Psychiatric comorbidity and greater hospitalization risk, longer length of stay, and higher hospitalization costs in older adults with heart failure

OBJECTIVES: To explore associations between psychiatric comorbidity and rehospitalization risk, length of hospitalization, and costs. DESIGN: Cross-sectional study of 1-year hospital administrative data. SETTING: Claims-based study of older adults hospitalized in the United States. PARTICIPANTS: Twenty-one thousand four hundred twenty-nine patients from a 5% national random sample of U.S. Medicare beneficiaries aged 65 and older, with at least one acute care hospitalization in 1999 with a Diagnostic-Related Group of congestive heart failure. MEASUREMENTS: The number of hospitalizations, mean length of hospital stay, and total hospitalization costs in calendar year 1999. RESULTS: Overall, 15.8% of patients hospitalized for heart failure (HF) had a coded psychiatric comorbidity; the most commonly coded comorbid psychiatric disorder was depression (8.5% of the sample). Most forms of psychiatric comorbidity were associated with greater inpatient utilization, including risk of additional hospitalizations, days of stay, and hospitalization charges. Additional hospitalization costs associated with psychiatric comorbidity ranged up to $7,763, and additional days length of stay ranged up to 1.4 days. CONCLUSION: Psychiatric comorbidity appears in a significant minority of patients hospitalized for HF and may affect their clinical and economic outcomes. The associations between psychiatric comorbidity and use of inpatient care are likely to be an underestimate, because psychiatric illness is known to be underdetected in older adults and in hospitalized medical patients.     

A situation-specific theory of heart failure self-care

Heart failure, a common syndrome in developed countries worldwide, is associated with poor quality of life, frequent rehospitalizations, and early death. Self-care is essential to improving outcomes in this patient population. The purpose of this article is to describe a situation-specific theory of heart failure self-care in which self-care is defined as a naturalistic decision-making process involving the choice of behaviors that maintain physiologic stability (maintenance) and the response to symptoms when they occur (management). Self-care maintenance is further defined to encompass routine symptom monitoring and treatment adherence. Self-care management is characterized as a process initiated by symptom recognition and evaluation, which stimulates the use of self-care treatments and treatment evaluation. Confidence in self-care is thought to moderate and/or mediate the effect of self-care on various outcomes. Four propositions were derived from the self-care of heart failure conceptual model: (1) symptom recognition is the key to successful self-care management; (2) self-care is better in patients with more knowledge, skill, experience, and compatible values; (3) confidence moderates the relationship between self-care and outcomes; and (4) confidence mediates the relationship between self-care and outcomes. These propositions were tested and supported using data obtained in previous research. Support of these propositions provides early evidence for this situation-specific theory of heart failure self-care.     

Thoughts, feelings, and motivations of bystanders who attempt to resuscitate a stranger: a pilot study.

BACKGROUND: Rates of bystander cardiopulmonary resuscitation remain low nationwide. Possibly, low rates can be explained by examining the reactions of laypersons who attempt to resuscitate a stranger. OBJECTIVE: To examine the thoughts, feelings, and motivations of laypersons who have attempted to resuscitate a stranger. METHOD: Survey methods were used to do a qualitative study of 12 laypersons who had provided bystander resuscitation. A 36-item questionnaire of predominately open-ended questions was used to elicit retrospective information about the laypersons' thoughts, feelings, and motivations during several stages of the resuscitation event. Data were analyzed by using content analysis. RESULTS: Thoughts about the event included curiosity, questioning of personal capability, and recognition of differences between classroom training and real-life events. Feelings included hope, euphoria, pride, relief, satisfaction, hopelessness, doubt, agitation, anger, sadness, and fear. Primary motivations were duty and responsibility, guilt and social pressure, and altruism. All participants reported that they had excellent recall of the event. CONCLUSION: These results provide insight into a population that acts on behalf of the medical community.     

Ontogeny of the Shell Bones of Embryos of Podocnemis unifilis (Troschel, 1848) (Testudines,Podocnemididae)

The aim of the present study was to investigate the sequence of shell bone formation in the embryos of the Pleurodira, Podocnemis unifilis. Their bones and cartilage were collected and cleared before staining. The shell was also examined by obtaining a series of histological slices. All the bony elements of the plastron have independent ossification centers, which subsequently join together and retain two fontanelles until the period of hatching. This turtle has a mesoplastra, which is characteristic of the Podocnemididae. The carapace begins to form concurrently with the ossification of the ribs at the beginning of stage 20. All the plates, except the suprapygal, initiate ossification during the embryonic period. The main purpose of the histological investigation was to highlight the relationship between the formation of the carapace and ribs with that of the neural plates. The costal and neural plates were found not to independent ossification centers, but to be closely related to components of the endoskeleton, originating as expansions of the perichondral collar of the ribs and the neural arches, respectively. Considering the ribs as an endoskeletal element of the carapace, the carapace and plastron begin ossification at the same stage in P. unifilis. This pattern reveals similarities with other Pleurodira, as well as evident variations, such as the presence of the seven neural bones and the presence of only one ossification center in the nuchal plate. Anat Rec, 2011. © 2011 Wiley‐Liss, Inc.     

Decompressive Surgery for Malignant Middle Cerebral Artery Infarcts: The Results of Randomized Trials Can Be Reproduced in Daily Practice

Background: In clinical randomized controlled trials (RCTs), decompressive surgery (DS) for malignant middle cerebral artery (MMCA) infarcts leads to a 50% absolute risk reduction in mortality, and improves the 1-year functional outcome. The reproducibility of these results in routine practice has never been evaluated. The purpose of this study was to test the hypothesis that the results of DS for MMCA in practice are similar to those observed in the surgical group of RCTs. Methods: We prospectively included the first 31 patients who underwent DS for MMCA. They were screened based on similar criteria as in the meta-analysis. The primary outcome was a modified Rankin Scale (mRS) score of ≤4, and secondary outcomes were mRS of ≤3 and death at 1 year. Results: Thirty-one patients underwent DS for MMCA. The 1-year mRS was ≤4 in 22 patients (71.0%) and ≤3 in 16 (51.6%). Seven patients died (22.6%). Conclusion: This observational study showed that DS for MMCA in a center without previous experience provides similar results as those obtained in the surgical arm of RCTs.     

Impact of stereotactic body radiation therapy on geriatric assessment and management for older patients with head and neck cancer using G8

PurposeManagement of head and neck cancers (HNC) in older adults is a common but challenging clinical scenario. We assess the impact of Stereotactic Body Radiation Therapy (SBRT) on survival utilizing the Geriatric-8 (G8) questionnaire.Materials and methods171 HNC patients, deemed medically unfit for definitive treatment, were treated with SBRT ± systemic therapy. G8 questionnaires were collected at baseline, at 4–6 weeks, and at 2–3 months post-treatment. Patients were stratified according to their baseline G8 score: <11 as ‘vulnerable’, 11–14 as ‘intermediate’, and >14 as ‘fit’. Overall survival (OS) was assessed through univariate Kaplan Meier analysis. Repeated measures ANOVA was used to determine if baseline characteristics affected G8 score changes.ResultsMedian follow-up was seventeen months. 60% of patients presented with recurrent HNC, 30% with untreated HNC primaries, and 10% with metastatic non-HNC primaries. Median age was 75 years. Median Charlson Comorbidity Index score was 2. 51% of patients were ‘vulnerable’, 37% were ‘intermediate’, and 12% were ‘fit' at baseline, with median survival of 13.2, 24.3, and 41.0 months, respectively (p = .004). Patients who saw a decrease in their follow-up G8 score (n = 69) had significantly lower survival than patients who had stable or increased follow-up G8 scores (n = 102), with median survival of 8.6 vs 36.0 months (p < .001).ConclusionThe G8 questionnaire may be a useful tool in upfront treatment decision-making to predict prognosis and prevent older patients from receiving inappropriate anti-cancer treatment. Decline in follow-up G8 scores may also predict worse survival and aid in goals of care following treatment.     

Risk of gastric cancer after Roux-en-Y gastric bypass

OBJECTIVE: To evaluate the risk of gastric cancer after Roux-en-Y gastric bypass (RYGB). DESIGN: Rats randomly underwent 1 of the following: RYGB, duodenojejunal bypass (DJB), or a sham operation. Postoperatively, rats underwent a protocol of cancer induction by means of both continuous (200 ppm in tap water for 16 weeks) and intermittent (50-mg/kg intraesophageal injection, once a week, for 12 weeks) administration of N-methyl-N-nitrosourea. SETTING: Institut de Recherche Contre les Canceurs de l'Appareil Digestif-European Institute of Telesurgery. STUDY ANIMALS: Fifty-five Fischer 344 rats. MAIN OUTCOME MEASURES: Seventeen weeks after the operation, we performed a pathologic examination of the whole stomach in all animals to assess for the presence of cancer and/or premalignant lesions. Bilirubin concentration, gastric bacterial flora, and any other pathologic findings were also recorded. RESULTS: In rats in the sham and DJB groups, the incidence of gastric cancer was 85% and 75%, respectively (P = .63), whereas only 23% of rats in the RYGB group developed gastric cancer (4-fold reduction; P = .002). The remnant stomach of rats in the RYGB group also showed a lower bilirubin concentration (P < .01) and a lower bacterial count (P < .05) compared with both the DJB and sham groups. CONCLUSIONS: This study shows that RYGB reduces the risk of gastric cancer in an experimental model of dietary-induced carcinogenesis. Lack of direct contact with carcinogens, lower bile reflux, and a lower bacteria concentration in the gastric content may be responsible for these observations. These data suggest that RYGB may be a safe option for the treatment of morbid obesity even in areas with high gastric cancer incidence.     

Human infections with Borna disease virus: seroprevalence in patients with chronic diseases and healthy individuals.

Borna disease virus (BDV) is as yet an unclassified infectious agent which causes a neurologic disease in horses and sheep and is transmissible to other animal species. Human sera were tested for BDV-specific antibodies by immunofluorescence and immunoprecipitation. The sera were collected from three thousand subjects in Europe, the USA, and Africa classified by clinical syndromes/infectious diseases, and from healthy controls. In all three continents, positive serum samples were detected which recognized the major BDV antigen of 38/40 KD present in the nuclei of infected cells. In contrast to 2% of seropositives among the normal population, significantly higher prevalences (13-14%) were present among patients with chronic progressive diseases of the brain and the immune system. In children, antibody frequencies were two to four times higher than in adults. The results suggest a latent infection with BDV in humans leading to low antigen expression in healthy subjects and frequent reactivation events in chronically ill patients.