Sheryl Ramdass

From hospital to community: Use of antipsychotics in hospitalized elders

Antipsychotic (AP) medications are often used in the hospitalized geriatric population for the treatment of delirium. Because of adverse events associated with APs, efforts have been made to reduce their use in hospitalized elders, but it is not clear if these recommendations have been widely adopted. We studied the use of APs in a cohort of hospitalized elders to better understand why APs are started and how often they are continued on discharge.

A Multicenter Evaluation of Adherence to 4 Major Elements of the Baveno Guidelines and Outcomes for Patients With Acute Variceal Hemorrhage

Goals: To determine the rate of and outcomes associated with guideline adherence in the care of acute variceal hemorrhage (AVH). Background: Four major elements of high-quality care for AVH defined by the Baveno consensus (VI) include timely endoscopy (⩽12 h), antibiotics, and somatostatin analogs before endoscopy and band ligation as primary therapy for esophageal varices. Study: We retrospectively evaluated 239 consecutive admissions of 211 patients with AVH admitted to 2 centers in Massachusetts from 2010 to 2015. The primary outcome was 6-week mortality; secondary outcomes included treatment failure (shock, hemoglobin drop by 3 g/dL, hematemesis, death ⩽5 d), length of stay, and 30-day readmission. Results: Guideline adherence was variable: endoscopy ⩽12 hours (79.9%), antibiotics (84.9%), band ligation (78.7%), and somatostatin analogs (90.8%). However, only 150 (62.8%) received care that was adherent to all indicated criteria. The 6-week mortality rate was 22.6%. Treatment failure occurred in 50 (21.0%) admissions. Among the 198 patients who survived to discharge, 41 (20.7%) were readmitted within 30 days. Octreotide before endoscopy was associated with a reduction in 30-day readmission (18.4% vs. 42.1%; P=0.03), whereas banding of esophageal varices was associated with a reduced risk of treatment failure (15.0% vs. 50.0%; P⩽0.001). However, adherence to quality metrics did not significantly reduce the risk of death within 6 weeks. Conclusions: Adherence to quality metrics may not reduce the risk of mortality but could improve secondary outcomes of AVH. Variation in practice should be addressed through quality improvement interventions.

Long-term outcomes of elders discharged on antipsychotics

BACKGROUND Despite limited evidence of efficacy, antipsychotics (APs) are commonly used to treat delirium. There has been little research on the long-term outcomes of patients who are started on APs in the hospital. METHODS Using a previously described retrospective cohort of 300 elders (≥65 years old) who were newly prescribed APs while hospitalized between October 1, 2012 and September 31, 2013, we examined the 1-year outcomes of patients alive at the time of discharge. We examined number of readmissions, reasons for readmission, duration of AP therapy, use of other sedating medications, and incidence of readmission. We used the National Death Index to describe 1-year mortality and then created a multivariable model to identify predictors of 1-year mortality. RESULTS The 260 patients discharged alive from their index admissions had a 1-year mortality rate of 29% (75/260). Of the 146/260 patients discharged on APs, 60 (41%) patients experienced at least 1 readmission. At the time of first readmission, 65% of patients were still taking the same APs on which they had been discharged. Eighteen patients received new APs during the readmission hospitalizations. Predictors of death at 1 year included discharge to postacute facilities after index admission (odds ratio [OR]: 2.28; 95% confidence interval [CI]: 1.10-4.73, P = 0.03) and QT interval prolongation >500 ms during index admission (OR: 3.41; 95% CI: 1.34-8.67, P = 0.01). CONCLUSIONS Initiating an AP in the hospital is likely to result in long-term use of these medications. Patients who received an AP during a hospitalization were at high risk of death in the following year. Journal of Hospital Medicine 2016;11:550-555.

Open access colonoscopy: Critical appraisal of indications, quality metrics and outcomes.

INTRODUCTION In an era of cost containment and measurement of value, screening for colon cancer represents a clear target for better accountability. Bundling payment is a real possibility and will likely have to rely on open-access colonoscopy (OAC). OAC is a method to allow patients to undergo endoscopy without prior evaluation by a gastroenterologist. We conducted a cross-sectional study to evaluate the indications and outcomes among patients scheduled for OAC or traditional colonoscopy at a tertiary medical center. We hypothesized that outcomes in OAC patients would be similar to those from traditional referral modes. METHOD Using a standardized data abstraction form, we documented indications for colonoscopy, clinical outcomes (complications, emergency room visits, phone calls), and compliance with quality indicators (QI) in a random sample of 1000 patients who underwent an outpatient colonoscopy at an academic medical center in 2013. We compared baseline characteristics and outcomes between two cohorts: OAC vs. patients who were scheduled after previous evaluation by a gastroenterologist or physician assistant or non-open access colonoscopy (NOAC). RESULTS Patients in the OAC group were more likely to be male, non-Hispanic, to be privately insured, and to have screening (vs. diagnostic) indication. However they were significantly less likely than those in the NOAC group to have a procedure performed once scheduled, (45.5% vs. 66.9%, p<0.001), due to no-show (24/178 or 13.5% vs. 60/822 or 7.3%), cancellation (56/178 or 31.5 vs. 156/822 or 19.0%), and non-compliance (9/178 or 5.1% vs. 20/822 or 2.4%). There were no clinically meaningful differences between groups with respect to outcomes such as polyp detection (35.6% OE vs. 39.5% NOE, p=0.54), postoperative call to GI practice (5.5% vs. 2.5%, p=0.41), or QI metrics such as documentation of prep quality (99.8% vs. 98.8%, p=0.24). CONCLUSION Patients undergoing OAC are more likely to have a screening colonoscopy but with overall similar clinical outcomes and compliance with QI to patients scheduled as NOAC. OAC remains handicapped by high cancellation and no-show rates.

Assessing Frailty and Vulnerability in Older Adults with Cancer

Purpose of ReviewAging is associated with decreased physiologic reserve, and older adults are more susceptible to cancer treatment toxicity. In this review, we discuss the implications of frailty and vulnerability in older patients with cancer. We also review a number of instruments that can be used to assess frailty and vulnerability and propose a practical approach to incorporate these tools in a general oncology or geriatric clinic.Recent FindingsIn older patients with cancer, frailty and vulnerability are associated with all-cause mortality, postoperative complications, and treatment intolerance/toxicities. If feasible, a comprehensive geriatric assessment should be used to assess of frailty and vulnerability. If a full geriatric assessment cannot be performed, screening tools such as the Balducci’s criteria, Vulnerable Elders Survey-13, Triage Risk Screening Tool, Groningen Frailty Index, and Geriatric 8 may be used.SummaryFuture studies should evaluate geriatric assessment domains that have the greatest predictive value for toxicity for each cancer type and treatment.

The Association of Frailty with Discharge Disposition for Hospitalized Community Dwelling Elderly Patients

BACKGROUND OBJECTIVE DESIGN, SETTING, PATIENTS INTERVENTION MEASUREMENTS CONCLUSIONS

Thrombosis in a bleeding disorder: case of thromboembolism in factor VII deficiency

Congenital factor VII deficiency (FVIID) is a rare disorder with a wide range of bleeding manifestations. The disorder does not protect patients against occurrence of thrombosis, and deep vein thrombosis can occur in the setting of surgery and recombinant factor VIIa replacement.

Association between thrombophilia and ischemic stroke: When is work-up for hypercoagulable state indicated?

Hypercoagulable state or thrombophilia are disorders of the hemostatic mechanisms that increases the risk of thrombosis, both arterial and venous [1]. Inherited thrombophilia is a well-recognized risk factor for venous thrombosis, but its association with arterial thrombosis has not been clearly established. There are also various acquired conditions that are associated with hypercoagulable state. Case-control studies and meta-analyses investigating thrombophilia and ischemic stroke have not been consistent [2]. Despite lack of strong evidence in literature many clinicians order these tests as part of ischemic stroke work-up [3]. We report a case of cryptogenic stroke and review the challenges associated with the hypercoagulable state in such common clinical scenarios. We also review the evidence-based recommendations about the use of coagulation tests in the work-up for ischemic stroke.

A Rare Cause of Cauda Equina Syndrome by Infiltration: Case of a Sacral Chordoma

is suggestive of variant CJD. DWI has been shown to be the most sensitive MR sequence. DW-MRI may show CJD-associated lesions 3 weeks after symptoms with high sensitivity (91%) and specificity (95%), although studies suggest that up to 80% of these abnormalities are missed, like in the current case, despite previous MRI, illustrating that awareness of MRI features of CJD is insufficient. In the current case, all other complementary investigations were inconclusive. EEG can show polymorphic and repetitive slower wave discharges, characteristic bior triphasic paroxysmal waves, or spike-slow waves in 60% of cases, but these abnormalities occur intermittently, and sensitivity of EEG periodic sharp wave complexes is only 66% with 74% specificity. With 88% sensitivity and 72% specificity, a negative CSF 14–3-3 assay does not exclude CJD, depending on of the evolution of the disease and disease subtype. Several biomarkers, including tau protein, neurospecific enolase, and S100b protein, have attracted great interest. CSF tau protein had better diagnostic accuracy than other protein detection, with 91% sensitivity and 88% specificity. In the current case, a search for prion protein gene mutation was performed for several reasons. Two of the woman’s children were alive, family history was missing, and clinical signs and course of the genetic form of the disease are usually comparable with those of the sporadic form. Geriatricians should recognize clinical and paraclinical signs of CJD, but diagnosis remains challenging. The clinical presentation can mimic dementia or stroke, but MRI, EEG, and biomarkers can assist in the diagnosis. According to international criteria, this woman had probable CJD, but no autopsy was performed.