Total joint arthroplasties (TJAs) of the knee and hip have been considered 2 of the most successful surgical procedures performed to date.
Frailty is defined as increased vulnerability to adverse ...outcomes with physiologic stress.
Preoperative optimization of frailty and metabolic bone conditions, including osteoporosis, vitamin D deficiency, and diabetes, through a multidisciplinary approach can help improve outcomes and minimize costs after TJA.
Traditional systems of anesthesia evaluation do not routinely incorporate cognitive screening into preoperative assessments of vital organ systems. Increasing recognition of the importance of ...preoperative cognitive assessment of the elderly surgical patient has resulted in a "call to action" from experts in this area. A paradigm shift will be necessary to make this screening routine and not just a research tool. We describe our preliminary experience with developing a training program and implementing routine cognitive screening in a preoperative evaluation clinic. We outline a process showing our successful clinical implementation of sustainable cognitive stratification and documentation of routine cognitive screening.
Frailty is an age-related, multi-dimensional state of decreased physiologic reserve that results in diminished resiliency and increased vulnerability to stressors. It has proven to be an excellent ...predictor of unfavorable health outcomes in the older surgical population. There is agreement in recommending that a frailty evaluation should be part of the preoperative assessment in the elderly. However, the consensus is still building with regards to how it should affect perioperative care. The Society for Perioperative Assessment and Quality Improvement (SPAQI) convened experts in the fields of gerontology, anesthesiology and preoperative assessment to outline practical steps for clinicians to assess and address frailty in elderly patients who require elective intermediate or high risk surgery. These recommendations summarize evidence-based principles of measuring and screening for frailty, as well as basic interventions that can help improve patient outcomes.
Several reports have suggested a benefit from radioactive iodine (RAI) therapy in Tg-positive, whole-body scan-negative patients with follicular cell-derived thyroid cancer, who were said to have ...high rates of visualization of uptake in metastases after therapeutic doses of RAI. We sought to evaluate the rate of visualization of RAI uptake in these patients and determine the effect of such therapy on tumor progression and Tg levels. We studied 24 consecutive patients who had been treated with high-dose RAI, four of whom had no evidence of metastasis or persistent cancer. Our results showed that four patients had some uptake in posttherapy scans: in the neck, lung, and mediastinal metastases in one patient, in the thyroid remnant in two, and in a possible neck microrecurrence in one. In 13 patients with macrometastases—tumors 1 cm or greater—tumors progressed and serum Tg increased; five have died of thyroid cancer. The disease remained stable in the seven patients with micrometastases. We concluded that in high-risk patients with follicular cell-derived thyroid cancer with high Tg levels and negative diagnostic whole-body scans, only a small number showed meaningful uptake after high doses of RAI. Therefore, widespread use of empiric RAI therapy for such patients who have a large tumor burden should not be encouraged.
Several reports have suggested a benefit from radioactive iodine (RAI) therapy in Tg-positive, whole-body scan-negative patients with follicular cell-derived thyroid cancer, who were said to have ...high rates of visualization of uptake in metastases after therapeutic doses of RAI. We sought to evaluate the rate of visualization of RAI uptake in these patients and determine the effect of such therapy on tumor progression and Tg levels. We studied 24 consecutive patients who had been treated with high-dose RAI, four of whom had no evidence of metastasis or persistent cancer. Our results showed that four patients had some uptake in posttherapy scans: in the neck, lung, and mediastinal metastases in one patient, in the thyroid remnant in two, and in a possible neck microrecurrence in one. In 13 patients with macrometastases-tumors 1 cm or greater-tumors progressed and serum Tg increased; five have died of thyroid cancer. The disease remained stable in the seven patients with micrometastases. We concluded that in high-risk patients with follicular cell-derived thyroid cancer with high Tg levels and negative diagnostic whole-body scans, only a small number showed meaningful uptake after high doses of RAI. Therefore, widespread use of empiric RAI therapy for such patients who have a large tumor burden should not be encouraged.
Objective:
To report a case of rash and liver dysfunction associated with lamotrigine treatment.
Case Summary:
An 81-year-old woman with a history of bipolar disorder presented to the emergency ...department with complaints of fever, chills, nausea, and headache. Two weeks prior to presentation, liver enzymes were normal. Lamotrigine 50 mg/day and sustained-release bupropion 200 mg/day were started after discontinuation of citalopram. The patient had previous exposure to bupropion and documented rash with exposure to penicillin and sulfa. On admission, laboratory tests revealed slightly elevated liver enzymes and slightly low serum albumin. All medications were continued. On hospital day 3, a diffuse maculopapular rash developed on the patient's chest, abdomen, neck, and upper extremities, which was pruritic and warm to the touch. Both lamotrigine and bupropion were discontinued. Liver enzymes increased to more than 3 times the upper limit of normal, and serum albumin decreased. Liver function tests improved on day 6, and the rash resolved.
Discussion:
Predictive risk factors associated with lamotrigine-induced rash and liver dysfunction include rapid dose titration, previously reported rash with other medications, age, and concurrent interacting medications. More serious adverse effects, such as Stevens–Johnson syndrome and fulminant hepatic failure, have also been associated with lamotrigine treatment. If rash appears at any time during treatment, lamotrigine must be discontinued. According to the Naranjo probability scale, an association between lamotrigine and rash and liver dysfunction could be considered probable in this case.
Conclusions:
A faster than recommended dose titration may lead to lamotrigine-induced adverse effects such as rash and liver dysfunction in patients with risk factors.
The decision to pursue surgery is often complicated in older adults. A multidisciplinary, shared approach to decision-making may improve communication between patients and their providers and ...facilitate complex risk assessment. We describe a case of an older adult presenting for complex surgery in which the preoperative anesthesia clinic visit was used to facilitate involvement of the geriatrics service. This multidisciplinary approach allowed for re-evaluation and reiteration of risks and benefits, in-depth discussion of the patient's values and goals, and recommendations for care teams downstream in the patient's surgical pathway to ensure treatment consistent with patient goals and clinical recommendations.
The relationship between skin colour and experimental exposure to ultraviolet radiation (UVR) B, with response measured as erythema was studied. Two reflectance methods were used to measure skin ...colour – tristimulus colorimetry using a Minolta instrument (summarized as the α characteristic angle) and the melanin index based on the Diastron reflectance instrument. As expected both measures are highly correlated (0.91). A dose–dependent relationship between skin colour measured as the α characteristic angle and UVR was established, with the gradient increasing from 0.99 at 119 mJ to 2.7 at 300 mJ, with the relevant standard errors being 0.39 and 0.47, respectively. Similarly, for the melanin index (where the scale goes in the opposite direction) the gradient differs between −0.49 for 119 mJ and −0.91 for 300 mJ, with the standard errors being 0.14 and 0.17 respectively. The proportion of variation explained is also greater at higher UVR challenge doses. Studies relating UVR sensitivity and pigmentation need to take account of the dose of UVR administered.
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