Steven R. Gambert

Benefits and risks of anticoagulation resumption following traumatic brain injury.

IMPORTANCE The increased risk of hemorrhage associated with anticoagulant therapy following traumatic brain injury creates a serious dilemma for medical management of older patients: Should anticoagulant therapy be resumed after traumatic brain injury, and if so, when? OBJECTIVE To estimate the risk of thrombotic and hemorrhagic events associated with warfarin therapy resumption following traumatic brain injury. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of administrative claims data for Medicare beneficiaries aged at least 65 years hospitalized for traumatic brain injury during 2006 through 2009 who received warfarin in the month prior to injury (n = 10,782). INTERVENTION Warfarin use in each 30-day period following discharge after hospitalization for traumatic brain injury. MAIN OUTCOMES AND MEASURES The primary outcomes were hemorrhagic and thrombotic events following discharge after hospitalization for traumatic brain injury. Hemorrhagic events were defined on inpatient claims using International Classification of Diseases, Ninth Revision, Clinical Modification codes and included hemorrhagic stroke, upper gastrointestinal bleeding, adrenal hemorrhage, and other hemorrhage. Thrombotic events included ischemic stroke, pulmonary embolism, deep venous thrombosis, and myocardial infarction. A composite of hemorrhagic or ischemic stroke was a secondary outcome. RESULTS Medicare beneficiaries with traumatic brain injury were predominantly female (64%) and white (92%), with a mean (SD) age of 81.3 (7.3) years, and 82% had atrial fibrillation. Over the 12 months following hospital discharge, 55% received warfarin during 1 or more 30-day periods. We examined the lagged effect of warfarin use on outcomes in the following period. Warfarin use in the prior period was associated with decreased risk of thrombotic events (relative risk [RR], 0.77 [95% CI, 0.67-0.88]) and increased risk of hemorrhagic events (RR, 1.51 [95% CI, 1.29-1.78]). Warfarin use in the prior period was associated with decreased risk of hemorrhagic or ischemic stroke (RR, 0.83 [95% CI, 0.72-0.96]). CONCLUSIONS AND RELEVANCE Results from this study suggest that despite increased risk of hemorrhage, there is a net benefit for most patients receiving anticoagulation therapy, in terms of a reduction in risk of stroke, from warfarin therapy resumption following discharge after hospitalization for traumatic brain injury.

Proteinuria in the elderly: evaluation and management

While aging is accompanied by many age-related changes in renal physiology and function, proteinuria should not be considered to be a part of “normal aging”. There are many age-prevalent illnesses that predispose one to developing proteinuria and early recognition, and treatment may help retard disease progression or offer an early cure. The presence of proteinuria warrants further evaluation and follow-up if one has any hope of avoiding its progression and delaying the initiation of treatment. This review article will discuss the anatomy and physiology of the aging kidney, the pathophysiology and etiology of proteinuria during later life, methods to evaluate proteinuria, and ways to monitor and manage this problem.

Stroke incidence following traumatic brain injury in older adults.

Objective:Following traumatic brain injury (TBI), older adults are at an increased risk of hemorrhagic and thromboembolic events, but it is unclear whether the increased risk continues after hospital discharge. We estimated incidence rates of hemorrhagic and ischemic stroke following hospital discharge for TBI among adults 65 years or older and compared them with pre-TBI rates. Participants:A total of 16 936 Medicare beneficiaries 65 years or older with a diagnosis of TBI in any position on an inpatient claim between June 1, 2006, and December 31, 2009, who survived to hospital discharge. Design:Retrospective analysis of a random 5% sample of Medicare claims data. Main Measures:Hemorrhagic stroke was defined as ICD-9 (International Classification of Diseases, Ninth Revision) codes 430.xx-432.xx. Ischemic stroke was defined as ICD-9 codes 433.xx-435.xx, 437.0x, and 437.1x. Results:There was a 6-fold increase in the rate of hemorrhagic stroke following TBI compared with the pre-TBI period (adjusted rate ratio, 6.5; 95% confidence interval, 5.3-7.8), controlling for age and sex. A smaller increase in the rate of ischemic stroke was observed (adjusted rate ratio, 1.3; 95% CI, 1.2-1.4). Conclusion:Future studies should investigate causes of increased stroke risk post-TBI as well as effective treatment options to reduce stroke risk and improve outcomes post-TBI among older adults.

Readmission and Prolapse Recurrence After Abdominal and Vaginal Apical Suspensions in Older Women.

OBJECTIVE: Our objective was to evaluate 30-day readmission, 12-month prolapse recurrence, and complications after apical surgeries in older women. METHODS: A retrospective cohort study was conducted using 2002–2011 Medicare data in women 65 years or older who underwent abdominal sacrocolpopexy with synthetic mesh, vaginal uterosacral, or sacrospinous colpopexy with 12 months follow-up. Vaginal mesh procedures were excluded. The primary outcome was 30-day inpatient readmission. Secondary outcomes were complications and prolapse recurrence, defined as either reoperation or pessary insertion. We used Pearson &khgr;2, Fisher exact tests, and analyses of variance to examine difference between surgical treatment groups. Odds ratios (ORs) utilizing Charlson Comorbidity Index, age, race, and procedure type were calculated to assess the differences in the outcomes probability. RESULTS: Of 3,015 women, 863 underwent abdominal sacrocolpopexy, 510—uterosacral and 1,642—sacrospinous ligament suspensions. The 30-day readmission was 7.4% (95% confidence interval [CI] 5.7–9.2%; OR 2.4, 95% CI 1.7–3.5, P<.01) after abdominal sacrocolpopexy and 4.5% (95% CI 2.7–6.3%; OR 1.3, 95% CI 0.8–2.1, P=.3) after uterosacral compared with 3.5% (95% CI 2.6–4.4% P<.01) after sacrospinous ligament suspensions. Prolapse recurrence did not differ between the groups (8.2%, 95% CI 6.4–10.1%; 10.6%, 95% CI 7.9–13.3%; and 9.9%, 95% CI 8.4–11.3%, P=.3, respectively). Women had 30-day gastrointestinal complications (6.1%, 95% CI 4.5–7.7%; 1.2%, 95% CI 0.2–2.1%; and 1.1%, 95% CI 0.6–1.6%, P<.01), surgical site infections (5.9%, 95% CI 4.3–7.5%; 3.1%, 95% CI 1.6–4.7%; and 3.7%, 95% CI 2.8–4.6%, P=.01), genitourinary complications (10.9%, 95% CI 8.8–13%; 17.7%, 95% CI 14.3–21%; and 13.6%, 95% CI 12–15.3%, P<.01), and medical complications (7.4%, 95% CI 5.7–9.2%; 7.8%, 95% CI 5.5–10.2%; and 4.4%, 95% CI 3.4–5.4%, P<.01; all after abdominal sacrocolpopexy, uterosacral, and sacrospinous ligament suspensions, respectively). CONCLUSION: Vaginal apical suspensions compared with abdominal sacrocolpopexy with synthetic mesh are associated with lower rates of postoperative 30-day readmission without an increase in prolapse recurrence among older women.

Warfarin usage among elderly atrial fibrillation patients with traumatic injury, an analysis of United States Medicare fee‐for‐service enrollees

This study examined warfarin usage for elderly Medicare beneficiaries with atrial fibrillation (AF) who suffered traumatic brain injury (TBI), hip fracture, or torso injuries. Using the 5% Chronic Condition Data Warehouse administrative claims data, this study included fee‐for‐service Medicare beneficiaries who had a single injury hospitalization (TBI, hip fracture, or major torso injury) between 1/1/2007 and 12/31/2009, with complete Medicare Parts A, B (no Medicare Advantage), and D coverage 6 months before injury, and who were aged 66 years or older and diagnosed with AF at least 1 year before injury. About 45% of the AF patients were using warfarin before TBI or torso injury, and 35% before hip fracture. After injury, there was a dramatic and persistent decrease in warfarin use in TBI and torso injury groups (30% for TBI and 37% for torso injury at 12 months after injury). Warfarin usage in hip fracture patients also dropped after injury but returned to pre‐injury level within 4 months. TBI and torso injury lead to significant decreases in warfarin usage in elderly AF patients. Further research is needed to understand reasons for the pattern and to develop evidence‐based management strategies in the post‐acute setting.

Comprehensive Geriatric Assessment

Caring for the older person is perhaps one of the most challenging tasks in clinical medicine. In addition to normal age-related changes that affect function and physiological response, certain age-prevalent diseases also accumulate. This may lead to even the most experienced clinician being surprised by the often atypical and nonspecific presentation of illness. Although a comprehensive geriatric assessment may be time- and labor-intensive, thoughtful screening is nonetheless crucial to assess an elderly person’s functional ability, physical health, cognitive and mental health, and socio-environmental situation.