Mortality is not increased with Diabetes in hospitalised very old adults: a multi-site review

Background: Few data exist regarding hospital outcomes in people with diabetes aged beyond 75 years. This study aimed to explore the association of diabetes with hospital outcome in the very old patient. Methods: A retrospective review was conducted of all presentations of patients aged 65 years or more admitted to three Sydney teaching hospitals over 6 years (2012–2018), exploring primarily the outcomes of in-hospital mortality, and secondarily the outcomes of length of stay, the development of hospital-acquired adverse events and unplanned re-admission to hospital within 28 days of discharge. Demographic and outcome data, the presence of diabetes and comorbidities were determined from ICD10 coding within the hospital’s electronic medical record. Logistic and negative binomial regression models were used to assess the association of diabetes with outcome. Results: A total of 139,130 separations (mean age 80 years, range 65 to 107 years; 51% female) were included, with 49% having documented comorbidities and 26.1% a diagnosis of diabetes. When compared to people without diabetes, diabetes was not associated with increased odds of mortality (OR: 0.89 SE (0.02), p < 0.001). Further, because of a significant interaction with age, diabetes was associated with decreased odds of mortality beyond 80 years of age. While people with diabetes overall had longer lengths of stay (10.2 days SD (13.4) v 9.4 days SD (12.3), p < 0.001), increasing age was associated with shorter lengths of stay in people aged more than 90 years. Diabetes was associated with increased odds of hospital-acquired adverse events (OR: 1.09 SE (0.02), p < 0.001) and but not 28-day re-admission (OR: 0.88 SE (0.18), p = 0.523). Conclusion: Diabetes has not been shown to have a negative impact on mortality or length of stay in hospitalised very old adults from data derived from hospital administrative records. This may allow a more measured application of diabetic guidelines in the very old hospitalised patient

Incidence and outcomes of humeral fractures in the older person

Summary: Humeral fractures are not well understood and thus we examined the incidence and outcomes of elderly humeral fractures at a single institution over a 3-year period. We found increasing incidence in humeral fractures with increasing age and negative outcomes comparable to hip fractures. Introduction: In this study, we report the incidence of humeral fractures in the older patient and their outcomes, including new nursing homes discharges and mortality, residing in the metropolitan referral area of a Sydney tertiary referral hospital. Methods: All admissions between 2013 and 2016, of patients aged 65 years or more, presenting to hospital with humeral fractures were reviewed. The data was explored primarily for outcomes (mortality and new admissions to residential aged care facility) and secondarily for clinical association with humeral fractures. Results: Two hundred eighty-one episodes of humeral fracture were identified. Incidence peaked in the above 85-year-old group at 670 per 100,000 persons per year. Proximal fractures were accounted for 84.3% of the cohort. 12.8% received operative management. The in-hospital mortality rate was 3.6%. Gender was a significant predictor for mortality (OR = 5.8, 95% CI 1.3–28.5, p value = 0.0032) with males six times more likely to experience in-hospital mortality compared to females. 17.8% of participants were admitted to a new nursing home. Logistical regression demonstrated age (OR = 1.10, 95% CI 1.04–1.17; p value = 0.001) and Charlson comorbidity index (OR = 1.32, 95% CI 1.04–1.66; p value = 0.02) were predictors of admission to a new nursing home. Conclusion: Humeral fractures are common in the older population and cause a substantial amount of new nursing home admissions and mortality. Further study is required to ascertain appropriate guidelines for treatment and rehabilitation

Protocol of the randomised placebo controlled pilot trial of the management of acute sciatica (SCIATICA): A feasibility study

Introduction Acute sciatica (symptom duration less than 4 weeks), a major cause of pain and disability, is a common presentation to medical practices and hospital emergency departments. Selective CT fluoroscopy transforaminal epidural steroid injection is often used with the hope of reducing pain and improving function. Recently, there has been interest in using systemic corticosteroids in acute sciatica. However, there is limited evidence to inform management of selective CT fluoroscopy transforaminal epidural steroid in subacute and chronic sciatica and there is no evidence in acute sciatica, even though the practice is widespread. There is also limited evidence for the use of systemic corticosteroids in acute sciatica. Furthermore, the management of selective CT fluoroscopy transforaminal epidural steroid versus systemic steroids has never been directly studied. Methods and analysis SCIATICA is a pilot/feasibility study of patients with acute sciatica designed to evaluate the feasibility of undertaking a blinded four-arm randomised controlled intervention study of (1) selective CT fluoroscopy transforaminal epidural steroid (arm 1), (2) selective CT fluoroscopy transforaminal epidural saline (arm 2), (3) 15 days tapering dose of oral steroids (arm 3) and (4) a sham epidural and oral placebo control (arm 4). This feasibility study is designed to evaluate head-to-head, route versus pharmacology of interventions. The primary outcome measure is the Oswestry Disability Index (ODI) at 3 weeks. Secondary outcome is the ODI at 48 weeks. Other outcomes include numerical rating scale for leg pain, Pain DETECT Questionnaire, quality of life, medication use, rescue procedures or surgery, and adverse events. Results of outcomes from this randomised controlled trial will be used to determine the feasibility, sample size and power calculations for a large multicentre study. Ethics and dissemination The study has been approved by South Eastern Sydney Local Health District Human Research Ethics Committee (HREC/15/331/POHW/586). Trial registration number NCT03240783; Pre-results

Management of Nursing Home Residents Following Acute Hospitalization: Efficacy of the “Regular Early Assessment Post-Discharge (REAP)” Intervention

Objectives: Rehospitalization of nursing home (NH) residents is frequent, costly, potentially avoidable and associated with diminished quality of life and poor survival. This study aims to evaluate the impact and cost-effectiveness of the Regular Early Assessment Post-Discharge (REAP) protocol of coordinated specialist geriatrician and nurse practitioner visits on rates of rehospitalization, hospital length of stay, and emergency department presentations for NH residents recently discharged from hospital. Design: Prospective randomized controlled study of recently hospitalized NH residents. Setting: Twenty-one of 24 eligible NHs within the geographical catchment area of St George Hospital, a 650-bed university hospital in Sydney, Australia. Participants: NH residents from eligible facilities admitted to St George Hospital's geriatric service were enrolled prior to hospital discharge. Intervention: REAP intervention of monthly coordinated specialist geriatrician and nurse practitioner assessments within participants' NHs for 6 months following hospital discharge. Measurements: Impact of the REAP intervention on hospital readmissions, hospital inpatient days, emergency department utilization, general practitioner visits, investigations and associated costs during the study intervention period. Results: Forty-three NH residents were randomly allocated to REAP intervention (n = 22) or control (n = 21) groups. The REAP intervention group had almost two-thirds fewer hospital readmissions (P =.03; Cohen's d = 0.73) and half as many emergency department visits than controls. Total costs were 50% lower in the REAP intervention group, with lower total hospital inpatient (P =.04; Cohen's d = 0.63) and total emergency department (P =.04; Cohen's d = 0.65) costs. Conclusion: Cost-effective reductions in the utilization of hospital-related services were demonstrated following implementation of the REAP intervention for NH residents recently discharged from hospital