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Tay HS, Wood AD, Carter B, Pearce L, McCarthy K, Stechman MJ, Myint PK, Hewitt J. Impact of Surgery on Older Patients Hospitalized With an Acute Abdomen: Findings From the Older Persons Surgical Outcome Collaborative. Front Surg 2020; 7:583653. [PMID: 33282905 PMCID: PMC7705344 DOI: 10.3389/fsurg.2020.583653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/22/2020] [Indexed: 11/16/2022] Open
Abstract
Background: The impact of surgery compared to non-surgical management of older general surgical patients is not well researched. Methods: We examined the association between management and adverse outcomes in a cohort of emergency general surgery patients aged > 65 years. This multi-center study included 727 patients (mean+/-SD, 77.1 ± 8.2 years, 54% female) admitted to five UK hospitals. Data were analyzed using multi-level crude and multivariable logistic regression. Outcomes were: mortality at Day 30 and 90, length of stay, and readmission within 30 days of discharge. Covariates assessed were management approach, age, sex, frailty, polypharmacy, anemia, and hypoalbuminemia. Results: Approximately 25% of participants (n = 185) underwent emergency surgery. Frailty and albumin were associated with mortality at 30 (frailty OR = 3.52 [95% CI 1.66–7.49], albumin OR = 3.78 ([95% CI 1.53–9.31]), and 90 days post discharge (frailty OR = 3.20 [95% CI 1.86–5.51], albumin OR=3.25 [95% CI 1.70–6.19]) and readmission (frailty OR = 1.56 [95% CI (1.04–2.35)]). Surgically managed patients and frailty had increased odds of prolonged hospitalization (surgery OR = 5.69 [95% CI 3.67–8.80], frailty OR = 2.17 [95% CI 1.46–3.23]). Conclusion: We found the impact of surgery on length of hospitalization in older surgical patients is substantial. Whether early comprehensive geriatric assessment and post-op rehabilitation would improve this outcome require further evaluation.
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Affiliation(s)
- Hui Sian Tay
- Department of Geriatric Medicine, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Adrian D Wood
- Department of Geriatric Medicine, Aberdeen Royal Infirmary, Aberdeen, United Kingdom.,Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Ben Carter
- Department of Biostatistics and Health Informatics, King's College, London, United Kingdom
| | - Lyndsay Pearce
- Department of General Surgery, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Kathryn McCarthy
- Department of General Surgery, North Bristol National Health Service (NHS) Trust, Bristol, United Kingdom
| | - Michael J Stechman
- Department of General Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Phyo K Myint
- Department of Geriatric Medicine, Aberdeen Royal Infirmary, Aberdeen, United Kingdom.,Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Jonathan Hewitt
- Department of Geriatric Medicine, Cardiff University, Cardiff, United Kingdom
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The Prevalence of Delirium in An Older Acute Surgical Population and Its Effect on Outcome. Geriatrics (Basel) 2019; 4:geriatrics4040057. [PMID: 31623269 PMCID: PMC6960557 DOI: 10.3390/geriatrics4040057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 10/04/2019] [Accepted: 10/05/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND With an ageing population, an increasing number of older adults are admitted for assessment to acute surgical units. Older adults have specific factors that may influence outcomes, one of which is delirium (acute cognitive impairment). OBJECTIVES To establish the prevalence of delirium on admission in an older acute surgical population and its effect on mortality. Secondary outcomes investigated include hospital readmission and length of hospital stay. METHOD This observational multi-centre study investigated consecutive patients, ≥65 years, admitted to the acute surgical units of five UK hospitals during an eight-week period. On admission the Confusion Assessment Method (CAM) score was performed to detect delirium. The effect of delirium on important clinical outcomes was investigated using tests of association and logistic regression models. RESULTS The cohort consisted of 411 patients with a mean age of 77.3 years (SD 8.1). The prevalence of admission delirium was 8.8% (95% CI 6.2-11.9%) and cognitive impairment was 70.3% (95% CI 65.6-74.7%). The delirious group were not more likely to die at 30 or 90 days (OR 1.1, 95% CI 0.2 to 5.1, p = 0.67; OR 1.4, 95% CI 0.4 to 4.1. p = 0.82) or to be readmitted within 30 days of discharge (OR 0.9, 95% CI 0.4 to 2.2, p = 0.89). Length of hospital stay was significantly longer in the delirious group (median 8 vs. 5 days respectively, p = 0.009). CONCLUSION Admission delirium occurs in just under 10% of older people admitted to acute surgical units, resulting in significantly longer hospital stays.
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Ablett AD, Browning A, Quan V, Tay HS, McCormack C, Carter B, Hewitt J, Myint PK. Anti-cholinergic burden and patient related clinical outcomes in an emergency general surgical setting. Asian J Surg 2018; 42:527-534. [PMID: 30420155 DOI: 10.1016/j.asjsur.2018.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 09/03/2018] [Accepted: 10/17/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND/OBJECTIVE The impact of medications with anti-cholinergic properties on morbidity and mortality of unselected adult patients admitted to the emergency general surgical setting has not been investigated. METHODS All cases were identified prospectively from unselected adult patients admitted to the emergency general surgical ward between May to July 2016 in a UK centre with a catchment population circa 500,000. Prescribed medication lists were ascertained from case notes and electronic medical records. Anti-Cholinergic Burden (ACB) was calculated from medication lists. Patients were categorised into three groups based on ACB; none (ACB score of 0); moderate (up to ACB score of two); high (ACB score more than two). The effect of increasing ACB on selected outcomes of 30- and 90-day mortality, hospital readmission within 30-days of discharge and increased length of hospital stay were examined using multivariable logistic regression models. RESULTS The 452 patients had a mean age (SD) of 51.7 (±20.6) years, 273 (60.4%) patients had no ACB burden, 106 (23.5%) had a ACB burden of up to two; and 73 (16.2%) had an ACB burden of > 2. Multivariable analyses showed no association between high ACB burden and 90-day (fully adjusted odds ratio [OR] 0.56 (95%CI 0.12-2.85); P = 0.48) and 30-day mortality (fully adjusted OR = 0.75 (95%CI 0.05-11.04); P = 0.84). A significant association was observed between moderate ACB burden and 30-day hospital readmission (fully adjusted OR = 2.01 (95%CI 1.09-3.71); P = 0.03). CONCLUSIONS Anti-cholinergic burden may be linked to hospital readmission in adults admitted to an emergency general surgical ward.
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Affiliation(s)
- Andrew D Ablett
- Institute of Applied Health Sciences, University of Aberdeen, UK
| | - Aimee Browning
- Department of Population Medicine, Cardiff University, UK
| | - Vincent Quan
- Department of Surgery, Dorset County Hospital, Dorchester, UK
| | - Hui S Tay
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychology Psychiatry and Neuroscience, King's College London, UK
| | | | - Phyo K Myint
- Institute of Applied Health Sciences, University of Aberdeen, UK; NHS Grampian, Foresterhill Road, Foresterhill, Aberdeen, UK
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Myint PK, Owen S, McCarthy K, Pearce L, Moug SJ, Stechman MJ, Hewitt J, Carter B. Is anemia associated with cognitive impairment and delirium among older acute surgical patients? Geriatr Gerontol Int 2018; 18:1025-1030. [PMID: 29498179 PMCID: PMC6099313 DOI: 10.1111/ggi.13293] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Revised: 12/12/2017] [Accepted: 01/24/2018] [Indexed: 12/31/2022]
Abstract
AIM The determinants of cognitive impairment and delirium during acute illness are poorly understood, despite being common among older people. Anemia is common in older people, and there is ongoing debate regarding the association between anemia, cognitive impairment and delirium, primarily in non-surgical patients. METHODS Using data from the Older Persons Surgical Outcomes Collaboration 2013 and 2014 audit cycles, we examined the association between anemia and cognitive outcomes in patients aged ≥65 years admitted to five UK acute surgical units. On admission, the Confusion Assessment Method was carried out to detect delirium. Cognition was assessed using the Montreal Cognitive Assessment, and two levels of impairment were defined as Montreal Cognitive Assessment <26 and <20. Logistic regression models were constructed to examine these associations in all participants, and individuals aged ≥75 years only. RESULTS A total of 653 patients, with a median age of 76.5 years (interquartile range 73.0-80.0 years) and 53% women, were included. Statistically significant associations were found between anemia and age; polypharmacy; hyperglycemia; and hypoalbuminemia. There was no association between anemia and cognitive impairment or delirium. The adjusted odds ratios of cognitive impairment were 0.95 (95% CI 0.56-1.61) and 1.00 (95% CI 0.61-1.64) for the Montreal Cognitive Assessment <26 and <20, respectively. The adjusted odds ratio of delirium was 1.00 (95% CI 0.48-2.10) in patients with anemia compared with those without. Similar results were observed for the ≥75 years age group. CONCLUSIONS There was no association between anemia and cognitive outcomes among older people in this acute surgical setting. Considering the retrospective nature of the study and possible lack of power, findings should be taken with caution. Geriatr Gerontol Int 2018; 18: 1025-1030.
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Affiliation(s)
- Phyo Kyaw Myint
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.,Department of Medicine for the Elderly, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Stephanie Owen
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Kathryn McCarthy
- Department of General Surgery, North Bristol NHS Trust, Bristol, UK
| | - Lyndsay Pearce
- Department of General Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Susan J Moug
- Department of General Surgery, Royal Alexandra Hospital, Paisley, Greater Glasgow, UK
| | - Michael J Stechman
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | | | - Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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Goeteyn J, Evans LA, De Cleyn S, Fauconnier S, Damen C, Hewitt J, Ceelen W. Frailty as a predictor of mortality in the elderly emergency general surgery patient. Acta Chir Belg 2017; 117:370-375. [PMID: 28602153 DOI: 10.1080/00015458.2017.1337339] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The number of surgical procedures performed in elderly and frail patients has greatly increased in the last decades. However, there is little research in the elderly emergency general surgery patient. The aim of this study was to assess the prevalence of frailty in the emergency general surgery population in Belgium. Secondly, we examined the length of hospital stay, readmission rate and mortality at 30 and 90 days. METHODS We conducted a prospective observational study at Ghent University Hospital. All patients older than 65 admitted to a general surgery ward from the emergency department were eligible for inclusion. Primary endpoint was mortality at 30 days. Secondary outcomes were mortality at 90 days, readmissions and length of stay. Cross-sectional observations were performed using the Fisher exact test, Mann-Whitney U-test, or one-way ANOVA. We performed a COX multivariable analysis to identify independent variables associated with mortality at 30 and 90 days as well as the readmission risk. RESULTS Data were collected from 98 patients in a four-month period. 23.5% of patients were deemed frail. 79% of all patients underwent abdominal surgery. Univariate analyses showed that polypharmacy, multimorbidity, a history of falls, hearing impairment and urinary incontinence were statistically significantly different between the non-frail and the group. Frail patients showed a higher incidence for mortality within 30 days (9% versus 1.3% (p = .053)). There were no differences between the two groups for mortality at 90 days, readmission, length of stay and operation. Frailty was a predictor for mortality at 90 days (p= .025) (hazard ratio (HR) 10.83 (95%CI 1.34-87.4)). Operation (p= .084) (HR 0.16 (95%CI 0.16-1.29)) and the presence of chronic cardiac failure (p= .049) (HR 0.38 (95%CI 0.14-0.99)) were protective for mortality at 90 days. CONCLUSION Frailty is a significant predictor for mortality for elderly patients undergoing emergency abdominal/general surgery. LEVEL OF EVIDENCE Level II therapeutic study.
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Affiliation(s)
- Jens Goeteyn
- Department of GI Surgery, University Hospital, Ghent, Belgium
| | - Louis A. Evans
- Department of Surgery, University Hospital Wales, Cardiff, UK
| | - Siem De Cleyn
- Department of GI Surgery, University Hospital, Ghent, Belgium
| | | | - Caroline Damen
- Department of GI Surgery, University Hospital, Ghent, Belgium
| | - Jonathan Hewitt
- Department of Population Medicine, Cardiff University, Cardiff, UK
| | - Wim Ceelen
- Department of GI Surgery, University Hospital, Ghent, Belgium
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Russo MP, Elizondo CM, Giunta DH, Grande Ratti MF. Prevalence of hyperglycemia and incidence of stress hyperglycemia in hospitalized patients: A retrospective cohort. Eur J Intern Med 2017; 43:e15-e17. [PMID: 28465029 DOI: 10.1016/j.ejim.2017.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 04/19/2017] [Indexed: 11/18/2022]
Affiliation(s)
- María Paula Russo
- Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | | | - Diego Hernán Giunta
- Internal Medicine Research Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Vogel TR, Smith JB, Kruse RL. The association of postoperative glycemic control and lower extremity procedure outcomes. J Vasc Surg 2017; 66:1123-1132. [PMID: 28433336 DOI: 10.1016/j.jvs.2017.01.053] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 01/03/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The effect of postoperative hyperglycemia in patients undergoing open and endovascular procedures on the lower extremities has not been fully characterized with regard to associated admission diagnoses, hospital complications, mortality, and 30-day readmission. This study evaluated the relationship of postoperative hyperglycemia on outcomes after lower extremity vascular procedures for peripheral artery disease. METHODS Patients with peripheral artery disease admitted for elective lower extremity procedures between September 2008 and March 2014 were selected from the Cerner Health Facts (Cerner Corporation, Kansas City, Mo) database using International Classification of Diseases, Ninth Edition, Clinical Modification diagnosis and procedure codes. Using χ2 analysis, we evaluated the relationship of postoperative hyperglycemia (>180 mg/dL) with sociodemographic characteristics, acute and chronic diagnoses, infections, hospital length of stay (LOS), and 30-day readmission. An adjusted multivariable logistic model was used to examine the association of postoperative hyperglycemia with infection and LOS. RESULTS Of 3586 patients in the study, 2812 (78%) had optimal postoperative glucose control, and 774 (22%) had suboptimal glucose control (hyperglycemia). On average, patients with postoperative hyperglycemia experienced longer hospital stays (6.9 vs 5.1 days; P < .0001), higher Charlson Comorbidity Index scores (3.4 vs 2.5, P < .0001), higher rates of infection (23% vs 14%, P < .0001), more acute complications (ie, fluid and electrolyte disorders, acute renal failure, postoperative respiratory complications), and chronic problems (ie, anemia, chronic heart disease, chronic kidney disease, and diabetes) than patients with optimal glucose control. Overall 30-day readmission was 10.9% and was similar between the groups (10.9% for both; P = .93). Major amputations did not differ between groups (P = .21). After adjusting for other risk factors using multivariable logistic regression, patients with hyperglycemia have 1.3-times the odds to have an infectious complication compared with those with optimal glucose control (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.06-1.69) and 1.7-times the odds to have a hospital LOS >10 days (OR, 1.69; 95% CI, 1.32-2.15). As well, patients with postoperative hyperglycemia have 8.4-times the odds of dying in the hospital (OR, 8.40; 95% CI, 3.95-17.9). CONCLUSIONS One in five patients undergoing vascular procedures had postoperative hyperglycemia. Postoperative hyperglycemia was associated with adverse events after lower extremity vascular procedures in patients with and without diabetes, including infection, increased hospital utilization, and mortality. No difference was found with respect to hospital readmission. Postprocedure glucose management may represent an important quality marker for improving outcomes after lower extremity vascular procedures.
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Affiliation(s)
- Todd R Vogel
- Division of Vascular Surgery, Department of Surgery, University of Missouri, School of Medicine, Columbia, Mo.
| | - Jamie B Smith
- Department of Family and Community Medicine, University of Missouri, School of Medicine, Columbia, Mo
| | - Robin L Kruse
- Department of Family and Community Medicine, University of Missouri, School of Medicine, Columbia, Mo
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