Factors Predictive of Mortality among Geriatric Patients Sustaining Low-Energy Blunt Trauma.

Background: In geriatric trauma patients, higher mortality rate is observed compared to younger patients. A significant portion of trauma sustained by this age group comes from low-energy mechanisms (fall from standing or sitting). We sought to investigate the outcome of these patients and identify factors associated with mortality. Methods: A retrospective review of 1285 geriatric trauma patients who came to our level 1 trauma center for trauma activation (hospital alert to mobilize surgical trauma service, emergency department trauma team, nursing, and ancillary staff for highest level of critical care) after sustaining low-energy blunt trauma over a 1-year period. IRB approval was obtained, data collected included demographics, vital signs, laboratory data, injuries sustained, length of stay and outcomes. Patients were divided into three age categories: 65−74, 75−84 and >85. Comorbidities collected included a history of chronic renal failure, COPD, Hypertension and Myocardial Infarction. Results: 1285 geriatric patients (age > 65 years) presented to our level 1 trauma center for trauma activation with a low-energy blunt trauma during the study period; 34.8% of the patients were men, 20.5% had at least one comorbidity, and 89.6% were white. Median LOS was 5 days; 37 (2.9%) patients died. Age of 85 and over (OR 3.44 with 95% CI 1.01−11.7 and 2.85 with 95% CI 1.0−6.76, when compared to 65−74 and 75−84, respectively), injury severity score (ISS) (OR 1.08, 95% CI 1.02 to 1.15) and the presence of more than one comorbidity (OR 2.68, 95% CI 1.26 to 5.68) were independently predictive of death on multi-variable logistic regression analysis. Conclusion: Age more than 85 years, higher injury severity score and the presence of more than one comorbidity are independent predictors of mortality among geriatric patients presenting with low-energy blunt trauma.

The Association of Gender and Mortality in Geriatric Trauma Patients.

The association of gender with mortality in trauma remains a subject of debate. Geriatric trauma patients have a higher risk of mortality compared to younger patients. We sought to evaluate the association of gender with mortality in a group of geriatric trauma patients presenting to an academic level 1 trauma center (trauma center designated by New York State capable of handling the most severe injuries and most complex cases). METHODS: We performed a retrospective review of geriatric trauma patients who were admitted to our trauma center between January 2018 and December 2020. Data collected included vital signs, demographics, injury, and clinical characteristics, laboratory data and outcome measures. The study controlled for co-morbidities, injury severity score (ISS), and systolic blood pressure (SBP) in the ED. Multivariable logistic regression analysis was performed to evaluate the association of gender and mortality. RESULTS: 4432 geriatric patients were admitted during the study period, there were 1635 (36.9%) men and 3859 (87.2%) were White with an average age of 81 ± 8.5 years. The mean ISS was 6.7 ± 5.4 and average length of stay was 6 ± 6.3 days. There were 165 deaths. Male gender (OR 1.94, 95% CI 1.38 to 2.73), ISS (OR 1.12, 95% CI 1.09 to 1.14), Emergency Department SBP less than 90 mmHg (OR 6.17, 95% CI 3.17 to 12.01), and having more than one co-morbidity (OR 2.28, 95% CI 1.55 to 3.35) were independently predictive of death on multivariable logistic regression analysis. CONCLUSION: Male gender, Emergency Department systolic blood pressure less than 90 mmHg, having more than one co-morbidity, and injury severity are independent predictors of mortality among geriatric trauma patients.

Medical home visit programs during COVID-19 state of emergency.

Elderly, homebound individuals comprise a vulnerable segment of society who have been disproportionately affected by the coronavirus disease 2019 (COVID-19) pandemic through a myriad of unique challenges. There is a significant amount of fear of acquiring COVID-19 by seeking health care services, which has adversely affected patients by worsening fixable situations. Another challenge is the decrease in diagnostic support for evaluating patients compared with a pre-COVID-19 world. Agencies providing at-home phlebotomy, portable radiology, and support services have had to limit their home visits due to an inability to access personal protective equipment. This loss of diagnostic and therapeutic support has had an emotional toll on patients and their caregivers. COVID-19 has had a tremendous impact on the health and finances of home health aides and their patients. Loss of long-term home health aides has adversely affected younger patients with ailments like Down syndrome as well as older patients with dementia. COVID-19 has also increased pressure on end-of-life decision making. Patients and their families are increasingly opting for palliative care and hospice programming to avoid separation. Families are being forced to consider advance directives under an increased emotional strain as patients become "persons under investigation" for COVID-19. Technology has allowed for the provision of services through telehealth, and changes to policy by CMS have aided widespread implementation of telemedicine. We anticipate continuing to be nimble in the face of challenge and to provide timely and meaningful care for those who depend on our efforts.

Perspective: What a Difference a Disaster Makes: The Telehealth Revolution in the Age of COVID-19 Pandemic.

Despite the existence of telemedicine since the late 1950s and early 1960s, it took a pandemic to bring this technology mainstream. The critical urgency of the pandemic drove an auspicious alignment of policy, economics, and technology to facilitate the widespread implementation of telehealth. It is imperative that this synchronicity be maintained in the post-COVID era in order to optimize our health care system to be ready for the next threat to the health of the United States.

Enduring Challenge of Latent Tuberculosis in Older Nursing Home Residents: A Brief Review.

Tuberculosis (TB) kills almost 4,000 people a day and is competing with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) as the most deadly infectious disease in the world. The gold standards of detection and management of latent tuberculosis infection (LTBI) have not been successful in complete eradication of the disease. Current screening modalities of TB include tuberculin skin testing (TST) and/or interferon-γ release assay (IGRA). However, these screening tests have been heavily studied in healthy populations but not in the elderly who are more likely to have multiple risk factors for progression to active TB from LTBI. The largest population that is harboring LTBI is the elderly, specifically those residing in nursing homes. Yet, unfortunately, guidelines for standards of detection and treatment for this specific group are lacking. In this review, we look at TST versus IGRA screening for LTBI in the elderly living in nursing homes. We review a cross-sectional study done at Staten Island University Hospital, and several other assessments of the sensitivity and accuracy of both screening tools. Furthermore, this review looks at the appropriateness of current LTBI treatment and prophylaxis in elderly patients residing in close quarters. The reviews point to the superiority of IGRA testing in the elderly for screening LTBI. The IGRA has been shown to be more sensitive to the detection of LTBI than TST. Additionally, medical complexities that the elderly population possesses may present challenges and resistance to standard treatments of LTBI. It is recommended via the literature that the addition of vitamin D, or alternative therapies (e.g. rifampin) could produce better outcomes for elderly patients with LTBI than the current 9 months of isoniazid (INH). As the older adults represent the fastest growing segment of our population and the largest LTBI reservoir in the USA, revisiting screening and treatment of LTBI in the elderly living in nursing homes may prove to lead to a path of TB eradication once and for all.

Obstructive Sleep Apnea Screening in Patients With Atrial Fibrillation: Missed Opportunities for Early Diagnosis.

BACKGROUND: "There is a high prevalence of obstructive sleep apnea (OSA) among patients with atrial fibrillation (AF). There is also strong evidence that proper OSA management can reduce AF recurrence." Polysomnography is the gold standard for OSA diagnosis, but screening tests, such as STOP-BANG, have been successful in identifying patients at risk for OSA. Our study assesses screening rates for OSA in patients with persistent AF, and willingness of patients at increased risk for OSA towards further diagnostic evaluation. METHODS: A total of 254 persistent AF patients were surveyed regarding prior screening for OSA, and if previously unscreened, assessed with STOP-BANG. Prior cardioversions and willingness to undergo further workup was also recorded. Patients at risk for OSA were given educational brochures. Subjects with diagnosis of OSA were asked about their compliance with positive airway pressure therapy. RESULTS: Sixty-six percent of AF patients were never screened for OSA; 75% unscreened participants (95% CI: 68-81%) were at high risk for OSA. Patients with previous hospitalizations or electrical cardioversions were more frequently screened for OSA (P = 0.02, P = 0.03, respectively). Forty-three percent of high-risk individuals had a BMI < 30. Among patients at risk for OSA (score ≥ 3), the majority (n = 99, 79%) were interested in follow-up with a sleep study (n = 93, 74%). CONCLUSIONS: Although there is a strong OSA-associated risk for AF, which is amenable to intervention, most patients with persistent AF are not assessed for OSA. Simple to use screening questionnaires are sensitive and can reliably identify patients at high risk for OSA, reserving costlier and somewhat inconvenient nocturnal polysomnography to only those at risk. We hope our study will help to push the AF and OSA connection into the spotlight in the primary care of patients with AF.

Unique synergistic formulation of curcumin, epicatechin gallate and resveratrol, tricurin, suppresses HPV E6, eliminates HPV+ cancer cells, and inhibits tumor progression.

Curcumin (from curry) (C) is highly potent against cervical cancer cells (CCC), but poor bioavailability has limited its clinical use. Similar natural polyphenols resveratrol (from grapes) (R), and epicatechin gallate (from green tea) (E) also display activity against CCC. By treating CCC (HeLa) with C, E, or R, or combinations of these compounds, we computed combination indices and observed a strong synergism among C, E, and R at the unique molar ratio 4:1:12.5. This combination, named as TriCurin, rapidly down regulated HPV18 E6 and NF-kB expression while concomitantly inducing the tumor suppressor protein p53 in HeLa cells. In the mouse c-Ha-ras and HPV16 E6, E7-expressing TC-1 CCC, both C and TriCurin elicited suppression of E6, induction of both p53 and acetyl-p53 (activated p53), and activation of caspase-3, but the TriCurin-evoked changes were several-fold greater than that produced by curcumin (4.7-fold for E6 inhibition, and 2-fold, 6-fold, and 1.7-fold for the induction of p53, acetyl-p53, and active caspase-3, respectively). Consequently, TriCurin was more potent in killing TC-1 and HeLa cells. Intralesional TriCurin treatment of tumors generated in mice by subcutaneously implanting the TC-1 CCC caused an 80-90% decrease in tumor growth. The ability of C to eliminate HeLa cells was significantly stabilized when delivered as TriCurin than when delivered alone. Topical application of TriCurin dispersed in a cream base afforded efficient transfer of C across the skin. Subcutaneous TriCurin injection yielded no adverse effect in tumor-naïve healthy mice. Thus, TriCurin is a safe and promising therapeutic agent against HPV-associated disease.

Diagnostic imaging of cervical intraepithelial neoplasia based on hematoxylin and eosin fluorescence.

BACKGROUND: Pathological classification of cervical intraepithelial neoplasia (CIN) is problematic as it relies on subjective criteria. We developed an imaging method that uses spectroscopy to assess the fluorescent intensity of cervical biopsies derived directly from hematoxylin and eosin (H&E) stained tissues. METHODS: Archived H&E slides were identified containing normal cervical tissue, CIN I, and CIN III cases, from a Community Hospital and an Academic Medical Center. Cases were obtained by consensus review of at least 2 senior pathologists. Images from H&E slides were captured first with bright field illumination and then with fluorescent illumination. We used a Zeiss Axio Observer Z1 microscope and an AxioVision 4.6.3-AP1 camera at excitation wavelength of 450-490 nm with emission captured at 515-565 nm. The 32-bit grayscale fluorescence images were used for image analysis. RESULTS: We reviewed 108 slides: 46 normal, 33 CIN I and 29 CIN III. Fluorescent intensity increased progressively in normal epithelial tissue as cells matured and advanced from the basal to superficial regions of the epithelium. In CIN I cases this change was less prominent as compared to normal. In high grade CIN lesions, there was a slight or no increase in fluorescent intensity. All groups examined were statistically different. CONCLUSION: Presently, there are no markers to help in classification of CIN I-III lesions. Our imaging method may complement standard H&E pathological review and provide objective criteria to support the CIN diagnosis.

A novel curcumin-based vaginal cream Vacurin selectively eliminates apposed human cervical cancer cells.

OBJECTIVE: Human papillomavirus (HPV) infections remain a leading cause of mortality worldwide. In the U.S. strategies via screening and vaccination prevent HPV-associated cervical neoplasms, but consume immense healthcare costs. The spice component curcumin has potent anticancer and antiviral properties, which have been difficult to harness as a treatment, due to its poor systemic bioavailability. This project tests the possibility of developing a curcumin-based therapy for cervical cancer. METHODS: Using four HPV(+) cervical cancer cell lines and normal fibroblasts we first tested the selectivity and potency of curcumin in eliminating HPV(+) cells. Subsequently, we developed a curcumin-based cervical cream and tested its efficacy in eliminating apposed HPV(+) cells and also its possible side effects on the vaginal epithelium of healthy mice. RESULTS: Curcumin selectively eliminates a variety of HPV(+) cervical cancer cells (HeLa, ME-180, SiHa, and SW756), suppresses the transforming antigen E6, dramatically inhibits the expression of the pro-cancer protein epidermal growth factor receptor (EGFR), and concomitantly induces p53. Additionally, Vacurin, a uniform colloidal solution of curcumin in a clinically used amphipathic vaginal cream, eliminates apposed HeLa cells while suppressing the expression of EGFR. In mice, daily intravaginal application of Vacurin for three weeks produced no change in body weight and when the mice were sacrificed, the vaginal tract epithelium showed no Vacurin-evoked adverse effects. CONCLUSION: We have developed a curcumin-based vaginal cream, which effectively eradicates HPV(+) cancer cells and does not affect non-cancerous tissue. Our preclinical data support a novel approach for the treatment of cervical HPV infection.

Endonuclease-resistant DNA: a novel histochemical marker for cervical intraepithelial neoplasia and cervical carcinoma.

The diagnosis of cervical intraepithelial neoplasia (CIN) has low interobserver reproducibility. The pathogenesis of human papillomavirus (HPV) from infection to high-grade CIN is well understood. In benign lesions, HPV-DNA is often packaged into virions, whereas malignant transformation disrupts virion assembly. It is conceivable that if cervical lesions were exposed to endonuclease digestion, HPV virions would alter nuclear susceptibility to DNA degradation. We propose that susceptibility to endonuclease digestion can serve as a simple marker to identify CIN grade. From paraffin-embedded tissue blocks, condyloma accuminata, CIN I-III, and cervical carcinoma cases were identified. Sections were placed in a bath containing DNAse I for DNA digestion. Residual DNA was stained by a Feulgen process. Endonuclease-resistant DNA (erDNA) staining was correlated to disease grade. In addition, 10 HPV (+) patients whose infection regressed and 8 whose infection progressed to CIN II or above had their initial HPV lesions stained for erDNA. erDNA was observed in 81% condylomas and 80% CIN I cases. All CIN II, III, and cancer cases were endonuclease sensitive with 100% of lesions showing no staining. Eighty percent of HPV lesions that regressed had erDNA staining, whereas 75% lesions that progressed had no erDNA staining. The spectrum of cervical disease caused by HPV has different susceptibilities to endonuclease digestion, which may aid in the diagnosis of CIN. Furthermore, in our small pilot study, erDNA status was associated with the clinical outcomes. Prospective studies are needed to confirm this observation. erDNA status is a promising novel biomarker.

Using Six Sigma methodology to reduce patient transfer times from floor to critical-care beds.

INTRODUCTION: In response to concerns regarding delays in transferring critically ill patients to intensive care units (ICU), a quality improvement project, using the Six Sigma process, was undertaken to correct issues leading to transfer delay. OBJECTIVE: To test the efficacy of a Six Sigma intervention to reduce transfer time and establish a patient transfer process that would effectively enhance communication between hospital caregivers and improve the continuum of care for patients. METHODS: The project was conducted at a 714-bed tertiary care hospital in Staten Island, New York. A Six Sigma multidisciplinary team was assembled to assess areas that needed improvement, manage the intervention, and analyze the results. RESULTS: The Six Sigma process identified eight key steps in the transfer of patients from general medical floors to critical care areas. Preintervention data and a root-cause analysis helped to establish the goal transfer-time limits of 3 h for any individual transfer and 90 min for the average of all transfers. CONCLUSIONS: The Six Sigma approach is a problem-solving methodology that resulted in almost a 60% reduction in patient transfer time from a general medical floor to a critical care area. The Six Sigma process is a feasible method for implementing healthcare related quality of care projects, especially those that are complex.

An inpatient fall prevention initiative in a tertiary care hospital.

BACKGROUND: In response to increasing inpatient fall rates, which reached 3.9 falls per 1000 inpatient-days in the last quarter of 2005, Staten Island University Hospital, a 714-bed, tertiary care hospital (Staten Island, New York), implemented a fall prevention initiative (FPI). The initiative was intended to decrease inpatient falls and associated injury by institutionalizing staff safety awareness; accountability, and critical thinking; eradicating historically acceptable system failures; and mandating a critical evaluation of safety precautions and application of fall prevention protocol. METHODS: The intervention included two phases (1) a review phase, in which existing fall prevention efforts were evaluated, and (2) the FPI implementation phase, in which systems were implemented to ensure fall risk assessments, fall incident investigations, identifying and confronting problem issues, planning and adherence to corrective action, and accountability for missed preventive opportunities. For all 1,098,471 inpatient-days of persons aged 18 years and older, with an admission lasting at least one day, between April 2006 and March 2010, data were collected for inpatient falls and fall-associated injuries per 1000 inpatient-days. RESULTS: Four-year inpatient fall rates decreased by 63.9% (p < .0001); the greatest reduction (72.3%) occurred between the first quarter (Q1) 2005 and Q4 2009. Minor and moderate fall-related injuries significantly decreased by 54.4% and 64.0%, respectively. Two falls with major injury occurred during the study. CONCLUSIONS: The FPI was associated with a significant reduction in fall and fall-related injury rates. The results suggest that increasing commitment to continuous quality improvement through enhanced safety awareness and accountability contributed to the initiative's success and led to a change of normative behavior and a culture of safety.

Severe refractory autoimmune hemolytic anemia with both warm and cold autoantibodies that responded completely to a single cycle of rituximab: a case report.

INTRODUCTION: Mixed warm and cold autoimmune hemolytic anemia runs a chronic course with severe intermittent exacerbations. Therapeutic options for the treatment of hemolysis associated with autoimmune hemolytic anemia are limited. There have been only two reported cases of the effective use of rituximab in the treatment of patients with mixed autoimmune hemolytic anemia. We report a case of severe mixed autoimmune hemolytic anemia that did not respond to steroids and responded to four weekly doses of rituximab (one cycle). CASE PRESENTATION: A 62-year-old Caucasian man presented with dyspnea, jaundice and splenomegaly. His blood work revealed severe anemia (hemoglobin, 4.9 g/dL) with biochemical evidence of hemolysis. Exposure to cold led to worsening of the patient's hemolysis and hemoglobinuria. A direct antiglobulin test was positive for immunoglobulin G and complement C3d, and cold agglutinins of immunoglobulin M type were detected. A bone marrow biopsy revealed erythroid hyperplasia. A positron emission tomographic scan showed no sites of pathologic uptake. There was no other evidence of a lymphoid or myeloid disorder. Initial therapy consisted of avoidance of cold, intravenous methylprednisolone and a trial of plasmapheresis. However, there was no clinically significant response, and the patient continued to be transfusion-dependent. He was then started on 375 mg/m2/week intravenous rituximab therapy. After two treatments, his hemoglobin stabilized and the transfusion requirement diminished. Rituximab was continued for a total of four weeks and led to the complete resolution of his hemolytic anemia and associated symptoms. At the patient's last visit, about two years after the initial rituximab treatment, he continued to be in complete remission. CONCLUSION: To the best of our knowledge, this is the first reported case of mixed-type autoimmune hemolytic anemia that did not respond to steroid therapy but responded completely to only one cycle of rituximab. The previous two reports of rituximab use in mixed autoimmune hemolytic anemia described an initial brief response to steroids and the use of rituximab at the time of relapse. In both of these case reports, the response to one cycle of rituximab was short-lived and a second cycle of rituximab was required. Our case report demonstrates that severe hemolysis associated with mixed autoimmune hemolytic anemia can be unresponsive to steroid therapy and that a single cycle of rituximab may lead to prompt and durable complete remission.

Fasting hyperglycemia upon hospital admission is associated with higher pneumonia complication rates among the elderly.

BACKGROUND: Hyperglycemia is an independent predictor of adverse outcomes during hospitalization. In patients who have pneumonia, significant hyperglycemia is associated with poor outcomes. This study evaluates the interaction of the degree of hyperglycemia and complication rates stratified by age in non-critically ill patients admitted to the hospital for care of community-acquired pneumonia. METHODS: Retrospective review of patient records coded for pneumonia. Analysis included 501 non-critically ill patients admitted to a tertiary care hospital in New York City. Data were stratified by diabetes status, age (less than 65 and 65 and over), and fasting blood glucose (FBG) within the first 24 hours of hospitalization. Among patients with no history of diabetes, FBG was stratified as "normal" [FBG /=126 mg/dl (7 mmol/l)]. The diabetic group included known diabetics regardless of FBG. The Pneumonia Severity Index (PSI) was calculated for all patients. Complications rates, hospital length of stay and mortality were compared among the groups. RESULTS: In patients age 65 and older, complication rates were 16.7% in normoglycemics, 27.5% in the "mild-hyperglycemia" group, 28.6% in the "severe hyperglycemia" group, and 25.5% in those with known diabetes. The mild and severe-hyperglycemics had similar complication rates (p = 0.94). Compared to the normal group, mild and severe groups had higher rates of complications, p = 0.05 and p = 0.03, respectively. PSI tended to be higher in those over the age of 65. PSI was not significantly different when the normal, mild, severe, and known diabetes groups were compared. PSI did not predict complications for new hyperglycemia (normals' mean score 87, mild 84.7, severe 93.9, diabetics 100). Hospital mortality did not differ among groups. Length of stay was longer (p = 0.05) among mild-hyperglycemics (days = 8.4 s.e. 14.3) vs. normals (days = 6.2 s.e.6.5). CONCLUSION: This study shows that FBS between 101-125 mg/dl (5.7-6.9 mmol/l) on hospital admission increases pneumonia complication rates among the elderly with no previous diagnosis of diabetes.

Glucose control in the hospitalized elderly--a concern not just for patients with diabetes.

Hyperglycemia is commonly noted yet undertreated among hospitalized patients. Older adults are particularly susceptible to the adverse effects of elevated glucose because of hyperglycemia-induced immune defects coupled with age-associated immune senescence. Although the American Diabetes Association (ADA) recommends maintaining fasting blood glucose (FBG) levels below 126 mg/dL and random glucose levels below 200 mg/dL in patients on general medical wards, there is limited evidence to support these targets since the recommendations are not based on randomized, controlled trials. We discuss the limitations of the current literature and present evidence from medical intensive-care studies that other glucose targets may lead to better outcomes. Furthermore, a study we conducted demonstrates that mild FBG elevations (100 to 126 mg/dL) were associated with increased morbidity among elderly patients on general medical wards. We advocate that all hospitalized patients be screened for hyperglycemia, and treatment should follow current ADA recommendations while studies are being completed to evaluate optimal targets.