Experience with dedicated geriatric surgical consult services: Meeting the need for surgery in the frail elderly

Rosemarie E Hardin1, Thierry Le Jemtel2, Michael E Zenilman11Department of Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA; 2Department of Medicine, Tulane Medical Center, New Orleans, LA, USABackground: Surgeons are increasingly faced with consultation for intervention in residents of geriatric centers or in patients who suffer from end stage medical disease. We review our experience with consult services dedicated to the needs of these frail patients.Study design: Patients were prospectively followed after being evaluated by three different geriatric surgical consult services: Group 1 was based at a geriatric center associated with a tertiary medical center, Group 2 was based at a community geriatric center, and Group 3 was based with an hospital-based service for ambulatory patients with end stage congestive heart failure.Results: A total of 256 frail elderly patients underwent of 311 general surgical procedures ranging from major abdominal and vascular procedures to minor procedures such as debridement of decubitus ulcers, long-term intravenous access, enterostomy and enteral tube placement. Almost half of the surgical volume in Group 1 and 3 were ‘maintenance’ (decubitus debridement, long term intravenous or stomal or tube care); all of Group 2 were for treatment of decubiti. There was minimal morbidity and mortality from surgery itself, and overall one year survival for Groups 1, 2, and 3 was 46%, 60%, and 79%, respectively. Multivariate analysis showed that each group had its own unique indicators of decreased survival: Group 1 dementia and coronary artery disease, in Group 2 gender and coronary artery disease, and Group 3, gender alone. Age, number of comorbid illnesses, and type of surgery (major vs minor) were not significant indicators.Conclusions: This is the first review of the role of dedicated surgical consult services which focused on residents of geriatric centers and frail elderly. Conditions routinely encountered in this population such as dementia, end stage disease, multiple comorbidities, polypharmacy, decreased functional and nutritional status are not frequently encountered by general surgeons. But the surgery is safe, and survival data is comparable to those in geriatric centers who did not undergo surgery. A multidisciplinary team approach gives the most effective care, with a primary goal of palliation.Keywords: surgery in the elderly, geriatrics, surgical consultations, nursing home residents, congestive heart failure, frailty, palliative care, dementia, coronary artery disease, surviva

Pancreatic regenerating protein (regⅠ) and regⅠreceptor mRNA are upregulated in rat pancreas after induction of acute pancreatitis

AIM: Pancreatic regenerating protein (regI) stimulates pancreatic regeneration after pancreatectomy and is mitogenic to ductal and β-cells. This suggests that regIand its receptor may play a role in recovery after pancreatic injury. We hypothesized that regIand its receptor are induced in acute pancreatitis. METHODS: Acute pancreatitis was induced in male Wistar rats by retrograde injection of 3% sodium taurocholate into the pancreatic duct. Pancreata and serum were collected 12, 24, and 36 hours after injection and from normal controls (4 rats/group). RegIreceptor mRNA, serum regIprotein, and tissue regIprotein levels were determined by Northern analysis, enzyme-linked immunosorbent assay (ELISA), and Western analysis, respectively. Immunohistochemistry was used to localize changes in regIand its receptor. RESULTS: Serum amylase levels and histology confirmed necrotizing pancreatitis in taurocholate treated rats. There was no statistically significant change in serum regIconcentrations from controls. However, Western blot demonstrated increased tissue levels of regIat 24 and 36 h. This increase was localized primarily to the acinar cells and the ductal cells by immunohistochemistry. Northern blot demonstrated a significant increase in regIreceptor mRNA expression with pancreatitis. Immunohistochemistry localized this increase to the ductal cells, islets, and acinar cells. CONCLUSION: Acute pancreatitis results in increased tissue regIprotein levels localized to the acinar and ductal cells, and a parallel threefold induction of regIreceptor in the ductal cells, islets, and acinar cells. These changes suggest that induction of regIand its receptor may be important for recovery from acute pancreatitis

Distinguishing importation from diversification of quinolone-resistant Neisseria gonorrhoeae by molecular evolutionary analysis

<p>Abstract</p> <p>Background</p> <p>Distinguishing the recent introduction of quinolone resistant gonococci into a population from diversification of resistant strains already in the population is important for planning effective infection control strategies. We applied molecular evolutionary analyses to DNA sequences from 9 housekeeping genes and <it>gyrA</it>, <it>parC </it>and <it>porB </it>of 24 quinolone resistant <it>N. gonorrhoeae </it>(QRNG) and 24 quinolone sensitive isolates collected in Israel during 2000–2001.</p> <p>Results</p> <p>Phylogenetic and eBURST analyses and estimates of divergence time indicated QRNG were introduced on 3 separate occasions and underwent limited diversification by mutation, deletion and horizontal gene transfer. Reconstruction of <it>N. gonorrhoeae </it>demography showed a slowly declining effective strain population size from 1976 to 1993, rapid decline between 1994 and 1999, and an increase from 1999 to 2001. This is partially attributable to declining gonorrhea case rates from 1973 to 1994. Additional contributing factors are selective sweeps of antibiotic resistant gonococci and increased transmission from sex workers. The abrupt decline in the mid-1990s heralded an increased incidence of gonorrhea from 1997 to the present. The subsequent increase in effective strain population size since 1999 reflects the increased gonococcal census population and introduction of quinolone resistance strains.</p> <p>Conclusion</p> <p>Our study demonstrates the effective use of population genetic approaches to assess recent and historical population dynamics of <it>N. gonorrhoeae</it>.</p

Castleman's disease in the head of the pancreas: report of a rare clinical entity and current perspective on diagnosis, treatment, and outcome

<p>Abstract</p> <p>Background</p> <p>Castleman's disease of the pancreas is a very rare condition that may resemble more common disease entities as well as pancreatic cancer.</p> <p>Case presentation</p> <p>Here we report the case of a 58-year-old African American male with an incidentally discovered lesion in the head of the pancreas. The specimen from his pancreaticoduodectomy contained a protuberant, encapsulated mass, exhibiting microscopic features most consistent with localized/unicentric Castleman's disease. These included florid follicular hyperplasia with mantle/marginal zone hyperplasia along with focal progressive transformation of germinal centers admixed with involuted germinal centers.</p> <p>Conclusion</p> <p>To date, eight cases of Castleman's disease associated with the pancreas have been described in the world literature. We report the first case of unicentric disease situated within the head of the pancreas. In addition, we discuss the diagnostic dilemma Castleman's disease may present to the pancreatic surgeon and review current data on pathogenesis, treatment, and outcome.</p

Human papillomavirus types 16, 18, and 31 serostatus and prostate cancer risk in the Prostate Cancer Prevention Trial

Since human papillomavirus (HPV) infection was first identified as a risk factor for cervical cancer, several seroepidemiologic and tissue-based studies have investigated HPV in relation to prostate cancer, another common genitourinary malignancy, with mixed results. To further inform this potential association, we conducted a large, prospective investigation of HPV types 16, 18, and 31 in relation to risk of prostate cancer in the Prostate Cancer Prevention Trial (PCPT). Cases were a sample of men diagnosed with prostate cancer after visit 2 or on their end-of-study biopsy (n=616). Controls were men not diagnosed with prostate cancer during the trial or on their end-of-study biopsy (n=616). Controls were frequency-matched to cases by age, treatment arm, and family history of prostate cancer. Sera from visit 2 were tested for IgG antibodies against HPV-16, -18 and -31. No associations were observed for weak or strong HPV-16 (odds ratio (OR) = 0.94, 95% confidence interval (CI): 0.53–1.64, and OR=1.07, 95% CI: 077–1.48, respectively), HPV-18 (OR=0.75, 95% CI: 0.27–2.04, and OR=0.87, 95% CI: 0.47–1.63) or HPV-31 seropositivity (OR=0.76, 95% CI: 0.45–1.28, and OR=1.15, 95% CI: 0.80–1.64) and risk of prostate cancer. Considering this finding in the context of the HPV and prostate cancer literature, HPV does not appear to be associated with risk of prostate cancer, at least by mechanisms proposed to date, and using epidemiologic designs and laboratory techniques currently available