Predicting Survival

Predicting Survival in Oldest Old People

In a cohort of oldest old people (over age 85), slow gait speed and Instrumental Activities of Daily Living disability are both predictors of survival.

Abstract 
Objective 
Measures of physical performance are regarded as useful objective clinical tools to estimate survival in elderly people. However, oldest old people, aged 85 years or more, are underrepresented in earlier studies and frequently unable to perform functional tests. We studied the association of gait speed and survival in a cohort of oldest old people and the association of Instrumental Activities of Daily Living by questionnaire and survival as an alternative prognostic marker of survival.

Methods 
The Leiden 85-plus Study was used, a prospective population-based study with a follow-up period of 12 years. The study comprised 599 participants all aged 85 years at baseline. Survival rate was the measurement. Results At age 85 years, 73 participants (12.2%) did not perform the walking test. Gait speed faster than 0.8 m/s was present in only 48 participants (9%), and gait speed faster than 1.0 m/s was present in 10 participants (1.9%). Risk for all-cause mortality was higher in participants with slow gait speed after 2 and 12 years of follow-up (hazard ratio [HR], 2.66; 95% confidence interval [CI], 1.49-4.75; P<.001; and HR, 2.04; 95% CI, 1.61-2.59; P=.100, respectively). Significance was lost after adjustment for common confounders. Poor Instrumental Activities of Daily Living ability was associated with an increased risk of mortality after 2 and 12 years of follow-up (HR, 6.11; 95% CI, 3.44-10.87; P<.001; and HR, 2.75; 95% CI, 2.22-3.40; P<.001, respectively). Adjustment for possible confounders attenuated the relation but remained significant.

Conclusions
The cutoff points for gait speed in oldest old people need to be reevaluated. In oldest old people aged 85 years, slow gait speed (≤0.40 m/s in women and ≤0.45 m/s in men) and Instrumental Activities of Daily Living disability are both predictors of survival. Assessment of Instrumental Activities of Daily Living could be a better tool for short- and long-term prognostication of survival in oldest old people.

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--Diana G. Taekema, MD, PhD, J. Gussekloo, MD, PhD, Rudi G.J. Westendorp, MD, PhD, Anton J.M. de Craen, PhD, Andrea B. Maier, MD, PhD 

--This article originally appeared in the December 2012 issue of The American Journal of Medicine.

Searching for the Holy Grail

The Search for the Holy Grail: Doing More with Less

In the movie Indiana Jones and the Holy Grail when Jones and others are confronted with numerous cups, only one of which is the Grail, the advice of the old Knight Templar is to “choose wisely.” In the movie, the cup that is least appealing is the Grail, and failure to make the right choice leads to death.

Likewise, the failure of physicians and patients to make the right choices puts the financial well-being of the United States at risk. Physicians are confronted with numerous tests or procedures that can be applied to our patients. We frequently do not choose wisely because we do not consider the cost in relationship to the benefit to the patient. Rather, physicians tend to select what is most expedient or new or likely to be of financial benefit to them. Approximately 18% of the US gross domestic product was spent on healthcare in 2011. It is estimated that 21% to 34% of this expenditure is wasted.1 Overtesting accounts for $210 billion of the $2.2 trillion the United States spends on healthcare each year.2 Options to control these costs are limited. One approach is to reduce reimbursement to providers and hospitals for the care being provided. Another and more appealing alternative is to reduce the waste.

The American Board of Internal Medicine Foundation has created Choosing Wisely, in which the American Board of Internal Medicine has partnered with 9 other societies to help physicians better manage our healthcare dollars. The stated goal is “while managing the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources”.3 Each of the societies has developed recommendations for certain disorders in which cost-effective decisions can be made between the patient and the physician. All of these recommendations can be found on choosingwisely.org.

--To read this article in its entirety, please visit our website.

--Thomas Boyer, MD

--This article originally appeared in the December 2012 issue of The American Journal of Medicine.

Related article: Tailoring Colorectal Cancer Screening by Considering Risk of Advanced Proximal Neoplasia

The Risk of Pill Cutter Sharing

The most frequent cause of secondary adrenal insufficiency is the prolonged exposure to exogenous glucocorticoids (GCs).(1) The source of GCs is most often obvious (oral or parenteral, or even inhaled), but it may be occasionally more difficult to identify, as GCs may be found in “traditional” or “alternative” medicines.(2) We describe here the case of a patient with secondary adrenal insufficiency due to using the same pill cutter for her medications and her dog's prednisone.

A 45-year-old woman with history of depression presented to her internist complaining of 4 weeks of decreased appetite, nausea, weakness, and 4-kg weight loss. Symptoms had started about 1 week after her dog died...

The patient denied ever taking oral, topical, or parenteral GCs or any alternative medicine preparation. Her dog had a history of Addison's disease and had been on prednisone for the past 6 years. She had been administering prednisone to the pet by breaking twice daily a 5-mg prednisone tablet into quarters, using a pill cutter. Over these years, she had frequently used the same pill cutter to cut her own antidepressant pills.

--To read this article in its entirety, please visit our website.

--Sritika Thapa, MD and Roberto Salvatori, MD

--This article originally appeared in the November 2012 issue of The American Journal of Medicine.

Surviving Bariatric Surgery

An Uncommon Option for Surviving Bariatric Surgery: Regaining Weight!

In November 2011, a 32-year-old woman was admitted to the intensive care unit for acute respiratory failure. She had felt well consistently until February (including 2 pregnancies), when she underwent a noncomplicated sleeve gastrectomy for obesity (body mass index, 47 kg/m2). Her weight gain, unrelated to any endocrine disease, had started with adolescence and was resistant to all attempts to lose weight. One month after bariatric surgery and a loss of 20 kg, she had a first episode of constant and diffuse abdominal pain with slightly increased plasma concentration of lipase, and pancreatitis was diagnosed. Recurrent monthly vomiting episodes occurred later with abdominal and leg pains unrelated to her menstrual cycle. To counter postoperative deficiencies, she was fully supplemented with all vitamins. She had been treated regularly with analgesic drugs in an attempt to relieve erratic pain. Three weeks before admission, leg pains intensified, and tetraparesis developed over 2 days. On admission (6 months after surgery), her body mass index was 21 kg/m2 and heart rate was 135 beats/min. She had tetraparesis with diffuse allodynia and paresthesias, facial diplegia, and swallowing disorders with alveolar hypoventilation requiring mechanical ventilation.

Laboratory test results showed hypokalemia (2.6 mmol/L), hyponatremia (134 mmol/L), and moderately elevated liver enzymes (alanine aminotransferase 79 UI/L and aspartate aminotransferase 47 UI/L) without cholestasis. Renal function, blood counts, hemostasis, and Lyme serology were normal, as well as dosages of vitamins. Repeated cerebrospinal fluid examinations showed normal protein concentration without cells. Electromyography was compatible with severe motor axonal polyneuropathy. Magnetic resonance imaging showed focal cervical hyperintensity compatible with myelitis. Electroencephalography was normal.

Supportive care was given, and immunoglobulins were infused to treat a possible Guillain-Barre syndrome. No improvement was noted during the first few days.

--To read this article in its entirety, please visit our website.

-- François Danion, Max Guillot, MD, Vincent Castelain, MD, PhD, Hervé Puy, MD, PhD, Jean-Charles Deybach, MD, PhD, Francis Schneider, MD, PhD

--This article originally appeared in the November 2012 issue of The American Journal of Medicine.

Computerized Patient Education

Using Animated Computer-generated Text and Graphics to Depict the Risks and Benefits of Medical Treatment

Computer-animated depictions of risks and benefits offer an effective means to describe medical risk/benefit statistics. Understanding and satisfaction were significantly better when the format matched the patient’s preference for message delivery.

 Abstract 
Objective 
Conventional print materials for presenting risks and benefits of treatment are often difficult to understand. This study was undertaken to evaluate and compare subjects' understanding and perceptions of risks and benefits presented using animated computerized text and graphics.

Methods
Adult subjects were randomized to receive identical risk/benefit information regarding taking statins that was presented on an iPad (Apple Corp, Cupertino, Calif) in 1 of 4 different animated formats: text/numbers, pie chart, bar graph, and pictograph. Subjects completed a questionnaire regarding their preferences and perceptions of the message delivery together with their understanding of the information. Health literacy, numeracy, and need for cognition were measured using validated instruments.

Results 
There were no differences in subject understanding based on the different formats. However, significantly more subjects preferred graphs (82.5%) compared with text (17.5%, P<.001). Specifically, subjects preferred pictographs (32.0%) and bar graphs (31.0%) over pie charts (19.5%) and text (17.5%). Subjects whose preference for message delivery matched their randomly assigned format (preference match) had significantly greater understanding and satisfaction compared with those assigned to something other than their preference.

Conclusions 
Results showed that computer-animated depictions of risks and benefits offer an effective means to describe medical risk/benefit statistics. That understanding and satisfaction were significantly better when the format matched the individual's preference for message delivery is important and reinforces the value of “tailoring” information to the individual's needs and preferences.

 --To read this article in its entirety, please visit our website.

 -- Alan R. Tait, PhD, Terri Voepel-Lewis, MSN, RN, Colleen Brennan-Martinez, BSN, MS, Maureen McGonegal, BA, Robert Levine, MD

 --This article originally appeared in the November 2012 issue of The American Journal of Medicine.

US Health Care in 2050

The Anatomy and Physiology of the US Health Care System in 2050? An Exercise in Prognostication, Fantasy, and Hope

The debate concerning the appropriate structure for the American medical system goes on. Almost every day, one reads a newspaper or magazine article focusing on the strengths and flaws of our health care network. Should we imitate successful systems elsewhere in the world? How can we insure all of our citizens without bankrupting the economy? How many physicians, nurses, and hospitals do we need and how many will we need in the future? These are just some of the questions that constantly bombard us. Like all physicians in the US, we have given these questions and many others considerable thought, which we will now share with the readers of The American Journal of Medicine. These are our own personal ideas and do not reflect the official attitudes or positions of the Journal, Elsevier, any political party, or the University of Arizona.

We anticipate that the current trend towards central control of medical care will continue, and that by 2050, most physicians will work for a health care system such as the one being formed by our university health care network here in Tucson.

Accountable care organizations involving community hospitals such as Tucson Medical Center already have been formed with community doctors and their Medicare patients. These will expand to incorporate more primary care and specialty physicians, along with patients outside of Medicare age.

Individual practitioners and small groups of physicians will gradually disappear, with large numbers of doctors working for the local or regional health system. Centralization will be focused in local entities rather than in Washington, DC or individual state capitals. Physicians will be salaried by these large health networks, with incentives given for productivity and performance.

The networks will contain many components, for example, inpatient and rehabilitation hospitals, outpatient clinics, ambulatory surgical and imaging centers, as well as satellite outpatient clinics and hospitals in outlying areas. The emergency medical system will be a patchwork of state, local community, and private entities that will work closely with the large health systems. Smaller cities may have only one health care network while major urban centers may contain a number of these integrated systems. It also is possible that some of the larger networks will have insurance companies embedded in their structure. Duty hours will be strictly regulated for both trainees and full-time employees.

Most, if not all, Americans will have some form of health insurance, with many still having coverage tied to employment. However, many individuals will receive insurance from regional or federal plans paid for, in part, by state and federal taxes.

--To read this article in its entirety, please visit our website.

--Joseph S. Alpert and Eve Shapiro

--This article originally appeared in the December 2012 issue of The American Journal of Medicine.

MI Risk & Antioxidants

Total Antioxidant Capacity from Diet and Risk of Myocardial Infarction: A Prospective Cohort of Women

There are no previous studies investigating the effect of all dietary antioxidants in relation to myocardial infarction. The total antioxidant capacity of diet takes into account all antioxidants and synergistic effects between them. The aim of this study was to examine how total antioxidant capacity of diet and antioxidant-containing foods were associated with incident myocardial infarction among middle-aged and elderly women.

In the population-based prospective Swedish Mammography Cohort of 49-83-year-old women, 32,561 were cardiovascular disease-free at baseline. Women completed a food-frequency questionnaire, and dietary total antioxidant capacity was calculated using oxygen radical absorbance capacity values. Information on myocardial infarction was identified from the Swedish Hospital Discharge and the Cause of Death registries. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated using Cox proportional hazard models.

--To read this article in its entirety, please visit our website.

--Susanne Rautiainen, MSc, Emily B. Levitan, DrPh, Nicola Orsini, PhD, Agneta Åkesson, PhD, Ralf Morgenstern, PhD, Murray A. Mittleman, MDDrPh, Alicja Wolk, DrMedSci

--This article originally appeared in the October 2012 issue of The American Journal of Medicine.

Rethinking the Way We Eat

Back to the Future: Rethinking the Way We Eat

In 1955, with the opening of the first McDonald's in Des Plaines, Illinois, post-war America took a quantum leap into the Fast Food Era. I vividly remember my family's first trip to a McDonald's—the gleaming white tile … the bright neon sign … the space age Golden Arches… food served in a bag and consumed in the car. We watched sea gulls glide over Lake Erie and we gobbled our little burgers, bags of fries, and chocolate shakes. As we tossed our burger bags in the trash and sped off in the car, we had no idea that our lives—and the lives of millions of other Americans—would never be the same.

From foraging to farming to fast food, the human diet has evolved over millions of years. The findings reported by Rautiainen et al in this issue of The American Journal of Medicine may prompt some of us to question if our diet is better now … or just different from our ancestors'.

--To read this article in its entirety, please visit our website.

--Pamela Powers Hannley, MPH (Managing Editor, The American Journal of Medicine)

--This article originally appeared in the October 2012 issue of The American Journal of Medicine.