Complete Blood Count Alterations Prior to the Diagnosis of Colorectal Cancer May Help in the Detection of Synchronous Liver Metastases.

Background and Aims: Colorectal cancer (CRC) represents 10% of all cancers worldwide with the highest incidence in developed countries; its incidence is also increasing in middle- and low-income countries. Population screening programs facilitate early diagnosis of the disease. When the diagnosis is carried out in advanced stages, approximately 80% of patients with liver metastases (LM) are considered unresectable at the time of diagnosis. In our study, variations in blood counts prior to CRC diagnosis were analyzed to assess whether they could be useful in identifying smaller, more manageable metastases at earlier stages for more effective treatment. Methods: A study was carried out using complete blood counts (CBCs) from CRC patients, obtained from primary health centers and the La Ribera University Hospital within La Ribera Health Department, Valencian Community, Spain, between July 2012 and September 2020. Data from CRC patients who presented synchronous liver metastasis (CRLM) were compared with those with CRC without LM at diagnosis (CRC patients). Results: Our analysis shows that at least 15 months before CRC diagnosis, a progressive alteration was observed in CBC parameters in both groups. A higher incidence of anemia (p < 0.001) was observed among CRLM patients in the three months prior to CRC diagnosis than in CRC patients showing no LM. Conclusions: A statistically significant deterioration of CBC was observed in patients with advanced-stage CRC and synchronous or early LM (CRLM) in the three months prior to diagnosis. The primary goal of incorporating CBC variations into predictive models is to identify individuals who are at a greater risk of developing metastatic colon cancer, leading to early diagnosis. Our research improves these models by highlighting a more pronounced and rapid decline in hemoglobin levels among CRLM patients. Identification of metastases at an earlier stage when they are smaller, more manageable, and more amenable to treatment may be a valuable tool to prevent their further progression.

Effect of Familial Longevity on Frailty and Sarcopenia: A Case-Control Study.

Familial longevity confers advantages in terms of health, functionality, and longevity. We sought to assess potential differences in frailty and sarcopenia in older adults according to a parental history of extraordinary longevity. A total of 176 community-dwelling subjects aged 65-80 years were recruited in this observational case-control study, pair-matched 1:1 for gender, age, and place of birth and residence: 88 centenarians' offspring (case group) and 88 non-centenarians' offspring (control group). The main variables were frailty and sarcopenia based on Fried's phenotype and the European Working Group on Sarcopenia in Older People (EWGSOP) definitions, respectively. Sociodemographics, comorbidities, clinical and functional variables, the presence of geriatric syndromes, and laboratory parameters were also collected. Related sample tests were applied, and conditional logistic regression was performed. Cases had a higher percentage of robust patients (31.8% vs. 15.9%), lower percentages of frailty (9.1% vs. 21.6%) and pre-frailty (59.1% vs. 62.5%) (p = 0.001), and lower levels of IL-6 (p = 0.044) than controls. The robust adjusted OR for cases was 3.00 (95% CI = 1.06-8.47, p = 0.038). No significant differences in muscle mass were found. Familial longevity was also associated with less obesity, insomnia, pain, and polypharmacy and a higher education level and total and low-density lipoprotein cholesterol. The results suggest an inherited genetic component in the frailty phenotype, while the sarcopenia association with familial longevity remains challenging.

Before-and-After Study of the First Four Years of the Enhanced Recovery after Surgery (ERAS®) Programme in Older Adults Undergoing Elective Colorectal Cancer Surgery.

BACKGROUND: The aim of this study was to determine whether the inclusion of older patients undergoing elective colorectal cancer resection in the Enhanced Recovery After Surgery (ERAS®) programme could improve clinical outcomes during hospital admission. METHODS: A before-and-after study in ≥70-year-old patients electively admitted for colorectal cancer resection was designed. In total, 213 patients were included in the ERAS® group, and 158 were included in the control group. RESULTS: The average age was 77.9 years old (SD 5.31) and 57.14% of them were men, with a Charlson Index score of 3.42 (SD 3.32). The ERAS® group presented a lower transfusion rate of 42 (19.7%), compared to 75 (47.5%) in the control group (p < 0.001). The crude odds ratio (OR) for transfusion was 0.27 (95% CI 0.17-0.43; p < 0.001), and the adjusted odds ratio was 0.26 (95% CI 0.14-0.48; p < 0.001). The ERAS® group had a lower percentage of patients with moderate-severe malnutrition on admission, at 23.4% (37 patients) against 36.2% in the control group (42 patients) (p = 0.023), with an OR of 0.47 (95% CI 0.29-0.75; p < 0.002) and an adjusted OR of 0.48 (95% CI 0.29-0.78; p = 0.003). The number of patients who required admission to the intensive care unit (ICU) was also markedly lower: 54 from the ERAS® group (25.4%) versus 71 from the control group (44.9%) (p < 0.001). CONCLUSIONS: The inclusion of ≥70-year-old adults in the ERAS® programme resulted in a decrease in transfusions, number of erythrocyte concentrates transfused, and number of ICU admissions, along with improved nutritional status.

Malnutrition and Increased Risk of Adverse Outcomes in Elderly Patients Undergoing Elective Colorectal Cancer Surgery: A Case-Control Study Nested in a Cohort.

BACKGROUND: Malnutrition increases worse outcomes during hospital admission for elective colorectal cancer (CRC) surgery in older adults. METHODS: This work was designed an observational, monocentric, case-control study nested in a cohort of patients undergoing elective surgery for CRC disease at the Hospital Universitario de la Ribera (HULR) (Alzira, Valencia, Spain) between 2011 and 2019. The study considered patients with a CONUT score in the range of moderate to severe malnutrition (>4 points), with control patients with normal nutritional situations or mild malnutrition. RESULTS: Moderate-to-severe malnutrition cases presented a greater length of stay (LOS), a higher incidence of adverse events (both medical and surgical complications), a higher incidence of surgical-wound infection, a greater need for blood transfusion, and a greater amount of transfused packed red blood cells. During hospitalization, the percentage of patients without nutritional risk decreased from 46 to 9%, and an increase in mild, moderate, and severe risk was observed. Patients with severe nutritional risk at hospital admission had significantly increased mortality at 365 days after discharge (HR: 2.96 (95% CI 1.14-7.70, p = 0.002)). After adjusting for sex, age, and Charlson index score, patients with severe nutritional risk at admission maintained a higher mortality risk (HR: 3.08 (95% CI 1.10-8.63, p = 0.032)). CONCLUSION: Malnutrition prevalence is high in older adults undergoing CRC elective surgery. Furthermore, this prevalence increases during hospital admission. Malnutrition is linked to worse outcomes, such as LOS, surgical and clinical complications, and mortality. For this reason, nutritional interventions are very important in the perioperative period.

Are Hospitals Safe? A Prospective Study on SARS-CoV-2 Prevalence and Outcome on Surgical Fracture Patients: A Closer Look at Hip Fracture Patients.

OBJECTIVES: To describe clinical characteristics of fracture patients, including a closer look to hip fracture patients, and determine how epidemiological variables may have influenced on a higher vulnerability to SARS-CoV-2 infection, as the basis for the considerations needed to reintroduce elective surgery during the pandemic. DESIGN: Longitudinal prospective cohort study. SETTING: Level I Trauma Center in the East of Spain. PATIENTS/PARTICIPANTS: One hundred forty-four consecutive fracture patients 18 years or older admitted for surgery. INTERVENTION: Patients were tested for SARS-CoV-2 with either molecular and/or serological techniques and screened for presentation of COVID-19. MAIN OUTCOME MEASUREMENTS: Patients were interviewed and charts reviewed for demographic, epidemiological, clinical, and surgical characteristics. RESULTS: We interviewed all patients and tested 137 (95.7%) of them. Three positive patients for SARS-CoV-2 were identified (2.1%). One was asymptomatic and the other 2 required admission due to COVID-19-related symptoms. Mortality for the whole cohort was 13 patients (9%). Significant association was found between infection by SARS-CoV-2 and epidemiological variables including: intimate exposure to respiratory symptomatic patients (P = 0.025) and intimate exposure to SARS-CoV-2-positive patients (P = 0.013). No association was found when crowding above 50 people was tested individually (P = 0.187). When comparing the 2020 and 2019 hip fracture cohorts we found them to be similar, including 30-day mortality. A significant increase in surgical delay from 1.5 to 1.8 days was observed on the 2020 patients (P = 0.034). CONCLUSIONS: Patients may be treated safely at hospitals if strict recommendations are followed. Both cohorts of hip fracture patients had similar 30-day mortality. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Influence of hospital adverse events and previous diagnoses on hospital care cost of patients with hip fracture.

Previous diagnoses of patients with hip fracture influence the hospitalization cost of these patients, either directly or by increasing the risk of in-hospital adverse events associated with increased costs. PURPOSE: To investigate how previous diagnoses influence the occurrence of in-hospital adverse events and how both factors impact on hospital costs. METHODS: This is a retrospective analysis of the hospital Minimum Basic Data Set. Patients aged 70 years or older admitted for hip fracture (HF) at a single University Hospital between January 2012 and December 2016. Both, previous diagnoses and adverse events, were defined according to the International Classification of Diseases (ICD-9/ICD-10). The anticipated cost of each admission was calculated based on diagnosis-related groups and using the "all patients refined" method (APR-DRG). The occurrence of adverse events during hospital stay was assessed by excluding all diagnoses present on admission. RESULTS: The record included 1571 patients with a mean (SD) age of 84 years. The most frequent previous diagnoses were diabetes (n = 432, 27.5%) and dementia (n = 251, 16.0%), and the most frequent adverse events were delirium (n = 238, 15.1%) and anemia (n = 188, 12.0%). The mean (SD) total acute care costs per patient were €8752.1 (1864.4). The presence of heart failure, COPD, and kidney disease at admission significantly increased the hospitalization cost. In-hospital adverse events of delirium, cardiac events, anemia, urinary tract infection, and digestive events significantly increased costs. The multivariate analyses identified kidney disease as a previous diagnosis significantly contributing to explain an increase in hospitalization costs, and delirium, cardiac disease, anemia, urinary infection, respiratory event, and respiratory infection as in-hospital adverse events significantly contributing to an increase of hospitalization costs. CONCLUSIONS: Although few baseline comorbidities have a direct impact on hospitalization costs, most previous diagnoses increase the risk of in-hospital adverse events, which ultimately influence the hospitalization cost.

A daily multidisciplinary assessment of older adults undergoing elective colorectal cancer surgery is associated with reduced delirium and geriatric syndromes.

OBJECTIVES: Comprehensive geriatric assessment (CGA) has shown to benefit older patients undergoing urological and orthopedic surgery. However, this approach has been scarcely assessed in patients elected for colorectal surgery. MATERIALS AND METHODS: Retrospective cohort of patients aged ≥70 years admitted for elective colorectal cancer surgery to a single hospital between 2008 and 2012. Upon admission, patients were assigned to a usual care (UC) plan or a CGA-based care (GS) plan conducted by a multidisciplinary team, according to standard clinical criteria.Analyzed outcomes included the incidence of delirium and other geriatric syndromes during hospital stay, mortality, readmissions, andnumber of perioperative complications. RESULTS: The cohort included 310 patients, 203 assigned to the GS group and 107 to the UC group. Patients in the GS group had significantly lower Barthel and Lawton scores, higher prevalence of dementia and heart failure, and higher comorbidity burden. Fifty-four (17.5%) patientsexperienced delirium (23 [11.3%] and 31 [29.2%] in the GS and UC groups, respectively; p < .001), and 49 (15.8%) patient experienced other geriatric syndromes (21 [10.3%] and 28 [26.2%] in the GS and UC groups, respectively; p < .001). Serious complications were more frequent in the GS group: 154 (75.9%) vs 60 (56.1%) in the UC group; p < .001. No significant differences were observed between groups regarding readmissions, and in-hospital and post-discharge (1 year follow-up) mortality. CONCLUSIONS: Despite the poorer clinical condition of patients in the GS group, the CGA-based intervention resulted in a lower incidence of delirium and other geriatric syndromes compared with the UC group.

Estimate of the Costs Caused by Adverse Effects in Hospitalised Patients Due to Hip Fracture: Design of the Study and Preliminary Results.

INTRODUCTION: Hip fracture is a health problem that presents high morbidity and mortality, negatively influencing the patient's quality of life and generating high costs. Structured analysis of quality indicators can facilitate decision-making, cost minimization, and improvement of the quality of care. METHODS: We studied 1571 patients aged 70 years and over with the diagnosis of hip fracture at Hospital Universitario de la Ribera in the period between 1 January 2012 and 31 December 2016. Demographic, clinical, functional, and quality indicator variables were studied. An indirect analysis of the costs associated with adverse events arising during hospital admission was made. A tool based on the "Minimum Basic Data Set (CMBD)" was designed to monitor the influence of patient risk factors on the incidence of adverse effects (AE) and their associated costs. RESULTS: The average age of the patients analysed was 84.15 years (SD 6.28), with a length of stay of 8.01 days (SD 3.32), a mean preoperative stay of 43.04 h (SD 30.81), and a mortality rate of 4.2%. Likewise, the percentage of patients with AE was 41.44%, and 11.01% of patients changed their cost as a consequence of these AEs suffered during hospital admission. The average cost of patients was €8752 (SD: 1,864) and the average cost increase in patients with adverse events was €2321 (SD: 3,164). CONCLUSIONS: Through the analysis of the main clinical characteristics and the indirect estimation of the complexity of the patients, a simple calculation of the average cost of the attention and its adverse events can be designed in patients who are admitted due to hip fracture. Additionally, this tool can fit the welfare quality indicators by severity and cost.

Orthogeriatric care: improving patient outcomes.

Hip fractures are a very serious socio-economic problem in western countries. Since the 1950s, orthogeriatric units have introduced improvements in the care of geriatric patients admitted to hospital because of hip fractures. During this period, these units have reduced mean hospital stays, number of complications, and both in-hospital mortality and mortality over the middle term after hospital discharge, along with improvements in the quality of care and a reduction in costs. Likewise, a recent clinical trial has reported greater functional gains among the affected patients. Studies in this field have identified the prognostic factors present upon admission or manifesting themselves during admission and that increase the risk of patient mortality or disability. In addition, improved care afforded by orthogeriatric units has proved to reduce costs. Nevertheless, a number of management issues remain to be clarified, such as the optimum anesthetic, analgesic, and thromboprophylactic protocols; the type of diagnostic and therapeutic approach best suited to patients with cognitive problems; or the efficiency of the programs used in convalescence units or in home rehabilitation care. Randomized clinical trials are needed to consolidate the evidence in this regard.

Severity of cognitive impairment as a prognostic factor for mortality and functional recovery of geriatric patients with hip fracture.

AIM: To identify how the severity of dementia influences functional recovery and mortality in elderly patients hospitalized for hip fracture. METHODS: An observational retrospective study of 1258 patients aged older than 69 years and diagnosed with hip fracture who received care within an orthogeriatrics unit from 2004 to 2008 was carried out. During a 12-month follow-up period, functional recovery and mortality outcomes were measured. RESULTS: Dementia was present in 383 (28.1%) patients: it was mild in 183 (48%), moderate in 102 (26.5%) and severe in 98 (25.5%). Compared with patients with preserved cognitive status, patients with dementia had the following statistically significant differences (means [standard deviation] or percentage): older age (preserved, 82.29 years [6.5 years]; mild, 83.63 years [6.1 years]; moderate, 83.47 years [5.9 years]; severe, 84.46 years [6.1 years]; P < 0.001); lower Barthel Index (89.7 [21.6], 72.7 [24.6], 58.9 [28.6], 38.0 [28.1]; P < 0.001); delirium (11.7%, 25.6%, 37.6%, 44.7%; P < 0.001); less ambulation at 6 months postdischarge (83.9%, 72.8%, 56.9%, 41.7%; P < 0.001); and higher mortality at discharge (4%, 5.7%, 8.2%, 10.6%; P < 0.001) and 12 months after discharge (21.2%, 32.3%, 46.3%, 53.5%; P < 0.001). Patients with severe dementia had lower probability of functional recovery at discharge (OR 0.272, 95% CI 0.140-0.526, P < 0.001) and 6 months after discharge (OR 0.439, 95% CI 0.197-0.979, P = 0.04), as well as a greater probability of dying (HR 1.640, 95% CI 1.020-2.635, P = 0.04). CONCLUSIONS: We observed higher 12-month mortality and less functional recovery with increasing severity of dementia.

Early interdisciplinary hospital intervention for elderly patients with hip fractures : functional outcome and mortality.

OBJECTIVES: Hip fractures are associated with high levels of co-morbidity and mortality. Orthogeriatric units have been shown to be effective with respect to functional recovery and mortality reduction. The aim of this study is to document the natural history of early multidisciplinary intervention in elderly patients with hip fractures and to establish the prognostic factors of mortality and walking ability after discharge. METHODS: This observational, retrospective study was performed in an orthogeriatric care unit on patients aged >70 years with a diagnosis of hip fracture between 2004 and 2008. This study included 1363 patients with a mean age of 82.7 + 6.4 years. RESULTS: On admission to the unit, the average Barthel score of these patients was 77.2 + 27.8 points, and the average Charlson index score was 2.14 + 2.05. The mean length of stay was 8.9 + 4.26 days, and the readmission rate was 2.3%. The in-hospital mortality rate was 4.7%, and the mortality rates at one, six, and 12 months after discharge were 8.7%, 16.9%, and 25.9%, respectively. The Cox proportional hazards model estimated that male sex, Barthel scale, heart failure, and cognitive impairment were associated with an increased risk of death. With regard to functionality, 63.7% of the patients were able to walk at the time of discharge, whereas 77.4% and 80.1% were able to walk at one month and six months post-discharge, respectively. The factors associated with a worse functional recovery included cognitive impairment, performance status, age, stroke, Charlson score, and delirium during the hospital stay. CONCLUSIONS: Early multidisciplinary intervention appears to be effective for the management of hip fracture. Age, male sex, baseline function, cognitive impairment and previous comorbidities are associated with a higher mortality rate and worse functional recovery.

Early interdisciplinary hospital intervention for elderly patients with hip fractures : functional outcome and mortality

OBJECTIVES: Hip fractures are associated with high levels of co-morbidity and mortality. Orthogeriatric units have been shown to be effective with respect to functional recovery and mortality reduction. The aim of this study is to document the natural history of early multidisciplinary intervention in elderly patients with hip fractures and to establish the prognostic factors of mortality and walking ability after discharge. METHODS: This observational, retrospective study was performed in an orthogeriatric care unit on patients aged >70 years with a diagnosis of hip fracture between 2004 and 2008. This study included 1363 patients with a mean age of 82.7 + 6.4 years. RESULTS: On admission to the unit, the average Barthel score of these patients was 77.2 + 27.8 points, and the average Charlson index score was 2.14 + 2.05. The mean length of stay was 8.9 + 4.26 days, and the readmission rate was 2.3%. The in-hospital mortality rate was 4.7%, and the mortality rates at one, six, and 12 months after discharge were 8.7%, 16.9%, and 25.9%, respectively. The Cox proportional hazards model estimated that male sex, Barthel scale, heart failure, and cognitive impairment were associated with an increased risk of death. With regard to functionality, 63.7% of the patients were able to walk at the time of discharge, whereas 77.4% and 80.1% were able to walk at one month and six months post-discharge, respectively. The factors associated with a worse functional recovery included cognitive impairment, performance status, age, stroke, Charlson score, and delirium during the hospital stay. CONCLUSIONS: Early multidisciplinary intervention appears to be effective for the management of hip fracture. Age, male sex, baseline function, cognitive impairment and previous comorbidities are associated with a higher mortality rate and worse functional recovery.