Given the higher incidence of emergency conditions in older inhabitants, the global increase in aged population will pose a challenge for emergency services. In this study we examined the burden ...caused to emergency health care by the aged population.
Consecutive patients aged 80 years or over visiting a high-volume, collaborative emergency department (ED) between 2015 and 2016 were included. The key factors under analysis were the incidence of emergency conditions and costs associated with emergency care.
A total of 6944 patients (median age 85 years, range 80-104 years; 67% female) aged ≥80 years representing 1.5% of the local population, made 17,769 ED visits during the two-year observation period accounting for 15% of all ED visits. Forty-two percent (n = 2884) of patients had a single ED visit, whereas 8.2% (n = 570) made ≥5 ED visits/year for a total of 1400 visits (7.9%). Thirty-two percent of those aged ≥80 years required ED services each year. The number of ED visits increased with age (p < 0.001); and was 768/1000 person-years among octogenarians and 1007/1000 among nonagenarians, in comparison to 233/1000 among those aged < 80 years. One in five of the study population were discharged with non-specific diagnoses. Typical diagnoses included pneumonia (4.8%), malaise and fatigue (4.5%) and heart failure (4.3%). Non-specific diagnoses were frequent, and examination of patients with non-specific diagnoses incurred costs similar to or higher than those of other patients. The mean cost per ED visit in older patients was 422 €.
We demonstrated a high incidence of emergency department visits in older patients. While our aim was not to solve how the growing demand should be met, it seems unlikely that increasing ED resources is feasible. Instead, the focus should be on chronic care of the aged and prevention of potentially avoidable ED visits.
Chronic pancreatitis (CP) leads to diabetes and pancreatic exocrine insufficiency (PEI). PEI may lead to maldigestion and malnutrition, which may cause fat-soluble vitamin deficiency, sarcopenia and ...abnormal bone density. We aim to study the prevalence of osteoporosis, sarcopenia and vitamin deficiency among CP patients.
Long-term (4-5 years) follow-up was implemented on CP patients. We recorded CP duration, BMI, smoking, alcohol consumption and medication. We determined the serum values for A, D and E vitamins, albumin, creatinine, haemoglobin, calcium and magnesium. Bone density measurement was taken from the proximal femur and lumbar spine. CT/MRI scans were used to measure for psoas muscle area.
A total of 33 patients (median age 62 39-81 years, 61% male) were included. None of these patients had earlier diagnosis of osteopathy, and none of them had known vitamin deficiency or were sarcopenic. Nineteen patients (57%) had pancreatic exocrine insufficiency and of these seven patients (37%) had no pancreatic enzyme replacement therapy (PERT) and one (5%) had inadequate enzyme therapy. During the study, osteoporosis was diagnosed in 20% and possible sarcopenia in 48% of patients. PEI and inadequate PERT was associated with low E vitamin levels (75% vs. 0%, p = 0.012), higher risk of osteoporosis (43% vs. 5.6%, p = 0.013) and sarcopenia (80% vs. 36%, p = 0.044).
This study demonstrates that chronic pancreatitis is associated with osteoporosis, sarcopenia and vitamin deficiency. If untreated, pancreatic exocrine insufficiency is associated with increased risk of these outcomes. This highlights the importance of identifying and treating PEI in CP patients.
Acute abdominal pain can be a diagnostic challenge even for experienced surgeons. Delayed diagnosis can lead to higher morbidity, mortality and increased costs. While readmission rate has been used ...to evaluate quality of surgical care, studies addressing the issue in emergency departments (ED) are rare. The role of emergency physicians in the care of patients with abdominal pain is increasing in many European countries, including Finland. It is not known whether this has an effect on the number of readmissions. Here we evaluate whether the increasing role of emergency physicians in examining patients presenting with abdominal pain has affected the rate of short-term revisits among patients with non-specific abdominal pain (NSAP).
We identified consecutive ED patients receiving a diagnosis of NSAP 1.1. 2015-31.12.2016 in the ED of Tampere University Hospital. Those revisiting the ED within 48 h were selected for further analysis. Data were obtained from electronic medical records. We compared the outcomes of those initially examined by surgeons and by emergency physicians.
During the study period, 173,630 patients visited our ED, of whom 6.1% (n = 10,609) were discharged with a diagnosis of NSAP. Only 3.0% of patients revisited the ED, 0.7% required hospitalization and 0.06% immediate surgery. The short-term revisit rates among those originally examined by surgeons and by emergency physicians were similar, 2.8 and 3.2% respectively (p = 0.193).
The rate of short-term revisits in patients with NSAP was altogether low. The increasing role of emergency physicians in the care of acute abdominal patients did not affect the revisit rate.
The narrow pelvis causes special challenges in surgery, and robotic-assisted surgery has been proven beneficial in these circumstances. While robotic surgery has some specific advantages in rectal ...cancer surgery, there is still limited evidence of the learning curve of the technique involved. The aim here was to study the transition from laparoscopic to robotic-assisted surgery among experienced laparoscopic surgeons. The data for this study were collected from a prospectively compiled register that includes patients operated on by the Da Vinci Xi robot in Tampere University Hospital. Each consecutive rectal cancer patient was included. The information on the surgical and oncological outcomes was analysed. The learning curve was assessed using cumulative sum (CUSUM) analysis. CUSUM already demonstrated an overall positively sloped curve at the beginning of the study, with neither the conversion rate nor morbidity reaching unacceptable thresholds. Conversions (4%) and postoperative complications (Clavien–Dindo III–IV 15%, no intraoperative complications) were rare. One patient died within one month and the death was not procedure-associated. While surgical and oncological outcomes were similar among all surgeons, the console times showed a decreasing trend and were shorter among those with more experience in laparoscopic rectal cancer surgery. Robotic-assisted rectal cancer surgery can be safely adapted by experienced laparoscopic colorectal surgeons.
Background
Endoscopic retrograde cholangiopancreatography (ERCP) is a frequent procedure in elderly patients.
Aims
We aimed to determine the safety and efficacy of acute ERCP in older patients.
...Methods
A prospectively managed, hospital-based registry containing all ERCP procedures and complications at a tertiary referral center was used to form the study population, which consisted of consecutive elderly (≥65 years) patients undergoing acute ERCP during the 5-year study period. Indications, details, outcome, and complications of the procedure were analyzed in relation to patient age, gender, and co-morbidities.
Results
A total of 480 elderly patients (median age 78; range 65–97; 48 % men) underwent 531 ERCPs during the study period. The most common indications were bile duct stones (56.1 %) and biliary obstruction caused by malignancy (33.7 %). Successful stone extraction was achieved in 72.8 %, and with an additional, planned ERCP in 96.6 % of the patients. Post-ERCP complications developed in 3.4 % of the patients. These included pancreatitis in 1.7 %, hemorrhage in 0.6 %, and duodenal perforation in 0.2 % of the patients. One of these (0.2 %) was considered severe as this patient required invasive treatments and prolonged hospital stay. The risk of complications was associated with chronic obstructive pulmonary disease and difficult cannulation. Procedure-related mortality was zero, but overall 30-day mortality was 10 %, being 24 % in the patients with malignancy.
Conclusions
ERCP can be safely and efficaciously performed on elderly patients. The high mortality should be taken into consideration when selecting therapeutic options.
Objectives
Structured medical records improve readability and ensure the inclusion of information necessary for correct diagnosis and treatment. This is the first study to assess the quality of ...computer-generated structured medical records by comparing them to conventional medical records on patients with acute abdominal pain.
Materials and methods
A prospective double-blinded study was conducted in a tertiary referral center emergency department between January 2018 and June 2018. Patients were examined by emergency department physicians and by experience and inexperienced researcher. The researchers used a new electronical medical records system, which gathered data during the examination and the system generate structured medical records containing natural language. Conventional medical records dictated by physician and computer-generated medical records were compared by a group of independent clinicians.
Results
Ninety-nine patients were included. The overall quality of the computer-generated medical records was better than the quality of conventional human-generated medical records – the structure was similar or better in 99% of cases and the readability was similar or better in 86% of cases, p < 0.001. The quality of medical history, current illness, and findings of physical examinations were likewise better with the computer-generated recording. The results were similar when patients were examined by experienced or inexperienced researcher using the computer-generated recording.
Discussion
The quality of computer-generated structured medical records was superior to that of conventional medical records. The quality remained similar regardless of the researcher’s level of experience. The system allows automatic risk scoring and easy access for quality control of patient care. We therefore consider that it would be useful in wider practice.
Key summary points
Aim
The main objective in this population-based study was to analyze the incidence of fall-related emergency department visits and recurrent falls among older people in a Finnish ...community.
Findings
Thirteen percent of all ED visits of patients aged 80 years and over are fall-related. One in four of those discharged home had a new fall-related injury.
Message
As the risk of subsequent fall-related injuries was high during the first month after the fall, we emphasize the need to intervene with the fall risk promptly.
Purpose
Fall-related injuries are a significant cause of morbidity, mortality and functional decline among older people. The aim of this study is to analyze the incidence of fall-related emergency department (ED) visits and compare the characteristics of single and recurrent fallers in a population-based sample.
Methods
Consecutive patients aged ≥ 80 years and living in the Tampere city region who visited collaborative emergency department within a two-year study period (1 January 2015 to 31 December 2016) due to fall-related injury were included. The incidence of fall-related injuries and recurrent falls was calculated using population statistics.
Results
A total of 6915 ≥ 80-year-old patients visited our ED 17,769 times during the study period. Thirteen percent of these visits (
n
= 2347, median 87 years, 80–103 years; 74% female) were fall-related. The incidence of fall-related ED visits increased from 94/1000 person-years to 171/1000 among those aged 80–89 years and ≥ 90 years, respectively. Twenty-four percent of patients had recurrent falls (range 2–5) during the observational period. Twenty-five percent of those discharged home had a subsequent fall-related injury within one month after the index visit. The distribution of diagnoses was similar among those with single and recurrent falls.
Conclusion
Fall-related injuries are a significant health issue. Almost one in eight of all ED visits were fall-related, and 24% of patients had recurrent fall-related injuries. The risk of subsequent injury was high during the first month after the first injury, emphasizing the need to intervene with the fall risk promptly.
Older patients with simultaneous main bile duct and gallbladder stones, especially those with high-surgical risks, create a common clinical dilemma. After successful endoscopic removal of main bile ...duct stones, should these patients undergo laparoscopic cholecystectomy to reduce risk of recurrent biliary events? In this population-based cohort study, we report long-term outcomes of a wait-and-see strategy after successful endoscopic extraction of main bile duct stones.
Consecutive patients 75 years or older undergoing endoscopic stone extraction without subsequent cholecystectomy in two tertiary academic centers between January 2010 and December 2018 were included. Primary outcome measure was recurrence of biliary events. Secondary outcome measures were operation-related morbidity and mortality.
A total of 450 patients (median age, 85 years; 61% female) were included, with a median follow-up time of 36 months (0-120 months). Recurrent biliary events occurred in 51 patients (11%), with a median time from index hospital admission to recurrence of 307 days (12-1993 days). The most common biliary event was acute cholecystitis (7.1%). Twelve patients had cholangitis (2.7%) and two biliary pancreatitis (0.4%). Only one patient (0.4%) underwent surgery due to later gallstone-related symptoms. Eighteen patients (4.0%) required endoscopic intervention and 16 (3.5%) underwent surgery. There were no operation-associated deaths or morbidity among those undergoing later surgical or endoscopic interventions.
In elderly patients, it is relatively safe to leave gallbladder in situ after successful sphincterotomy and endoscopic common bile duct stone removal. In elderly and frail patients, a wait-and-see strategy without routine cholecystectomy rarely leads to clinically significant consequences.
Therapeutic/Care Management; Level III.
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