Identifying elderly patients for early discharge after hospitalization for hip fracture.

BACKGROUND: Some elderly patients can be successfully treated in hospitals with lengths of stay (LOS) shorter than the norms developed by the diagnosis-related groups. This study was designed to test the hypothesis that elderly patients with short LOS after hip fracture have characteristics that can be identified shortly after hospital admission. METHODS: A retrospective chart review was performed of 216 patients over age 55 discharged alive from a university hospital after hip fracture. Demographic, medical, and functional data available within 48 hours of admission were used to develop an algorithm to identify patients eligible for early discharge. A prospective study of an additional 33 patients was undertaken to test this algorithm and to examine the predictive value of additional functional and psychosocial information not routinely recorded in the chart. RESULTS: Retrospective chart review identified 4 predictors of short LOS in multivariate analysis: age less than 75, admission from a nursing home, normality of admission laboratory results, and "no surgery or surgery by day three." These variables explain 25% of the total variation of LOS. In our prospective study the variable "day of surgery" had the greatest variance explanation (30.5%) in multivariate analysis. A model including day of surgery and the presence of dementia explained 42.5% of the variance of LOS. CONCLUSION: Short LOS can be predicted within 48 hours of admission utilizing data that measure severity of illness, functional status, and available support. The development of algorithms to identify patients eligible for early discharge would be beneficial to care managers.

Mechanisms underlying the antiarrhythmic properties of beta-adrenoceptor blockade against ischaemia-induced arrhythmias in acutely prepared rats.

1. The mechanism underlying the limited antiarrhythmic effects of beta-adrenoceptor blocking agents against occlusion-induced arrhythmias in acutely prepared, pentobarbitone-anaesthetized rats has been investigated. 2. Atenolol, ICI 111,581 and propranolol were given at low, medium and high doses calculated to shift dose-response curves to exogenous agonists by factors of 10-30, 100-300 and 1000-3000, respectively. 3. Arrhythmias, blood pressure, heart rate, ECG changes and serum K+ were measured. 4. Antiarrhythmic activity was seen with beta-blocker treatment. This was minimal with atenolol (0.1, 1 and 10 mg kg-1) and only statistically significant with the highest dose of ICI 111,581 (5 mg kg-1), and propranolol (10 mg kg-1). 5. Treatment with beta-adrenoceptor blockers elevated serum potassium concentrations, as compared with saline controls, especially when measured at 30 min post-occlusion. 6. Only ICI 111,581 (5 mg kg-1) and propranolol (1 and 10 mg kg-1) prolonged P-R interval. 7. In order to evaluate possible mechanisms of antiarrhythmic action, attempts were made to correlate antiarrhythmic activity with beta-blockade, serum potassium concentrations, and/or with changes in the P-R interval of the ECG. 8. Reductions in arrhythmias did not correlate well with presumed beta-blockade. Better correlation was obtained with elevations of serum potassium concentration, and with prolongation of P-R interval (a presumed Class I antiarrhythmic action). 9. These results suggested that antiarrhythmic effects of adrenoceptor blocking agents in acutely-prepared anaesthetized rats, subjected to occlusion of a coronary artery, are unrelated to cardiac beta-blockade. The limited antiarrhythmic effects which were observed could be attributed to elevations in serum potassium concentration (due to peripheral beta-blockade) and/or possible Class I antiarrhythmic actions.

The use of extracorporeal shock wave lithotripsy in aviators.

Nephrolithiasis presents a common management problem for the flight surgeon, whose patients must be excluded from flying duties for weeks or months during diagnosis and treatment. Extracorporeal shock wave lithotripsy (ESWL) has recently become available for clinical use and represents a totally noninvasive method of managing urinary tract calculi. The extremely low risk and rapid recovery time associated with ESWL make it preferable not only to conservative medical management and conventional surgical treatment but also to the newer invasive procedures, such as percutaneous nephrolithotomy. A case is described in which a military pilot is eligible for return to flying status within 3 weeks of initial consultation following treatment of symptomatic nephrolithiasis with ESWL. The contraindications and potential complications of ESWL are also discussed.