Anupam Chandra

Risk factors for pressure ulceration in an older community-dwelling population.

BACKGROUND:Older adults frequently experience pressure ulcers (PrUs) and suffer the risks of the ulceration. Risk factors for PrUs remain unclear in a community population. OBJECTIVE:The objective of this study was to determine the risk factors for future pressure ulceration in a community sample. DESIGN:This was a retrospective cohort study. PATIENTS:All patients older than 60 years in a primary care panel in Olmsted County, Minnesota, on January 1, 2005, were enrolled (n = 12,650). METHODS AND OUTCOMES:The primary outcome was a new diagnosis of pressure ulceration within 40 months of index date. The predictor risk variables included demographic and comorbid health risk factors. The data were analyzed using univariable and multivariable logistic regression. The authors created a final model based on multivariable risk factors. MAIN RESULTS:Of 12,650 patients, 366 patients developed an incident PrU (2.9%). In the final model, age, male sex, and long-term-care facility admission were significant factors. Prior pressure ulceration with an odds ratio of 5.60 (95% confidence interval, 3.86-8.14) was the largest risk factor. Diabetes, falls, cataracts, renal insufficiency, and peripheral vascular disease were also associated with PrU development. CONCLUSION:PrU development involves important risk factors of prior PrU development and long-term-care facility placement as the 2 largest risk factors. Both factors are easily determined by history. Increasing age and comorbid medical conditions also impact PrU development as important risk factors for PrU development.

Patient-Reported Geriatric Symptoms as Risk Factors for Hospitalization and Emergency Department Visits

There is an urgent need to identify predictors of adverse outcomes and increased health care utilization in the elderly. The Mayo Ambulatory Geriatric Evaluation (MAGE) is a symptom questionnaire that was completed by patients aged 65 years and older during office visits to Primary Care Internal Medicine at Mayo Clinic in Rochester, MN. It was introduced to improve screening for geriatric conditions. We conducted this study to explore the relationship between self-reported geriatric symptoms and hospitalization and emergency department (ED) visits within 1 year of completing the survey. This was a retrospective cohort study of patients who completed the MAGE from April 2008 to December 2010. The primary outcome was an ED visit or hospitalization within 1 year. Predictors included responses to individual questions in the MAGE. Data were obtained from the electronic medical record and administrative records. Logistic regression analyses were performed from significant univariate factors to determine predictors in a multivariable setting. A weighted scoring system was created based upon the odds ratios derived from a bootstrap process. The sensitivity, specificity, and AUC were calculated using this scoring system. The MAGE survey was completed by 7738 patients. The average age was 76.2 ± 7.68 years and 57% were women. Advanced age, a self-report of worse health, history of 2 or more falls, weight loss, and depressed mood were significantly associated with hospitalization or ED visits within 1 year. A score equal to or greater than 2 had a sensitivity of 0.74 and specificity of 0.45. The calculated AUC was 0.60. The MAGE questionnaire, which was completed by patients at an outpatient visit to screen for common geriatric issues, could also be used to assess risk for ED visits and hospitalization within 1 year.

Central Anticholinergic Syndrome Following Dobutamine–Atropine Stress Echocardiography

We present a case of central anticholinergic syndrome following dobutamine–atropine stress echocardiography in an elderly female. Although atropine toxicity is a recognized complication of stress echocardiography, no case reports are currently available. The central nervous system side effects of atropine are varied in severity (mild cognitive impairment to severe coma) and spectrum (agitation or somnolence), and thus are often overlooked. Management includes prompt recognition, stopping the offending agent, providing supportive care, and consideration of physiostigmine. Atropine is used in up to 60% of dobutamine stress echocardiograms, and has the potential to cause morbidity. (Echocardiography 2011;28:E205‐E206)

The Relationship Between Elder Risk Assessment Index Score and 30-Day Readmission from the Nursing Home

Abstract Objective: Preventable early readmission to the hospital is expensive, and identification of patients at risk is an important task for health care providers. The objective of this study was to determine the relationship between a high score on the Elder Risk Assessment (ERA) Index and 30-day readmission to the hospital in older patients discharged to a nursing home. Patients: Patients aged > 60 years residing in the community on January 1, 2005 and subsequently admitted to a local nursing home following hospitalization were included. The cohort was selected from all patients in a primary care internal medicine practice in Rochester, MN. Methods: This was a retrospective cohort study that used an electronically archived administrative risk index, the ERA Index, which was derived from demographic and clinical factors. The primary outcome was hospital readmission within 30 days following initial admission to a nursing home. The predictor variable was the ERA Index score. Univariate association between the total ERA Index score and individual components of the ERA Index and 30-day rehospitalization were determined. The ERA Index score cutoff with optimal sensitivity and specificity for hospital readmission was also identified. Results: Of 12 650 patients in the population, 800 were admitted to a facility between 2005 and 2007. Thirty-day readmission was not higher in the group with the highest ERA Index score (top quartile), with a relative risk of 1.72 (95% confidence interval [CI], 0.93–3.56) compared with the lowest-scoring group. The second- and third-highest quartiles were significantly associated with higher 30-day readmission. The individual component of the ERA Index that had the strongest association with early readmission was dementia, with an odds ratio of 2.69 (95% CI, 1.71–4.23). A cutoff score of 5 on the ERA Index resulted in a sensitivity of 0.81 and a specificity of 0.34 with an area under the curve of 0.55. Discussion: Those with the highest ERA Index score, the top quartile, were not at risk for early hospital readmission. The ERA Index does not predict readmissions from the nursing home to the hospital. There is a need to develop a unique index to predict rehospitalizations in nursing home residents.

Telemedicine: an enhanced emergency care program for older adults

Recent changes and consolidations in health care systems have resulted in an increase in new health care delivery models. Telemedicine holds great promise as one of these models. There is a great potential for new patient evaluation and treatment models in emergency care (EC), especially when patients are miles away from a medical team. Evaluations can be performed in a patients home, a nursing care facility, and in hospitals that focus on advanced subspecialty care. Due to rapid developments in this area, current care models are constantly being evaluated and modified. This review article outlines current telemedicine models for EC and summarizes their potential benefits to patients and the health care system. The review examines the role that the telephone, a fundamental tool of telemedicine, plays in these new models. The review also examines evidence of improved health care outcomes by highlighting the role of telemedicine in reducing hospitalizations. The patient is the primary focus; as a result, this review also examined patient experiences and satisfaction levels regarding telemedicine health care teams. The authors support these technological advances and their potential for information transfer. Health care providers need to continue developing these models by making use of increasing amounts of information. One of the main implementation barriers of these new models in the US and other countries is the issue of payment and reimbursement. Despite this, advancements in EC telemedicine continue.

Imaging findings of mammary and systemic silicone deposition secondary to breast implants

In patients with silicone breast implants, implant rupture can occur, which can be intra- or extracapsular. Following implant rupture, silicone can travel through the lymphatic system into regional and distant lymph nodes. The purpose of this pictorial essay is to present findings of silicone implant rupture with intramammary and systemic silicone deposition as seen on dual energy CT, ultrasound, mammogram, PET/CT and MRI. We include imaging findings of silicone deposition in the breast in cases of intra- and extracapsular rupture. We also present silicone deposition in mediastinal, axillary, and internal mammary lymph nodes, as well as in the liver and spleen. To our knowledge, deposition of silicone in the liver and spleen has not been previously demonstrated on cross-sectional imaging. While all imaging modalities were able to detect silicone in the spleen, ultrasound appeared to be more sensitive than dual energy CT or MRI for detection of silicone deposition in the liver.

A 37-lb Tumor

Mayo Clin Proc. n November 2013;88(11):e135 n http://dx.doi.org/ www.mayoclinicproceedings.org n a 2013 Mayo Foundation for M revealed a diffuse, symmetric, painless soft mass in the upper back. Surgical debulking was performed. The specimen removed weighed 37 lb (16.8 kg) (Figures 2 and 3). Histological examination revealed mature adipose tissue. A clinical diagnosis of benign symmetric lipomatosis, or Madelung disease, was made. It is a rare disorder characterized by benign, nonencapsulated fatty masses of the neck, upper trunk, and back. The disease predominantly affects middle-aged men with chronic alcohol abuse. The etiology remains largely unknown, and recurrence is common. The patient was satisfied with the appearance and her ability to walk shortly after the operation.