Recent Publications by CFE Educators

BACKGROUND

Many older adults who are independent prior to hospitalization develop a new disability by hospital discharge. Early risk stratification for new-onset disability may improve care. Thus, this study's objective was to develop and validate a clinical index to determine, at admission, risk for new-onset disability among older, hospitalized adults at discharge.

DESIGN

Data analyses derived from two prospective studies.

SETTING

Two teaching hospitals in Ohio.

PARTICIPANTS

Eight hundred eighty-five patients aged 70 years and older were discharged from a general medical service at a tertiary care hospital (mean age 78, 59% female) and 753 patients discharged from a separate community teaching hospital (mean age 79, 63% female). All participants reported being independent in five activities of daily living (ADLs: bathing, dressing, transferring, toileting, and eating) 2 weeks before admission.

MEASUREMENTS

New-onset disability, defined as a new need for personal assistance in one or more ADLs at discharge in participants who were independent 2 weeks before hospital admission.

RESULTS

Seven independent risk factors known on admission were identified and weighted using logistic regression: age (80-89, 1 point; ≥90, 2 points); dependence in three or more instrumental ADLs at baseline (2 points); impaired mobility at baseline (unable to run, 1 point; unable to climb stairs, 2 points); dependence in ADLs at admission (2-3 ADLs, 1 point; 4-5 ADLs, 3 points); acute stroke or metastatic cancer (2 points); severe cognitive impairment (1 point); and albumin less than 3.0 g/dL (2 points). New-onset disability occurred in 6%, 13%, 18%, 34%, 35%, 45%, 50%, and 87% of participants with 0, 1, 2, 3, 4, 5, 6, and 7 or more points, respectively, in the derivation cohort (area under the receiver operating characteristic curve (AUC)=0.784), and in 8%, 10%, 27%, 38%, 44%, 45%, 58%, and 83%, respectively, in the validation cohort (AUC=0.784). The risk score also predicted (P.001) disability severity, nursing home placement, and long-term survival.

CONCLUSION

This clinical index determines risk for new-onset disability in hospitalized older adults and may inform clinical care.

BACKGROUND

We examined the impact of obesity on 30-day outcomes of adrenalectomy using a multi-institutional database.

METHODS

Patients who underwent adrenalectomy in 2005-2008 according to the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) data set were grouped by body mass index (BMI): normal weight (BMI=18.5-24.9 kg/m2), overweight (BMI=25.0-29.9 kg/m2), obese (BMI=30.0-34.9 kg/m2), and morbidly obese (BMI≥35 kg/m2). Outcomes of the higher BMI groups were compared to those of the normal BMI group using χ2, analysis of variance (ANOVA), and multivariate regression.

RESULTS

There were 1,629 patients in the study: 22% were normal weight, 31% overweight, 22.2% obese, and 24.7% morbidly obese. Compared to normal-weight patients, obese and morbidly obese patients had a 12.5 and 16.7% increase in operation times (129 vs. 145 and 150 min, respectively, p≤0.01) and sustained more wound complications (0.2 vs. 0.4 and 1.2%, p0.001), including superficial and deep wound infections (p0.001 and p0.01, respectively). Morbid obesity independently predicted overall complications (odds ratio [OR] 2.9, 95% confidence interval [CI]: 1.7-5.7), wound complications (OR 6.1, 95% CI: 2.0-18.9), and septic complications (OR 3.1, 95% CI: 1.1-8.8). Obesity independently predicted longer total time in the operating room (p0.006). There were no differences in rates of reoperation and length of hospital stay by BMI category.

CONCLUSION

Obesity is an independent risk factor that needs to be considered in surgical decisions regarding adrenalectomy. Morbidly obese adrenalectomy patients are particularly at risk for wound and septic complications.

BACKGROUND

Gallstone disease increases with age. The aims of this study were to measure short-term outcomes from cholecystectomy in hospitalized elderly patients, assess the effect of age, and identify predictors of outcomes.

METHODS

This was a cross-sectional analysis, using the Health Care Utilization Project Nationwide Inpatient Sample (1999-2006), of elderly patients (aged 65-79 and ≥80 years) and a comparison group (aged 50-64 years) hospitalized for cholecystectomy. Linear and logistic regression models were used to evaluate age and outcome relationships. Main outcomes were in-hospital mortality, complications, discharge disposition, mean length of stay, and cost.

RESULTS

A total of 149,855 patients aged 65 to 79 years, 62,561 patients aged ≥ 80 years, and 145,675 subjects aged 50 to 64 years were included. Elderly patients had multiple biliary diagnoses and longer times to surgery from admission and underwent more open procedures. Patients aged 65 to 79 years and those aged ≥80 years had higher adjusted odds of mortality (odds ratios [ORs], 2.36 and 5.91, respectively), complications (ORs, 1.57 and 2.39), nonroutine discharge (ORs, 3.02 and 10.76), longer length of stay (ORs, 1.11 and 1.31), and higher cost (ORs, 1.09 and 1.22) than younger patients.

CONCLUSIONS

Elderly patients undergoing inpatient cholecystectomy have complex disease, with worse outcomes. Longer time from admission to surgery predicts poor outcome.

Student-run clinics (SRCs) are widespread, but studies on their educational impact are limited. We surveyed preclinical medical, nursing, and pharmacy students about their experiences in a hepatitis B elective which provided opportunities to they could volunteer at hepatitis B screening and vaccination SRCs. Student responses revealed positive perceptions of the volunteer experience. Benefits included interacting with patients, developing clinical skills, providing service to disadvantaged populations, and collaborating with health professional peers. Students who participated in clinic reported enhanced skills compared to those who did not attend. SRCs play a valuable role in instilling positive attitudes and improving skills.

BACKGROUND

Obesity is a national epidemic. Prior studies of the impact of body mass index (BMI) on surgical outcomes from cervical endocrine procedures have come from high-volume, single institutions. Our study characterizes the 30-day clinical and economic outcomes in patients with high BMI from a multi-institutional database.

METHODS

Patients undergoing thyroidectomy or parathyroidectomy in the American College of Surgeons National Surgery Quality Improvement Program, 2005-2008 were categorized into 4 groups BMI based on: normal, overweight, obese, and morbidly obese. Overweight, obese, and morbidly obese patients were compared with patients with normal BMI using a χ(2) test and an analysis of variance. Multivariable linear/logistic regression models were used to adjust for preoperative risk factors.

RESULTS

In all, 18,825 patients underwent thyroidectomy. Overweight, obese, and morbidly obese patients were more likely to have total thyroidectomy, substernal thyroids, general anesthesia, operations of greater duration, and an overall or wound complication (all P .01). On a multivariable analysis, morbidly obese patients had an increased risk for urinary complications (P .05); obese and morbidly obese patients had an increased risk for overall or wound complications (P .01); overweight, obese, and morbidly obese patients had operations of greater duration (P .05). In all, 8,039 patients underwent parathyroidectomy. Overweight, obese, and morbidly obese patients were more likely to have general anesthesia and operations of greater duration (all P .01). On multivariable analysis, morbidly obese patients had operations of greater duration (P .05) and more wound complications (P = .05).

CONCLUSION

Patients with high BMI seem to require operations of greater duration and sustain more morbidity after cervical endocrine procedures than patients with normal BMI, but these differences may not be clinically significant. Thyroidectomy and parathyroidectomy can be performed safely, with appropriate surgical decision making.

OBJECTIVE

To evaluate whether vitamin D is associated with multiple sclerosis (MS) status and disease severity in African Americans.

METHODS

Serum 25-hydroxyvitamin D was compared in a cross-sectional sample of 339 African Americans with MS and 342 African American controls. Correlations between disease severity (Multiple Sclerosis Severity Score [MSSS]) and 25-hydroxyvitamin D levels were sought.

RESULTS

A total of 71% of controls and 77% of patients with MS were vitamin D deficient (50 nmol/L; 20 ng/mL), and 93% of controls and 94% of patients with MS were vitamin D insufficient (75 nmol/L; 30 ng/mL). Median unadjusted (29.7 vs 36.6 nmol/L, p = 0.0001) and deseasonalized (p = 0.0013) 25-hydroxyvitamin D levels were lower in the MS group. Multivariable analysis revealed that differences in latitude and ultraviolet index accounted for much of this association. The median (interquartile range) MSSS was 6.1 (4.8-8.1). There was no apparent association between the MSSS and vitamin D status. A greater proportion of European genetic ancestry, a measure of genetic admixture, was positively correlated with 25-hydroxyvitamin D (p = 0.007).

CONCLUSIONS

Levels of 25-hydroxyvitamin D were lower in African Americans with MS than controls, an observation primarily explained by differences in climate and geography. There was no apparent association between vitamin D status and disease severity. These results are consistent with observations in other populations that lower 25-hydroxyvitamin D is associated with having MS, but also highlight the importance of climate and ancestry in determining vitamin D status.