Cardiovascular events are not associated with MTHFR polymorphisms, but are associated with methotrexate use and traditional risk factors in US veterans with rheumatoid arthritis.

OBJECTIVE: C677T and A1298C polymorphisms in the enzyme methylenetetrahydrofolate reductase (MTHFR) have been associated with increased cardiovascular (CV) events in non-rheumatoid arthritis (RA) populations. We investigated potential associations of MTHFR polymorphisms and use of methotrexate (MTX) with time-to-CV event in data from the Veterans Affairs Rheumatoid Arthritis (VARA) registry. METHODS: VARA participants were genotyped for MTHFR polymorphisms. Variables included demographic information, baseline comorbidities, RA duration, autoantibody status, and disease activity. Patients' comorbidities and outcome variables were defined using International Classification of Diseases-9 and Current Procedural Terminology codes. The combined CV event outcome included myocardial infarction (MI), percutaneous coronary intervention, coronary artery bypass graft surgery, and stroke. Cox proportional hazards regression was used to model the time-to-CV event. RESULTS: Data were available for 1047 subjects. Post-enrollment CV events occurred in 97 patients (9.26%). Although there was a trend toward reduced risk of CV events, MTHFR polymorphisms were not significantly associated with time-to-CV event. Time-to-CV event was associated with prior stroke (HR 2.01, 95% CI 1.03-3.90), prior MI (HR 1.70, 95% CI 1.06-2.71), hyperlipidemia (HR 1.57, 95% CI 1.01-2.43), and increased modified Charlson-Deyo index (HR 1.23, 95% CI 1.13-1.34). MTX use (HR 0.66, 95% CI 0.44-0.99) and increasing education (HR 0.87, 95% CI 0.80-0.95) were associated with a lower risk for CV events. CONCLUSION: Although MTHFR polymorphisms were previously associated with CV events in non-RA populations, we found only a trend toward decreased association with CV events in RA. Traditional risk factors conferred substantial CV risk, while MTX use and increasing years of education were protective.

Preoperative cognitive dysfunction is related to adverse postoperative outcomes in the elderly.

BACKGROUND: Preoperative risk stratification is commonly performed by assessing end-organ function (such as cardiac and pulmonary) to define postoperative risk. Little is known about impaired preoperative cognition and outcomes. The purpose of this study was to evaluate the impact of baseline impaired cognition on postoperative outcomes in geriatric surgery patients. STUDY DESIGN: Subjects 65 years and older undergoing a planned elective operation requiring postoperative ICU admission were recruited prospectively. Preoperative baseline cognition was assessed using the validated Mini-Cog test. Impaired cognition was defined as a Mini-Cog score of ≤ 3. Delirium was assessed using the Confusion Assessment Method-ICU by a trained research team. Adverse outcomes were defined using the Veterans Affairs Surgical Quality Improvement Program definitions. RESULTS: One hundred and eighty-six subjects were included, with a mean age of 73 ± 6 years. Eighty-two subjects (44%) had baseline impaired cognition. The impaired cognition group had the following unadjusted outcomes: increased incidence of 1 or more postoperative complications (41% vs 24%; p = 0.011), higher incidence of delirium (78% vs 37%; p < 0.001), longer hospital stays (15 ± 14 vs 9 ± 9 days; p = 0.001), higher rate of discharge institutionalization (42% vs 18%; p = 0.001), and higher 6-month mortality (13% vs 5%; p = 0.040). Adjusting for potential confounders determined by univariate analysis, logistic regression found impaired cognition was still associated with the occurrence of 1 or more postoperative complications (odds ratio = 2.401; 95% CI, 1.185-4.865; p = 0.015). Kaplan-Meier survival analysis revealed higher mortality in the impaired cognition group (log-rank p = 0.008). CONCLUSIONS: Baseline cognitive impairment in older adults undergoing major elective operations is related to adverse postoperative outcomes including increased complications, length of stay, and long-term mortality. Improved understanding of baseline cognition and surgical outcomes can aid surgical decision making in older adults.

Accumulated frailty characteristics predict postoperative discharge institutionalization in the geriatric patient.

BACKGROUND: Frailty is a state of increased vulnerability to health-related stressors and can be measured by summing the number of frailty characteristics present in an individual. Discharge institutionalization (rather than discharge to home) represents disease burden and functional dependence after hospitalization. Our aim was to determine the relationship between frailty and need for postoperative discharge institutionalization. STUDY DESIGN: Subjects ≥ 65 years undergoing major elective operations requiring postoperative ICU admission were enrolled. Discharge institutionalization was defined as need for institutionalized care at hospital discharge. Fourteen preoperative frailty characteristics were measured in 6 domains: comorbidity burden, function, nutrition, cognition, geriatric syndromes, and extrinsic frailty. RESULTS: A total of 223 subjects (mean age 73 ± 6 years) were studied. Discharge institutionalization occurred in 30% (n = 66). Frailty characteristics related to need for postoperative discharge institutionalization included: older age, Charlson index ≥ 3, hematocrit <35%, any functional dependence, up-and-go ≥ 15 seconds, albumin <3.4 mg/dL, Mini-Cog score ≤ 3, and having fallen within 6 months (p < 0.0001 for all comparisons). Multivariate logistic regression retained prolonged timed up-and-go (p < 0.0001) and any functional dependence (p < 0.0001) as the variables most closely related to need for discharge institutionalization. An increased number of frailty characteristics present in any one subject resulted in increased rate of discharge institutionalization. CONCLUSIONS: Nearly 1 in 3 geriatric patients required discharge to an institutional care facility after major surgery. The frailty characteristics of prolonged up-and-go and any functional dependence were most closely related to the need for discharge institutionalization. Accumulation of a higher number of frailty characteristics in any one geriatric patient increased their risk of discharge institutionalization.