Postoperative rehospitalization in older surgical patients: an age-stratified analysis.

BACKGROUND: Older adults comprise 40% of surgical inpatients and are at increased risk of postoperative rehospitalization. A decade ago, 30-day rehospitalizations for Medicare patients were reported as 15%, and more than 70% was attributed to medical causes. In the interim, there have been several large-scale efforts to establish best practice for older patients through surgical quality programs and national initiatives by Medicare and the National Health Service. To understand the current state of rehospitalization in the USA, we sought to report the incidence and cause of 30-day rehospitalization across surgical types by age. STUDY DESIGN: We performed a retrospective study utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset from 2015 to 2019. Our primary exposure of interest was age. Patients were categorized into four groups: 18-49, 50-64, 65-74, and 75 + years old. Reasons for rehospitalization were evaluated using NSQIP defined causes and reported International Classification of Disease (ICD)-9 and ICD-10 codes. Our primary outcome was the incidence of unplanned 30-day rehospitalization and secondary outcome the cause for rehospitalization. Variables were summarized by age group through relative (%) and absolute (n) frequencies; chi-square tests were used to compare proportions. Since rehospitalization is a time-to-event outcome in which death is a competing event, the cumulative incidence of rehospitalization at 30 days was estimated using the procedure proposed by Gray. The same strategy was used for estimating the cumulative incidence for unplanned rehospitalizations. RESULTS: A total of 2,798,486 patients met inclusion criteria; 198,542 had unplanned rehospitalization (overall 7.09%). Rehospitalization by age category was 6.12, 6.99, 7.50, and 9.50% for ages 18-49, 50-64, 65-74, and 75 + , respectively. Complications related to the digestive system were the single most common cause of rehospitalization across age groups. Surgical site infection was the second most common cause, with the relative frequency decreasing with age as follows: 21.74%, 19.08%, 15.09%, and 9.44% (p < .0001). Medical causes such as circulatory or respiratory complications were more common with increasing age (2.10%, 4.43%, 6.27%, 8.86% and 3.27, 4.51, 6.07, 8.11%, respectively). CONCLUSION: We observed a decrease in overall rehospitalization for older surgical patients compared to studies a decade ago. The oldest (≥ 75) surgical patients had the highest 30-day rehospitalization rates (9.50%). The single most common reason for rehospitalization was the same across age groups and likely attributed to surgery (ileus). However, the aggregate of medical causes of rehospitalization was more common in older patients; surgical and respiratory reasons were twice as common in this group. Rehospitalization increased by age for some surgery types, e.g., lower extremity bypass, more than others, e.g., ventral hernia repair. Future investigations should focus on interventions to reduce medical complications and further decrease postoperative rehospitalization for older surgical patients undergoing high-risk procedures.

Cognitive impairment and frailty screening in older surgical patients: a rural tertiary care centre experience.

INTRODUCTION: Despite a clear association between cognitive impairment and physical frailty and poor postoperative outcomes in older adults, preoperative rates are rarely assessed. We sought to implement a preoperative cognitive impairment and frailty screening programme to meet the unique needs of our rural academic centre. METHODS: Through stakeholder interviews, we identified five primary drivers underlying screening implementation: staff education, technology infrastructure, workload impact, screening value and patient-provider communication. Based on these findings, we implemented cognitive dysfunction (AD8, Mini-Cog) and frailty (Clinical Frailty Scale) screening in our preoperative care clinic and select surgical clinics. RESULTS: In the preoperative care clinic, many of our patients scored positive for clinical frailty (428 of 1231, 35%) and for cognitive impairment (264 of 1781, 14.8%). In our surgical clinics, 27% (35 of 131) and 9% (12 of 131) scored positive for clinical frailty and cognitive impairment, respectively. Compliance to screening improved from 48% to 86% 1 year later. CONCLUSION: We qualitatively analysed stakeholder feedback to drive the successful implementation of a preoperative cognitive impairment and frailty screening programme in our rural tertiary care centre. Preliminary data suggest that a clinically significant proportion of older adults screen positive for preoperative cognitive impairment and frailty and would benefit from tailored inpatient care.

Telemedicine for Surgical Consultations - Pandemic Response or Here to Stay?: A Report of Public Perceptions.

OBJECTIVE: This study aims to determine the public's perception of telemedicine surgical consultations, during the COVID-19 pandemic and beyond. SUMMARY BACKGROUND DATA: With rapid expansion and uptake of telemedicine during the pandemic, many have posited that virtual visits will endure even as in-person visits are reinstated. The public's perception of telemedicine for an initial surgical consultation has not been previously studied. METHODS: A 43-question survey assessed respondents' attitudes toward telemedicine for initial consultations with surgeons, both in the context of COVID-19 and during "normal circumstances." Participants were recruited through Amazon Mechanical Turk, an online crowd-sourcing marketplace. RESULTS: Based on 1827 analyzable responses, we found that a majority (86%) of respondents reported being satisfied (either extremely or somewhat) with telemedicine encounters. Interestingly, preference for in-person versus virtual surgical consultation reflected access to care, with preference for telemedicine decreasing from 72% to 33% when COVID-related social distancing ends. Preferences for virtual visits decreased with increasing complexity of the surgical intervention, even during the pandemic. A majority felt that "establishing trust and comfort" was best accomplished in person, and the vast majority felt it was important to meet their surgeons before the day of surgery. CONCLUSIONS: The public views telemedicine as an acceptable substitute for in-person visits, especially during the pandemic. However, it seems that an in-person interaction is still preferred when possible for surgical consultations. If telemedicine services are to persist beyond social distancing, further exploration of its impact on the patient-surgeon relationship will be needed.

Domestic mite antigens in floor and airborne dust at workplaces in comparison to living areas: a new immunoassay to assess personal airborne allergen exposure.

OBJECTIVES: Allergens produced by domestic mites (DM) are among the most common allergic sensitizers and risk factors for asthma. To compare exposure levels between workplaces and living areas a new assay able to measure airborne DM antigen concentrations was developed. METHODS: At workplaces and in living areas, 213 floor dust samples and 92 personal inhalable dust samples were collected. For sensitive quantification of DM antigens, a new enzyme immunoassay (EIA) based on polyclonal antibodies to Dermatophagoides farinae extract was developed. Reactivity of five house dust mite and four storage mite species was tested. All dust samples were tested with the new EIA and with the Der f 1 and Der p 1-EIAs (Indoor Biotechnologies, UK) which detect major allergens from D. farinae and D. pteronyssinus by monoclonal antibodies. Samples below the detection limit in the DM-EIA were retested in an assay variant with a fluorogenic substrate (DM-FEIA). RESULTS: The newly developed DM-EIA detects antigens from all nine tested domestic mite species. It has a lower detection limit of 200 pg/ml of D.farinae protein, compared to 50 pg/ml for the DM-FEIA. DM antigens were detected by DM-EIA/FEIA in all floor dust and 80 (87%) of airborne samples. Der f 1 was found in 133 (62%) floor dust and in only 6 airborne samples, Der p 1 was found in 70 (33%) of floor samples and in one airborne sample. Der f 1 and DM concentrations were highly correlated. DM-antigens were significantly higher in inhalable airborne samples from textile recycling, bed feather filling, feed production, grain storage and cattle stables in comparison to living areas. CONCLUSIONS: A new sensitive EIA directed at DM antigens was developed. DM antigen quantities were well correlated to Der f 1 values and were measurable in the majority (87%) of airborne dust samples. Some workplaces had significantly higher DM antigen concentrations than living areas.

Passive airborne dust sampling to assess mite antigen exposure in farming environments.

The aim of this study was to estimate mite antigen exposure in farming environments by passive sampling of airborne dust. Antigen concentrations were measured with enzyme immunoassays specific for three storage mites (SM): Acarus siro, Lepidoglyphus destructor, Tyrophagus putrescentiae and the house dust mite (HDM) Dermatophagoides pteronyssinus. Dust samples were collected with electrostatic dust fall collectors (EDCs) in three different areas of cattle farms. EDCs were placed in cow stables (working area), in changing rooms (transit area) and in different rooms of farmer dwellings (living area). Mite concentrations in the living area of farm homes were compared to those of urban homes. In dust samples from stables, antigens of all four mite species could be detected. The highest exposure level was to L. destructor (median 56.7 µg/m(2)), the lowest to A. siro (median 14.4 µg/m(2)). Mite concentrations of different species showed no correlation within the cow stables. In comparison to stables, the median mite concentrations in farm homes were significantly lower, ranging from below the detection limit to 1.5 µg/m(2). Antigens of SM were predominantly found in changing rooms and kitchens, and HDM antigens were mainly detected in bedrooms. Antigens of all mites were measured the least often in living rooms. T. putrescentiae was the most prevalent mite in all room types, and the exposure levels correlated strongly between different rooms. The number of SM positive samples in farm homes was considerably higher than in urban homes, while the percentage of HDM positive samples did not differ significantly.

Development of a sandwich ELISA to measure exposure to occupational cow hair allergens.

BACKGROUND: Cow hair and dander are important inducers of occupational allergies in cattle-exposed farmers. To estimate allergen exposure in farming environments, a sensitive enzyme immunoassay was developed to measure cow hair allergens. METHODS: A sandwich ELISA was developed using polyclonal rabbitantibodies against a mixture of hair extracts from different cattle breeds. To assess the specificity of the assay, extracts from other mammalian epithelia, mites, molds and grains were tested. To validate the new assay, cow hair allergens were measured in passive airborne dust samples from the stables and homes of farmers. Dust was collected with electrostatic dust fall collectors (EDCs). RESULTS: The sandwich ELISA was found to be very sensitive (detection limit: 0.1 ng/ml) and highly reproducible, demonstrating intra- and interassay coefficients of variation of 4 and 10%, respectively. The assay showed no reactivity with mites, molds and grains, but some cross-reactivity with other mammalian epithelia, with the strongest reaction with goat. Using EDCs for dust sampling, high concentrations of bovine allergens were measured in cow stables (4,760-559,400 µg/m²). In addition, bovine allergens were detected in all areas of cattle farmer dwellings. A large variation was found between individual samples (0.3-900 µg/m²) and significantly higher values were discovered in changing rooms. CONCLUSION: The ELISA developed for the detection of cow hair proteins is a useful tool for allergen quantification in occupational and home environments. Based on its low detection limit, this test is sensitive enough to detect allergens in passive airborne dust.

Development of a two-site enzyme immunoassay based on monoclonal antibodies to measure airborne exposure to (1-->3)-beta-D-glucan.

(1-->3)-beta-D-glucan is found in cell walls of some fungi, bacteria and plants. It plays a crucial role in bioaerosol-induced inflammatory reactions. To estimate the level of airborne (1-->3)-beta-D-glucan exposure, a monoclonal antibody-based two-site enzyme immunoassay (mAb-EIA) was developed. The results obtained with the mAb-EIA were compared with the results of a Limulus amoebocyte lysate-based assay for (1-->3)-beta-D-glucan. Three mAbs produced by mouse immunization with bovine serum albumin-conjugated laminarin were enriched by in vitro production in a modular mini-fermenter and affinity purified. Two mAbs were selected for the development of a two-site EIA specific for (1-->3)-beta-D-glucan. Different polysaccharides, fungal and plant seed extracts, and airborne inhalable dust from workplaces (poultry farms, pig stables, grain storage houses, and a laboratory animal facility) were sampled with portable pumps and measured with both the mAb-EIA and Glucatell assay. Using carboxymethylated curdlan as a standard, the mAb-EIA gave a steep dose-response curve for concentrations between 0.36-15 ng/ml. The mAb-EIA was specific for (1-->3)-beta-D-glucan and was sufficiently sensitive to detect (1-->3)-beta-D-glucan in airborne dust samples. In comparing the EIA results to the values obtained with the Glucatell assay, the correlation was found to be high (coefficient of correlation r(2)=0.91), and the mean ratio of the values was 1.7. Depending on the dust source, either the Glucatell assay or the mAb-EIA gave higher results. The mAb-EIA is sensitive enough to detect (1-->3)-beta-D-glucan in airborne dust samples collected with portable pumps. Thus, the assay is suited for the investigation of the health effects induced by exposure to this class of biologically active molecules.