Doctors and numbers: an assessment of the critical risk interpretation test.

BACKGROUND: Risk interpretation affects decision making. Yet, there is no valid assessment of how clinicians interpret the risk data that they commonly encounter. OBJECTIVE: To establish the reliability and validity of a 20-item test of clinicians' risk interpretation. METHODS: The Critical Risk Interpretation Test (CRIT) measures clinicians' abilities to 1) modify the interpretation based on meaningful differences in the outcome (e.g., disease specific v. all-cause mortality) and time period (e.g., lifetime v. 10-year mortality), 2) maintain a stable interpretation for different risk framings (e.g., relative v. absolute risk), and 3) correctly interpret how diagnostic testing modifies risk. There were 658 clinicians and medical trainees who participated: 116 nurse practitioners (NPs) at a national conference, 273 medical students at 1 institution, 148 residents in internal medicine at 2 institutions, and 121 internists at 1 institution. Participants completed a self-administered paper test during educational conferences. Seventeen evidence-based medicine experts took the test online and formally assessed content validity. Eighteen second-year medical students were recruited to take the test and a retest 3 weeks later to explore test-retest correlation. RESULTS: Expert review supported test clarity and content validity. Factor analysis supported that the CRIT identifies at least 3 separable areas of clinician knowledge. Test-retest correlation was fair (intraclass correlation coefficient = 0.65; standard error = 0.15). Scores on our test correlated with other tests of related abilities. Mean test scores varied among groups, with differences in prior evidence-based medicine training and experience (93 for NPs, 101 for medical students, 101 for residents, 103 for academic internists, and 110 for physician experts; P < 0.001). CONCLUSIONS: Our results provide supporting evidence for the reliability and validity of the CRIT as an index of critical risk interpretation abilities, which is acceptable and feasible to administer in an educational setting.

Accumulated frailty characteristics predict postoperative discharge institutionalization in the geriatric patient.

BACKGROUND: Frailty is a state of increased vulnerability to health-related stressors and can be measured by summing the number of frailty characteristics present in an individual. Discharge institutionalization (rather than discharge to home) represents disease burden and functional dependence after hospitalization. Our aim was to determine the relationship between frailty and need for postoperative discharge institutionalization. STUDY DESIGN: Subjects ≥ 65 years undergoing major elective operations requiring postoperative ICU admission were enrolled. Discharge institutionalization was defined as need for institutionalized care at hospital discharge. Fourteen preoperative frailty characteristics were measured in 6 domains: comorbidity burden, function, nutrition, cognition, geriatric syndromes, and extrinsic frailty. RESULTS: A total of 223 subjects (mean age 73 ± 6 years) were studied. Discharge institutionalization occurred in 30% (n = 66). Frailty characteristics related to need for postoperative discharge institutionalization included: older age, Charlson index ≥ 3, hematocrit <35%, any functional dependence, up-and-go ≥ 15 seconds, albumin <3.4 mg/dL, Mini-Cog score ≤ 3, and having fallen within 6 months (p < 0.0001 for all comparisons). Multivariate logistic regression retained prolonged timed up-and-go (p < 0.0001) and any functional dependence (p < 0.0001) as the variables most closely related to need for discharge institutionalization. An increased number of frailty characteristics present in any one subject resulted in increased rate of discharge institutionalization. CONCLUSIONS: Nearly 1 in 3 geriatric patients required discharge to an institutional care facility after major surgery. The frailty characteristics of prolonged up-and-go and any functional dependence were most closely related to the need for discharge institutionalization. Accumulation of a higher number of frailty characteristics in any one geriatric patient increased their risk of discharge institutionalization.

Stress-related cardiomyopathy in a 31-year-old woman.

Stress-related cardiomyopathy (SRC), initially referred to as Tako-Tsubo cardiomyopathy and later as apical ballooning syndrome, has been largely observed in postmenopausal women. It is frequently precipitated by a stressful event. This is a case report of a 31-year-old woman who experienced SRC immediately after a bilateral mastectomy.

Redefining geriatric preoperative assessment using frailty, disability and co-morbidity.

OBJECTIVES: (1) Determine the relationship of geriatric assessment markers to 6-month postoperative mortality in elderly patients. (2) Create a clinical prediction rule using geriatric markers from preoperative assessment. BACKGROUND: Geriatric surgery patients have unique physiologic vulnerability requiring preoperative assessment beyond the traditional evaluation of older adults. The constellation of frailty, disability and comorbidity predict poor outcomes in elderly hospitalized patients. METHODS: Prospectively, subjects > or =65 years undergoing a major operation requiring postoperative intensive care unit admission were enrolled. Preoperative geriatric assessments included: Mini-Cog Test (cognition), albumin, having fallen in the past 6-months, hematocrit, Katz Score (function), and Charlson Index (comorbidities). Outcome measures included 6-month mortality (primary) and postdischarge institutionalization (secondary). RESULTS: One hundred ten subjects (age 74 +/- 6 years) were studied. Six-month mortality was 15% (16/110). Preoperative markers related to 6-month mortality included: impaired cognition (P < 0.01), recent falls (P < 0.01), lower albumin (P < 0.01), greater anemia (P < 0.01), functional dependence (P < 0.01), and increased comorbidities (P < 0.01). Similar statistical relationships were found for all 6 markers and postdischarge institutionalization. Logistic regression identified any functional dependence (odds ratio 13.9) as the strongest predictor of 6-month mortality. Four or more markers in any one patient predicted 6-month mortality with a sensitivity of 81% (13/16) and specificity of 86% (81/94). CONCLUSIONS: Geriatric assessment markers for frailty, disability and comorbidity predict 6-month postoperative mortality and postdischarge institutionalization. The preoperative presence of > or =4 geriatric-specific markers has high sensitivity and specificity for 6-month mortality. Preoperative assessment using geriatric-specific markers is a substantial paradigm shift from the traditional preoperative evaluation of older adults.

Panniculectomy--an option for people who are morbidly obese.

Obesity is becoming a major health issue across the nation. Surgical procedures to alleviate problems of severely limited ambulation, development of open wounds, and overeating may be an option for people who are morbidly obese. A gastric bypass procedure and panniculectomy are among the surgical options available. In this article, the preoperative, intraoperative, and postoperative care of a patient undergoing a panniculectomy are presented. A safe, complication-free procedure can be performed with preplanning; a precise, detailed team effort; and an informed, motivated patient.