Rahul Dhanda

Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery.

OBJECTIVE: Internists frequently evaluate preoperative cardiopulmonary risk and comanage cardiac and pulmonary complications, but the comparative incidence and clinical importance of these complications are not clearly delineated. This study evaluated incidence and length of stay for both cardiac and pulmonary complications after elective laparotomy.DESIGN: Nested case-control.SETTING: University-affiliated Department of Veterans Affairs Hospital.PATIENTS: Computerized registry of all 2,291 patients undergoing elective abdominal operations from 1982 to 1991.MEASUREMENT AND MAIN RESULTS: Strategy for ascertainment and verification of complications was systematic and explicit. The charts of all 116 patients identified by the registry as having complications and 412 (19%) randomly selected from 2,175 remaining patients were reviewed to verify presence or absence of cardiac or pulmonary complications, using explicit criteria and independent abstraction of pre- and postoperative components of charts. From these 528 validated cases and controls (23% of the cohort), 96 cases and 96 controls were matched by operation type and age within ten years. Hospital and intensive care unit stays were significantly longer (p<0.0001) for the cases than for the controls (24.1 vs 10.3 and 5.8 vs 1.5 days, respectively). All 19 deaths occurred among the cases. Among the cases, pulmonary complications occurred significantly more often than cardiac complications (p<0.00001) and were associated with significantly longer hospital stays (22.7 vs 10.4 days, p=0.001). Combined cardiopulmonary complications occurred among 26% of the cases. Misclassification-corrected incidence rates for the entire cohort were 9.6% (95% CI 7.2–12.0) for pulmonary and 5.7% (95% CI 3.8–7.7) for cardiac complications.CONCLUSIONS: For noncardiac surgery, previous research has focused on cardiac risk. In this study, pulmonary complications were more frequent, were associated with longer hospital stay, and occurred in combination with cardiac complications in a substantial proportion of cases. These results suggest that further research is needed to fully characterize the clinical epidemiology of postoperative cardiac and pulmonary complications and better guide preoperative risk assessment.

Case-finding for depression in primary care: a randomized trial∗ ∗

PURPOSE Depression is a highly prevalent, morbid, and costly illness that is often unrecognized and inadequately treated. Because depression questionnaires have the potential to improve recognition, we evaluated the accuracy and effects on primary care of two case-finding instruments compared to usual care. SUBJECTS AND METHODS The study was conducted at three university-affiliated and one community-based medical clinics. Consecutive patients were randomly assigned to be asked a single question about mood, to fill out the 20-item Center for Epidemiologic Studies Depression Screen, or to usual care. Within 72 hours, patients were assessed for Diagnostic and Statistical Manual of Mental Disorders Third Revised Edition (DSM-III-R) disorders by an assessor blinded to the screening results. Process of care was assessed using chart audit and administrative databases; patient and physician satisfaction was assessed using Likert scales. At 3 months, depressed patients and a random sample of nondepressed patients were re-assessed for DSM-III-R disorders and symptom counts. RESULTS We approached 1,083 patients, of whom 969 consented to screening and were assigned to the single question (n = 330), 20-item questionnaire (n = 323), or usual care (n = 316). The interview for DSM-III-R diagnosis was completed in 863 (89%) patients; major depression, dysthymia, or minor depression was present in 13%. Both instruments were sensitive, but the 20-item questionnaire was more specific than the single question (75% vs 66%, P = 0.03). The 20-item questionnaire was less likely to be self-administered (54% vs 90%) and took significantly more time to complete (15 vs 248 seconds). Case-finding with the 20-item questionnaire or single question modestly increased depression recognition, 30/77 (39%) compared with 11/38 (29%) in usual care (P = 0.31) but did not affect treatment (45% vs 43%, P = 0.88). Effects on DSM-III-R symptoms were mixed. Recovery from depression was more likely in the case-finding than usual care groups, 32/67 (48%) versus 8/30 (27%, P = 0.03), but the mean improvement in depression symptoms did not differ significantly (1.6 vs 1.5 symptoms, P = 0.21). CONCLUSIONS A simple question about depression has similar performance characteristics as a longer 20-item questionnaire and is more feasible because of its brevity. Case-finding leads to a modest increase in recognition rates, but does not have consistently positive effects on patient outcomes.

Barriers to and benefits of leisure time physical activity in the elderly: Differences across cultures

The purpose of this study was to compare ethnic differences in attitudes toward barriers and benefits of leisure‐time physical activity (LTPA) in sedentary elderly Mexican (MAs) and European Americans (EAs). An in‐home, cross‐sectional survey was performed on 210 community‐dwelling elders from 10 primary care practices in south Texas that are part of the South Texas Ambulatory Research Network, a practice‐based research network. Analytical variables included ethnicity, age, sex, income, education, marital status, and LTPA. Fisher exact test was used to analyze the 100 sedentary elders (LTPA <500kcal/wk; 63 MAs and 37 EAs). Self‐consciousness and lack of self‐discipline, interest, company, enjoyment, and knowledge were found to be the predominant barriers to LTPA in both groups. Both groups held similar beliefs about benefits gained from exercise, such as improved self‐esteem, mood, shape, and health, but the beliefs about the positive benefits of exercise were more prevalent in MAs. These findings remained after adjusting for age, income, education, marital status, and sex. Some might think that a major barrier lies in misconception about benefits of LTPA, but in this study, both ethnic groups were accurate in their perceived benefits of LTPA. When attempting to engage elderly in LTPA, it is important not only to consider what barriers exist but also what beliefs about the benefits exist.

Body fatness and increased injury rates in high school football linemen

ObjectiveTo determine whether associations exist between body fatness and injury rates in high school football linemen. DesignProspective, injury surveillance study during a 2-week preseason and 10-week regular season. Setting10 public high schools in Texas. ParticipantsTwo hundred fifteen varsity and junior varsity high school football linemen. Main Outcome MeasuresInjury rates (injuries per 1000 hours of playing time) for groups of players above a given body fat level and at or below a given body fat level. Rates were computed as the number of injuries per group divided by the groups aggregate playing time (practice + game time). The null hypothesis was that there is no difference in injury rates between players above a given level of body fat and those at or below that level of body fat. Body fat was determined from chest, abdomen, and thigh skinfold measurements using standard conversion equations. Body mass index (BMI) (kg/m2) was also calculated for each player. ResultsThe overall injury rate was 5.66 injuries per 1000 hours of playing time. Percent body fat ranged from 9.3% to 40.2%. BMI ranged from 19.9 to 46.6 kg/m2. Sixty-seven players sustained 86 injuries, the most common of which were ankle sprains and medial collateral ligament sprains. No difference in overall injury rates between higher and lower fat groups was seen at any body fat level. Players in higher body fat groups, however, had significantly greater lower extremity injury rates than did players in lower fat groups between 18% and 27% body fat and again 32% to 33%, but not at intermediate levels of >33%. Players in higher BMI groups had significantly greater lower extremity injury rates than did players in lower BMI groups throughout the range from 24 to 36 kg/m2, except at 34 kg/m2. ConclusionBoth higher body fatness and BMI were associated with increased rates of lower extremity injury among high school football linemen. BMI appears to be associated more consistently with increased lower extremity injury rates than is body fat.

Determinants of hip and knee flexion range: Results from the San Antonio longitudinal study of aging

OBJECTIVE We analyzed data from the San Antonio Longitudinal Study of Aging, a neighborhood-based study of community-dwelling elderly people, to identify factors that determine the flexion range (FR) of hips and knees. METHODS The FR of hips and knees was measured in a cohort of 687 subjects aged 65 to 79 years. We used multivariate models to examine the associations among the FR of hips and knees, and between these and age, gender, ethnicity, body mass index (BMI), pain and its location, self-reported arthritis, and diabetes mellitus. The functional relevance of hip and knee FR was tested by measuring its association with 50-foot walking velocity. RESULTS More than 90 degrees of flexion in both hips and both knees was observed in 619 subjects (90.1%). Correlations among the FR of hips and knees ranged from 0.54 to 0.80 (P < 0.001 for Spearman r values). Multivariate analysis revealed a pattern of significant associations between each of the joints and its contralateral mate and ipsilateral partner joints that was consistent for both hips and both knees. Using each individual joint as the unit of analysis, the following variables were independently associated with hip or knee FR in multivariate models: rising BMI and female sex with reduced FR of both hips and knees, a Mexican American ethnic background with decreased hip FR, and knee pain with decreased knee FR. The functional importance of the FR of these two important joints was supported by its significant association with walking velocity in a model that adjusted for age, gender, ethnic background, BMI, and hip or knee pain. CONCLUSIONS Most community-dwelling elderly people have a FR of hips and knees that can be considered functional. The ipsilateral and contralateral hip or knee are significant independent determinants of the FR of each of these joints. Obesity, a health problem potentially amenable to preventive and therapeutic interventions, is a factor significantly associated with decreased FR of hips and knees.

Helplessness predicts the development of hypertension in older Mexican and European Americans

OBJECTIVE The mechanisms by which depression is associated with an elevated risk of cardiovascular disease remain unclear. It is possible that depressive symptoms could increase the risk of hypertension, which in turn could predispose to cardiovascular disease. The goal of this study was to explore whether individual depressive symptoms might predict the incidence of hypertension in a cohort of 240 initially normotensive Mexican-American and European-American elders. METHODS Subjects were 65-78 years old on entering the San Antonio Longitudinal Study of Aging, an epidemiologic survey, at which time they completed the 30-item Geriatric Depression Scale in English or Spanish. Their blood pressure was reassessed a mean of 7.0 years later. Responses to six key scale items (depressed mood, decreased interest, worthlessness, hopelessness, helplessness, and fatigue) were evaluated for the ability to predict incident hypertension. RESULTS In univariate analyses, only helplessness significantly predicted incident hypertension (chi-square 13.5, df=1, P=.0003). In a Cox proportional hazards model adjusted for sex, education, number of comorbid diseases, current drinking, social well-being, and marital status, helplessness remained a very strong predictor [hazard ratio (HR) 4.99, 95% confidence interval (CI) 1.90-13.12, P=.0011]. Total depression score also predicted incident hypertension, but less strongly (HR 1.08, CI 1.00-1.17, P=.0339). CONCLUSION Helplessness may predict the development of hypertension in the elderly. Further research into this relationship might lead to interventions to reduce the risk of cardiovascular disease.

Development and validation of a performance-based measure of upper extremity functional limitation

Background and aims: While the standardized lower extremity physical performance battery (LEPPB) is widely used to measure lower body functional limitation, no corresponding measure has been developed for upper body functional limitation. We combined three standard measures (William’s Hand Test, Hand Signature, Functional Reach) to develop an upper extremity physical performance battery (UEPPB) analogous to the LEPPB, and examined its validity. Methods: We used baseline data from a community-dwelling cohort of 749 Mexican American and European American elders and combined times to complete the William’s Hand Board, Hand Signature, and distance on Functional Reach into a single composite measure, using scoring methods analogous to those for the LEPPB. We summarize concurrent, discriminant, and construct validity evidence for the UEPPB, based on observed associations with established measures of physical functional limitation, disability, and dependence. Results: All correlations were in the expected direction. Shared variance with self-reported upper and lower extremity functional limitation was 10 and 5%, respectively, and with self-reported ADL disability, ADL dependency, and IADL dependency it was 32, 26, and 31%, respectively. In multivariate models of self-reported and performance-based disability and dependency, the UEPPB and LEPPB made significant, independent contributions and, net of contextual variables (age, sex, ethnic group, education, income) explained 4 to 10% of the variance in disability and dependency. Conclusions: The UEPPB is a valid performance-based measure of upper extremity functional limitation and makes an independent contribution beyond LEPPB in explaining disability and dependence.

Modeling impairment: using the disablement process as a framework to evaluate determinants of hip and knee flexion.

Elders often present to health care providers with multiple inter-related conditions that determine an individual’s ability to function. The disablement process provides a generalized sociomedical framework for investigating the complex pathways from chronic disease to disability. At each stage of the main pathway, associations may exist among primary physical factors and modifying variables that ultimately have downstream effects on the progression toward disability. The purpose of the present analysis is to examine the inter-relationships between a cohesive set of variables primarily at the level of impairment that may affect hip and knee flexion range of motion (ROM). The San Antonio Longitudinal Study of Aging enrolled 833 community dwelling Mexican (MA) and European American (EA) elders aged 64–78 years between 1992 and 1996. Of these, 647 had complete data from both a home-based and performance-based battery of assessments for these analyses. Concerning impairments, hip ROM was measured using an inclinometer, and knee ROM using a goniometer. Pain location and intensity were assessed using the McGill Pain Questionnaire. Peripheral vascular disease was assessed using doppler brachial and ankle systolic blood pressures. Ankle and knee reflexes, and vibratory sensation were assessed by a standardized neurological examination. As to diseases, diabetes was assessed using a combination of blood glucose levels and self-report, and arthritis by self-report. Concerning modifying variables, height and weight were directly measured and used to calculate BMI. Activity level was assessed with the Minnesota Leisure Time Questionnaire. Analgesic use was assessed by direct observation of medications taken within the past two weeks. We used structural equation modeling to test associations between the variables that were specified a priori. These analyses demonstrate the central role of BMI as a determinant of hip and knee flexion ROM. For an increase in level of BMI, the coefficients [SEM] for changes in levels of hip and knee ROM were −0.38 [0.05] and −0.26 [0.05], respectively. A higher BMI resulted in lower hip and knee ROM. BMI was also directly associated with prevalent diabetes (0.10 [0.05]) and arthritis (0.17 [0.05]). However, after adjustment for BMI, diabetes and arthritis did not have direct independent associations with either hip or knee ROM. BMI was also indirectly associated with knee, but not hip, ROM through paths including lower-leg pain, pain intensity, and neurosensory impairments. Diabetes had an indirect association with hip, but not knee ROM, through a path including peripheral vascular disease. In conclusion, BMI is a primary direct determinant of hip and knee ROM. The paths by which diabetes and arthritis lead to physical disability may be mediated, in part, at the level of impairment by BMI’s association with joint range of motion. Interventions designed to decrease the impact of diabetes and arthritis on disability should track changes in BMI and joint ROM to measure the paths that account for the intervention’s success. The observed associations suggest that interventions targeted to decrease BMI itself may lead to improved function in part through improved joint ROM.

Appendicitis: Higher risk in Mexican Americans?

OBJECTIVES Mexican Americans (MAs), compared to white non-Hispanics (WNHs), have higher rates of biliary disease, noninsulin dependent diabetes, and endstage renal disease but lower rates of lung cancer, hip fractures, and mortality from coronary heart disease. Relatively little research has been done to identify other ethnic differences in disease incidence. We used surgical procedure rates to confirm known ethnic differences and to explore our clinical suspicion that MAs have higher rates of appendectomy than WNHs. METHODS We used a registry of surgical procedures at two teaching hospitals in South Texas to calculate proportional operation ratios (PORs) for MAs versus WNHs. These two hospitals are the primary source of acute hospital care for the indigent in the area. The POR is arithmetically identical to proportional incidence and mortality ratios. RESULTS MAs underwent appendectomy proportionally more often than WNHs at both hospitals (POR = 1.41 and 1.75, p < 0.0001). Other significant PORs were consistent with known ethnic disease differences in biliary tract operations, vascular access for chronic hemodialysis, lung cancer, and coronary artery bypass. CONCLUSIONS These findings support the hypothesis that MAs may undergo appendectomy more often than WNHs and so may be at higher risk of appendicitis.

Classifying change with the Sickness Impact Profile for Nursing Homes (SIP-NH)

The aim of this cohort study was to evaluate the concordance of the Sickness Impact Profile for Nursing Homes (SIP- NH) and Sickness Impact Profile (SIP) in classifying change. Subjects consisted of 194 consecutive long- stay nursing home residents at one academic department of the V.A. and in 8 community proprietary nursing homes in San Antonio, Texas. They were to have more than 3 months residency; to be ⩾61 years; and to be dependent in at least 2 ADLs with an MMSE score of ⩾15. Subjects were administered a 128- item SIP and a reduced 66- item SIP- NH at baseline and 4, 8, and 12- month follow- up. At each follow- up, subjects were classified into 3 mutually exclusive change categories using a change score of ⩾5 points. Concordance of the classification of subjects by the SIP- NH and SIP was evaluated. The misclassification rate as well as its direction was also assessed. Both instruments classified a little over one- quarter of the subjects as better, over a third as being unchanged, and another third as being worse at the four- month follow- up. More subjects were classified as worse by both instruments at 8 and 12 months. All kappas ranged from 0.52 to 0.78, indicating good to excellent agreement. Overall, the SIP- NH characterized persons as changed more often than the SIP with no systematic directional bias. In conclusion, the SIP- NH was concordant with the SIP in classifying change in subjects. However, we cannot say which of the two is better for detecting change. Future research must focus on defining a change score which has clinical meaning, and evaluate responsiveness to change. (Aging Clin. Exp. Res. 7: 228–233, 1995)