188 LETTERS TO THE EDITOR
1 JAGS
combinations in which more than 20% of frequencies
were less than five. Statistical significance was defined as a
P < .05.
A comparison of the rates of susceptibility between
the age-stratified antibiograms can be seen in Table 1.
Statistically significant differences were identified for
four combinations of species and antimicrobial agents:
Proteus mirabilis and ampicillin (P = .004), Proteus mira-
bilis and cefazolin (P = .01), Staphylococcus aureus and
clindamycin (P = .01), and Enterococcus faecalis and levo-
floxacin (P = .02). Despite these differences, the facility-
wide antibiogram did not overestimate susceptibility rates
from the geriatric antibiogram. Rates of resistance were
generally seen to be higher in the geriatric antibiogram
(Table 1).
Within the WJB Dorn VAMC, the age-stratified geri-
atric antibiogram created during this study was not found
to be significantly different from the 2013 facility-wide
antibiogram. In a previously published study, hospital-
wide, age- and location-stratified susceptibility results
were analyzed for Staphylococcus aureus, Escherichia
coli, and Streptococcus pneumoniae and lower antibiotic
susceptibility was found in older adults, which was
obscured in the institution-wide antibiogram.3 The health
system from which the aforementioned results were iden-
tified serves a much more diverse population than a
VAMC. At a VAMC, all final culture and sensitivity data
used to create the annual facility-wide antibiogram come
from isolates collected from adults. It is likely that this
difference in the core population, as well as the high
rates of older adults served at the WJB Dorn VAMC,
resulted in the minimal differences found between the
geriatric and facility-wide antibiograms.
This study has several limitations. Combinations of
species and antimicrobial agents assessed were heavily reli-
ant on the culture and sensitivity data merged into the
electronic medical record. Sample size and number of resis-
tant isolates are much smaller when data are separated
into age-stratified groupings; the small sample size may
have obscured or overemphasized trends in resistance.
Because of differences in the sampling methods between
the facility-wide and age-stratified antibiograms, statistical
analysis could not be performed to assess possible differ-
ences more completely.
In summary, susceptibility data for older adults as
interpreted through the geriatric antibiogram were not
overestimated in the WJB Dorn VAMC facility-wide
antibiogram, so an alternative antibiogram does not need
to be created for older adults cared for at this VAMC and
associated community-based outpatient clinics at this time.
As the average age of the population served at VAMCs
continues to decrease because of increased enrollment of
Operation Iraqi Freedom, Operation Enduring Freedom,
and Operation New Dawn veterans, it may be necessary to
revisit this topic in the future.
MaryAnne M. Ventura, PharmD
Kevin Brittain, PharmD
William Jennings Bryan Dorn Veterans Affairs Medical
Center, Columbia, South Carolina
JANUARY 2015–VOL. 63, NO.
Jennifer Pruskowski, PharmD
William Jennings Bryan Dorn Veterans Affairs Medical
Center, Columbia, South Carolina
James J. Peters Veterans Affairs Medical Center, Bronx,
New York
Diana Hogan, PharmD
Tiffany Walker, PharmD
William Jennings Bryan Dorn Veterans Affairs Medical
Center, Columbia, South Carolina
ACKNOWLEDGMENTS
The authors would like to acknowledge Dr. Christie De-
Bruhl for her assistance with development of methods and
Dr. Aubrey Cartwright for reviewing the manuscript.
Conflict of Interest: There are no financial or personal
conflicts of interest for authors.
Author Contributions: Ventura: data collection, analy-
sis, and interpretation; manuscript preparation. Brittain:
study concept and design, data analysis and interpretation,
manuscript review. Pruskowski, Walker: study concept
and design, manuscript review. Hogan: data analysis and
interpretation, manuscript review.
Sponsor’s Role: None.
REFERENCES
1. Lacy MK, Klutman NE, Horvat RT et al. Antibiograms: New NCCLS
guidelines, development and clinical application. Hosp Pharm 2004;39:542–
553.
2. Clinical and Laboratory Standards Institute. Analysis and Presentation of
Cumulative Antimicrobial Susceptibility Test Data, 3rd Ed. (Approved
guideline M39-A3). Wayne, PA: Clinical and Laboratory Standards Insti-
tute, 2009.
3. Swami SK, Banerjee R. Comparison of hospital-wide and age and location-
stratified antibiograms of S. aureus, E. coli, and S. pneumoniae: Age- and
location-stratified antibiograms. Springerplus 2013;2:63.
4. American Geriatrics Society 2012 Beers Criteria Update Expert Panel.
American Geriatrics Society updated Beers Criteria for potentially inap-
propriate medication use in older adults. J Am Geriatr Soc 2012;60:616–
631.
CUTANEOUS SURGERY COMPLICATIONS IN
INDIVIDUALS AGED 80 AND OLDER VERSUS
YOUNGER THAN 80 AFTER EXCISION OF
NONMELANOMA SKIN CANCER
To the Editor: Nonmelanoma skin cancer (NMSC) is the
most common cancer worldwide, and its incidence is
increasing;1 these facts and the aging of the population in
the developed world suggest that dermatologists will be
faced with an increasing number of very elderly adults pre-
senting with skin cancers.2 Several studies have analyzed
the outcome of surgery in elderly adults in other surgical
disciplines but few in dermatological surgery. Some
authors have demonstrated that skin surgery is a safe and
effective therapy in elderly adults.3 The most important
decision is how best to treat these patients with these skin
conditions that progress slowly and are usually not fatal.4
JAGS JANUARY 2015–VOL. 63, NO. 1 LETTERS TO THE EDITOR 189

Table 1. Baseline Demographic Characteristics and Complications According to Age

Characteristic ≥80, n = 130 <80, n = 130 P-Value

Age, mean ( standard deviation) 84.1 (3.5) 69.1 (4.5)

Male (%) 73 (56.2) 82 (63.1) .26
Charlson Comorbidity Index, n (%)
0–1 91 (70.0) 103 (79.2) .10
2 25 (19.2) 13 (10.0)
≥3 14 (10.8) 14 (10.8)
Main comorbidities, n (%)
Uncomplicated diabetes mellitus 32 (24.6) 32 (24.6) >.99
Dementia 21 (16.2) 0 (0.0) <.001
Acute myocardial infarction 16 (12.3) 14 (10.8) .70
Congestive heart failure 17 (13.1) 4 (3.1) .03
Stroke 13 (10.0) 2 (1.5) .03
Surgical technique, n (%)
Excision and direct closure 90 (55.2) 88 (56.1) .97
Excision and flap 48 (29.4) 60 (38.2) .97
Excision and graft 25 (15.3) 9 (5.7) .005
Surgical complications, n (%)
Wound infection 3 (1.8) 0 (0.0) .24
Hemorrhagic complication 42 (25.8) 26 (16.7) .04
Dehiscence 3 (1.8) 3 (1.9) .99
Flap or graft necrosis 7 (9.6) 4 (6.9) .41
Incompletely excised tumors, n (%) 8 (4.9) 3 (1.9) .10

commonly excluded from dermatological surgery exclu-

METHODS
This study was conducted in the Dermatology Department
of University Hospital, Elche, Spain. The study group con-
sisted of individuals aged 80 and older treated with sur-
gery for NMSC. For each individual included, a patient
younger than 80 treated with surgery for NMSC was
included in a control group. The principal investigator
(JCP) reported complications from surgery (classified
as hemorrhagic (postoperative hemorrhage, hematoma,
ecchymosis), infectious, wound dehiscence, and flap or
graft necrosis) during routine procedures.
RESULTS
Each group had 130 subjects, and 320 tumors were
removed (163 in the older group, 157 in the control
group). Baseline demographic characteristics and complica-
tions are summarized in Table 1. Solid basal cell carci-
noma was the most common diagnosis in both groups.
Most tumors were located on the head and neck. The most
common type of closure in both groups was direct closure,
skin flaps were frequently used, but skin grafts were more
commonly used in the older subjects (P = .005). The inci-
dence of complications from cutaneous surgery was low
(excluding ecchymoses). Hemorrhagic complications were
more common in the older group (P = .04), but most were
only ecchymoses, with one postoperative bleeding in the
whole study. Only three wound infections were recorded,
all in the older group.
DISCUSSION
The skin of the elderly adults is vulnerable to trauma and
poor wound repair.5 Elderly adults with NMSC are
sively because of their age,6 but greater morbidity with der-
matological surgery in older adults has not been detected.7,8
The current study found a low rate of complications, even
with the frequent use of flaps and grafts in both groups.
Only hemorrhagic complications were more common in the
older group, probably because of loss of elastic fibers and
collagen in elderly adults, which is associated with greater
skin fragility. The main limitations of the study were the
small number of participants and that it was performed in a
single institution. The results of this study suggest that com-
plications from dermatological surgery are similar in older
and younger adults and that surgery is a viable treatment in
very elderly adults with NMSC.
Jos
e C. Pascual, PhD
Isabel Belinch
on, PhD
Department of Dermatology, Hospital General
Universitario, Alicante, Spain
Jos
e M. Ramos, PhD
Department of Internal Medicine, Hospital General
Universitario, Alicante, Spain
ACKNOWLEDGMENTS
Conflict of Interest: The editor in chief has reviewed the
conflict of interest checklist provided by the authors and
has determined that the authors have no financial or any
other kind of personal conflicts with this paper.
Author Contributions: All authors contributed to writ-
ing this letter.
Sponsor’s Role: There were no sponsors or funding
for this paper.
190 LETTERS TO THE EDITOR JANUARY 2015–VOL. 63, NO. 1 JAGS

REFERENCES A 5
**

Odds ratio for low IADL

1. Lomas A, Leonardi-Bee J, Bath-Hextall F. A systemic review of worldwide
incidence of nonmelanoma skin cancer. Br J Dermatol 2012;166: 4
1069–1080.
2. Pascual JC, Belinch
on I, Ramos JM et al. Skin tumors in patients aged 3
90 years and older. Dermatol Surg 2004;30:1017–1019.
*

in baseline
3. Alam M, Norman RA, Goldberg LH. Dermatologic surgery in geriatric 2
patients: Psychosocial considerations and perioperative decision-making.
Dermatol Surg 2002;28:1043–1050.
4. Audisio RA, Bozzetti F, Gennari R et al. The surgical management of 1
elderly cancer patients; recommendations of the SIOG surgical task force.
Eur J Cancer 2004;40:926–938. 0
5. Gossain A, DiPietro LA. Aging and wound healing. World J Surg NGT IGT DM
2004;28:321–326. (n) (212) (127) (39)
6. Linos E, Parvataneni R, Stuart SE et al. Treatment of nonfatal conditions at
B

Odds ratio for decline

the end of life: Nonmelanoma skin cancer. JAMA Intern Med 3 #
2013;173:1006–1012.
7. MacFarlane DF, Pustelny BL, Goldberg LH. An assessment of the suitability 2

of IADL
of Mohs micrographic surgery in patients aged 90 years and older. Derma-
tol Surg 1997;23:389–392.
8. Dhiwakar M, Khan NA, McClymont LG. Surgery for head and neck skin 1
tumors in the elderly. Head Neck 2007;29:851–856.
0
NGT IGT DM
C
(n) (170) (93) (26)

Odds ratio for decline

EFFECT OF EARLY DIAGNOSIS AND LIFESTYLE 1.2
MODIFICATION ON FUNCTIONAL ACTIVITIES IN 1.0

of IADL
COMMUNITY-DWELLING ELDERLY ADULTS WITH 0.8
GLUCOSE INTOLERANCE: 5-YEAR LONGITUDINAL 0.6
STUDY
0.4 *
To the Editor: Older people with diabetes mellitus fre- 0.2 䗈
0
quently have functional impariment,1–4 but there are few
reports of the protective effects of longitudinal interventions NGT IGT DM
(n) (108) (62) (53) (40) (15) (11)
on functional decline in older people newly diagnosed
according to an oral glucose tolerance test (OGTT).5 The Participation <3 >4 <3 >4 < 3 > 4 (times)
association between glucose intolerance and decline in Group 1) 2) 3) 4) 5) 6)
instrumental activities of daily living (IADL) was examined
to verify the hypothesis that annual education on lifestyle Figure 1. (A) Cross-sectional association between glucose
modification can help prevent IADL decline in people with intolerance and instrumental activity of daily living (IADL)
glucose intolerance in a 5-year longitudinal study. disability at baseline (N = 378). P < *.05, **0.01 using multi-
Community-dwelling people aged 60 and older were ple logistic regression. (B) Longitudinal association between
screened using an OGTT (World Health Organization crite- glucose intolerance and IADL decline over 5 years (n = 289).
ria) for the first time in 2006 in Tosa, Japan5 (N = 378; 212 #P < .10 using multiple logistic regression. (C) Protective
effect of participation of follow-up on IADL decline over
with normal glucose tolerance (NGT), 127 with impaired
5 years in impaired glucose tolerance (IGT) and normal glu-
glucose tolerance (IGT), 39 with diabetes mellitus (DM)).
cose tolerance (NGT) groups (n = 289). *P < .05 (NGT), †P
The prevalence at baseline of disability in IADLs (≤4 of five
< .05 (IGT) using multiple logistic regression. DM = diabetes
of the IADL items in the Tokyo Metropolitan Institute of
mellitus.
Gerontology index),6,7 was 9.0% for NGT, 15.7% for IGT,
and 30.8% for DM (P < .001, chi-square test). DM
(odds ratio (OR) = 4.42, 95% confidence interval
(CI) = 1.62–12.08, P = .004) and IGT (OR = 2.23, 95% P = .04), depression (OR = 2.77, 95% CI = 0.94–8.15,
CI = 1.03–4.82, P = .04) were associated with IADL disabil- P = .06), age, sex, falling, and BMI (Figure 1B).
ity as assessed using multiple logistic regression after adjust- All subjects were invited to participate in the five
ing for dependent basic activities of living (ADL) annual glucose intolerance and geriatric functional analyses
(OR = 5.12, 95% CI = 1.99–13.18, P < .001),8 age, sex, and education about lifestyle modification during the 5-year
depression,9 body mass index (BMI), and falling (Figure 1A). study period.5,10 To analyze the preventive effect of follow-
Of the 289 participants who were independent in IADLs up participation of participants with NGT, IGT and DM
(score of 5) at baseline, who could be followed up during the on IADL decline, all subjects were assigned to one of two
5-year study, the incidence of IADL disability was 15.6% for groups: more participation (≥4) or less participation (≤3).
NGT, 11.8% for IGT, and 23.1% for DM groups. DM
(OR = 2.70, 95% CI = 0.87–8.39 vs NGT, P = .09) was 1 NGT with less participation (n = 108, 16.7% with
mildly associated with decline in IADL ability, but IGT was not, IADL decline).
as indicated by multiple logistic regression after adjusting for 2 NGT with more participation (n = 62, 14.5% with
dependence in ADLs (OR = 3.01, 95% CI = 1.03–8.82, IADL decline).
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