Publications

BACKGROUND

Nutritional risk and low BMI are common among community-dwelling older adults, but it is unclear what associations these factors have with health services utilization and mortality over long-term follow-up. The aim of this study was to assess prospective associations of nutritional risk and BMI with all-cause, nonsurgical, and surgical hospitalization; nursing home admission; and mortality over 8.5 years.

METHODS

Data are from 1,000 participants in the University of Alabama at Birmingham Study of Aging, a longitudinal, observational study of older black and white residents of Alabama aged 65 and older. Nutritional risk was assessed using questions associated with the DETERMINE checklist. BMI was categorized as underweight (<18.5), normal weight (18.5-24.9), overweight (25.0-29.9), class I obese (30.0-34.9), and classes II and III obese (≥35.0). Cox proportional hazards models were fit to assess risk of all-cause, nonsurgical, and surgical hospitalization; nursing home admission; and mortality. Covariates included social support, social isolation, comorbidities, and demographic measures.

RESULTS

In adjusted models, persons with high nutritional risk had 51% greater risk of all-cause hospitalization (95% confidence interval: 1.14-2.00) and 50% greater risk of nonsurgical hospitalizations (95% confidence interval: 1.11-2.01; referent: low nutritional risk). Persons with moderate nutritional risk had 54% greater risk of death (95% confidence interval: 1.19-1.99). BMI was not associated with any outcomes in adjusted models.

CONCLUSIONS

Nutritional risk was associated with all-cause hospitalizations, nonsurgical hospitalizations, and mortality. Nutritional risk may affect the disablement process that leads to health services utilization and death. These findings point to the need for more attention on nutritional assessment, interventions, and services for community-dwelling older adults.

INTRODUCTION

Coronary artery fistulae (CAF) are anomalous connections from a coronary artery to a recipient pulmonary vessel or cardiac chamber, and are reported in 0.2 % of the general population. The prevalence of CAF in the modern orthotopic heart transplant (OHT) population has been demonstrated to be significantly higher. The mechanism is unknown but one proposal is endothelial and vascular growth factor activation from injury. We hypothesize an incremental increase in CAF prevalence with the complexity of surgery, such that patients who have undergone OHT surgery would have an increased prevalence of CAF, as compared with patients who have undergone coronary artery bypass (CABG) surgery with valve surgery and as compared with patients who have undergone CABG surgery only.

PATIENTS AND METHODS

Consecutive angiograms of 481 patients after CABG surgery and 432 patients after OHT were reviewed. Patients who had previous valve surgery in addition to CABG were identified. Presence of CAF was determined. The chi-squared test was used for statistical analysis.

RESULTS

In all, 436 patients had CABG only (group A), 45 patients had CABG with valve surgery (group B), and 432 patients had OHT (group C). The mean age of patients at the time of surgery for group A, B, and C was 59.0, 66.1, and 55.3 years, respectively. The percentage of male patients was 78.4, 77.8, and 77.1 %, respectively. We found 10 patients (2.3 %) with CAF in group A compared with 4 patients (8.9 %) in group B, and 88 patients (20.4 %) in group C, which was statistically significant (p < 0.001). All CAF were small, were not associated with hemodynamic compromise or significant adverse events, and were managed conservatively.

CONCLUSION

There is an increased prevalence of CAF formation both after CABG and OHT compared with the general population. The higher prevalence of CAF in patients who additionally underwent valve surgery or who underwent OHT may be attributed to differences in surgical complexity. The increased prevalence of CAF formation after OHT compared with CABG should be further investigated.

Palpitations is a common complaint in patients who visit the emergency department (ED), with causes ranging from benign to life threatening. We analyzed the ED component of the National Hospital Ambulatory Medical Care Survey for 2001 through 2010 for visits with a chief complaint of palpitations and calculated nationally representative weighted estimates for prevalence, demographic characteristics, and admission rates. ED and hospital discharge diagnoses were tabulated and categorized, and recursive partitioning was used to identify factors associated with admission. An estimated 684,000 visits had a primary reason for visit of "palpitations" representing a national prevalence of 5.8 per 1,000 ED visits (0.58%, 95% confidence interval 0.52 to 0.64). Women and non-Hispanic whites were responsible for most visits. A cardiac diagnosis made up 34% of all ED diagnoses. The overall admission rate was 24.6% (95% confidence interval 21.2 to 28.1), with higher rates seen in the Midwest and Northeast compared with the West. Survey-weighted recursive partitioning revealed several factors associated with admission including age >50 years, male gender, cardiac ED diagnosis, tachycardia, hypertension, and Medicare insurance. In conclusion, palpitations are responsible for a significant minority of ED visits and are associated with a cardiac diagnosis roughly 1/3 of the time. This was associated with a relatively high admission rate, although significant regional variation in these rates exists.