne Gaby, M.D., of the consultation-liaison psychiatry faculty at George Washington University Medical Center in Washington, D.C.Griffith told Psychiatric News that several years ago he and Gaby reviewed 100 psychiatric consultations that had been conducted either by themselves or by psychiatry residents they supervised. All of the consultations had been undertaken in response to medical and surgical colleagues' request to “evaluate and treat a patient's depression,” which is the most common reason why medical colleagues ask them to consult on their cases.Griffth and Gaby found that in 52 of the 100 consultations, patients had been given “a depressive disorder” as the primary psychiatric diagnosis (the average Hamilton Depression Rating Scale score was 20), whereas in the remaining 48 consultations, patients had been given“ demoralization” as the primary psychiatric descriptor (the average Hamilton score was 11, which is just higher than the normal range).Thus, demoralization rather than a mood disorder was the major problem for many of these patients, Griffith said.Moreover, Griffith continued, “We have learned that these patients respond quickly and robustly to two kinds of interventions.... [The interventions are] taking immediate steps at the bedside to relieve either physical or emotional suffering and helping patients regain a sense of hope or dignity or purpose in living that they lost.”For example, Griffith explained, a psychiatrist can do the following:Normalize the patient's distress. State to the patient, “I do not believe that you have a psychiatric disorder. You are someone coping normally with a hard situation. Almost anyone would feel as badly as you are feeling in this situation.”Inquire about the patient's priority of concerns. Ask, for example,“ What are you most concerned about?”Partner with the patient in managing some aspect of the situation. This might be relieving physical suffering, such as physical pain, nausea, or insomnia; mobilizing friends or family to visit; or making a phone call to get financial affairs in order.Ask existential questions that mobilize resilience. For example:“ During hard times like this, from where do you draw hope?”“ Which people or what things give you reason to want to live?”Griffith and Gaby offered other suggestions on how to help demoralized patients, as well as vignettes illustrating those suggestions, in the April Psychosomatics.The article “Brief Psychotherapy at the Bedside: Countering Demoralization From Medical Illness” is posted online at<http://psy.psychiatryonline.org/cgi/content/full/46/2/109>.▪ Psychosomatics 2005 46 109 ISSUES NewArchived

Reawakening to the Existence of Juvenile Xanthogranuloma

From the Lauren V. Ackerman Laboratory of Surgical Pathology, Washington University Medical Center, Barnes-Jewish and St. Louis Children's Hospitals, St. Louis, MO. Reprints: Louis P. Dehner, MD, Campus Box 8118, 660 S. Euclid Ave., St. Louis, MO 63110 (e-mail: [email protected]).