An aging population and growing disease burden will require a large and specialized health care workforce by 2025

Comparison of Dermatologist Density Between Urban and Rural Counties in the United States

Importance

As the US population continues to increase and age, there is an unmet need for dermatologic care; therefore, it is important to identify and understand the characteristics and patterns of the dermatologist workforce.

Objective

To analyze the longitudinal dermatologist density and urban-rural disparities using a standardized classification scheme.

Design, Setting, and Participants

This study analyzed county-level data for 1995 to 2013 from the Area Health Resources File to evaluate the longitudinal trends and demographic and environmental factors associated with the geographic distribution of dermatologists.

Main Outcomes and Measures

Active US dermatologist and physician density.

Results

In this study of nationwide data on dermatologists, dermatologist density increased by 21% from 3.02 per 100 000 people to 3.65 per 100 000 people from 1995 to 2013; the gap between the density of dermatologists in urban and other areas increased from 2.63 to 3.06 in nonmetropolitan areas and from 3.41 to 4.03 in rural areas. The ratio of dermatologists older than 55 years to younger than 55 years increased 75% in nonmetropolitan and rural areas (from 0.32 to 0.56) and 170% in metropolitan areas (from 0.34 to 0.93). Dermatologists tended to be located in well-resourced, urban communities.

Conclusions and Relevance

Our findings suggest that substantial disparities in the geographic distribution of dermatologists exist and have been increasing with time. Correcting the workforce disparity is important for patient care.

[What is actually adult spinal deformity? : Development, classification, and indications for surgical treatment]

BACKGROUND

Adult spinal deformity (ASD) is a complex entity that has had emerging significance for spine surgeons in the last decade. Sagittal and/or coronary deformities can have a high impact (disability, pain) on the quality of patients' life. Radiologic diagnostics determine the common spinopelvic parameters as the basis for classification of ASD.

TREATMENT

Conservative treatment options may be sufficient in mild cases. The deformity's complexity frequently demands the entire spectrum of methods and techniques in spinal surgery. This article gives an overview on the development of the ASD, the correct classification as well as the indication for surgical therapy.

Postoperative Delirium as a Target for Surgical Quality Improvement

OBJECTIVE

To explore hospital-level variation in postoperative delirium using a multi-institutional data source.

BACKGROUND

Postoperative delirium is closely related to serious morbidity, disability, and death in older adults. Yet, surgeons and hospitals rarely measure delirium rates, which limits quality improvement efforts.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Geriatric Surgery Pilot (2014 to 2015) collects geriatric-specific variables, including postoperative delirium using a standardized definition. Hierarchical logistic regression models, adjusted for case mix [Current Procedural Terminology (CPT) code] and patient risk factors, yielded risk-adjusted and smoothed odds ratios (ORs) for hospital performance. Model performance was assessed with Hosmer-Lemeshow (HL) statistic and c-statistics, and compared across surgical specialties.

RESULTS

Twenty thousand two hundred twelve older adults (≥65 years) underwent inpatient operations at 30 hospitals. Postoperative delirium occurred in 2427 patients (12.0%) with variation across specialties, from 4.7% in gynecology to 13.7% in cardiothoracic surgery. Hierarchical modeling with 20 risk factors (HL = 9.423, P = 0.31; c-statistic 0.86) identified 13 hospitals as statistical outliers (5 good, 8 poor performers). Per hospital, the median risk-adjusted delirium rate was 10.4% (range 3.2% to 27.5%). Operation-specific risk and preoperative cognitive impairment (OR 2.9, 95% confidence interval 2.5-3.5) were the strongest predictors. The model performed well across surgical specialties (orthopedic, general surgery, and vascular surgery).

CONCLUSION

Rates of postoperative delirium varied 8.5-fold across hospitals, and can feasibly be measured in surgical quality datasets. The model performed well with 10 to 12 variables and demonstrated applicability across surgical specialties. Such efforts are critical to better tailor quality improvement to older surgical patients.

Caregiving for Community-Dwelling Older Persons in South Korea: Current Formal and Informal Care Use and Expectation

The aim of this study is to examine formal and informal care use among community-dwelling older Korean adults. Older adults aged between 65 and 85 ( N = 516) in mid-size city, selected using the probability proportional sampling method, were interviewed in person. One third reported having at least one caregiver. Compared to respondents who did not use any informal/formal care, those who used any formal or informal care were older and were more likely to be prefrail or frail and experienced at least one hospitalization or emergency department use in the past year. Living alone or being experienced with any hospitalization was associated with formal care use. Most care recipients received informal care from families, specifically spouses. Among participants who received no formal/informal care, 19% of them expected to receive formal care support in the future. Substantial support programs for informal caregivers are needed to address the increase in demand and expectation for long-term care.

Socioeconomic determinants of out-of-pocket pharmaceutical expenditure among middle-aged and elderly adults based on the China Health and Retirement Longitudinal Survey

OBJECTIVE

Out-of-pocket pharmaceutical expenditure (OOPPE) is a considerable burden for middle-aged and elderly adults due to their high prevalence of diseases, insufficient income and absence of medical insurance in China. The objective of this study was to assess the determinants of OOPPE among Chinese middle-aged and elderly adults.

METHODS

This is a cross-sectional study based on the China Health and Retirement Longitudinal Survey conducted in 2015. The Andersen behavioural health model was used to select the factors. Binary multivariable logistic and generalised linear regressions were both applied to examine the determinants of OOPPE.

RESULTS

Of the respondents, 15.28%, 5.20% and 51.35% reported an OOPPE for outpatient services, inpatient services and self-medication, respectively. The OOPPE for outpatient services, inpatient services and self-medication was US$6.66, US$17.93 and US$15.32, respectively. Increased age significantly influenced the likelihood of OOPPE, and older people (aged >65 years) had lower OOPPE for outpatient services. Having health insurance significantly reduced the likelihood of OOPPE for outpatient and inpatient services but increased OOPPE for self-medication. In general, compared with the low-income group, higher income groups had a significantly lower likelihood of having an OOPPE, and when they did the amounts were less. Generally, middle-aged and elderly people with poor self-reported health status, limitation of daily activities, and critical or chronic diseases had a significantly higher likelihood of having an OOPPE and at a significantly higher amount.

CONCLUSION

Policy-making efforts should focus on reducing self-medication OOPPE and alleviating its associated socioeconomic determinants to ease the economic burden of diseases among middle-aged and elderly adults in China.

Geriatric Physiology and the Frailty Syndrome

Understanding geriatric physiology is critical for successful perioperative management of older surgical patients. The frailty syndrome is evolving as an important, potentially modifiable process capturing a patient's biologic age and is more predictive of adverse perioperative outcomes than chronologic age. Use of frailty in risk stratification and perioperative decision-making allows providers to effectively diagnose, risk stratify, and treat patients in the perioperative setting. Further study is needed to develop a universal definition of frailty, to identify comprehensive yet feasible screening tools that allow for accurate detection of frailty in the perioperative setting, and to refine treatment programs for frail surgical patients.

The pediatric dental workforce in 2016 and beyond

BACKGROUND

Childhood caries is a major oral and general health problem, particularly in certain populations. In this study, the authors aimed to evaluate the adequacy of the supply of pediatric dentists.

METHODS

The authors collected baseline practice information from 2,546 pediatric dentists through an online survey (39.1% response rate) in 2017. The authors used a workforce simulation model by using data from the survey and other sources to produce estimates under several scenarios to anticipate future supply and demand for pediatric dentists.

RESULTS

If production of new pediatric dentists and use and delivery of oral health care continue at current rates, the pediatric dentist supply will increase by 4,030 full-time equivalent (FTE) dentists by 2030, whereas demand will increase by 140 FTE dentists by 2030. Supply growth was higher under hypothetical scenarios with an increased number of graduates (4,690 FTEs) and delayed retirement (4,320 FTEs). If children who are underserved experience greater access to care or if pediatric dentists provide a larger portion of services for children, demand could grow by 2,100 FTE dentists or by 10,470 FTE dentists, respectively.

CONCLUSIONS

The study results suggest that the supply of pediatric dentists is growing more rapidly than is the demand. Growth in demand could increase if pediatric dentists captured a larger share of pediatric dental services or if children who are underserved had oral health care use patterns similar to those of the population with fewer access barriers.

PRACTICAL IMPLICATIONS

It is important to encourage policy changes to reduce barriers to accessing oral health care, to continue pediatric dentists' participation with Medicaid programs, and to urge early dental services for children.

Quantification of fat and skeletal muscle tissue at abdominal computed tomography: associations between single-slice measurements and total compartment volumes

PURPOSE

Body composition is of great prognostic value in several severe diseases, including different types of cancer as well as cardiometabolic disorders. We aimed to investigate the correlations of skeletal muscle mass and abdominal adipose tissue compartments between volumetric and single-slice measurements to study the usefulness of several anatomical landmarks for estimation of total compartment volumes using abdominal CT-scans.

METHODS

In this retrospective study volumetric quantifications of paraspinal skeletal muscles (SM) and adipose tissue compartments (visceral adipose tissue, VAT; subcutaneous adipose tissue, SAT) were performed in 50 consecutive patients (26 male; mean age, 63 ± 15 years) who underwent abdominal multislice-CT for diagnostic purposes using an in-house software. Associations between total volumes of SM, VAT, and SAT with single-slice measurements at eight predefined anatomical landmarks (median intervertebral disk spaces T12/L1 to L5/S1; level of the umbilicus (U); level of the radix of the superior mesenteric artery (SMA)) were studied using correlation coefficients.

RESULTS

Statistical analysis revealed a strong association between single-slice measurements of adipose tissue compartments with total VAT and SAT volume (VAT: all r > 0.89, P < 0.001; SAT: all r > 0.95, P < 0.001). The strongest associations with total SM volume were found for single-slice measurements obtained at L3/4 (r = 0.94, P < 0.001) and were further improved by normalization to height (r = 0.98, P < 0.001).

CONCLUSIONS

Single-slice measurements of SM, VAT, and SAT at several anatomical landmarks are strongly associated with total compartment volumes and therefore allow for easy and simultaneous assessment of skeletal muscle mass and adipose tissue compartment volumes.

Stages of Change: Moving Community Pharmacies From a Drug Dispensing to Population Health Management Model

Given their clinical training and accessibility, community pharmacists are well positioned to support primary care, especially in providing medication management services. There is limited evidence, however, on implementation of community pharmacist-led services in coordination with other health care providers. The aim of this study was to examine the implementation process of community pharmacies in North Carolina participating in a Medicaid population health management intervention. We conducted semistructured interviews with 40 representatives from high- and low-performing community pharmacies from June to August 2017. We analyzed for themes organized around Rogers's Stages in the Innovation Process in Organizations. Community pharmacies employed numerous implementation strategies such as developing relationships with providers and redefining job responsibilities to ensure pharmacists and pharmacy technicians are working at the top of their license. Findings also revealed differences in the implementation process among high- and low-performing pharmacies. Continued research is needed to determine which implementation strategies improve program performance.

A Potential Antifungal Effect of Chitosan Against Candida albicans Is Mediated via the Inhibition of SAGA Complex Component Expression and the Subsequent Alteration of Cell Surface Integrity

Due to the high incidence of nosocomial Candida albicans infection, the first-line drugs for C. albicans infection have been heavily used, and the emergence of drug-resistant strains has gradually increased. Thus, a new antifungal drug or therapeutic method is needed. Chitosan, a product of chitin deacetylation, is considered to be potentially therapeutic for fungal infections because of its excellent biocompatibility, biodegradability and low toxicity. The biocidal action of chitosan against C. albicans shows great commercial potential, but the exact mechanisms underlying its antimicrobial activity are unclear. To reveal these mechanisms, mutant library screening was performed. ADA2 gene, which encodes a histone acetylation coactivator in the SAGA complex, was identified. Transmission electronic microscopy images showed that the surface of chitosan-treated ada2Δ cells was substantially disrupted and displayed an irregular morphology. Interestingly, the cell wall of ada2Δ cells was significantly thinner than that of wild-type cells, with a thickness similar to that seen in the chitosan-treated wild-type strain. Although ADA2 is required for chitosan tolerance, expression of ADA2 and several Ada2-mediated cell wall-related genes (ALS2, PGA45, and ACE2) and efflux transporter genes (MDR1 and CDR1) were significantly inhibited by chitosan. Furthermore, GCN5 encoding a SAGA complex catalytic subunit was inhibited by chitosan, and gcn5Δ cells exhibited phenotypes comparable to those of ada2Δ cells in response to chitosan and other cell surface-disrupting agents. This study demonstrated that a potential antifungal mechanism of chitosan against C. albicans operates by inhibiting SAGA complex gene expression, which decreases the protection of the cell surface against chitosan.

Association between hospital community services and county population health in the USA

OBJECTIVES

Little research has utilized population level data to test the association between community health outcomes and (i) hospital-sponsored community services that facilitate access to care and (ii) hospital-sponsored community building services in the USA. Therefore, the purpose of this study was to examine these relationships.

METHODS

A secondary data analysis of the 2016 County Health Rankings and American Hospital Association databases was conducted via zero-truncated negative Binomial regression.

RESULTS

Findings indicate a statistically significant difference between the number of community healthcare access services and community building services with county's rank of health behavior. However, no statistically significant differences were found between the number of community healthcare access services and community building services with county rankings of length of life, quality of life or clinical care.

CONCLUSIONS

Our findings suggest that quality measures of services may play a more important role in community health improvement and that there is opportunity for hospitals to revamp the way in which community health needs assessments are conducted. Additional federal action is needed to standardize hospital sponsored community health service data reporting so that practitioners, hospital administrators and researchers can more specifically define hospitals' role in public health protection in the USA.

Health care staff responses to disinvestment-A systematic search and qualitative thematic synthesis

BACKGROUND

Health care services must deliver high-quality, evidence-based care that represents sound value. Disinvestment is the process of withdrawing resources from any existing health care practices that deliver low gain for their cost and reallocating these toward practices that are more effective, efficient, and cost-effective, thus benefiting patients and the community.

PURPOSE

This is the first review to examine the responses of health care staff to disinvestment and investigate the factors that increase the likelihood of these staff accepting disinvestment or reallocation of resources from the health services they provide.

METHODS

We conducted a systematic search of five electronic databases using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) framework. A critical appraisal process of the quality of the included studies was performed by two authors. We undertook a thematic synthesis of the qualitative data to develop an overarching narrative.

RESULTS

Twelve studies were identified for synthesis and all found that the disinvestment process was challenging and controversial for those health care staff involved. Negative staff reactions to disinvestment identified were anxiety, disempowerment, distrust, and feelings of being dismissed and disrespected. Engagement with disinvestment was observed when staff were invited to participate in a process they considered transparent and in the best interests of the community.

PRACTICE RECOMMENDATIONS

Health care staff have a strong professional identity associated with autonomy in their decision making in the provision of health care services. Disinvestment from a service that health care staff can usually choose to provide threatens this identity. Engaging clinical champions to lead change, using rigorous patient outcome data, and transparent decision-making processes may assist health care staff to embrace a new identity as innovators and accept disinvestment in low-value health care.

Changes in prescription pattern, pharmaceutical expenditure and quality of care after introduction of reimbursement restriction in diabetes in Korea

Background

To ensure effective prescription practices and reduce diabetes-related pharmaceutical expenditures, Korea adopted a clinical practice guideline for the reimbursement system. Health care providers cannot receive reimbursement from National Health Insurance(NHI) unless it is for an appropriate prescription under the predefined clinical condition. The aim of this study was to evaluate prescription patterns in oral hypoglycemic agents, costs and effects on patient care since the introduction of the diabetes reimbursement restriction.

Methods

We used claim data from 2008 to 2013, which included 26 315 diabetes patients and 9907 hospitals. An interrupted time series study design using generalized estimating equations was used to evaluate changes in patterns of single and combination therapy, brand name drug prescriptions, cost and hospital admission following the reimbursement restriction.

Results

Following reimbursement restriction initiation, we found a statistically significant decrease in the average prescription rate of brand name drugs (-6.2%), whereas single therapy prescription increased (9.9%). There was also a reduction in trend change in the monthly prescription rate for combination therapy (-1.7%) and brand name drugs (-0.8%). For single therapy, the trend change in prescription rate increased after the intervention (0.8%). A reduction of trend change in pharmaceutical costs (-0.3%) was observed. However, we did not find a significant change in hospital admission for diabetes.

Conclusions

Reimbursement restriction affects both pharmaceutical costs and physicians' decisions to prescribe oral hypoglycemic agents. We did not observe a significant reduction in quality of care following the intervention. Collectively, these findings indicate that reimbursement restriction has improved effective drug utilization and decreased health expenditures.

The Importance of Sensory Processing in Mental Health: A Proposed Addition to the Research Domain Criteria (RDoC) and Suggestions for RDoC 2.0

The time is ripe to integrate burgeoning evidence of the important role of sensory and motor functioning in mental health within the National Institute of Mental Health's [NIMH] Research Domain Criteria [RDoC] framework (National Institute of Mental Health, n.d.a), a multi-dimensional method of characterizing mental functioning in health and disease across all neurobiological levels of analysis ranging from genetic to behavioral. As the importance of motor processing in psychopathology has been recognized (Bernard and Mittal, 2015; Garvey and Cuthbert, 2017; National Institute of Mental Health, 2019), here we focus on sensory processing. First, we review the current design of the RDoC matrix, noting sensory features missing despite their prevalence in multiple mental illnesses. We identify two missing classes of sensory symptoms that we widely define as (1) sensory processing, including sensory sensitivity and active sensing, and (2) domains of perceptual signaling, including interoception and proprioception, which are currently absent or underdeveloped in the perception construct of the cognitive systems domain. Then, we describe the neurobiological basis of these psychological constructs and examine why these sensory features are important for understanding psychopathology. Where appropriate, we examine links between sensory processing and the domains currently included in the RDoC matrix. Throughout, we emphasize how the addition of these sensory features to the RDoC matrix is important for understanding a range of mental health disorders. We conclude with the suggestion that a separate sensation and perception domain can enhance the current RDoC framework, while discussing what we see as important principles and promising directions for the future development and use of the RDoC.

Rapid and selective mobilization of specific stem cell types after consumption of a polyphenol-rich extract from sea buckthorn berries (Hippophae) in healthy human subjects

Purpose

The aim of this study was to evaluate the effects of a proanthocyanidin-rich extract of sea buckthorn berry (SBB-PE) on the numbers of various types of adult stem cells in the blood circulation of healthy human subjects.

Study design and methods

A randomized, double-blind, placebo-controlled, cross-over trial was conducted in 12 healthy subjects. Blood samples were taken immediately before and at 1 and 2 hours after consuming either placebo or 500 mg SBB-PE. Whole blood was used for immunophenotyping and flow cytometry to quantify the numbers of CD45dim CD34+ CD309+ and CD45dim CD34+ CD309− stem cells, CD45− CD31+ CD309+ endothelial stem cells, and CD45− CD90+ mesenchymal stem cells.

Results

Consumption of SBB-PE was associated with a rapid and highly selective mobilization of CD45dim CD34+ CD309− progenitor stem cells, CD45− CD31+ CD309+ endothelial stem cells, and CD45− CD90+ lymphocytoid mesenchymal stem cells. In contrast, only minor effects were seen for CD45dim CD34+ CD309+ pluripotential stem cells.

Conclusion

Consumption of SBB-PE resulted in selective mobilization of stem cell types involved in regenerative and reparative functions. These data may contribute to the understanding of the traditional uses of SBB for preventive health, regenerative health, and postponing the aging process.

Trends in Geospatial Drivers of Fall-Related Hospitalizations and Asset Mapping of Fall Prevention Interventions for Vulnerable Older Adults

Objective: Given that one in four older adults suffer potentially preventable falls annually, we aimed to identify areas with (a) delivery gaps of evidence-based programs (EBPs) targeting fall prevention among older adults, namely A Matter of Balance (AMOB), and (b) high rates of fall-related hospitalizations—hotspots. Method: Analyses included multiple geospatially linked datasets. Results: EBPs were delivered ≥1 time in 84 counties in 2012 and 90 counties in 2014. Factors associated with EPB delivery gaps (absence; p<.05) included high-density older adult areas, non-fall-related hospitalization hotspots, lower population density, nonmetropolitan areas, high-density Hispanic adult areas, and areas with limited access to home health care agencies. Hotspots for fall-related hospitalization numbered 64 in 2012 and 62 in 2014. Factors associated with hotspots included low-density older adult areas, having AMOB delivered ≥1 time annually, high population density, and high-density Hispanic adult areas. Discussion: In resource-finite settings (e.g., the aging services sector), identifying high priority areas allows for precise allocation of limited resources.

Tempo de espera e absenteísmo na atenção especializada: um desafio para os sistemas universais de saúde

RESUMO O objetivo do estudo foi analisar o absenteísmo em relação ao tempo de espera por consultas e exames especializados nos 20 municípios que compõem a Região de Saúde Metropolitana do estado do Espírito Santo (RSM-ES), Brasil. Estudo descritivo retrospectivo realizado a partir da análise do Banco de Dados da Secretaria de Estado da Saúde do Espírito Santo (Sesa). Foram considerados 1.002.719 encaminhamentos dos usuários residentes na RSM-ES para consultas/exames especializados fora do município no período de janeiro de 2014 a dezembro de 2016, que correspondem a todos os agendamentos. O tempo médio de espera pela consulta foi de 419 dias (desvio padrão = 29,3, mediana = 17,0) em 2014, de 687 dias (desvio padrão = 70,5, mediana = 16,0) em 2015, de 1.077 dias (desvio padrão = 140,3, mediana = 20,0) em 2016, aumento progressivo da espera com o passar dos anos. As análises de correlação do estudo apontaram que o tempo de espera e o porte municipal são fatores correlacionados às taxas de absenteísmo em consultas e exames especializados (p-valor<5%). O impacto do absenteísmo nos serviços ambulatoriais, influenciado pelo tempo de espera, constitui-se em um grande desafio para a estruturação de um sistema público de saúde no Brasil. Conhecer como certos fatores impactam o comportamento de não comparecimento a compromissos agendados em municípios pode subsidiar mudanças nas políticas de agendamento de consultas/exames especializados.

Building dementia knowledge globally through the Understanding Dementia Massive Open Online Course (MOOC)

The prevalence of dementia is escalating world-wide and knowledge deficits remain a barrier to community inclusiveness and quality care. The need for quality, comprehensive education has been identified as a key priority for global action plans on dementia. The Understanding Dementia Massive Open Online Course (UDMOOC) offers the potential to improve dementia knowledge globally. Completion rates for the UDMOOC (2016-2017) were on average 42% of enrolments, and 69% of participants care or have cared for people with dementia. The current study shows baseline dementia knowledge was positively related to previous learning about dementia from various types of exposure to the condition including having family members and/or working with people with the condition, and having undertaken dementia education. However, knowledge of all participant groups showed substantial improvements after completion of the UDMOOC. This was shown regardless of educational background and previous experience of dementia, and group differences after completing the UDMOOC were minimised. The UDMOOC is therefore an effective knowledge translation strategy to improve dementia knowledge for a diverse, international learner group.

MiRNA-10b Reciprocally Stimulates Osteogenesis and Inhibits Adipogenesis Partly through the TGF-β/SMAD2 Signaling Pathway

As the population ages, the medical and socioeconomic impact of age-related bone disorders will further increase. An imbalance between osteogenesis and adipogenesis of mesenchymal stem cells (MSCs) can lead to various bone and metabolic diseases such as osteoporosis. Thus, understanding the molecular mechanisms underlying MSC osteogenic and adipogenic differentiation is important for the discovery of novel therapeutic paradigms for these diseases. miR-10b has been widely reported in tumorigenesis, cancer invasion and metastasis. However, the effects and potential mechanisms of miR-10b in the regulation of MSC adipogenic and osteogenic differentiation have not been explored. In this study, we found that the expression of miR-10b was positively correlated with bone formation marker genes ALP, RUNX2 and OPN, and negatively correlated with adipogenic markers CEBPα, PPARγ and AP2 in clinical osteoporosis samples. Overexpression of miR-10b enhanced osteogenic differentiation and inhibited adipogenic differentiation of human adipose-derived mesenchymal stem cells (hADSCs) in vitro, whereas downregulation of miR-10b reversed these effects. Furthermore, miR-10b promoted ectopic bone formation in vivo. Target prediction and dual luciferase reporter assays identified SMAD2 as a potential target of miR-10b. Silencing endogenous SMAD2 expression in hADSCs enhanced osteogenesis but repressed adipogenesis. Pathway analysis indicated that miR-10b promotes osteogenic differentiation and bone formation via the TGF-β signaling pathway, while suppressing adipogenic differentiation may be primarily mediated by other pathways. Taken together, our findings imply that miR-10b acts as a critical regulator for balancing osteogenic and adipogenic differentiation of hADSCs by repressing SMAD2 and partly through the TGF-β pathway. Our study suggests that miR-10b is a novel target for controlling bone and metabolic diseases.

Identification of service improvement opportunities in an Australian community transition care program

BACKGROUND

Transition care programs (TCPs) are designed to optimise functional recovery and independence in older adults post-hospitalisation. These programs are under high demand, and understanding inefficiencies in patient flow are a key step towards service improvement.

AIMS

To identify service improvement opportunities in an Australian community TCP service.

METHODS

An in-depth retrospective study of 113 community TCP clients.

RESULTS

TCP occupancy was high (94%) and client functional level improved across the program. Inefficiencies experienced included: admission delays to the program; low completion rates (61%) predominantly due to re-hospitalisation; variable response times by Allied Health services (5-20 days); and discharge delays-the latter attributed to waiting for services such as Home Care Packages through Non-Government Organisations.

DISCUSSION

This study identified several opportunities for service improvement in a community TCP service. Health practitioners should be regularly provided with up-to-date information on efficiency of TCP services.

Vascular Surgery and Geriatric Patients

As the population ages, surgical decision-making in vascular surgery has become more complex. Older patients may not have been offered vascular surgical intervention in the past because of prohibitive physiologic demands and poor health. Patients now have more aggressive management of vascular risk factors with medications, such as statin therapy, and less invasive endovascular or hybrid treatment options. Outcomes in elderly patients may not be comparable with younger patients for entities such as aortic aneurysm repair, carotid endarterectomy, or lower extremity revascularization. Despite this, desirable outcomes can be successfully achieved and should be offered to carefully selected elderly individuals.

The workforce trends of physician assistants in Iowa (1995-2015)

BACKGROUND

Physician assistants are expected to have an important role in providing both primary and specialty care. Iowa has a large rural (and aging) population and faces challenges to provide equitable access to care. This study examined changes in the Iowa physician assistant workforce (1995-2015) focusing on practice setting (primary v. subspecialty care) and geographic location (rural/urban, Health Professional Shortage Area). Documenting their current locations and service in HPSAs for primary care will help health planners track future changes.

METHODS

Data from 1995-2015 from the Iowa Health Professions Inventory (Office of Statewide Clinical Education Programs, Carver College of Medicine, University of Iowa) were combined with US census data on rural location and HPSA status. SPSS was used to compare Iowa and national data. Growth trends were analyzed using joinpoint regression.

RESULTS

The overall Iowa physician assistant workforce increased 161% between 1995 and 2015. In 2015, more than two-thirds (71%) were female and more than 30% practiced in rural counties. The average annual growth rate of primary care PAs (per 100,000 population) was significantly higher in the periods from 1995-1997 and 1997-2001 (22.4% and 7.4% respectively) than in period from 2001-2015 (3.8%). By 2015, 56% of Iowa's physician assistants practiced in primary care (versus 29.6% nationally). Of these, 44% of primary care physician assistants in Iowa practiced in counties, geographic locations or worksites designated as Health Professional Shortage Areas for primary care.

CONCLUSIONS

A high proportion of Iowa's physician assistant workforce practiced in primary care and many served patients in Health Professional Shortage Areas. The number of physician assistants in Iowa will continue to grow and serve an important role in providing access to health care, particularly to rural Iowans.

Frailty and anesthesia - risks during and post-surgery

Frailty is a state of decreased physiologic reserve and resistance to stressors. Its prevalence increases with age and is estimated to be 26% in those aged above 85 years. As the population ages, frailty will be increasingly seen in surgical patients receiving anesthesia. Here, we evaluate the instruments which have been developed and validated for measuring frailty in surgical patients and summarize frailty tools used in 110 studies linking frailty status with adverse outcomes post-surgery. Frail older people are vulnerable to geriatric syndromes, and complications such as postoperative cognitive dysfunction and delirium are explored. This review also considers how frailty, with its decline of organ function, affects the metabolism of anesthetic agents and may influence the choice of anesthetic technique in an older person. Optimal perioperative care includes the identification of frailty, a multisystem and multidisciplinary evaluation preoperatively, and discussion of treatment goals and expectations. We conclude with an overview of the emerging evidence that Comprehensive Geriatric Assessment can improve postoperative outcomes and a discussion of the models of care that have been developed to improve preoperative assessment and enhance the postoperative recovery of older surgical patients.

Paging the eCardiologist: insights into referral behaviour of primary care physicians from qualitative analysis of a cardiology eConsult service

Objective

The purpose of this study is to investigate determinants of primary care physician cardiology referrals by performing qualitative analysis of questions asked by primary care physicians in cardiology electronic consultation services (eConsults).

Setting

A health region in eastern Ontario, Canada, where primary care providers have had access to an eConsult service since 2010.

Participants

We included all consecutive cardiology eConsults initiated by registered primary care provider users of our eConsult service and who initiated one or more eConsult between July 2014 and January 2015. We excluded eConsults in which the primary care provider attached a document without asking a question. A convenience sample of 100 consecutive eConsults initiated by 61 primary care providers was analysed after excluding 14 eConsults.

Primary and secondary outcome measures: Primary care provider eConsult questions are categorised into thematic categories based on the constant comparison method of qualitative analysis with external validation by content experts. Secondary outcomes include sample primary care provider eConsult questions to illustrate each theme and any emergent subthemes.

Results

Thematic saturation occurred after analysis of 30 eConsults. An additional 70 eConsults were coded with no new emergent themes. Themes include exceptions to clinical guidelines (n=13), non-cardiac treatment in a cardiac patient (n=13), specific investigation/management (n=18), interpretation of diagnostic testing (n=46), clinical concerns despite normal testing (n=4) and screening for positive family history (n=6). Subthemes include multiple comorbidities and mild abnormalities on cardiac tests.

Conclusions

We report categories of clinical questions that drive primary care provider cardiology eConsults. Multimorbidity leads to cardiology eConsults as primary care providers try to apply treatment guidelines in medically complex patients. Mild test abnormalities unrelated to clinical problems commonly lead to cardiology eConsult requests. Further research is needed to determine how guidelines can better account for multimorbidity, and how cardiologists can better communicate with primary care providers to put cardiac test results in clinical context.

Responding to disruptive behaviors in nursing: A longitudinal, quasi-experimental investigation of training for nursing students

OBJECTIVES

The objective of this study was to determine the impact of a cognitive rehearsal intervention on nursing students' self-efficacy to respond effectively to disruptive behaviors.

DESIGN

This quantitative study was part of a longitudinal, quasi-experimental program of research.

SETTING

Interventions were conducted on site at facilities provided by participating pre-licensure nursing programs.

PARTICIPANTS

A total of 129 nursing students enrolled in their final academic year in three traditional format, pre-licensure nursing programs in the Midwestern United States were recruited to participate in this study.

METHODS

A cognitive rehearsal intervention was delivered to increase self-efficacy to respond to disruptive behaviors in the nursing workplace. Data were collected in writing immediately prior to and following the intervention. Three months later, data were collected in electronic format through a link sent by text message to their mobile phones. Study data were collected on the Self-efficacy to Respond to Disruptive Behaviors Survey, a 10-point Likert scale measuring self-efficacy and its dimensions: knowledge, previous behavioral engagement, affect, and motivation toward responding effectively to disruptive behaviors.

RESULTS

129 students completed the surveys at pre and post-test; 109 completed the survey three months later. Measures of overall self-efficacy and knowledge (p < 0.000), and both measures of situational self-efficacy (p = 0.002; p = 0.020) remained significantly increased three months after the intervention, compared to pre-test. Past behaviors increased on post-test but returned to baseline at the three-month follow-up. The intervention did not significantly impact affect scores. Changes in motivation toward effective responses were mixed between measurements immediately following the intervention and three months later.

CONCLUSION

Cognitive rehearsal interventions can increase self-efficacy to respond to disruptive behaviors with sustained effects up to three months later. Further research is needed to determine the effects of self-efficacy to respond once participants have entered the nursing workplace.

Association between serum activin A and metabolic syndrome in older adults: Potential of activin A as a biomarker of cardiometabolic disease

Cardiovascular disease imposes substantial burdens of morbidity and mortality that increase with population aging. Estimating cardiometabolic risk accurately and expediently is challenging, and no single biomarker is satisfactory; hence, we investigated the potential of serum activin A for this purpose. Study data were collected from 433 community-dwelling adults age ≥53 years from Yilan County, Taiwan. Data included: demographics and medical history; physical measurements (blood pressure, body mass index, waist circumference); comprehensive functional assessments (frailty, cognitive function, depressive symptoms, nutritional status); fasting blood biochemistry (glucose, high-density lipoprotein cholesterol, triglycerides, high-sensitivity C-reactive protein, insulin-like growth factor-1, activin A, stratified into high, medium and low tertiles, and others); and dual-energy X-ray absorptiometry. Metabolic syndrome was considered a proxy for overall cardiometabolic risk. Subjects mean age was 69.3 ± 9.2 years, 48.3% were males. Compared to women, men had higher systolic blood pressure, education levels, relative appendicular skeletal muscle mass, waist circumference, physical activity, walking speed, free androgen index, and levels of serum uric acid, alanine aminotransferase, and dehydroepiandrosterone sulfate. High activin A was significantly associated with age, relative appendicular skeletal muscle mass in both gender, waist circumference in women, current alcohol drinking, hypertension, and Charlson Comorbidity Index. There were dose-dependent relationships (low to high) between serum activin A and frailty, cognitive impairment, malnutrition, metabolic syndrome, uric acid, and high-sensitivity C-reactive protein. Logistic regression analyses showed older age, serum uric acid, and metabolic syndrome were significantly associated with medium and high activin-A status, whereas, skeletal muscle mass, insulin-like growth factor-1 and dehydroepiandrosterone sulphate were associated with high, but not medium, serum activin A. This discovery of a dose-dependent association between serum activin A levels, age, and metabolic syndrome, suggests activin A may be a biomarker of overall cardiometabolic risk; however, further studies are needed to evaluate its potential applications in assessing and managing cardiometabolic risk.

Associations of Race and Ethnicity With Patient-Reported Outcomes and Health Care Utilization Among Older Adults Initiating a New Episode of Care for Back Pain

STUDY DESIGN

Secondary analysis of the Back Pain Outcomes using Longitudinal Data (BOLD) cohort study.

OBJECTIVE

To characterize associations of self-reported race/ethnicity with back pain (BP) patient-reported outcomes (PROs) and health care utilization among older adults with a new episode of care for BP.

SUMMARY OF BACKGROUND DATA

No prior longitudinal studies have characterized associations between multiple race/ethnicity groups, and BP-related PROs and health care utilization in the United States.

METHODS

This study included 5117 participants ≥65 years from three US health care systems. The primary BP-related PROs were BP intensity and back-related functional limitations over 24 months. Health care utilization measures included common diagnostic tests and treatments related to BP (spine imaging, spine-related relative value units [RVUs], and total RVUs) over 24 months. Analyses were adjusted for multiple potential confounders including sociodemographics, clinical characteristics, and study site.

RESULTS

Baseline BP ratings were significantly higher for blacks vs. whites (5.8 vs. 5.0; P < 0.001). Participants in all race/ethnicity groups showed statistically significant, but modest improvements in BP over 24 months. Blacks and Hispanics did not have statistically significant improvement in BP-related functional limitations over time, unlike whites, Asians, and non-Hispanics; however, the magnitude of differences in improvement between groups was small. Blacks had less spine-related health care utilization over 24 months than whites (spine-related RVU ratio of means 0.66, 95% confidence interval [CI] 0.51-0.86). Hispanics had less spine-related health care utilization than non-Hispanics (spine-related RVU ratio of means 0.60; 95% CI 0.40-0.90).

CONCLUSION

Blacks and Hispanics had slightly less improvement in BP-related functional limitations over time, and less spine-related health care utilization, as compared to whites and non-Hispanics, respectively. Residual confounding may explain some of the association between race/ethnicity and health outcomes. Further studies are needed to understand the factors underlying these differences and which differences reflect disparities.

LEVEL OF EVIDENCE

3.

Periarticular Soft Tissue Envelope Size and Postoperative Wound Complications Following Total Knee Arthroplasty

BACKGROUND

Periprosthetic joint infection following total knee arthroplasty (TKA) is a serious complication often related to obesity which leads to poor patient outcomes and increased resource utilization. A periarticular soft tissue index (PASTI) may help predict postoperative wound complications than BMI alone.

METHODS

Three hundred seventy-six TKA patients with a preoperative, lateral knee X-ray radiograph and 1 year of follow up were analyzed. We used 2 pairs of soft tissue and bony measurements, one referencing the femur and the other the tibia. A high PASTI was defined as a ratio >3.0. Minor complications involved clinical interventions related to the surgical wound. Major complications involved return to the operating room.

RESULTS

More minor complications occurred in high PASTI for both tibial (20.9% vs 6.4%; odds ratio 3.89, 95% confidence interval 1.94-7.79, P < .001) and femoral measurements (15.3% vs 7.2%; odds ratio 2.09, 95% confidence interval 1.06-4.15, P = .013). Major complications were also more frequent in high PASTI, though not statistically significant. The proportion of obesity (BMI > 30) in both minor (12.4% vs 7.7%, P = .140) and major complications (2.8% vs 3.3%, P = .788) was not statistically different.

CONCLUSION

More wound complications occurred in patients with high PASTI, while no difference was seen using BMI. BMI has traditionally approximated patient size, but does not describe variations in body habitus. PASTI is a more reliable and direct way to assess the periarticular soft tissue envelope size, which is associated with postoperative wound complications in the knee.

Are US degree-granting institutions associated with better community health determinants and outcomes?

OBJECTIVES

The impact of individual education level on health outcomes is well-established, but the effect of degree-granting institutions on county health rankings (CHRs) is unknown. The objective of this study is to determine if there is an association between the presence of degree-granting institutions and CHRs.

STUDY DESIGN

This is an ecologic study.

METHODS

Data for 3062 counties were derived from the Robert Wood Johnson County Health Rankings and the Integrated Postsecondary Education Data System for year 2016. Ordinal logistic regression was utilized to determine the association between presence of a degree-granting institution and county rankings for health behaviors, health outcomes, clinical care, social and economic factors, and physical environment. All models were adjusted for potential confounding factors including age, sex, race/ethnicity, English language proficiency, and urban/rural location.

RESULTS

The presence of a degree-granting institution was positively associated with CHRs for length of life (odds ratio [OR] = 1.28; 95% confidence interval [CI]: 1.05, 1.58), health behaviors (OR = 1.46; 95% CI: 1.19, 1.79), and clinical care (OR = 1.36; 95% CI: 1.11, 1.67). Counties with the highest rankings in one health category were more likely to score in the highest rankings for other health categories.

CONCLUSIONS

These findings suggest that degree-granting institutions are associated with CHRs. Partnerships between public health agencies and degree-granting institutions are recommended to improve population health.

Using patient cases to educate health professionals, patients, institutions, and society: the swallowing disorder example

The problems and symptoms of patients are at the heart of medicine and pertinent to information, communication, and education. Patients present their problems to health professionals looking for relief and a cure, while institutions collect data about symptoms of patients and the way health professionals treated them to support society's care providers in administrating and managing care. The information on the problems of patients and the way health professionals treated them, which is gathered and stored in patient files, is valuable as educational material in the field of medicine. Driven by the fast developments of new technical tools case-based information, communication and education starts to enter educational domains beyond the field of medicine, such as school systems and public health services. In our discussion we seek to understand and outline how to use the material gathered and stored in patient files to educate health professionals. Additionally, this paper gives examples of case-based education for all members of society.

What are the contents of patient engagement interventions for older adults? A systematic review of randomized controlled trials

OBJECTIVE

To describe the contents of interventions reported in RCTs focusing on patient engagement of older adults.

METHODS

A systematic literature review based on a search for "patient engagement/activation/empowerment/involvement/participation". Interventions were classified according to: (i) specific components (micro level), (ii) single/multiple dimensions (educational, behavioral, affective) (meso level), and (iii) the studies' main educational, behavioral or affective dimension (macro level).

RESULTS

After screening 2749 articles, 35 were included. 20 unique components were identified, mostly behavioral or educational (45.5% each) (e.g., goal setting or written informational materials). Most interventions with a single-focus were classified as educational (31%), one was solely affective (3%). Half of the interventions covered more than one dimension, with four (11%) combining all three dimensions. Studies mainly focusing on the affective dimension included older participants (72 vs. 67 years), had a higher proportion of females (71% vs. 44%), and included other dimensions more frequently (67% vs. 31%) than did studies with a main focus on the educational dimension.

CONCLUSION

The contents of the interventions that focused on patient engagement of older adults tend to focus more on behavioral and educational dimensions than the affective dimension.

PRACTICE IMPLICATIONS

The possibility of adding the affective dimension into behavioral and/or educational interventions should be explored.

Diagnostic accuracy of whole slide imaging for cutaneous, soft tissue, and melanoma sentinel lymph node biopsies with and without immunohistochemistry

BACKGROUND

Diagnostic accuracy with whole slide imaging (WSI) for complex inpatient and outpatient dermatopathology cases with immunohistochemistry (IHC) is unknown.

METHODS

WSI (Leica Aperio AT2 Digital Pathology scanner, N = 151 cases) was performed for Emory inpatient and outpatient skin (N = 105), soft tissue (N = 30), and melanoma sentinel lymph node biopsies (N = 16) collected between 2000 and 2016. Resultant images were uploaded to an online cloud storage system for review by 2 board-certified dermatopathologists (reviewers 1 and 2) with greater than 5 years of dermatopathology experience and 1 dermatopathology fellow (reviewer 3).

RESULTS

Reviewers 1 (diagnostic accuracy = 97%) and 2 (diagnostic accuracy = 95%) demonstrated high diagnostic accuracy with WSI. Diagnostic accuracy was greater than 90% for inpatient biopsies, melanocytic lesions, melanoma sentinel lymph node biopsies, and cases with immunohistochemistry, but was slightly lower for soft tissue cases (reviewer 1 = 89%; reviewer 2 = 89%). The dermatopathology fellow (reviewer 3) demonstrated lower diagnostic accuracy (84%).

CONCLUSIONS

Diagnostic accuracy with WSI for skin, soft tissue, and melanoma sentinel lymph node biopsies with and without immunohistochemistry was greater than 95% for 2 reviewers with greater than 5 years of dermatopathology experience. Professional experience signing out dermatopathology cases may impact diagnostic accuracy with WSI.

If we keep doing what we're doing we'll keep getting what we're getting: A need to rethink "academic" medicine

PURPOSE

For generations there have been warnings of the need to reform medical education at all levels. Today the voices pushing reform are louder, the need is greater, and there is an urgency not seen before. Approaches that have worked in the past to train physicians are no longer as relevant today as demographics, disease patterns, human resources, practice behaviors, technology, and attention to costs demand new collaborative approaches to clinical practice. To prepare for this practice tomorrow's doctors will need a different type of educational model, a different type of learning, in different environments, often taught by different faculty. This paper provides one innovative approach to redefine "academic medicine".

METHODS

After reviewing current trends in medical education, this paper describes one approach being taken by a large nonprofit American health care system to move medical education and discovery (research) out of traditional academic universities and placing it within a health care delivery system.

CONCLUSIONS

The creation of a learning laboratory in a high functioning health care delivery system allows for leveraging the successes in quality health care delivery to transform medical education with a focus on prevention, improving health care quality, reducing disparities in health, and promoting practical evidence-based clinical and outcomes focused research.

Validation of the King's transaction process for healthcare provider-patient context in the pharmaceutical context

BACKGROUND

With the impressive advantages of patient-pharmacist communication being advocated and poor pharmacist-patient communication in different settings, it is of great significance and urgency to explore the mechanism of the pharmacist-patient communicative relationship. The King's theory of goal attainment is proposed as one of the most promising models to be applied, because it takes into consideration both improving the patient-pharmacist relationship and attaining patients' health outcomes.

OBJECTIVES

This study aimed to validate the King's transaction process and build the linkage between the transaction process and patient satisfaction in a pharmaceutical context.

METHODS

A cross-sectional study was conducted in four tertiary hospitals in two provincial cities (Wuhan and Shanghai) in central and east China in July 2017. Patients over 18 were investigated in the pharmacies of the hospitals. The instrument for the transaction process was revised and tested. Path analysis was conducted for the King's transaction process and its relationship with patient satisfaction.

RESULTS

Five hundred eighty-nine participants were investigated for main study. Prior to the addition of covariates, the hypothesised model of the King's transaction process was validated, in which all paths of the transaction process were statistically significant (p < 0.001). The transaction process had direct effects on patient satisfaction (p < 0.001). After controlling the effects of covariates, the Multiple Indicators, Multiple Causes (MIMIC) model showed good fit to data (Tucker-Lewis index [TLI] = 0.99, comparative fit index [CFI] = 0.99, root mean square error of approximation [RMSEA] = 0.05, weighted root mean square residual [WRMR] = 1.00). The MIMIC model showed that chronic disease and site were predictors for both identifying problems and patient satisfaction (p < 0.05).

CONCLUSIONS

Based on the well-fitting path analytic model, the transaction process was established as one valid theoretical framework of healthcare provider-patient communication in a pharmaceutical context.

Quality of Prescribing by Physicians, Nurse Practitioners, and Physician Assistants in the United States

OBJECTIVE

Nurse practitioners (NPs) and physician assistants (PAs) have increasingly broad prescribing authority in the United States, yet little is known regarding how the quality of their prescribing practices compares with that of physicians. The objective of this study was to compare the quality of prescribing practices of physicians and nonphysician providers.

METHODS

A serial cross-sectional analysis of the 2006-2012 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey was performed. Ambulatory care services in physician offices, hospital emergency departments, and outpatient departments were evaluated using a nationally representative sample of patient visits to physicians, NPs, and PAs. Main outcome measures were 13 validated outpatient quality indicators focused on pharmacologic management of chronic diseases and appropriate medication use.

RESULTS

A total of 701,499 sampled patient visits were included during the study period, representing ~8.33 billion visits nationwide. Physicians were the primary provider for 96.8% of all outpatient visits examined; NPs and PAs each accounted for 1.6% of these visits. The proportion of eligible visits where quality standards were met ranged from 34.1% (angiotensin-converting enzyme inhibitor use for congestive heart failure) to 89.5% (avoidance of inappropriate medications among elderly). The median overall performance across all indicators was 58.7%. On unadjusted analyses, differences in quality of care between nonphysicians and physicians for each indicator did not consistently favor one practitioner type over others. After adjustment for potentially confounding patient and provider characteristics, the quality of prescribing by NPs and PAs was similar to the care delivered by physicians for 10 of the 13 indicators evaluated, and no consistent directional association was found between provider type and indicator fulfillment for the remaining measures.

CONCLUSIONS

Although significant shortfalls exist in the quality of ambulatory prescribing across all practitioner types, the quality of care delivered by nonphysicians and physicians was generally comparable.

Management of care transition and hospital discharge

Current demographic and epidemiological trends highlight a growing task in surgical departments by elderly patients, characterized by high prevalence of comorbidity, complexity, and functional disability. Of consequence, discharge of an elderly patient must be considered in a new cultural perspective and should be imagined as a well-structured process starting from admission to surgical department and finishing with the patient discharge in a setting able to support her/him in the best possible way. The lack of a suitable discharge planning and of a proper transition program in the elderly subjects increases the risk of quick re-admission and may negatively affect the functional and the status quality of life of patients and caregivers. To reduce the risk of negative outcome it is essential a hospital organization dedicated to the discharge of frail older patients considering: (1) adequate attention to assess the comprehensive clinical/social/care conditions; (2) respect of the expectations of the patient and her/his relatives; (3) formalization of institutional roles or teams designated to the planning and coordination of discharge; (4) good knowledge of management programs of transitional care, and (5) strong communication/information ability in patients transition between hospital, home care and community settings.

Osteocalcin in the brain: from embryonic development to age-related decline in cognition

A remarkable, unexpected aspect of the bone-derived hormone osteocalcin is that it is necessary for both brain development and brain function in the mouse, as its absence results in a profound deficit in spatial learning and memory and an exacerbation of anxiety-like behaviour. The regulation of cognitive function by osteocalcin, together with the fact that its circulating levels decrease in midlife compared with adolescence in all species tested, raised the prospect that osteocalcin might be an anti-geronic hormone that could prevent age-related cognitive decline. As presented in this Review, recent data indicate that this is indeed the case and that osteocalcin is necessary for the anti-geronic activity recently ascribed to the plasma of young wild-type mice. The diversity and amplitude of the functions of osteocalcin in the brain, during development and postnatally, had long called for the identification of its receptor in the brain, which was also recently achieved. This Review presents our current understanding of the biology of osteocalcin in the brain, highlighting the bony vertebrate specificity of the regulation of cognitive function and pointing toward where therapeutic opportunities might exist.

Perioperative outcome of elderly versus younger patients undergoing major hepatic or pancreatic surgery

Objective

The aim of this study was to determine the safety of elderly cancer patients (≥70 years) undergoing hepatic resection (HR) or pancreaticoduodenectomy (PD) in comparison with younger adults (<70 years).

Methods

A total of 1,012 consecutive patients undergoing HR or PD were included. The incidence and severity of morbidity were documented within 30 days postoperatively and compared between elderly and younger groups. Risk factors associated with postoperative morbidity were investigated by multivariate logistic regression analysis.

Results

Elderly patients (n=111, 11.0%) had more comorbidities and worse preoperative general condition and liver function versus younger patients (n=901, 89.0%), and thus were more likely to develop infectious (eg, systemic sepsis and urinary tract infection, both p<0.01) and technical-associated complications (intraperitoneal bleeding and biliary/pancreatic fistula, p=0.029 and p=0.074, respectively). However, the incidence and severity of complications were comparable between elderly and younger patients in the whole cohort, and also in HR and PD surgery groups separately. Preoperative hemoglobin (odds ratio [OR] 1.4, p=0.007) and intraoperative blood transfusion (OR 1.9, p=0.002), rather than age, were independently associated with postoperative morbidity. Hepatitis (OR 2.9, p=0.001), preoperative hemoglobin (OR 1.6, p=0.036), and pancreatic versus hepatic surgery (OR 2.3, p=0.005) were independently associated with postoperative infectious. For elderly patients only, American Society of Anesthesiologists (ASA) score III (OR 2.1, p=0.033) and intraoperative blood transfusion (OR 3.2, p=0.030) were independently associated with postoperative morbidity.

Conclusion

HR and PD can be safely performed in selected elderly patients versus younger patients. Elderly patients with ASA score III or above should be cautiously selected for major surgeries.

Population stress: A spatiotemporal analysis of population change and land development at the county level in the contiguous United States, 2001-2011

The past century has witnessed rapidly increasing population-land conflicts due to exponential population growth and its many consequences. Although the measures of population-land conflicts are many, there lacks a model that appropriately considers both the social and physical contexts of population-land conflicts. In this study we introduce the concept of population stress, which identifies areas with populations growing faster than the lands available for sustainable development. Specifically, population stress areas are identified by comparing population growth and land development as measured by land developability in the contiguous United States from 2001 to 2011. Our approach is based on a combination of spatial multicriteria analysis, zonal statistics, and spatiotemporal modeling. We found that the population growth of a county is associated with the decrease of land developability, along with the spatial influences of surrounding counties. The Midwest and the traditional "Deep South" counties would have less population stress with future land development, whereas the Southeast Coast, Washington State, Northern Texas, and the Southwest would face more stress due to population growth that is faster than the loss of suitable lands for development. The factors contributing to population stress may differ from place to place. Our population stress concept is useful and innovative for understanding population stress due to land development and can be applied to other regions as well as global research. It can act as a basis towards developing coherent sustainable land use policies. Coordination among local governments and across different levels of governments in the twenty-first century is a must for effective land use planning.