Adults with spina bifida are at risk of developing secondary health conditions that are causally related to the primary condition and are to some degree preventable. By investigating preventable secondary conditions in adults with spina bifida, we can determine the burden of care that might be reduced if preventive strategies were developed. We audited hospitalizations of adults with spina bifida to gain insight into serious secondary conditions in this population. We reviewed all admissions of adults with spina bifida to a large American tertiary care center (Johns Hopkins Hospital; Baltimore, Maryland) over 11 years. We determined the discharge diagnoses for each admission and the hospital costs associated with admission. We defined preventable secondary conditions in this adult population and calculated the percentage of total admissions and of total costs for these secondary conditions. The patient population consisted of spina bifida patients 18 years and over admitted from January 1982 to December 1992, including 59 females and 39 males. 77 of our patients were identified as white, 20 as black, and 1 as "other". Patient age ranged from 18 to 61 years with an average age of 25.8 years. There were 353 admissions and admissions per patient ranged from 1 to 25 over the 11-year period. The average number of admissions per patient was 3.6 and the average length of stay for all admissions was 11.2 days. Of the 353 total admissions, 166 (47.0%) were due to potentially preventable secondary conditions such as serious urologic infections, renal calculi, pressure ulcers, and osteomyelitis. For admissions due to these secondary conditions, the average length of stay was 12.5 days. The total hospital costs, excluding professional fees, were $175,885, $247,355, and $437,262 for 1990, 1991, and 1992 respectively. Permanent loss of function resulting from secondary conditions, not investigated in this study, can also be a source of long-term financial and psychological cost to the patient. This study found a high number of patients with multiple admissions and that many admissions qualified as potentially preventable. More information is needed if we are to understand the factors associated with secondary health conditions in adults with spina bifida. We need to investigate the roles played by physician and patient knowledge, attitudes, and behaviors in contributing to patient outcome.

Abstract. Objective: To determine the diagnoses and outcomes of geriatric patients with abdominal pain, and to identify variables associated with adverse outcomes. Methods: Geriatric emergency patients (aged 65 years and older) with a complaint of abdominal pain were participants in this longitudinal case series. Eligible patients were followed by telephone contact and chart review, to determine outcomes and final diagnoses. Results: Of 380 eligible patients, follow-up information was available for 375 (97%), for the two months following the ED visit. Final diagnoses included infection (19.2%), mechanical-obstructive disorders (15.7%), ulcershypersecretory states (7.7%), urinary tract disease (7.7%), malignancy (7.2%), and others. Although 5.3% of the patients died (related to presenting condition), most (61.3%) patients ultimately recovered. Surgical intervention was required for 22.1% of the patients. Variables associated with adverse outcomes (death, and need for surgical intervention) included hypotension, abnormalities on abdominal radiography, leukocytosis. ahnormal bowel sounds, and advanced age. Most physical examination findings were not helpful in identifying patients with adverse outcomes. This study demonstrated a higher incidence of malignancy (7.2%) and a lower incidence of disease necessitating surgical intervention (22.1%) than previously reported. Conclusions: The majority of geriatric emergency patients with abdominal pain have significant disease necessitating hospital admission. Morbidity and mortality among these patients are high, and specific variables are strongly associated with death and the need for surgical intervention. Absence of these variables does not preclude significant disease. Physical examination findings cannot reliably predict or exclude significant disease. These patients should be strongly considered for hospital admission, particularly when fever, hypotension, leukocytosis, or abnormal bowel sounds are present. Key words: abdominal pain; geriatrics; elder; adverse outcomes; predictors; diagnosis. ACADEMIC EMERGENCY MEDICINE 1998; 511163-1168 ERIATRIC persons (aged 65 years and older) G represent the fastest growing segment of the population, and currently comprise 12% of the U.S. population. The diseases of geriatric emergency patients have posed significant diagnostic and management challenges, in part due to patients' tendency to delay seeking medical care, the atypical presentations, presence of coexisting diseases, atypical physical examination findings, atypical laboratory values, and higher morbidity and mortality.l-I6 Previous studies have demonstrated a diagnostic accuracy of only 40% to 65% in geriatric patients with abdominal ~a i n . * -~.~, I~We undertook this investigation to ascertain fi- nal diagnoses and outcomes of geriatric ED patients with abdominal pain. We also wanted to determine which routinely available clinical variables are associated with higher likelihood of the need for surgical intervention, and death within a two-month period among this pa...

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