Differences in the association between epidural analgesia and length of stay by surgery type: an observational study.

INTRODUCTION: Despite a decline in the use of thoracic epidural analgesia related in part to concerns for delayed discharge, it is unknown whether changes in length of stay (LOS) associated with epidural analgesia vary by surgery type. Therefore, we determined the degree to which the association between epidural analgesia (vs no epidural) and LOS differed by surgery type. METHODS: We conducted an observational study using data from 1747 patients who had either non-emergent open abdominal, thoracic, or vascular surgery at a single tertiary academic hospital. The primary outcome was hospital LOS and the incidence of a prolonged hospital LOS defined as 21 days or longer. Secondary endpoints included escalation of care, 30-day all-cause readmission, and reason for epidural not being placed. The association between epidural status and dichotomous endpoints was examined using logistic regression. RESULTS: Among the 1747 patients, 85.7% (1499) received epidural analgesia. 78% (1364) underwent abdominal, 11.5% (200) thoracic, and 10.5% (183) vascular surgeries. After adjustment for differences, receiving epidural analgesia (vs no epidural) was associated with a 45% reduction in the likelihood of a prolonged LOS (p<0.05). This relationship varied by surgery type: abdominal (OR 0.42, 95% CI 0.23 to 0.79, p<0.001), vascular (OR 1.66, 95% CI 0.17 to 16.1, p=0.14), and thoracic (OR 1.07, 95% CI 0.20 to 5.70, p=0.93). Among abdominal surgical patients, epidural analgesia was associated with a median decrease in LOS by 1.4 days and a 37% reduction in the likelihood of 30-day readmission (adjusted OR 0.63, 0.41 to 0.97, p<0.05). Among thoracic surgical patients, epidural analgesia was associated with a median increase in LOS by 3.2 days. CONCLUSIONS: The relationship between epidural analgesia and LOS appears to be different among different surgical populations.

Fever, pancytopenia, and elevated D-dimer in a 95-year-old woman with ehrlichiosis: a case report.

BACKGROUND: Pancytopenia, fever, and elevated D-dimer are significant clinical findings. The differential diagnosis includes hematological malignancies, severe coronavirus disease 2019 (COVID-19), tick-borne illnesses, and other etiologies. CASE PRESENTATION: We report the case of a 95-year-old woman who presented with high fever (103.6 °F), pancytopenia, and markedly elevated D-dimer (32.21 mg/L; reference range ≤ 0.95 mg/L) in late-autumn during the COVID-19 pandemic at a large academic institution. After remaining persistently febrile, a peripheral blood smear was ordered and revealed parasites consistent with Ehrlichia spp. Doxycycline monotherapy led to symptomatic improvement and resolution of her pancytopenia. During her hospital stay, a computed tomography angiogram of the chest revealed pulmonary emboli, and esophagogastroduodenoscopy uncovered arteriovenous malformations. After appropriate treatment, she was discharged on hospital day 7 and has since done well. CONCLUSIONS: Overall, our case offers a dramatic, unexpected presentation of ehrlichiosis in a nonagenarian. To our knowledge, this is the first report of concurrent ehrlichiosis and pulmonary embolus.

Genome Editing with Engineered Nucleases in Economically Important Animals and Plants: State of the Art in the Research Pipeline.

After induced mutagenesis and transgenesis, genome editing is the next step in the development of breeding techniques. Genome editing using site-directed nucleases - including meganucleases, zinc-finger nucleases (ZFNs), transcription activator-like effector nucleases (TALENs), and the CRISPR/Cas9 system - is based on the mechanism of double strand breaks. The nuclease is directed to cleave the DNA at a specific place of the genome which is then repaired by natural repair mechanisms. Changes are introduced during the repair that are either accidental or can be targeted if a DNA template with the desirable sequence is provided. These techniques allow making virtually any change to the genome including specific DNA sequence changes, gene insertion, replacements or deletions with unprecedented precision and specificity while being less laborious and more straightforward compared to traditional breeding techniques or transgenesis. Therefore, the research in this field is developing quickly and, apart from model species, multiple studies have focused on economically important species and agronomically important traits that were the key subjects of this review. In plants, studies have been undertaken on disease resistance, herbicide tolerance, nutrient metabolism and nutritional value. In animals, the studies have mainly focused on disease resistance, meat production and allergenicity of milk. However, none of the promising studies has led to commercialization despite several patent applications. The uncertain legal status of genome-editing methods is one of the reasons for poor commercial development, as it is not clear whether the products would fall under the GMO regulation. We believe this issue should be clarified soon in order to allow promising methods to reach their full potential.

Validity and reliability of the geriatric sexuality inventory.

Effective health care for older adults requires that providers assess and manage sexual health needs with high priority. This assessment begins with an effective sexuality assessment tool. A two-step, research approach was undertaken to develop and test the Geriatric Sexuality Inventory (GSI). Literature and expert review resulted in a 34-item instrument that was initially completed by 34 older adults ages 60 to 91 (mean age = 75). The testing was repeated in 19 of the original participants. The sample was 75% women, and 88% Caucasian with 9% single, 27% married, 18% divorced, and 46% widowed participants. Internal consistency reliability was run on all 53 responses and revealed adequate reliability (alpha = 0.74). Test-retest analysis also revealed good initial instrument reliability (r = 0.78; p < 0.001). Responses to open-ended questions regarding sexual information and care needs supported evidence gathered from the literature. Initial testing of the GSI revealed content validity and good internal consistency and test-retest reliability.

Cognitive impairment in older adults with heart failure: prevalence, documentation, and impact on outcomes.

BACKGROUND: Despite the fact that 80% of patients with heart failure are aged more than 65 years, recognition of cognitive impairment by physicians in this population has received relatively little attention. The current study evaluated physician documentation (as a measure of recognition) of cognitive impairment at the time of discharge in a cohort of older adults hospitalized for heart failure. METHODS: We performed a prospective cohort study of older adults hospitalized with a primary diagnosis of heart failure. Cognitive status was evaluated with the Folstein Mini-Mental State Examination at the time of hospitalization. A score of 21 to 24 was used to indicate mild cognitive impairment, and a score of ≤20 was used to indicate moderate to severe impairment. To evaluate physician documentation of cognitive impairment, we used a standardized form with a targeted keyword strategy to review hospital discharge summaries. We calculated the proportion of patients with cognitive impairment documented as such by physicians and compared characteristics between groups with and without documented cognitive impairment. We then analyzed the association of cognitive impairment and documentation of cognitive impairment with 6-month mortality or readmission using Cox proportional hazards regression. RESULTS: A total of 282 patients completed the cognitive assessment. Their mean age was 80 years of age, 18.8% were nonwhite, and 53.2% were female. Cognitive impairment was present in 132 of 282 patients (46.8% overall; 25.2% mild, 21.6% moderate-severe). Among those with cognitive impairment, 30 of 132 (22.7%) were documented as such by physicians. Compared with patients whose cognitive impairment was documented by physicians, those whose impairment was not documented were younger (81.3 vs 85.2 years, P<.05) and had less severe impairment (median Mini-Mental State Examination score 22.0 vs 18.0, P<.01). After multivariable adjustment, patients whose cognitive impairment was not documented were significantly more likely to experience 6-month mortality or hospital readmission than patients without cognitive impairment. CONCLUSIONS: Cognitive impairment is common in older adults hospitalized for heart failure, yet it is frequently not documented by physicians. Implementation of strategies to improve recognition and documentation of cognitive impairment may improve the care of these patients, particularly at the time of hospital discharge.

Brief report: the medical care of adults with autism spectrum disorders: identifying the needs.

There is a lack of information concerning adults with autism spectrum disorder (ASD), especially with regards to their access to health care. A paper and electronic survey was sent to 1,580 primary care physicians in Connecticut. 346 respondents returned a survey and provided care to adults with an ASD. This physician survey provides data on adults with ASD such as: reasons for physician visits, living arrangements, employment status, and any services they are receiving. Responses revealed inadequate training in the care of adults with an ASD and physicians interest in obtaining additional training. The ability to provide a medical home for adults with autism will need to address effective strategies to train current and future physicians.

A survey assessing the presence of "medical home" for adults with disabilities in Connecticut.

BACKGROUND: The medical home model has been recommended as the best design for healthcare management for individuals with disabilities by the American Academy of Pediatrics and the American Academy of Family Physicians. As set forth by these guidelines, a medical home contains the following elements: access to health care, usual source of care, personal doctor or nurse, referrals for specialty care, coordinated care, andperson-centered care. OBJECTIVE/HYPOTHESIS: This study aimed to gather information from adults with disabilities in Connecticut, and the barriers to achieving the medical home model. The study focused on each of the components that make up the medical home model definition. METHODS: An adultwith a disabilitywas defined as a person 18 years or older with any physical or mental disability that significantly impacted one or more major life activities, as defined by the Americans with Disabilities Act. The adults with disabilities were recruited by email through a variety of list servers and flyers that were mailed to employers of people with disabilities. The study consisted of 88 adults with disabilities who were interviewed via telephone with a 54-item survey that was developed based on the research of medical home models. RESULTS: The most common types of disabilities represented were physical (51%), psychiatric (28%), and neurological (24%). The results ofthe study found that 22% of participants were found to have access to health care, 92% of participants reported they had a usual place they go to receive health care, 77% of participants reported having no problems with the process of referrals, 37% of participants were found to have adequate coordinated care, and 90% of participants were identified as having person-centered care. CONCLUSIONS: Overall, only 7% of participants met the criteria for all aspects of the medical home model. The conclusions drawn from this study indicate a need for increased access to health care, more efficiently designed coordinated care, and more accessible referrals to specialists for adults with disabilities, with access being the largest barrier to adequate health care.

Medical conditions and medication use in adults with Down syndrome: a descriptive analysis.

BACKGROUND: We examined the presence of medical conditions and medication use within a sample of adults with Down syndrome. METHODS: Retrospective chart review using a sample of 141 adults with Down syndrome and age range of 30 to 65 years. RESULTS: We identify 23 categories of commonly occurring medical conditions and 24 categories of medications used by adults with Down syndrome. CONCLUSION: Approximately 75 of older adults with Down syndrome in our sample experience memory loss and dementia. Hypothyroidism, seizures, and skin problems also occur commonly. The prevalence of cancer (i.e., solid tumours) and hypertension is extremely low. Older adults with Down syndrome use anticonvulsant more often than younger adults with Down syndrome. The use of multivitamins and medications such as pain relievers, prophylactic antibiotics, and topical ointments is common.

Health and psychosocial correlates of disordered gambling in older adults.

OBJECTIVE: A number of regional prevalence studies suggest that disordered gambling is a clinically significant problem among older adults. However, little research has evaluated whether older adults with a gambling disorder experience increased health, psychiatric, substance use, and social problems as compared with older adults without a gambling disorder. METHODS: A group of 48 older-adult disordered gamblers and 48 older adult non/infrequent gamblers, matched by age, sex, race, and recruitment site, completed the Addiction Severity Index (ASI), Brief Symptom Inventory (BSI), and Short Form-36 Health Survey (SF-36). Multivariate general-linear models evaluated between-group differences on these indices. RESULTS: Compared with non/infrequent gamblers, disordered gamblers reported increased severity of medical, family/social, psychiatric, and alcohol problems on the ASI. They also scored higher on depression, anxiety, paranoid ideation, and psychoticism subscales of the BSI, and lower on vitality, physical functioning, role-physical, general health, and social functioning subscales of the SF-36. CONCLUSIONS: These results suggest that older adults with a gambling disorder experience increased severity of health and psychosocial problems, compared with older adult non/infrequent gamblers matched by age, sex, race, and recruitment site.

Whole-carcass residues of the rodenticide difenacoum in anticoagulant-resistant and -susceptible rat strains (Rattus norvegicus).

The present study investigated the whole-carcass residue carried by resistant and susceptible laboratory rat strains following 5, 10, or 20 d of feeding on a diet of 25 mg difenacoum/kg bait. The mean whole-carcass residue of difenacoum was determined by high-performance liquid chromatography to be between 0.52 and 0.74 mg/kg body weight in all three rat strains tested. These values were considerably lower than some comparable data previously reported for other species and second-generation rodenticides as well as from mathematical models. The whole-carcass residue of extractable (i.e., nonrefractory) parent compound carried by highly resistant rats fed for 20 d (0.74 mg/kg body wt) is unlikely to present a significantly increased risk to predators compared to the amount carried by susceptible rats after 5 d of feeding (0.52 mg/kg body wt). However, resistant rats are more likely to be available for predation and to be carrying a whole-carcass residue of anticoagulant throughout the duration of a control program.

Physician attitudes and practices on providing care to individuals with intellectual disabilities: an exploratory study.

A dearth of literature exists regarding barriers to physicians providing medical care to patients with intellectual disabilities. Using an exploratory study, we assessed current physician practice for this population of patients. We mailed a 17-question anonymous survey to primary care physicians (PCPs) in Connecticut. Results showed that many physicians care for patients with intellectual disabilities, but approximately 62% of physicians believed caring for this group to be more difficult compared to other groups. Lack of training and education pertaining to patients with intellectual disabilities, issues of communication, and interruptions in continuity of patient care affect physicians' ability to care for this population. Future research should establish best practices and examine nationwide practices in providing care to patients with intellectual disabilities.

Gambling participation and problems among older adults.

Few studies have evaluated rates of gambling participation and problems in older adults. This study recruited 492 adults aged 65 years and older from bingo sites (n = 132) and senior centers (n = 360). Compared to those recruited from senior centers, participants recruited at bingo events had higher South Oaks Gambling Screen (SOGS) scores and greater gambling frequency and expenditures. Lifetime rates of combined problem and pathological gambling were 12.9% in the bingo sample and 9.7% in the senior center sample (10.6% overall). Compared to non-problem gamblers, problem and pathological gamblers were more likely to be younger (73 versus 76 years) and male (52% versus 27%). Overall, 39.1% reported gambling at least twice per month over the past year, and 33.7% wagered dollars 50 or more over the prior 2 months. This study suggests that subsets of active older adults have high rates of gambling participation and problems.