Non-specific presentation of illness

Failure to Thrive Following Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy: Causes and Consequences

BACKGROUND

Failure to thrive (FTT) is a complex syndrome of nutritional failure and functional decline. Readmission for FTT following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS HIPEC) is common but underexamined. This study aims to determine features, risk factors, and prognostic significance of FTT following CRS HIPEC.

PATIENTS AND METHODS

We reviewed patients who underwent CRS HIPEC from 2010 to 2018 at our institution. Patients were categorized into no readmission, FTT readmission, and other readmission. FTT was determined by coding and chart review. We compared baseline characteristics, oncologic data, perioperative outcomes, and survival among the three cohorts.

RESULTS

Of 1068 discharges examined, 379 patients (36%) were readmitted within 90 days, of which 134 (12.5%) were labeled as FTT. Patients with FTT readmission had worse preoperative functional status, higher rates of malnutrition, more complex resections, longer hospital stays, and more postoperative complications (all p < 0.001). Ostomy creation [relative risk ratio (RRR) 4.06], in-hospital venous thromboembolism (VTE), discharge to nursing home (RRR 2.48), pre-CRS HIPEC chemotherapy (RRR 1.98), older age (RRR 1.84), and female gender (RRR 1.69) were all independent predictors for FTT readmission on multinomial regression (all p < 0.01). FTT readmission was associated with worse median overall survival on multivariate analysis [hazard ratio (HR) 1.60, p < 0.001] after controlling for oncologic, perioperative, and baseline factors.

CONCLUSIONS

FTT is common following CRS HIPEC and appears to be associated with baseline patient characteristics, operative burden, and postoperative complications. Perioperative strategies for improving nutrition and activity, along with early recognition and intervention in FTT may improve patient outcomes.

Evaluation of older adults hospitalized with a diagnosis of failure to thrive

BACKGROUND

older adults are sometimes hospitalized with the admission diagnosis of failure to thrive (FTT), often because they are not felt safe to be discharged back to their current living arrangement. It is unclear if this diagnosis indicates primarily a social admission or suggests an acute medical deterioration. The objective of this study was to explore the level of acuity and medical investigations commonly conducted among older hospitalized adults with a diagnosis of FTT.

METHODS

We conducted a retrospective cohort study at three hospitals in Calgary, Alberta. Data were extracted from the electronic medical records of the 603 admissions of patients 65 years or older with a diagnosis of FTT between January 2010 and January 2011. Markers of medical acuity were evaluated.

RESULTS

The vast majority of patients had short hospital stays. Specialist physicians were consulted for 323 cases (54%). Allied health-care professionals were consulted in 151 cases (25%). While in hospital, patients underwent extensive investigations, including CT scans, ultrasounds, and echo-cardiograms. Many patients received IV fluids (71%) and IV antibiotics (35%).

CONCLUSIONS

The data suggest that acute illnesses, and not social factors, were the primary reason for admission among those given a diagnosis of FTT.

Age, co-morbidity and poor mobility: no evidence of predicting in-patient death and acute hospital length of stay in the oldest old

BACKGROUND

The oldest old (aged over 90 years) are the fastest growing section of the UK population. Limited data exist regarding the effect of age, location, co-morbidity and physical performance status on outcome of acute illness in this age group.

METHODS

We performed a prospective study in people aged ≥ 90 years using hospital audit data in three hospitals in England and Scotland. We examined the characteristics of those admitted over three consecutive calendar months and calculated risk ratios of death and prolonged length of acute hospital stay (>7 days).

RESULTS

A total of 419 patients were included in this study (68% female, median age 93 years). There were similarities in presentation and diagnoses, but patients in Scotland (n = 164) were more likely to be admitted from sheltered housing or nursing homes than those in England (n = 255). Patients in England were significantly less likely to be able to mobilize < 10 m (41 vs. 34%, P < 0.001) but had lower prevalence of hypertension (40 vs. 55%, P = 0.02), ischaemic heart disease (30% vs. 45%, P = 0.02) and fewer prescribed medications (median 2 vs. 3, P < 0.001). Mortality was similar for the England and Scotland centres (P = 0.98). Previously recognized risk factors for death following hospital admission and length of stay e.g. older age, higher number of co-morbidities and poor mobility were not predictive in this study.

CONCLUSION

The 'oldest old' should not be considered as a homogenous group and findings from single-centre studies involving this age group may not be generalizable. We found no conclusive evidence that patient-related factors predict outcome in this age group in acute medical admission settings.

Decreasing clinically significant adverse events using feedback to emergency physicians of telephone follow-up outcomes

STUDY OBJECTIVE

We evaluate the effect on adverse events of a telephone follow-up quality improvement program.

METHODS

This was a before-and-after intervention comparison based on prospectively collected data in a tertiary care hospital emergency department (ED) (82,000 visits per year). The first half (April 15 to July 31, 2001) served as control, and the second half (August 1 to November 15, 2001) served as intervention with feedback to physicians on telephone follow-up outcomes of discharged patients and resident training about the uncertain presentations of serious diseases and the need to use additional evaluation on selected patients (observation unit, hospital admission). Telephone follow-up of the high-risk patients and retrospective review of 3-day return visits were used to quantify outcome measures: return visits to EDs and clinically significant adverse events (return visits with serious misdiagnoses or an erroneous management plan). The differences in proportions of outcomes were measured with 95% confidence intervals (CIs).

RESULTS

High-risk patients were enrolled: 566 (13.7%) of 4,139 discharged patients in the before-intervention period and 397 (11.3%) of 3,507 in the after-intervention period. The quality improvement initiative decreased return visits on enrolled patients from 10.1% (57/566) to 4.9% (19/397) (5.2% difference with 95% CI 1.8% to 8.8%) and decreased clinically significant adverse events from 4.1% (23/566) to 1.5% (6/397) (2.6% difference with 95% CI 0.3% to 4.8%). For all ED discharged patients, clinically significant adverse events decreased from 0.9% (39/4,139) to 0.4% (15/3,507) (0.5% difference with 95% CI 0.1% to 0.9%). During the study, the observation rate increased 4.3% (95% CI 2.8% to 5.7%), and the admission rate increased 3.4% (95% CI 2.1% to 4.8%).

CONCLUSION

A quality improvement program with feedback to physicians of telephone follow-up and resident education can decrease clinically significant adverse events in ED discharged patients.

Interpreting the effect of common medical conditions on voiding dysfunction in the elderly

Medical conditions often have an important causal role in urinary incontinence in the elderly. Aside from causing functional impairments, such diseases directly may involve the genitourinary system--particularly its neurologic control--resulting in specific lower urinary tract pathophysiology. Knowledge of the specific effects that medical conditions may have on the genitourinary system and continence can assist the urologic specialist in determining the often complex cause(s) of UI in older persons.

Clinical manifestations. Failure to thrive in the elderly

1. Failure to thrive (FTT) is a diagnosis used with increasing frequency in the acute care setting. The purpose of this study was to determine how the diagnosis of FTT was being applied to the geriatric population. 2. FTT was used in the study population to describe the general deterioration seen in patients with chronic or incurable illnesses. Many patients were near the terminal stage. The diagnosis was not used specifically for the geriatric population; there was a lack of specificity in the diagnosis and treatment of FTT. 3. Common complaints of patients diagnosed as FTT included ADL changes, weight loss, and anorexia. Nursing care can significantly contribute to the management of symptoms and the prevention of complications.

Principles of surgical risk assessment of the elderly patient

Treatment of the elderly will comprise increasingly higher proportions of practice time in the future, and issues regarding this treatment are more salient now than ever before. Because more elders are seeking treatment, surgeons need to be comfortable with assessing the potential risks associated with surgical procedures in their elderly patients, many of whom have multiple chronic diseases. Risks that need to be considered are those physiologic changes normal for aging, pathologic changes due to disease, and psychosocial changes that may occur with aging. This article assesses the contribution each of these changes makes to surgical risk, and discusses the principles of gerontology and geriatric medicine that are relevant to risk assessment.

Taking to bed. Rapid functional decline in an independently mobile older population living in an intermediate-care facility

The objective of this study was to determine the incidence and selected clinical outcomes of taking to bed among a population of independently ambulating older individuals. It was designed as a retrospective case series and was conducted in the intermediate-care facility of a not-for-profit, teaching nursing home. Our study group was composed of individuals over 65 years of age who became bed bound. Thirty-six taking-to-bed episodes occurred in 36 individuals during one calendar year, giving an incidence of 13 per 1,000 resident-months (95% CI, 4 to 23 per 1,000). Twelve of the 36 died within 3 months, and 17 within 6 months, but almost all who survived regained ambulation. Survival was significantly shorter for the five without localizing symptoms (P less than .05). Orthopedic, neurologic, psychiatric, and iatrogenic conditions were most commonly identified as concurrent medical events. Almost half who took to bed had multiple concurrent medical events, and these residents were more likely to present without localizing symptoms (P less than .05). Twenty-one (58%) of the episodes occurred after a fall. The incidence of taking to bed in this population indicates that clinicians caring for older persons should be alert to its occurrence. The dramatic decline in mobility deserves careful assessment because it initiated a period of relatively rapid change in the health careers of the individuals we studied: almost half died within 6 months, but nearly all who survived regained ambulation. Those without localizing symptoms may have more complex interacting medical problems and a worse prognosis.

Clinicians, the Elderly and Drugs

The increase of the elderly within our population makes for increased chronic disease and, hence, greater use of sophisticated medications now available. This paper reviews current knowledge of the pharmacodynamics and pharmacokinetics among elderly users of drugs and estimates the prevalence of use of prescribed drugs. Less is known of specifics of prescribing patterns, but evidence clearly suggests the strong influence of patient/doctor communication in compliance and control of side effects. There is little hard evidence on the populations considered at high risk for inappropriate prescribing and use and for side effects. The influence of race, socioeconomic class and age are all suggested Since drugs and their uses increase daily, it is important to investigate the area of high-risk populations in order to accumulate evidence which can lead to appropriate interventions.

Medication and the elderly. Issues of prescription and use

Use of medication has become an increasingly important issue in the health and health care of older populations. The demographic changes resulting in greater numbers of individuals 65 and over, accompanied by a higher prevalence of chronic disease, focus attention on prescription and over-the-counter drugs, the major strategy in treatment regimens for these conditions. In addition, the numbers of new and powerful drugs being developed increase daily. This article reviews and evaluates existing information on the prevalence of medication use and adverse drug reactions. It examines the role of physicians and patients in occurrence and management of side effects of drugs and in patterns of prescription and use. Following this, it identifies areas of research necessary to address the gaps in the current state of knowledge in these areas and discusses the need for strong and substantial information about this essential therapeutic strategy in health care for older people.

The medical evaluation and management of the elderly surgical patient

Contrary to earlier findings, elderly patients are not at significantly greater risk of perioperative morbidity or mortality than younger patients simply because of advanced age. Increased risk, when present, is attributable to pathologic changes that are not uniformly seen in all geriatric patients. Most perioperative morbidity is caused by cardiovascular and pulmonary complications. The author discusses an appropriate preoperative evaluation and recommends selective ancillary tests to screen for high-risk patients.

Drug therapy in the elderly: the clinical pharmacology of aging

It is becoming increasingly apparent that age and the changes of aging are factors to be taken into account in drug therapy and in the study of drug actions. Older people have more adverse reactions to drugs than do younger people. Several studies in hospitalized patients have confirmed the fact that the incidence of untoward reactions to drugs increases with advancing age.