Reports of financial disability predict functional decline and death in older patients discharged from the hospital

BACKGROUND: The financial ability to pay for food and medical care is needed to maintain health in older persons following a serious illness. Therefore, we hypothesize that the inability to pay for basic needs, which we call financial disability, predicts adverse health outcomes in older patients discharged from the hospital. OBJECTIVES: To determine the frequency of reported financial disability in older adults being discharged from a hospital, to determine patient characteristics associated with financial disability, and to examine the relationship between financial disability and functional decline and mortality. DESIGN: Prospective cohort study. SETTING/PARTICIPANTS: Two thousand two hundred patients 70 years and older admitted to the general medicine services at two teaching hospitals in Ohio. MAIN OUTCOME MEASURES: Respondents were interviewed at the time of discharge to determine patients' financial ability to pay for 6 needs: groceries, general bills, medications, medical bills, a small emergency, and a major emergency. We determined functional decline in ability to perform activities of daily living from discharge to 90 days post-hospital discharge, and death 1 year after hospital discharge. RESULTS: Financial disability was reported to be severe (unable to pay for 3-6 needs) for 21% of patients and moderate (unable to pay for 1-2 needs) for 36%. Financial disability was more common and more severe (P<.001) in persons with an annual household income less than $10,000, in persons with fewer than 12 years of formal education, in African Americans, and in women. In patients with no financial disability, moderate financial disability, and severe financial disability, functional decline 3 months after hospital discharge occurred in 15%, 20%, and 25%, respectively (P=.001), and 1-year mortality rates were 24%, 27%, and 32%, respectively (P=.002). After adjustment for potential confounders, the association of financial disability with functional decline (P=.003) and mortality (P=.02) remained significant. CONCLUSION: Reports of financial disability at hospital discharge identified vulnerable older adults with increased risk for functional decline and death. Interventions that alleviate financial disability may improve health outcomes in older adults discharged from hospital.     

Global and regional left ventricular response to bicycle exercise in coronary artery disease. Assessment by quantitative radionuclide angiocardiography.

The left ventricular response to bicycle exercise was evaluated in 60 patients with coronary artery disease and in 13 normal control subjects. Left ventricular ejection fraction, mean normalized ejection rate and regional wall motion were determined using first-pass radionuclide angiocardiograms obtained at rest and again during peak graded bicycle exercise. All normal subjects demonstrated improved left ventricular function with exercise. Left ventricular ejection fraction increased significantly from 67 ± 3 per cent (mean ± SE) at rest to 82 ± 4 per cent with exercise (p < 0.001). Similarly, the left ventricular ejection rate increased significantly from 3.47 ± 0.31 sec^?1 to 6.53 ± 0.42 sec^?1(p < 0.001). In contrast, in 44 of 60 patients with coronary artery disease, the ejection fraction or ejection rate either decreased or remained the same with exercise. New or exaggerated regional wall motion abnormalities were detected in 28 of 60 patients with coronary artery disease. Over-all, global or regional evidence of compromised left ventricular reserve was found in 48 of 60 patients with coronary artery disease.The major determinant of an abnormal left ventricular response to exercise was the presence or absence of electrocardiographic evidence of myocardial ischemia. Left ventricular ejection fraction decreased or remained the same with exercise in all patients with coronary artery disease and electrocardiographic ischemia. New regional wall motion abnormalities were detected in 20 of these patients. In this group, the left ventricular ejection fraction decreased from 66 ± 2 per cent at rest to 58 ± 2 per cent with exercise (p < 0.001), whereas the ejection rate was unchanged by exercise (rest 3.33 ± 0.21 sec^?1; exercise 3.34 ± 0.22 sec^?1, p > 0.05). Of the 30 patients with coronary artery disease who exercised to symptom-limiting fatigue without electrocardiographic ischemia, 18 demonstrated compromised left ventricular reserve with exercise. Twelve of the remaining patients with coronary artery disease had normal left ventricular reserve, in eight of whom ventricular function was completely normal both at rest and during exercise. In this group exercised to fatigue, the left ventricular ejection fraction increased from 53 ± 4 per cent at rest to 58 ± 2 per cent with exercise (p < 0.001). The ejection rate also increased from 2.48 ± 0.24 sec^?1 to 3.67 ± 0.39 sec^?1 (p < 0.001). The direction and magnitude of the left ventricular responses to exercise were not affected by long-term oral propranolol administration in 22 patients. Based upon either abnormal exercise left ventricular reserve or abnormal global and regional left ventricular function at rest, the over-all sensitivity of this radionuclide technic for the detection of coronary artery disease was 87 per cent (52 of 60 patients). These data demonstrate that exercise ventricular performance studies provide important physiologic insights into left ventricular functional reserve as well as a sensitive noninvasive approach for the detection of coronary artery disease.     

Clock drawing as an assessment tool for dementia.

Clock drawing has recently been shown to lie useful in differentiating Alzieimer's disease patients from normal controls. Our procedure for clock drawing differed from other published reports in that a copy condition was employed and patients were asked to set clock hands to read "ten after eleven". We found both clock drawing procedures to be correlated with tests related to executive and visuospatial functioning. In both conditions, nondemented controls performed significantly better than demented patients. In the command condition there was no difference between Alzheimer patients and patients with cerebrovascular dementia. In the copy condition, patients with cerebrovascular dementia performed significantly worse than Alzheimer patients. The inclusion of a copy condition appears to greatly expand the utility of this test. Although our scoring system did not differentiate between various dementing disorders in the command condition, if clock drawing is used as a screening instrument, lack of improvement in the copy condition in comparison to the command condition may be a sign of a vascular involvement.     

Single-Center Comparison of Overall Survival and Toxicities in Patients with Infiltrative Hepatocellular Carcinoma Treated with Yttrium-90 Radioembolization or Drug-Eluting Embolic Transarterial Chemoembolization

Purpose

To compare overall survival and toxicities after yttrium-90 (⁹⁰Y) radioembolization and chemoembolization with drug-eluting embolics (DEE) in patients with infiltrative hepatocellular carcinoma (HCC).

Geographic, seasonal, and precipitation chemistry influence on the abundance and activity of biological ice nucleators in rain and snow

Biological ice nucleators (IN) function as catalysts for freezing at relatively warm temperatures (warmer than −10 °C). We examined the concentration (per volume of liquid) and nature of IN in precipitation collected from Montana and Louisiana, the Alps and Pyrenees (France), Ross Island (Antarctica), and Yukon (Canada). The temperature of detectable ice-nucleating activity for more than half of the samples was ≥ −5 °C based on immersion freezing testing. Digestion of the samples with lysozyme (i.e., to hydrolyze bacterial cell walls) led to reductions in the frequency of freezing (0–100%); heat treatment greatly reduced (95% average) or completely eliminated ice nucleation at the measured conditions in every sample. These behaviors were consistent with the activity being bacterial and/or proteinaceous in origin. Statistical analysis revealed seasonal similarities between warm-temperature ice-nucleating activities in snow samples collected over 7 months in Montana. Multiple regression was used to construct models with biogeochemical data [major ions, total organic carbon (TOC), particle, and cell concentration] that were accurate in predicting the concentration of microbial cells and biological IN in precipitation based on the concentration of TOC, Ca²⁺, and NH₄⁺, or TOC, cells, Ca²⁺, NH₄⁺, K⁺, PO₄³⁻, SO₄²⁻, Cl⁻, and HCO₃⁻. Our results indicate that biological IN are ubiquitous in precipitation and that for some geographic locations the activity and concentration of these particles is related to the season and precipitation chemistry. Thus, our research suggests that biological IN are widespread in the atmosphere and may affect meteorological processes that lead to precipitation.     

The London Position Statement of the World Congress of Gastroenterology on Biological Therapy for IBD with the European Crohn's and Colitis Organization: when to start, when to stop, which drug to choose, and how to predict response?

The advent of biological therapy has revolutionized inflammatory bowel disease (IBD) care. Nonetheless, not all patients require biological therapy. Selection of patients depends on clinical characteristics, previous response to other medical therapy, and comorbid conditions. Availability, reimbursement guidelines, and patient preferences guide the choice of first-line biological therapy for luminal Crohn's disease (CD). Infliximab (IFX) has the most extensive clinical trial data, but other biological agents (adalimumab (ADA), certolizumab pegol (CZP), and natalizumab (NAT)) appear to have similar benefits in CD. Steroid-refractory, steroid-dependent, or complex fistulizing CD are indications for starting biological therapy, after surgical drainage of any sepsis. For fistulizing CD, the efficacy of IFX for inducing fistula closure is best documented. Unique risks of NAT account for its labeling as a second-line biological agent in some countries. Patients who respond to induction therapy benefit from systematic re-treatment. The combination of IFX with azathioprine is better than monotherapy for induction of remission and mucosal healing up to 1 year in patients who are na?ve to both agents. Whether this applies to other agents remains unknown. IFX is also effective for treatment-refractory, moderate, or severely active ulcerative colitis. Patients who have a diminished or loss of response to anti-tumor necrosis factor (TNF) therapy may respond to dose adjustment of the same agent or switching to another agent. Careful consideration should be given to the reasons for loss of response. There are insufficient data to make recommendations on when to stop anti-TNF therapy. Preliminary evidence suggests that a substantial proportion of patients in clinical remission for >1 year, without signs of active inflammation can remain in remission after stopping treatment.     

The Individual and Organizational Role of Physicians in Mitigating the Biological,Psychological and Social Health Consequences of Displacement

The number of Internally Displaced People is growing globally with a significant number travelling to countries such as Canada. These individuals have unique health care needs that are significantly impacted by several social determinants of health, which provides a challenge to the physician as they must address the biological, psychological and social factors in order to effectively improve the health of this population. The physician must work at the individual, national, and international levels and collaborate with other health care workers in order to effectively address these complex health care issues. Some recent strategies that show promise in targeting these complex care issues include knowledge sharing among medical professionals, specialized treatment approaches including treatment through telemedicine as well as political advocacy. The application of strategies such as these, along with increased awareness and commitment from physicians, will work to improve health care and prevent negative health outcomes in this growing population.