Using a Claims-Based Frailty Index to Investigate Frailty, Survival, and Healthcare Expenditures among Older Adults Hospitalized for COVID-19 at an Academic Medical Center.

BACKGROUND: Frailty is associated with mortality in older adults hospitalized with COVID-19, yet few studies have quantified healthcare utilization and spending following COVID-19 hospitalization. OBJECTIVE: To evaluate whether survival and follow-up healthcare utilization and expenditures varied as a function of claims-based frailty status for older adults hospitalized with COVID-19. DESIGN: Retrospective cohort study. PARTICIPANTS: 136 patients aged 65 and older enrolled in an Accountable Care Organization (ACO) risk contract at an academic medical center and hospitalized for COVID-19 between March 11, 2020 - June 3, 2020. MEASUREMENTS: We linked a COVID-19 Registry with administrative claims data to quantify a frailty index and its relationship to mortality, healthcare utilization, and expenditures over 6 months following hospital discharge. Kaplan Meier curves and Cox Proportional Hazards models were used to evaluate survival by frailty. Kruskal-Wallis tests were used to compare utilization. A generalized linear model with a gamma distribution was used to evaluate differences in monthly Medicare expenditures. RESULTS: Much of the cohort was classified as moderate to severely frail (65.4%), 24.3% mildly frail, and 10.3% robust or pre-frail. Overall, 27.2% (n=37) of the cohort died (n=26 during hospitalization, n=11 after discharge) and survival did not significantly differ by frailty. Among survivors, inpatient hospitalizations during the 6-month follow-up period varied significantly by frailty (p=0.02). Mean cost over follow-up was $856.37 for the mild and $4914.16 for the moderate to severe frailty group, and monthly expenditures increased with higher frailty classification (p <.001). CONCLUSIONS: In this cohort, claims-based frailty was not significantly associated with survival but was associated with follow-up hospitalizations and Medicare expenditures.

Comparative performance of current definitions of sarcopenia against the prospective incidence of falls among community-dwelling seniors age 65 and older.

UNLABELLED: In this study, we compare the extent to which seven available definitions of sarcopenia and two related definitions predict the rate of falling. Our results suggest that the definitions of Baumgartner and Cruz-Jentoft best predict the rate of falls among sarcopenic versus non-sarcopenic community-dwelling seniors. INTRODUCTION: The purpose of the study is to compare the extent to which seven available definitions of sarcopenia and two related definitions predict the prospective rate of falling. METHODS: We studied a cohort of 445 seniors (mean age 71 years, 45 % men) living in the community who were followed with a detailed fall assessment for 3 years. For comparing the rate of falls in sarcopenic versus non-sarcopenic individuals, we used multivariate Poisson regression analyses adjusting for gender and treatment (original intervention tested vitamin D plus calcium against placebo). Of the seven available definitions, three were based on low lean mass alone (Baumgartner, Delmonico 1 and 2) and four required both low muscle mass and decreased performance in a functional test (Fielding, Cruz-Jentoft, Morley, Muscaritoli). The two related definitions were based on low lean mass alone (Studenski 1) and low lean mass contributing to weakness (Studenski 2). RESULTS: Among 445 participants, 231 fell, sustaining 514 falls over the 3-year follow-up. The prospective rate of falls in sarcopenic versus non-sarcopenic individuals was best predicted by the Baumgartner definition based on low lean mass alone (RR = 1.54; 95 % CI 1.09-2.18) with 11 % prevalence of sarcopenia and the Cruz-Jentoft definition based on low lean mass plus decreased functional performance (RR = 1.82; 95 % CI 1.24-2.69) with 7.1 % prevalence of sarcopenia. Consistently, fall rate was non-significantly higher in sarcopenic versus non-sarcopenic individuals based on the definitions of Delmonico 1, Fielding, and Morley. CONCLUSION: Among the definitions investigated, the Baumgartner definition and the Cruz-Jentoft definition had the highest validity for predicting the rate of falls.

Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials.

OBJECTIVE: To test the efficacy of supplemental vitamin D and active forms of vitamin D with or without calcium in preventing falls among older individuals. DATA SOURCES: We searched Medline, the Cochrane central register of controlled trials, BIOSIS, and Embase up to August 2008 for relevant articles. Further studies were identified by consulting clinical experts, bibliographies, and abstracts. We contacted authors for additional data when necessary. Review methods Only double blind randomised controlled trials of older individuals (mean age 65 years or older) receiving a defined oral dose of supplemental vitamin D (vitamin D(3) (cholecalciferol) or vitamin D(2) (ergocalciferol)) or an active form of vitamin D (1alpha-hydroxyvitamin D(3) (1alpha-hydroxycalciferol) or 1,25-dihydroxyvitamin D(3) (1,25-dihydroxycholecalciferol)) and with sufficiently specified fall assessment were considered for inclusion. RESULTS: Eight randomised controlled trials (n=2426) of supplemental vitamin D met our inclusion criteria. Heterogeneity among trials was observed for dose of vitamin D (700-1000 IU/day v 200-600 IU/day; P=0.02) and achieved 25-hydroxyvitamin D(3) concentration (25(OH)D concentration: <60 nmol/l v >or=60 nmol/l; P=0.005). High dose supplemental vitamin D reduced fall risk by 19% (pooled relative risk (RR) 0.81, 95% CI 0.71 to 0.92; n=1921 from seven trials), whereas achieved serum 25(OH)D concentrations of 60 nmol/l or more resulted in a 23% fall reduction (pooled RR 0.77, 95% CI 0.65 to 0.90). Falls were not notably reduced by low dose supplemental vitamin D (pooled RR 1.10, 95% CI 0.89 to 1.35; n=505 from two trials) or by achieved serum 25-hydroxyvitamin D concentrations of less than 60 nmol/l (pooled RR 1.35, 95% CI 0.98 to 1.84). Two randomised controlled trials (n=624) of active forms of vitamin D met our inclusion criteria. Active forms of vitamin D reduced fall risk by 22% (pooled RR 0.78, 95% CI 0.64 to 0.94). CONCLUSIONS: Supplemental vitamin D in a dose of 700-1000 IU a day reduced the risk of falling among older individuals by 19% and to a similar degree as active forms of vitamin D. Doses of supplemental vitamin D of less than 700 IU or serum 25-hydroxyvitamin D concentrations of less than 60 nmol/l may not reduce the risk of falling among older individuals.

Effect of seasonality and weather on fracture risk in individuals 65 years and older.

UNLABELLED: In this large population-based study, fracture rates for hips, distal forearms, proximal humeri, and ankles were higher in winter than in other seasons, although the winter peak was small for hip fractures (p < 0.05 at all sites). Younger age between 65 and 80, living in warmer states and male gender were associated with increased winter morbidity due to fractures. INTRODUCTION: The objective was to investigate seasonal variation in the incidence of four common fractures, and explore the association of weather with risk. METHODS: Population-based analysis of individuals age 65 and older, including fractures of the hip, the distal forearm, the proximal humerus and the ankle. Weather information was obtained from the US National Oceanic and Atmospheric Administration website. RESULTS: For all fractures, rates were highest in winter and lowest in summer (p < 0.05 at all sites). Winter peaks were more pronounced in warm climate states, in men, and in those younger than 80 years old. In winter, total snowfall was associated with a reduced risk of hip fracture (-5% per 20 inches) but an increased risk of non-hip fractures (6-12%; p < 0.05 at all sites). In summer, hip fracture risk tended to be lower during sunny weather (- 3% per 2 weeks of sunny days; p = 0.13), while other fractures were increased (15%-20%; p < 0.05) in sunny weather. CONCLUSION: Fractures contribute considerably to winter morbidity in older individuals. Younger age between 65 and 80, living in warmer states and male gender are risk factors for increased winter morbidity due to fractures. Weather affects hip fracture risk differently than the other fractures studied.

A randomized blinded trial of combination therapy with cyclophosphamide in patients-with active multiple sclerosis on interferon beta.

OBJECTIVE: To evaluate the efficacy and safety of combination therapy with pulse cyclophosphamide given with methylprednisolone (MP) and interferon beta (IFNbeta)-Ia in multiple sclerosis (MS) patients with active disease during IFNbeta monotherapy. METHODS: This was a randomized, single-blind, parallel-group, multicenter trial in MS patients with a history of active disease during IFNbeta treatment. Patients were randomized to either cyclophosphamide 800 mg/m2 plus methylprednisolone 1 g IV (CY/MP) or methylprednisolone once a month for six months and then followed for an additional 18 months. All patients received three days of methylprednisolone 1 g IV at screening and 30 mcg IFNbeta-Ia IM weekly for the entire 24 months. The primary endpoint was change from baseline in the mean number of gadolinium-enhancing (Gd+) lesions. Secondary clinical endpoints included time to treatment failure. RESULTS: Fifty-nine patients were randomized to treatment: 30 to CY/MP and 29 to MP Change from baseline in the number of Gd+ lesions was significantly different between treatment groups at three (P =0.01), six (P =0.04) and 12 months (P =0.02), with fewer lesions in the CY/MP group. The cumulative rate of treatment failure was significantly lower in the CY/MP group compared with the MP group (rate ratio =0.30; 95% confidence interval, 0.12-0.75; P =0.011). CY/MP treatment was well tolerated. CONCLUSION: Combination therapy with CY/MP and IFNbeta-Ia decreased the number of Gd+ lesions and slowed clinical activity in patients with previously active disease on IFNbeta alone.

Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery.

BACKGROUND: Major surgical procedures are performed with increasing frequency in elderly persons, but the impact of age on resource use and outcomes is uncertain. OBJECTIVE: To evaluate the influence of age on perioperative cardiac and noncardiac complications and length of stay in patients undergoing noncardiac surgery. DESIGN: Prospective cohort study. SETTING: Urban academic medical center. PATIENTS: Consecutive sample of 4315 patients 50 years of age or older who underwent nonemergent major noncardiac procedures. MEASUREMENTS: Major perioperative complications (cardiac and noncardiac), in-hospital mortality, and length of stay. RESULTS: Major perioperative complications occurred in 4.3% (44 of 1015) of patients 59 years of age or younger, 5.7% (93 of 1646) of patients 60 to 69 years of age, 9.6% (129 of 1341) of patients 70 to 79 years of age, and 12.5% (39 of 313) of patients 80 years of age or older (P < 0.001). In-hospital mortality was significantly higher in patients 80 years of age or older than in those younger than 80 years of age (0.7% vs. 2.6%, respectively). Multivariate analyses indicated an increased odds ratio for perioperative complications or in-hospital mortality in patients 70 to 79 years of age (1.8 [95% CI, 1.2 to 2.7]) and those 80 years of age or older (OR, 2.1 [CI, 1.2 to 3.6]) compared with patients 50 to 59 years of age. Patients 80 years of age or older stayed an average of 1 day more in the hospital, after adjustment for other clinical data (P = 0.001). CONCLUSIONS: Elderly patients had a higher rate of major perioperative complications and mortality after noncardiac surgery and a longer length of stay, but even in patients 80 years of age or older, mortality was low.

The use of a simple Likert scale to measure quality of life in brain tumor patients.

The use of a self-administered 10-Point Likert self-assessment quality of life scale was explored in a convenience sample of patients attending a brain tumor clinic. The original scale, developed by Priestman, was modified to be more brain-tumor specific. A total of 430 patients completed the scale at 535 different points of measurement. The patients had a variety of brain tumors ranging from meningiomas to high-grade gliomas. The Total Score of the original scale and the Modified Total Score of the brain-specific version were explored in relationship to patient demographics and available clinical characteristics: age, gender, severity of tumor, location of tumor, survival rates, prior surgery, radiation, radiosurgery, and chemotherapy. We also examined the relationship between sub-scales and these variables. On a scale of 10-100, the average Total Score was 67.83, not significantly different from the Modified Score. There were no differences between bilateral, midline, or left- versus right-sided lesions. Patients with the worst prognosis in terms of tumor type were 5-6 points lower in quality of life than patients with intermediate or relatively good prognosis. In a multiple regression model, adjusted for age, the overall score was related only to tumor severity and to gender, with women having significantly poorer functional status than men by 4 points. Both the Modified and Total Scores were significantly associated with higher mortality risk, and more specifically, poor scores on well-being, mood, physical function, house/job performance, self-care, concentration, and energy all predicted higher mortality risk. We suggest that the simplicity of this instrument may make it particularly useful for longitudinal assessment of quality of life in brain tumor patients.

The impact of group psychological interventions on distress in infertile women.

Infertile women express higher levels of distress than fertile women, with distress peaking between the 2nd and 3rd year. The purpose of this study was to determine whether group psychological interventions could prevent this surge. One hundred eighty-four women who had been trying to conceive between 1 and 2 years were randomized into either a cognitive-behavioral group, a support group, or a control group. All experimental participants attended a 10-session group program. Participants completed psychological questionnaires at intake and again at 6 and 12 months. Substantial attrition occurred, particularly in the control group. The cognitive-behavioral and support participants experienced significant psychological improvement at 6 and 12 months compared with the control participants, with the cognitive-behavioral participants experiencing the greatest positive change.

Hemoconcentration is an early marker for organ failure and necrotizing pancreatitis.

In a previous retrospective case-control study, hemoconcentration was associated with the development of pancreatic necrosis. The aim of the present study was to determine in a cohort study whether hemoconcentration is a marker for both organ failure and necrotizing pancreatitis. A cohort study was performed on patients admitted with acute pancreatitis from February 1996 to April 1997. Pancreatic necrosis was defined by findings on dynamic contrast-enhanced computed tomography scan or magnetic resonance imaging. Of 128 total patients with acute pancreatitis, 53 underwent computed tomography or magnetic resonance imaging. Eighteen of 53 had necrotizing pancreatitis. Logistic regression identified an admission hematocrit > or = 44% and a failure of admission hematocrit to decrease at 24 hours as the best binary predictors of necrotizing pancreatitis and organ failure. By 24 hours, 17 of 18 patients with necrotizing pancreatitis versus 11 of 35 with interstitial pancreatitis met one or the other criterion for necrosis (p < 0.001). By 24 hours, 13 of 15 with organ failure versus 36 of 104 without organ failure met one or the other criterion (p < 0.001). The negative predictive value by 24 hours was 96% for necrotizing pancreatitis and 97% for organ failure. Hemoconcentration with an admission hematocrit > or = 44% and/or failure of admission hematocrit to decrease at approximately 24 hours was associated with the development of necrotizing pancreatitis and organ failure. Patients who did not experience hemoconcentration were very unlikely to develop pancreatic necrosis or organ failure.

A comparison of the preventive health care provided by women's health centers and general internal medicine practices.

OBJECTIVE: To evaluate women's health centers as alternatives to traditional internal medicine practices. DESIGN: Cross-sectional mailed survey. SETTING: A women's health center and an internal medicine practice at each of three university-affiliated teaching hospitals. PATIENTS: There were 3,035 female patients randomly selected to receive a mailed survey after their office visits. MEASUREMENTS AND MAIN RESULTS: The survey asked for patient characteristics, patient satisfaction, and rates of gender-specific preventive health services. The survey response rate was 64% (1, 942/3,035). Patients at women's health centers were younger, more educated, had higher physical functioning but lower mental health functioning, and more of them were single and employed. Patient satisfaction was similar at the two types of practices, although patients at women's health centers were more satisfied with certain aspects of the patient-provider interaction. After adjusting for measured differences in patient characteristics and site, patients at women's health centers were more likely to receive discussions on hormone replacement therapy (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.1, 2.2) and dietary calcium (OR 1.3; 95% CI 1.1, 1. 6). They were also more likely to receive their gender-specific preventive health services from their primary care provider: breast examination (OR 2.0; 95% CI 1.5, 2.6), Pap smear (OR 2.4; 95% CI 1.9, 3.1), hormone replacement therapy discussion (OR 2.2; 95% CI 1.5, 3. 3), and dietary calcium discussion (OR 2.6; 95% CI 1.7, 3.9). These findings remained when the analyses were limited to patients of female providers only. CONCLUSIONS: In this study, patients at women's health centers were more likely to receive gender-specific health prevention counseling than patients at internal medicine practices. Moreover, patients were more likely to receive their gender-specific preventive health services from their primary care providers.

Panic disorder patients and their medical care.

The goal of the study was to examine the functional status and medical care of general medical outpatients with panic disorder. One hundred patients completed self-report questionnaires and a diagnostic interview for panic disorder. They were compared with a random sample of patients without panic disorder. Medical morbidity was assessed from the medical record, and the patients' clinic physicians completed a questionnaire about them. The prevalence of current (1 month) panic disorder was 6.7%-8.3%. The panic disorder patients had fewer serious medical diagnoses, but more medical utilization and more role impairment than the comparison group. The clinic physicians rated the panic patients as more anxious, more depressed, more hypochondriacal, and more difficult to care for. Sixty-one percent of the panic disorder patients recalled receiving an anxiety disorder diagnosis. These findings add to a growing body of evidence that panic disorder imposes a significant burden on those with this illness and that it is a seriously underdiagnosed condition in primary care practice.

Complications of dual chamber pacemaker implantation in the elderly. Pacemaker Selection in the Elderly (PASE) Investigators.

Pacemakers are frequently implanted, yet accurate prospective data on implant complications are limited. Elderly patients may be at increased risk of implant complications and are increasingly being referred for pacemaker implantation. The purpose of the present analysis was to define the incidence and possible predictors of serious complications of dual chamber permanent pacemaker implantation in the elderly. Therefore, we sought to prospectively identify the incidence and predictors of pacemaker implant complications in a large multicenter trial involving patients receiving a dual chamber pacemaker. The Pacemaker Selection in the Elderly (PASE) study was a prospective trial designed to evaluate quality of life in dual chamber pacemaker recipients age 65 years or older randomized to DDDR versus VVIR programming. In addition to being age 65 years or older, patients enrolled in this study were in normal sinus rhythm, and had standard indications for permanent pacemaker implantation. All patients received dual chamber pacemakers and were randomized to DDDR versus VVIR pacing. Pacemaker implant complications were collected on standardized forms which were completed at pacemaker implantation and during follow-up appointments. In this study of 407 patients, there were 26 complications occurring in 25 patients (6.1%). The most frequent complication was lead dislodgment which occurred in 9 patients. This was followed by pneumothorax (8 patients) and cardiac perforations (4 patients). In 18 patients (4.4%) repeat surgical procedures (including chest tubes) were required. Complications were noted prior to discharge in only 18 patients. There were no significant predictors of overall complications. Pneumothorax was more frequent in patients > or = 75 years old, and was observed only in patients with subclavian venous access. In conclusion, complications from pacemaker implantation in the elderly are seen in 6.1% of patients and 4.4% of patients require a repeat surgical procedure. Other than advanced age and lower weight predicting for pneumothorax, there are no significant clinical predictors of complications.

Hemoconcentration as an early risk factor for necrotizing pancreatitis.

OBJECTIVE: The aim of our study was to determine whether measurement of serum hematocrit during the first 24 h helps in distinguishing necrotizing from mild pancreatitis. METHODS: From May 1992 to June 1996, a case-control study was performed with cases of patients with necrotizing pancreatitis. We selected as a control the next patient admitted with mild pancreatitis. RESULTS: There were 32 patients in each group. Logistic regression identified an admission hematocrit of > or = 47% and a failure of admission hematocrit to decrease at 24 h as the best binary risk factors for necrotizing pancreatitis. At admission, more patients with necrotizing pancreatitis than with mild pancreatitis had a hematocrit > or = 47% (11/32 vs 3/32; p = 0.03). At 24 h, 15 additional patients with necrotizing pancreatitis versus only one with mild pancreatitis showed no decrease in admission hematocrit (p < 0.01). Thus, by 24 h, 26 of 32 patients with necrotizing pancreatitis versus only four of 32 patients with mild pancreatitis met one or the other criterion (p < 0.01). The sensitivity and specificity at admission were 34% and 91%; at 24 h, 81% and 88%. CONCLUSIONS: Hemoconcentration with an admission hematocrit > or = 47% or failure of admission hematocrit to decrease at approximately 24 h were strong risk factors for the development of pancreatic necrosis.

Cardiorespiratory symptoms in response to physiological arousal.

OBJECTIVE: To develop a laboratory paradigm for assessing the tendency to amplify somatic symptoms and report bodily distress. METHOD: Reports of four different cardiopulmonary symptoms were obtained during standardized, treadmill exercise, while the physiological parameters which induce these symptoms were simultaneously measured. Two indices were developed to compare symptom reporting across patients: symptom severity after reaching 80% of predicted, maximal exercise capacity; and the magnitude of physiological arousal necessary to induce an initial sensation of discomfort. RESULTS: Fifty-one medical outpatients with a chief complaint of palpitations were studied. Symptom distress at 80% of maximal exercise capacity was significantly associated with state anxiety and daily life stress. The complaint of "heart racing" first occurred at a significantly lower heart rate for patients who were older, more anxious, and reported more daily life stress. Measures of hypochondriasis, somatization, bodily amplification, and bodily absorption were not significantly associated with either symptom measure. CONCLUSIONS: Standardized exercise testing may provide a suitable paradigm with which to study the tendency to amplify symptoms and to somatize. The distress reported by different subjects at 80% of maximal exercise capacity may be considered an index of the discomfort engendered by a standardized stimulus, whereas the point of onset of discomfort may be a measure of the patient's threshold for becoming symptomatic. These findings are not conclusive, but do suggest that patients who are more anxious and under more stress tend to report more intense cardiopulmonary symptoms at comparable levels of physiological arousal, and to have a lower threshold for experiencing discomfort.

The impact of postoperative pain on the development of postoperative delirium.

UNLABELLED: We performed a prospective observational study to examine the role of postoperative pain and its treatment on the development of postoperative delirium. Pain was measured in direct patient interviews using a visual analog scale (VAS) and was assessed for pain at rest, pain with movement, and maximal pain over the previous 24 h. Postoperative delirium was diagnosed during these interviews by using the confusion assessment method (CAM) and/or by using data from the medical record and the hospital's nursing intensity index. The method of postoperative analgesia, type of opioid, and cumulative opioid dose were also recorded. After controlling for known preoperative risk factors for delirium (age, alcohol abuse, cognitive function, physical function, serum chemistries, and type of surgery), higher pain scores at rest was associated with an increased risk of delirium over the first 3 postoperative days (adjusted risk ratio 1.20, P = 0.04). Pain with movement and maximal pain were not associated with delirium. Method of postoperative analgesia, type of opioid, and cumulative opioid dose were not associated with an increased risk of delirium. We conclude that more effective control of postoperative pain reduces the incidence of postoperative delirium. IMPLICATIONS: We performed daily interviews in a large population of patients undergoing noncardiac surgery to measure their level of pain and development of delirium. We found an association between higher pain levels at rest and the development of delirium. Our results suggest that better control of postoperative pain may reduce this serious complication.

Serial neuropsychological assessment and magnetic resonance imaging analysis in multiple sclerosis.

OBJECTIVE: To assess the correlation between cognitive dysfunction and disease burden in multiple sclerosis (MS) during a 1-year period. DESIGN: The Brief, Repeatable Battery of Neuropsychological Tests in Multiple Sclerosis was performed at entrance and 1 year. Patients underwent at least 20 proton density (range, 20-24) and T2-weighted axial magnetic resonance imaging (MRI) brain scans except for stable patients who were scanned monthly. Magnetic resonance imaging was evaluated using computer-automated, 3-dimensional volumetric analysis. SETTING: A research clinic of a university hospital. PATIENTS: Forty-four patients with MS of the following disease categories: relapsing-remitting (14), relapsing-remitting progressive (12), chronic progressive (13), and stable (5). MAIN OUTCOME MEASURES: The relationships between scores on the Brief, Repeatable Battery of Neuropsychological Tests in Multiple Sclerosis and 2 MRI measures (total lesion volume and brain to intracranial cavity volume ratio) were assessed using linear regression. These MRI measures were also compared with cognitive status at 1 year using analysis of variance. RESULTS: Overall, there was no decline in mean cognitive test performance during 1 year. Significant correlations were found between baseline neuropsychological test scores of nonverbal memory, information-processing speed, and attention and both MRI measures. Patients with chronic progressive MS demonstrated the strongest correlations. At 1 year, change in information-processing speed and attention correlated with change in total lesion volume. The mean increase in total lesion volume was 5.7 mL for 4 patients whose cognitive status worsened compared with 0.4 mL for 19 patients who improved and 0.5 mL for 21 patients who remained stable. CONCLUSIONS: During a 1-year period mean cognitive performance did not worsen. Automated volumetric MRI measures of total lesion volume and brain to intracranial cavity volume ratio correlated with neuropsychological performance, especially in patients with chronic progressive MS. Worsening MRI lesion burden correlated with cognitive decline.

Patient experience of pain after elective noncardiac surgery.

The purpose of this study was to examine the extent and evolution of pain after common major surgical procedures and to establish correlates of three types of pain: pain at rest, pain with movement, and maximum pain over the previous 24 h. Patients completed a preoperative questionnaire to obtain data on age, gender, narcotic use, baseline level of pain, chronicity of pain, and level of anxiety. Patients were then interviewed on Postoperative Days 1, 2, and 3 to assess their pain on a scale of 0 (none) to 10 (worst imaginable). The mean pain score at rest was 2.6 on Postoperative Day 1 and decreased to 2.3 on Postoperative Day 3 (P = 0.06). The mean pain score with movement was 4.5 on Postoperative Day 1, which decreased to 4.2 on Postoperative Day 3 (P = 0.03). The mean maximum pain score over the previous 24 h was 6.3, which decreased to 5.6 (P = 0.0001). Preoperative narcotic use and high baseline preoperative pain, defined as a score > or = 4, were significantly (P < 0.05) associated with increased pain at rest, pain with movement, and maximum pain. Epidural analgesia was the only mode of analgesia significantly associated with both decreased postoperative pain at rest and decreased pain with movement (P < 0.05). These relatively high pain scores and minimum decreases in pain from Postoperative Days 1 to 3 emphasizes the need for more effective pain management continuing into the postoperative period to facilitate mobilization and recovery.

Correlation of ribonucleic acid polymerase chain reaction, acid dissociated p24 antigen, and neopterin with progression of disease. A retrospective, longitudinal study of vertically acquired human immunodeficiency virus type 1 infection in children.

OBJECTIVE: We investigated the relationship between cell-free viral load, neopterin, age-adjusted CD4+ cell concentration, and clinical events in 49 children with vertically acquired human immunodeficiency virus type 1 infection. STUDY DESIGN: Viral load was measured by quantitating viral ribonucleic acid in serum by polymerase chain reaction and measurement of immune complex dissociated p24 antigen in serum and plasma. Children were followed for an average of 2 1/2 years, with an average of 6 samples per child. Medical records were reviewed for weight, CD4+ cell count and clinical events. RESULTS: High virus copy number in serum was predictive of a decrease in weight-for-age zscore during the subsequent 6 months. High viral load, low CD4+ cell count, and high neopterin level were correlated with encephalopathy. High viral load correlated with opportunistic infections. All of these relationships held regardless of treatment status, although viral load decreased significantly after treatment was begun. CONCLUSIONS: Measurements of viral load were useful prognostic indicators for poor weight gain. Elevated serum virus levels and neopterin values and low CD4+ cell counts were all associated with encephalopathy.

1995 IPA/Bayer Research Awards in Psychogeriatrics. Late-life consequences of affective spectrum disorder.

Recent research suggests that affective disorder is associated with increased mortality and physical morbidity, but the reasons for this association remain uncertain. This report describes a 50-year prospective study of 240 men evaluated from the time they were university students in 1940-1942. A family history of mental illness was obtained and the men's habits, psychological adjustment, and marital and occupational satisfaction were followed every 2 years and their objective physical health was tracked every 5 years until age 70. Twenty-five men were identified as having affective spectrum disorder prior to age 53. Of the variables studied, the presence of affective spectrum disorder was the most powerful predictor of poor psychosocial outcome at age 65 and one of the most powerful predictors of poor physical health. Alcohol abuse and cigarette abuse accounted for the observed increased rates of heart disease and cancer. When alcohol abuse, smoking, and suicide were controlled for, affective disorder made a significant contribution to physical morbidity by age 70, but not to mortality from natural causes. Affective spectrum disorder, even in an educated population without antisocial trends, carries a profound negative risk to late-life physical and social adjustment.