Mitigation of a Coronavirus Disease 2019 Outbreak in a Nursing Home Through Serial Testing of Residents and Staff.

Nursing homes and long-term care facilities represent highly vulnerable environments for respiratory disease outbreaks, such as coronavirus disease 2019 (COVID-19). We describe a COVID-19 outbreak in a nursing home that was rapidly contained by using a universal testing strategy of all residents and nursing home staff.

In-hospital and 6-month mortality rates after open elective vs open emergent colectomy in patients older than 80 years.

BACKGROUND: There are few reports of long-term outcomes in elderly patients after open colectomy. OBJECTIVE: This study aimed to determine the in-hospital and 6-month outcomes and identify the variables associated with mortality after colectomy in patients ≥ 80 years of age. DESIGN: The charts of patients ≥ 80 years of age, who underwent open colectomy, were analyzed. Data included indications for operation, underlying diagnoses, preoperative functional status, type of procedure, length of procedure, length of stay, ASA grade, complications, and in-hospital and 6-month mortality rates. Univariate and multivariate logistic regression analyses were conducted to ascertain risk factors for mortality. P values of < .05 were considered significant. MAIN OUTCOME MEASURES: The main outcome measures were in-hospital and 6-month mortality. RESULTS: One hundred sixty-two patients ≥ 80 years of age underwent colectomy: 99 patients emergently; 63, electively. Postoperative acute renal failure (3% vs 19%, P = .0032) and in-hospital deaths were significantly higher (4.7% vs 28%, P = .0002) among the patients undergoing emergent colectomies. The mortality rate among emergent cases rose from 28% in-hospital to 52% at 6 months. Mortality among the elective cases increased similarly from 4.7% to 28.5%. Admission from a nursing facility was associated with higher in-hospital mortality (47.6% vs 14.9%, P = .0005). Discharge to a skilled nursing facility was associated with a higher 6-month mortality rate compared with discharge to home (40% vs 17%). Length of procedure, postoperative complications, perioperative blood transfusion, and emergent indications for operation independently predicted in-hospital mortality. Postoperative complications and emergent diagnosis independently predicted 6-month mortality. The 6-month mortality rate varied according to the underlying diagnosis as follows: fulminant Clostridium difficile colitis (86%); ischemic colitis (60%); gastrointestinal bleeding (37%), and volvulus (40%). LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Emergent open colectomy in elderly patients is associated with a high morbidity and mortality rate. The mortality rate rises by >20% in both elective and emergent cases at discharge to 6 months. Length of procedure, postoperative complications, and colectomy for emergent indications predicted mortality.

Laparoscopic repair of colonic anastomotic leak in an elderly patient.

BACKGROUND: Laparoscopy to repair iatrogenic colonoscopic perforation of the colon has proven to be a safe, effective, and reproducible means to treat these potentially devastating emergencies. The use of the laparoscope provides exceptional diagnostic yield, and under the hand of a trained surgeon, produces excellent therapeutic results while minimizing recovery time for the patient. METHODS: We report the case of an 86-year-old man who underwent emergent laparoscopic repair of a postoperative anastomotic leak following sigmoid colectomy. RESULTS: The patient underwent laparoscopic oversewing of a colonic anastomotic leak, omental patch, and diverting loop ileostomy. The patient recovered fully from his emergency procedure without any further complications. CONCLUSION: Laparoscopic surgery can be extended to a wider variety of colorectal emergencies in a carefully selected group of patients, including the elderly.

Alimentary tract surgery in the nonagenarian: elective vs. emergent operations.

The objective of this study was to compare elective with emergent surgery in patients over the age of 90 years. We retrospectively reviewed the records of patients over 90 years of age who underwent alimentary tract surgery between 1994 and 2002 at a community teaching hospital. Of 100 patients (mean age 92 years; range 90 to 98 years), 82 were women and 18 were men. Seventy-three percent were admitted from private homes or assisted-living facilities, and 27% came from a skilled-nursing facility (SNF). Major comorbid conditions existed in 93%. Procedures included right hemicolectomy (22%), adhesiolysis and/or small bowel resection (19%), cholecystectomy (14%), left-sided or sigmoid colectomy (11%), and perineal proctectomy (8%). Overall morbidity and mortality were 36% and 15%, respectively. Postoperative complications included respiratory failure and pneumonia (11%), arrhythmias (9%), delirium (7%), congestive heart failure and myocardial infarction (6%), and urinary complications (4%). Twenty-eight percent of the operations were elective, and 72% were emergent. Morbidity and mortality were higher in the emergent group (41% and 19%, respectively) than in the elective group (26% and 4%, respectively; P=0.04), especially for patients with an emergent surgical problem who came from a nursing home (22%). Average length of stay was 12 +/- 10 days (range 2 to 69 days) with little difference between elective and emergent cases. Sixty-four percent of patients were discharged to skilled-nursing facilities. Alimentary tract surgery can be performed safely in nonagenarians, and they should not be denied surgical care solely because of age.

Urinary tract infections. How to manage nursing home patients with or without chronic catheterization.

Urinary tract infections (UTIs)--including cystitis, pyelonephritis, and catheter-associated infections--are among the most common nursing home-acquired infections. Asymptomatic bacteriuria can be identified in 20 to 50% of nursing home residents who do not have bladder catheters and in 100% of those who do. Diagnostic tests for nursing home patients with suspected UTI include urinalysis, urine culture, and sensitivity testing. Treatment of cystitis can usually be managed in the nursing home with oral antibiotics. Initial therapy with a parenteral agent is often recommended in nursing home-acquired pyelonephritis.

Decreasing the incidence of falls in the nursing home in a cost-conscious environment: a pilot study.

OBJECTIVE: To evaluate the prevalence of falls and determine the effectiveness of three simple interventions in decreasing the number of falls in a frail nursing home population. METHODS: Charts and records were reviewed to determine the prevalence of falls. Falls were tracked according to severity and time and place of occurrence. Interventions were made in three areas: (1) Environmental: Room furniture was repositioned. (2) Staffing: One additional staff member was added (by schedule change) at the time when the incidence of falls was highest. (3) Restorative activity program: A program was added at the time when the incidence of falls was high. Falls data were again collected after the intervention. RESULTS: Before intervention, there were 479 falls resulting in 16 fractures; 221 (46%) of the falls occurred during the 3-11 shift and resulted in 63% (n = 10) of the fractures. After intervention, there were a total of 299 falls and 8 fractures. This represents a statistically significant 38% reduction in the total number of falls and a 50% reduction in the total number of fractures during this period. Additionally, falls on the evening and night shifts were significantly reduced from 221 to 115 falls and 91 to 29 falls, respectively. CONCLUSION: Our interventions may have contributed to a decrease in the overall number of falls and resultant fractures. Our data suggest these simple, practical, and easy to implement methods may positively impact the number of falls in other institutions as well.

Home-based leg-strengthening exercise improves function 1 year after hip fracture: a randomized controlled study.

OBJECTIVES: To compare the effectiveness of a short-term leg-strengthening exercise program with that of attentional control on improving strength, walking abilities, and function 1 year after hip fracture. DESIGN: Randomized controlled pilot study. SETTING: Patients' homes. PARTICIPANTS: Community-dwelling older adults (n=26) 6 months after hip fracture at baseline. INTERVENTION: Exercise and control participants received interventions from physical therapists twice a week for 10 weeks. The exercise group received high-intensity leg-strengthening exercises. The control group received transcutaneous electrical nerve stimulation and mental imagery. MEASUREMENTS: Isometric force production of lower extremity muscles, usual and fast gait speed, 6-minute walk (6-MW) distance, modified Physical Performance Test (mPPT), and Medical Outcomes Study 36-item Short Form Survey (SF-36) physical function. RESULTS: The primary endpoint was 1 year after fracture. Isometric force production (P=.006), usual (P=.02) and fast (P=.03) gait speed, 6-MW distance (P=.005), and mPPT score (P<.001) were improved 1 year after fracture with exercise. Effect sizes were 0.79 for strength, 0.81 for mPPT score, 0.56 for gait speed, 0.49 for 6-MW, and 0.30 for SF-36 score. More patients in the exercise group made meaningful changes in gait speed and 6-MW distance than control patients (chi-square P=.004). CONCLUSION: A 10-week home-based progressive resistance exercise program was sufficient to achieve moderate to large effects on physical performance and quality of life and may offer an alternative intervention mode for patients with hip fracture who are unable to leave home by 6 months after the fracture. The effects were maintained at 3 months after completion of the training program.

Laparoscopic colectomy in octogenarians and nonagenarians: a preferable option to open surgery?

OBJECTIVES: To determine if laparoscopic colectomy is safer and more effective than open colectomy in patients older than 80 years of age. METHODS: An operating room database of all colectomies performed on patients >or=80 years, from January 2002 to September 2007, was analyzed retrospectively. Data reviewed included type of operation, type of resection, length of procedure, length of stay (LOS), estimated blood loss, American Society of Anesthesiologists (ASA) grade, diagnosis, complications, mortality rates, and discharge destination, with p-values <0.05 considered significant. RESULTS: One hundred thirty-nine patients underwent open procedures (Open group) during the study period versus 150 patients who underwent laparoscopic procedures (Lap group). Of the Lap group, 15 patients were converted to open cases. Forty-four patients from the Open group were excluded from the analysis as they were treated emergently, leaving 95 patients in the Open group. The mortality for open procedures was significantly higher at 9/95 (9.4%), compared with 3/150 (2%) following laparoscopic procedures (p = 0.0132). LOS was significantly longer for open procedures (11.16 days) versus laparoscopic procedures (7.11 days), p = 0.0001. Open procedures were associated with an increased risk of postoperative ileus (p < 0.02). The Open group had a higher likelihood of discharge to a nursing facility (43/87) than the Lap group (33/147), p < 0.0001. There were no significant differences in the length of procedure, estimated blood loss and postoperative complications. CONCLUSIONS: Laparoscopic colectomy is a safer option that offers an improved outcome compared with open colectomy in elderly patients. Significant improvements in LOS, mortality rates, and discharge destination were observed.

Diagnosis and treatment of Paget's disease of bone.

Paget's disease of bone (also known as osteitis deformans) is a nonmalignant disease involving accelerated bone resorption followed by deposition of dense, chaotic, and ineffectively mineralized bone matrix. The origin of the disease is unknown, and it is frequently asymptomatic; however, the patient may present with symptoms depending on the bones involved. The most common symptom is pain in the affected bone; neurologic, hearing, vision, cardiac, and oncologic complications are possible. Diagnosis is primarily made by radiographs. Bisphosphonates are the most common treatment.