Association between preadmission frailty and care level at discharge in older adults undergoing emergency laparotomy

Background

Older adults undergoing emergency abdominal surgery have significantly poorer outcomes than younger adults. For those who survive, the level of care required on discharge from hospital is unknown and such information could guide decision-making. The ELF (Emergency Laparotomy and Frailty) study aimed to determine whether preoperative frailty in older adults was associated with increased dependence at the time of discharge.

Methods

The ELF study was a UK-wide multicentre prospective cohort study of older patients (65 years or more) undergoing emergency laparotomy during March and June 2017. The objective was to establish whether preoperative frailty was associated with increased care level at discharge compared with preoperative care level. The analysis used a multilevel logistic regression adjusted for preadmission frailty, patient age, sex and care level.

Results

A total of 934 patients were included from 49 hospitals. Mean(s.d.) age was 76·2(6·8) years, with 57·6 per cent women; 20·2 per cent were frail. Some 37·4 per cent of older adults had an increased care level at discharge. Increasing frailty was associated with increased discharge care level, with greater predictive power than age. The adjusted odds ratio for an increase in care level was 4·48 (95 per cent c.i. 2·03 to 9·91) for apparently vulnerable patients (Clinical Frailty Score (CFS) 4), 5·94 (2·54 to 13·90) for those mildly frail (CFS 5) and 7·88 (2·97 to 20·79) for those moderately or severely frail (CFS 6 or 7), compared with patients who were fit.

Conclusion

Over 37 per cent of older adults undergoing emergency laparotomy required increased care at discharge. Frailty scoring was a significant predictor, and should be integrated into all acute surgical units to aid shared decision-making and discharge planning.

The Cutaneous Lupus Erythematosus Disease Activity and Severity Index: expansion for rheumatology and dermatology

OBJECTIVE

To evaluate the validity of the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) for use by rheumatologists via reliability testing, and to extend the validation for dermatologists.

METHODS

Fourteen subjects with cutaneous lupus erythematosus (CLE; n = 10), a mimicker skin disease only (a cutaneous lesion that may appear clinically similar to CLE; n = 1), or both (n = 3) were rated with the CLASI by academic-based dermatologists (n = 5) and rheumatologists (n = 5).

RESULTS

The dermatology intraclass correlation coefficient (ICC) was 0.92 for activity and 0.82 for damage; for rheumatology the ICC was 0.83 for activity and 0.86 for damage. For intrarater reliability, the dermatology Spearman's rho was 0.94 for activity and 0.97 for damage; for rheumatology the Spearman's rho was 0.91 for activity and 0.99 for damage.

CONCLUSION

Our data confirm the reliability of the CLASI when used by dermatologists and support the CLASI as a reliable instrument for use by rheumatologists.

Turnover rates of nitrogen stable isotopes in the salt marsh mummichog, Fundulus heteroclitus, following a laboratory diet switch

Nitrogen stable isotopes are frequently used in ecological studies to estimate trophic position and determine movement patterns. Knowledge of tissue-specific turnover and nitrogen discrimination for the study organisms is important for accurate interpretation of isotopic data. We measured delta15 N turnover in liver and muscle tissue in juvenile mummichogs, Fundulus heteroclitus, following a laboratory diet switch. Liver tissue turned over significantly faster than muscle tissue suggesting the potential for a multiple tissue stable isotope approach to study movement and trophic position over different time scales; metabolism contributed significantly to isotopic turnover for both liver and muscle. Nitrogen diet-tissue discrimination was estimated at between 0.0 and 1.2 per thousand for liver and -1.0 and 0.2 per thousand for muscle. This is the first experiment to demonstrate a significant variation in delta15 N turnover between liver and muscle tissues in a fish species.

Using action research to improve cardiac care

The increasing frequency of telephone calls from patients discharged after cardiac surgery indicated the need for a patient helpline. The telephone helpline revealed several issues of concern to discharged patients. By using an action research approach, cardiac support nurses were able to respond to patient concerns directly by changing related practice.

Communication for osteopathic manipulative treatment (OMT): the language of lived experience in OMT pedagogy

Questions about the scientific merits of osteopathic manipulative treatment (OMT) and the search for consistent, effective teaching methods for OMT persist in the discourse of the osteopathic medical curriculum. Although grounded on scientific principles, the philosophy of osteopathic medicine in the words of Andrew Taylor Still, William G. Sutherland, and other prominent osteopathic medical scholars advances concepts in metaphoric language that may seem obscure and dated to many of today's students. Evidence in the literature of osteopathic medicine supports the congruence of phenomenology with the philosophy and methods used to teach OMT. Phenomenology offers an alternative paradigm to address questions of scientific merit and could provide a consistent language to a rigorous, scientific approach to communication for OMT pedagogy. The authors propose a solution for the tactical adaptation of a communication strategy based on an interpretation of osteopathic medical methodology and phenomenology.