J. Kathleen Tracy

Comparison of 2 frailty indexes for prediction of falls, disability, fractures, and death in older women

BACKGROUND Frailty, as defined by the index derived from the Cardiovascular Health Study (CHS index), predicts risk of adverse outcomes in older adults. Use of this index, however, is impractical in clinical practice. METHODS We conducted a prospective cohort study in 6701 women 69 years or older to compare the predictive validity of a simple frailty index with the components of weight loss, inability to rise from a chair 5 times without using arms, and reduced energy level (Study of Osteoporotic Fractures [SOF index]) with that of the CHS index with the components of unintentional weight loss, poor grip strength, reduced energy level, slow walking speed, and low level of physical activity. Women were classified as robust, of intermediate status, or frail using each index. Falls were reported every 4 months for 1 year. Disability (> or =1 new impairment in performing instrumental activities of daily living) was ascertained at 4(1/2) years, and fractures and deaths were ascertained during 9 years of follow-up. Area under the curve (AUC) statistics from receiver operating characteristic curve analysis and -2 log likelihood statistics were compared for models containing the CHS index vs the SOF index. RESULTS Increasing evidence of frailty as defined by either the CHS index or the SOF index was similarly associated with an increased risk of adverse outcomes. Frail women had a higher age-adjusted risk of recurrent falls (odds ratio, 2.4), disability (odds ratio, 2.2-2.8), nonspine fracture (hazard ratio, 1.4-1.5), hip fracture (hazard ratio, 1.7-1.8), and death (hazard ratio, 2.4-2.7) (P < .001 for all models). The AUC comparisons revealed no differences between models with the CHS index vs the SOF index in discriminating falls (AUC = 0.61 for both models; P = .66), disability (AUC = 0.64; P = .23), nonspine fracture (AUC = 0.55; P = .80), hip fracture (AUC = 0.63; P = .64), or death (AUC = 0.72; P = .10). Results were similar when -2 log likelihood statistics were compared. CONCLUSION The simple SOF index predicts risk of falls, disability, fracture, and death as well as the more complex CHS index and may provide a useful definition of frailty to identify older women at risk of adverse health outcomes in clinical practice.

Blood transfusion, independent of shock severity, is associated with worse outcome in trauma.

BACKGROUND We have previously shown that blood transfusion in the first 24 hours is an independent predictor of mortality, intensive care unit (ICU) admission, and increased ICU length of stay in the acute trauma setting when controlling for Injury Severity Score, Glasgow Coma Scale score, and age. Indices of shock such as base deficit, serum lactate level, and admission hemodynamic status (systolic blood pressure, heart rate) and admission hematocrit were considered potential confounding variables in that study. The objectives of this study were to evaluate admission anemia and blood transfusion within the first 24 hours as independent predictors of mortality, ICU admission, ICU length of stay (LOS), and hospital LOS, with serum lactate level, base deficit, and shock index (heart rate/systolic blood pressure) as covariates. METHODS Prospective data were collected on 15,534 patients admitted to a Level I trauma center over a 3-year period (1998-2000) and stratified by age, gender, race, Glasgow Coma Scale score, and Injury Severity Score. Admission anemia and blood transfusion were assessed as independent predictors of mortality, ICU admission, ICU LOS, and hospital LOS by logistic regression analysis, with base deficit, serum lactate, and shock index as covariates. RESULTS Blood transfusion was a strong independent predictor of mortality (odds ratio [OR], 2.83; 95% confidence interval [CI], 1.82-4.40; p < 0.001), ICU admission (OR, 3.27; 95% CI, 2.69-3.99; p < 0.001), ICU LOS (p < 0.001), and hospital LOS (Coef, 4.37; 95% CI, 2.79-5.94; p < 0.001) when stratified by indices of shock (base deficit, serum lactate, shock index, and anemia). Patients who underwent blood transfusion were almost three times more likely to die and greater than three times more likely to be admitted to the ICU. Admission anemia (hematocrit < 36%) was an independent predictor of ICU admission (p = 0.008), ICU LOS (p = 0.012), and hospital LOS (p < 0.001). CONCLUSION Blood transfusion is confirmed as an independent predictor of mortality, ICU admission, ICU LOS, and hospital LOS in trauma after controlling for severity of shock by admission base deficit, lactate, shock index, and anemia. The use of other hemoglobin-based oxygen-carrying resuscitation fluids (such as human or bovine hemoglobin substitutes) in the acute postinjury period warrants further investigation.

Trauma in the elderly: Intensive care unit resource use and outcome

BACKGROUND As the population ages, the elderly will constitute a prominent proportion of trauma patients. The elderly suffer more severe consequences from traumatic injuries compared with the young, presumably resulting in increased resource use. In this study, we sought to examine ICU resource use in trauma on the basis of age and injury severity. METHODS This study was a retrospective review of trauma registry data prospectively collected on 26,237 blunt trauma patients admitted to all trauma centers (n = 26) in one state over 24 months (January 1996-December 1997). Age-dependent and injury severity-dependent differences in mortality, ICU length of stay (LOS), and hospital LOS were evaluated by logistic regression analysis. RESULTS Elderly (age > or = 65 years, n = 7,117) patients had significantly higher mortality rates than younger (age < 65 years) trauma patients after stratification by Injury Severity Score (ISS), Revised Trauma Score, and other preexisting comorbidities. Age > 65 years was associated with a two- to threefold increased mortality risk in mild (ISS < 15, 3.2% vs. 0.4%; < 0.001), moderate (ISS 15-29, 19.7% vs. 5.4%; < 0.001), and severe traumatic injury (ISS > or = 30, 47.8% vs. 21.7%; < 0.001) compared with patients aged < 65 years. Logistic regression analysis confirmed that elderly patients had a nearly twofold increased mortality risk (odds ratio, 1.87; confidence interval, 1.60-2.18; < 0.001). Elderly patients also had significantly longer hospital LOS after stratifying for severity of injury by ISS (1.9 fewer days in the age 18-45 group, 0.89 fewer days in the age 46-64 group compared with the age > or = 65 group). Mortality rates were higher for men than for women only in the ISS < 15 (4.4% vs. 2.6%, < 0.001) and ISS 15 to 29 (21.7% vs. 17.6%, = 0.031) groups. ICU LOS was significantly decreased in elderly patients with ISS > or = 30. CONCLUSION Age is confirmed as an independent predictor of outcome (mortality) in trauma after stratification for injury severity in this largest study of elderly trauma patients to date. Elderly patients with severe injury (ISS > 30) have decreased ICU resource use secondary to associated increased mortality rates.

Epidemiology of sepsis in patients with traumatic injury.

Objective:To characterize the epidemiology of sepsis in trauma. Design:Analysis of a prospectively collected administrative database (Pennsylvania trauma registry). Setting:All trauma centers in the state of Pennsylvania (n = 28) Patients:All patients (n = 30,303) with blunt or penetrating injury admitted to Pennsylvania trauma centers over a 2-yr period (January 1996–December 1997). Interventions:None. Measurements and Main Results:Incidence of sepsis in trauma, independent predictors of sepsis, and associated mortality were evaluated. Analyses controlled for age, gender, preexisting disease, injury type, Revised Trauma Score, Injury Severity Score, and admission vital signs. Sepsis occurred in 2% of all patients and was associated with a significant increase in mortality (23.1% vs. 7.6%, p < .001) compared with nonseptic patients. Respiratory tract infections were the most common cause of sepsis. Septic trauma patients had increased ICU length of stay (21.8 vs. 4.7 days, p < .001) and hospital length of stay (34.1 vs. 7.0 days, p < .001). Logistic regression identified Injury Severity Score, Revised Trauma Score, lower admission Glasgow Coma Scale score, and preexisting diseases as significant independent predictors of sepsis, whereas female gender was associated with a decreased risk of sepsis. Increasing injury severity measured by Injury Severity Score was associated with increased incidence of sepsis. Moderate (Injury Severity Score 15–29) and severe injury (Injury Severity Score ≥30) had a six-fold and 16-fold, respectively, increased incidence of sepsis compared with mild injury. Multivariate analysis confirmed that the effect of sepsis on mortality was greater in trauma patients with mild injury than those with moderate or severe injury. Conclusions:This study reports the incidence of sepsis and its associated mortality and critical care resource utilization in a large, state-wide population-based trauma registry. Increasing injury severity, measured by Injury Severity Score, was a significant independent predictor of sepsis in trauma and was associated with increased intensive care unit resource utilization and mortality. These results suggest that future studies should attempt to delineate interventional strategies to prevent sepsis in trauma patients with moderate and severe injury, given their significantly increased risk.

Abdominal wall hernias: risk factors for infection and resource utilization

BACKGROUND Abdominal wall hernia repairs are common surgical procedures. Several recent reports have studied the outcomes of elderly patients undergoing inguinal hernia repair and documented a morbidity rate ranging from 5-57% and a mortality rate ranging from 1.6-14%. However, there has been limited data documenting the risk factors associated with postoperative morbidity and mortality from abdominal wall hernia repairs in general. Therefore, we sought to investigate the incidence of complications in patients undergoing abdominal wall hernia repair and to evaluate the risk factors for infection and resource utilization in these patients. METHODS Prospective data (NSQIP) were collected on 6301 noncardiac surgical patients at the VA Maryland Healthcare System from 1995 to 2000. From this data set, 487 (7.7%) patients underwent abdominal wall hernia repairs and comprised the study cohort. Logistic and linear regression analyses were performed to identify risk factors for infection and hospital length of stay. RESULTS The mean age of the study cohort was 60 +/- 14 and the mean ASA class was 2.4 +/- 0.7. Descriptive data revealed 99% were male, 43% used tobacco, 8.4% were diabetic, 7.4% used alcohol, 6.3% had chronic obstructive pulmonary disease (COPD), 2.1% were malnourished (defined as >/= 10% weight loss over prior 6 months), 1.6% used steroids, 1.2% had ascites, and 0.2% had coronary artery disease (CAD). The mortality rate was low at 1% but the morbidity rate was higher with a 4.3% incidence of wound infections and a 15.1% incidence of recurrent hernias. The mean preoperative serum albumin level was 4.1 +/- 0.6 g/dL, and the mean hospital length of stay was 1.4 +/- 4.8 days. Multiple logistic and linear regression analyses documented that CAD, COPD, low preoperative serum albumin, and steroid use were independent risk factors for increased postoperative wound infections (P < 0.05) and increased hospital length of stay (P < 0.05). CONCLUSIONS Abdominal wall hernia repair is associated with significant morbidity in this predominantly elderly cohort but mortality rates were low. COPD and low preoperative serum albumin were independent predictors of wound infections and CAD, COPD, low preoperative serum albumin, and steroid use were independent predictors of increased hospital length of stay. Therefore, consideration should be given to optimizing patients cardiopulmonary and nutritional status before abdominal wall hernia repair.

Male Gender Is Associated With Increased Risk For Postinjury Pneumonia

Nosocomial pneumonia in trauma patients is a significant source of resource utilization and mortality. We have previously described increased rates of pneumonia in male trauma patients in a single institution study. In that study, female trauma patients had a lower incidence of postinjury pneumonia but a higher relative risk for mortality when they did develop pneumonia. We sought to investigate the hypothesis that male trauma patients have an increased incidence of postinjury pneumonia in a separate population-based dataset. Prospective data were collected on 30,288 trauma patients (26,231 blunt injuries, 4057 penetrating injuries) admitted to all trauma centers (n = 26) in Pennsylvania over 24 months (January 1996 to December 1997). Gender differences in pneumonia were determined for the entire dataset. A second analysis examined all blunt injury patients and excluded all patients with a hospital length of stay less than 24 h, eliminating patients who expired early after admission. In trauma patients with minor injury (ISS < 15), there was no significant difference between male and female patients in the rate of postinjury pneumonia (male 1.37%, female 1.11%). In the moderate-injury group (ISS > 15), male trauma patients had a significantly increased incidence of postinjury pneumonia (ISS 15–30, male 8.85%, female 6.45%; ISS > 30, male 24.35%, female 17.30%). Logistic regression analysis of blunt trauma patients revealed that gender, ISS, injury type, admission Revised Trauma Score (RTS), admission respiratory rate, history of cardiac disease, and history of cancer were all independent predictors of pneumonia. Trauma patients with nosocomial pneumonia had a significantly higher mortality rate (P < 0.001) than patients without pneumonia. There was no gender-specific difference in mortality among pneumonia patients. Male gender is significantly associated with an increased incidence of postinjury pneumonia. In contrast to our initial study, there was no gender difference in postinjury pneumonia mortality rates identified in this population-based study.

Lesbians and cancer: an overlooked health disparity

ObjectiveTo evaluate the breast, cervical, ovarian, lung, and colorectal cancer literatures using a novel application of the cancer disparities grid to identify disparities along domains of the cancer continuum focusing on lesbians as a minority population.MethodsComputerized databases were searched for articles published from 1981 to present. Cumulative search results identified 51 articles related to lesbians and disparities, which were classified by domain.ResultsThe majority of articles identified were related to breast and cervical cancer screening. Barriers to adequate screening for both cancers include personal factors, poor patient-provider communication, and health care system factors. Tailored risk counseling has been successful in increasing lesbian’s mammography and Pap screening. Ovarian, lung, and colorectal cancer have been virtually unexplored in this population. An “Adjustment to Illness/Quality of Life” domain was added to capture literature on psychosocial aspects of cancer.ConclusionsThis review revealed a lack of research for specific cancers and for specific aspects of the cancer continuum. The limited number of studies identified focused on issues related to screening/prevention in cervical and breast cancers, with almost no attention to incidence, etiology, diagnosis, treatment, survival, morbidity, or mortality. We present implications for social and public health policy, research, and prevention.

A Statewide Population Based Study of Gender Differences in Trauma: Validation of a Prior Single Institution Study.

BACKGROUND Women usually have lower mortality rates than men do at any age. This pattern is observed for most causes of death from chronic diseases. Significant controversy still exists about gender differences in outcomes in trauma. We previously reported no differences in in-hospital mortality based on gender in a large single-institution study (n= 18,892) that had a significant limitation in that it was not population based. This current study was performed to validate our earlier findings in a separate, statewide, population-based dataset of trauma victims. STUDY DESIGN Prospective data were collected on 22,332 trauma patients (18,432 blunt, 3,900 penetrating) admitted to all trauma centers (n = 26) in Pennsylvania over 24 months (January 1996 to December 1997). Gender differences in in-hospital mortality were determined for the entire dataset and for the subsets of blunt and penetrating injury patients. A second analysis examined all blunt injury patients and excluded all patients with a hospital length of stay of less than 24 hours, eliminating patients who expired soon after admission. The null hypothesis was that female gender is protective in trauma outcomes. RESULTS Multiple logistic regression analysis identified age (odds ratio [OR] 1.03, confidence interval [CI] 1.02 to 1.03), Injury Severity Score (OR 1.06, CI 1.05 to 1.06), non-Caucasian race (OR 1.72, CI 1.39 to 2.15), blunt injury type (OR 0.327, CI 0.26 to 0.41), and Revised Trauma Score (OR 0.44, CI 0.41 to 0.47) as independent predictors of in-hospital mortality in trauma. Preexisting diseases, including cardiac disease (OR 1.53, CI 1.12 to 2.09) and malignancy (OR 4.08, CI 1.64 to 10.17), were also identified as independent predictors of in-hospital mortality in trauma. Female gender was not associated with decreased mortality (OR 0.83, CI 0.67 to 1.03, p = 0.093). A second multiple regression analysis in blunt trauma patients admitted for longer than 24 hours (which eliminated early deaths and patients with minor injuries) determined that in-hospital mortality was not significantly different in male or female blunt trauma patients stratified by Injury Severity Score and age. The same factors that were predictive of in-hospital mortality in the total dataset were also significant in this secondary analysis. CONCLUSIONS These population-based data confirm that female gender does not adversely affect in-hospital mortality in trauma when patients are appropriately stratified for other variables, including Injury Severity Score and age, that do significantly affect outcomes.

Relations among Menopausal Symptoms, Sleep Disturbance and Depressive Symptoms in Midlife

OBJECTIVES To investigate the relations among hot flashes, other menopausal symptoms, sleep quality and depressive symptoms in midlife women. METHODS A large population-based cross-sectional study of 639 women (ages 45-54 years) consisting of a questionnaire including the Center for Epidemiologic Studies-Depression (CES-D) Scale, demographics, health behaviors, menstrual history, and menopausal symptoms. RESULTS After controlling for menopausal status, physical activity level, smoking status and current self-reported health status elevated CES-D score is associated with frequent nocturnal hot flashes, frequent trouble sleeping, experiencing hot flashes, nausea, headaches, weakness, visual problems, vaginal discharge, irritability, muscle stiffness, and incontinence. CONCLUSIONS The present study found significant links between depressive symptoms and several menopausal symptoms including hot flashes, sleep disturbance, irritability, muscle stiffness, and incontinence after controlling for covariates. These findings suggest that a potential mechanism in which bothersome menopausal symptoms may influence depressed mood during the midlife is through sleep disturbance.

Racial differences in rate of decline in bone mass in older men: the Baltimore men's osteoporosis study.

Older black men have higher adjusted BMD than older white men. Using data from a longitudinal cohort study of older men followed for a mean of 18.8 ± 6.5 (SD) months, we found that older black men have a higher rate of decline in femoral neck and total hip BMD and femoral neck BMAD than older white men.