Emergency laparotomy in older adults with geriatric medicine input implications of demographics, frailty and comorbidities on outcomes.

BACKGROUND: We (1) describe West Australian (WA) older adults undergoing emergency laparotomy (EL) in a tertiary-centre Acute Surgical Unit (ASU) with proactive geriatrician input and (2) explore the impact of Clinical Frailty Scale (CFS) and Charlson's Comorbidity Index (CCI) on patient outcomes. METHODS: We performed a prospective cohort-study of older adults undergoing EL, between April 2021 and April 2022, in a tertiary ASU, with dedicated geriatrician-led perioperative care via the Older Adult Surgical Inpatient Service (OASIS). RESULTS: Of 114 patients, average age was 76.7 ± 7.61 years-old (range 65-96), with 35.1% (n = 40) frail (CFS 5-7), 18.4% (n = 21) vulnerable (CFS 4) and 46.5% (n = 74) not frail (CFS 1-3). 61.4% (n = 70) were severely comorbid (CCI ≥5), 34.2% (n = 39) moderately comorbid (CCI 3-4), and 4.4% (n = 5) mildly comorbid (CCI 1-2). 95.9% (n = 109) EL patients were reviewed by OASIS. Inpatient mortality was 7.9% (n = 9) and 1-year mortality 16.7% (n = 19). Majority, 64.9% (n = 74), were discharged directly home with 17.5% (n = 20) discharged with in-home rehabilitation. Each increment in CCI was associated with increased in-hospital (HR 1.38, p = 0.034) and 1-year (HR 1.39, p = 0.006) mortality, and each increment in CFS with 1-year mortality (HR 1.62, p = 0.016). Higher CFS but not CCI was associated with increased level of care at discharge. Age was not statistically significant with any outcomes. CONCLUSION: We describe demographics, frailty and comorbidity of 114 older adults undergoing EL in ASU. We suggest CFS and CCI as independent risk-stratification tools, and proactive management of both comorbidity, and frailty, should be incorporated into preoperative optimisation.

Uptake of Best Medical Therapy: Secondary Prevention of Cardiovascular Disease in Vascular Surgical Patients in Western Australia.

Best medical therapy (BMT) for peripheral arterial disease (PAD), carotid artery stenosis (CAS) and abdominal aortic aneurysm (AAA) involving concomitant use of antiplatelets, lipid-lowering agents, and blood pressure control, improves patient survival and prevents clinical cardiovascular disease (CVD). We performed a single-center cross-sectional study, over a 4-year period, describing BMT use in Western Australian patients with symptomatic PAD, CAS and AAA in the community. Overall, 45.3% of our cohort (n = 1689) were on appropriate BMT (CAS, 58.1%; PAD, 43.1%; AAA, 41.1%). There was highest uptake of blood pressure control at 93.0% (lipid-lowering agents, 65.3%; antithrombotics 63.5%). PAD was associated with highest uptake of blood pressure control (PAD 93.9%; CAS, 91.4%; AAA, 91.1%, P = .092) whilst CAS had highest uptake of antithrombotics (CAS 76.3%; PAD, 61.0%; AAA 60.4%, P < .001) and lipid-lowering agents (CAS 78.7%; PAD, 63.1%; AAA, 60.4%, P < .001). Our study indicates suboptimal use of BMT in patients with vascular disease in the community. The risk of CVD in CAS is likely misperceived as higher than PAD and AAA.

Extent of Abdominal Aortic Calcification Is Associated With Incident Rapid Weight Loss Over 5 Years: The Perth Longitudinal Study of Ageing Women.

BACKGROUND: Abdominal aortic calcification (AAC), a marker of vascular disease, is associated with disease in other vascular beds including gastrointestinal arteries. We investigated whether AAC is related to rapid weight loss over 5 years and whether rapid weight loss is associated with 9.5-year all-cause mortality in community-dwelling older women. METHODS: Lateral spine images from dual-energy x-ray absorptiometry (1998/1999) were used to assess AAC (24-point AAC scoring method) in 929 older women. Over 5 years, body weight was assessed at 12-month intervals. Rapid weight loss was defined as >5% decrease in body weight within any 12-month interval. Multivariable-adjusted logistic regression was used to assess AAC and rapid weight loss and Cox regression to assess the relationship between rapid weight loss and 9.5-year all-cause mortality. RESULTS: Mean±SD age of women was 75.0±2.6 years. During the initial 5 years, 366 (39%) women presented with rapid weight loss. Compared with women with low AAC (24-point AAC score 0-1), those with moderate (24-point AAC score 2-5: odds ratio, 1.36 [95% CI, 1.00-1.85]) and extensive (24-point AAC score 6+: odds ratio, 1.59 [95% CI, 1.10-2.31]) AAC had higher odds for presenting with rapid weight loss. Results remained similar after further adjustment for dietary factors (alcohol, protein, fat, and carbohydrates), diet quality, blood pressure, and cholesterol measures. The estimates were similar in subgroups of women who met protein intake (n=599) and physical activity (n=735) recommendations (extensive AAC: odds ratios, 1.81 [95% CI, 1.12-2.92] and 1.58 [95% CI, 1.02-2.44], respectively). Rapid weight loss was associated with all-cause mortality over the next 9.5 years (hazard ratio, 1.49 [95% CI, 1.17-1.89]; P=0.001). CONCLUSIONS: AAC extent was associated with greater risk for rapid weight loss over 5 years in older women, a risk for all-cause mortality. Since the association was unchanged after taking nutritional intakes into account, these data support the possibility that vascular disease may play a role in the maintenance of body weight.

Femoral canal lipoma presenting as chronic venous insufficiency.

Lower limb venous obstruction secondary to a lipoma is a rare occurrence. Patients with these benign soft tissue tumors can be asymptomatic, or may experience symptoms of pain, parasthesia, paralysis and swelling secondary to compression on adjacent neurovascular structures. Duplex ultrasound examination is the first-line investigation, but has its limitations. We report on a case of venous obstruction syndrome misdiagnosed as chronic venous insufficiency on duplex ultrasound examination, from a deep-seated giant lipoma compressing on the common femoral and distal external iliac vein in a patient with Dercum's disease.

Bowel Ischemia Secondary to Campylobacter Enterocolitis: A Case Series and Review of the Literature.

Campylobacter is the most common cause of diarrheal illness worldwide and is generally self-limiting. We present two cases of Campylobacter enterocolitis complicated by bowel ischemia in a 79-year-old male and a 53-year-old male, both presenting with abdominal pain and diarrhea and elevated lactate and C-reactive protein (CRP) levels. CT demonstrated common findings of pneumatosis intestinalis (PI) and portal venous gas. Exploratory laparotomy performed on the former demonstrated extensive small bowel infarction that was noncompatible with life and he was palliated postoperatively. The latter improved clinically after resection of the ischemic section of the small bowel with primary stapled anastomosis and closure. Clinicians need to be aware of the potentially fatal complications of Campylobacter-associated enterocolitis and should maintain a high clinical index of suspicion so that early surgical intervention can be considered in this patient population.

Abdominal aortic calcification, cardiac troponin I and atherosclerotic vascular disease mortality in older women.

OBJECTIVE: Examine if two inexpensive measures of atherosclerotic vascular diseases (ASVD), abdominal aortic calcification (AAC) and high-sensitivity cardiac troponin I (hs-cTnI) provide complementary information for 10-year ASVD mortality and all-cause mortality risk in older women. METHODS: 908 community-dwelling women without prevalent ASVD (≥75 years) were followed-up between 2003 and 2013. AAC and plasma hs-cTnI measures were obtained in 2003. AAC was assessed on lateral spine images using a semiquantitative method (AAC24). Linked health records were used for mortality outcomes. RESULTS: Mean±SD age was 79.9±2.6 years. 276 (30.4%) women died during follow-up, including 138 (15.2%) ASVD-related deaths. AAC24 and hs-cTnI were independently associated with ASVD and all-cause mortality (p<0.001). The cohort was dichotomised into four groups: (1) low AAC24 (AAC24: 0 or 1) and 1) and