Abstract Background Hip fractures are common in the elderly and have a high risk of early mortality. Identification of patients at high risk of early mortality could contribute to enhanced quality of ...care. A simple scoring system is essential for preoperative identification of patients at high risk of early mortality in clinical practice. Of risk models published, The Nottingham Hip Fracture Score (NHFS) shows the most promising results so far. However, there is still room for improvement. Methods A cohort study including 850 patients was conducted over a period of 5,5 yr. The NHFS was adjusted for cognitive impairment (NHFS-a) and tested. Patients who died within 30 days following hip fracture surgery (early mortality group) were compared to survivors. Independent risk factors for early mortality were assessed. A new hip fracture score for frail elderly was developed: the Almelo Hip Fracture Score (AHFS). The NHFS-a and the AHFS were compared for accuracy and predictive validity. Results Sixty-four (7.5%) patients died within 30 days following hip fracture surgery. The AHFS predicts the risk of early mortality better than the NHFS-a (p < 0.05). Using cut-off points of AHFS ≤ 9 and AHFS ≥ 13, patients could be divided into a low, medium or high risk group. The area under the curve improved with the AHFS compared to the NHFS-a (0.82 versus 0.72). The likelihood ratio test reveals a significantly better fit of the AHFS in comparison with the NHFS-a (p < 0.001). Conclusions The AHFS can identify frail elderly at high risk of early mortality following hip fracture surgery accurately. With the AHFS, the patient can be classified into the low, medium or high risk group, which contributes to enhanced quality of care in clinical practice.
Summary
Hip fractures are a serious public health issue with major consequences, especially for frail community dwellers. This study found a poor prognosis at 6 months post-trauma with regard to life ...expectancy and rehabilitation to pre-fracture independency levels. It should be realized that recovery to pre-trauma functioning is not a certainty for frail community-dwelling patients.
Introduction
Proximal femoral fractures are a serious public health issue in the older patient. Although a significant rise in frail community-dwelling elderly is expected because of progressive aging, a clear overview of the outcomes in these patients sustaining a proximal femoral fracture is lacking. This study assessed the prognosis of frail community-dwelling patients who sustained a proximal femoral fracture.
Methods
A multicenter retrospective cohort study was performed on frail community-dwelling patients with a proximal femoral fracture who aged over 70 years. Patients were considered frail if they were classified as American Society of Anesthesiologists score ≥ 4 and/or a BMI < 18.5 kg/m
2
and/or Functional Ambulation Category ≤ 2 pre-trauma. The primary outcome was 6-month mortality. Secondary outcomes were adverse events, health care consumption, rate of institutionalization, and functional recovery.
Results
A total of 140 out of 2045 patients matched the inclusion criteria with a median age of 85 (P
25
–P
75
80–89) years. The 6-month mortality was 58 out of 140 patients (41%). A total of 102 (73%) patients experienced adverse events. At 6 months post-trauma, 29 out of 120 (24%) were readmitted to the hospital. Out of the 82 surviving patients after 6 months, 41 (50%) were unable the return to their home, and only 32 (39%) were able to achieve outdoor ambulation.
Conclusion
Frail community-dwelling older patients with a proximal femoral fracture have a high risk of death, adverse events, and institutionalization and often do not reobtain their pre-trauma level of independence. Foremost, the results can be used for realistic expectation management.
The external globus pallidus (GPe) of the basal ganglia is in a unique and powerful position to influence processing of motor information by virtue of its widespread projections to all basal ganglia ...nuclei. Despite the clinical importance of the GPe in common motor disorders such as Parkinson's disease, there is only limited information about its cellular composition and organizational principles. In this review, recent advances in the understanding of the diversity in the molecular profile, anatomy, physiology and corresponding behaviour during movement of GPe neurons are described. Importantly, this study attempts to build consensus and highlight commonalities of the cellular classification based on existing but contentious literature. Additionally, an analysis of the literature concerning the intricate reciprocal loops formed between the GPe and major synaptic partners, including both the striatum and the subthalamic nucleus, is provided. In conclusion, the GPe has emerged as a crucial node in the basal ganglia macrocircuit. While subtleties in the cellular makeup and synaptic connection of the GPe create new challenges, modern research tools have shown promise in untangling such complexity, and will provide better understanding of the roles of the GPe in encoding movements and their associated pathologies.
In this issue, Hegeman et al. seek to provide a comprehensive review of neuronal diversity in the external globus pallidus (GPe). By offering an exhaustive analysis of the literature, the authors argue that the cellular composition and the wiring properties of the GPe is in fact complex. While two principal neuron classes are identified, a plethora of outstanding questions remain. Finally, the behavioral and clinical relevance of the GPe and its relationship with different neuron classes is also discussed.
: Post-cardiotomy cardiogenic shock (PCCS), which is defined as severe low cardiac output syndrome after cardiac surgery, has a mortality rate of up to 90%. No study has yet been performed to compare ...patients with PCCS treated by conservative means to patients receiving additional mechanical circulatory support with veno-arterial extracorporeal membrane oxygenation (ECMO).
: A single-center retrospective analysis from January 2018 to June 2022 was performed.
: Out of 7028 patients who underwent cardiac surgery during this time period, 220 patients (3%) developed PCCS. The patients were stratified according to their severity of shock based on the Stage Classification Expert Consensus (SCAI) group. Known risk factors for shock-related mortality, including the vasoactive-inotropic score (VIS) and plasma lactate levels, were assessed at structured intervals. In patients treated additionally with ECMO (
= 73), the in-hospital mortality rate was 60%, compared to an in-hospital mortality rate of 85% in patients treated by conservative means (non-ECMO;
= 52). In 18/73 (25%) ECMO patients, the plasma lactate level normalized within 48 h, compared to 2/52 (4%) in non-ECMO patients. The morbidity of non-ECMO patients compared to ECMO patients included a need for dialysis (42% vs. 60%), myocardial infarction (19% vs. 27%), and cerebrovascular accident (17% vs. 12%).
: In conclusion, the additional use of ECMO in PCCS holds promise for enhancing outcomes in these critically ill patients, more rapid improvement of end-organ perfusion, and the normalization of plasma lactate levels.
Hybrid minimally invasive left ventricular reconstruction is used to treat patients with ischemic heart failure with reduced ejection fraction (HFrEF) and antero-apical scar. Pre- and post-procedural ...regional functional left ventricular assessment with current imaging techniques remains limited. We evaluated 'inward displacement' as a novel technique of assessing regional left ventricular function in an ischemic HFrEF population who underwent left ventricular reconstruction with the Revivent System.
Inward displacement adopts three standard long-axis views obtained during cardiac MRI or CT and assesses the degree of inward endocardial wall motion towards the true left ventricular center of contraction. For each of the standard 17 left ventricular segments, regional inward displacement is measured in mm and expressed as a percentage of the maximal theoretical distance each segment can contract towards the centerline. The left ventricle was divided into three regions, obtaining the arithmetic average of inward displacement or speckle tracking echocardiographic strain at the left ventricular base (segments 1-6), mid-cavity (segments 7-12) and apex (segments 13-17). Inward displacement was measured using computed tomography or cardiac magnetic resonance imaging and compared pre- and post-procedurally in ischemic HFrEF patients who underwent left ventricular reconstruction with the Revivent System (
= 36). In a subset of patients who underwent baseline speckle tracking echocardiography, pre-procedural inward displacement was compared with left ventricular regional echocardiographic strain (
= 15).
Inward displacement of basal and mid-cavity left ventricular segments increased by 27% (
< 0.001) and 37% (
< 0.001), respectively, following left ventricular reconstruction. A significant overall decrease in both the left ventricular end systolic volume index and end diastolic volume index of 31% (
< 0.001) and 26% (
< 0.001), respectively, was detected, along with a 20% increase in left ventricular ejection fraction (
= 0.005). A significant correlation between inward displacement and speckle tracking echocardiographic strain was noted within the basal (R = -0.77,
< 0.001) and mid-cavity left ventricular segments (R = -0.65,
= 0.004), respectively. Inward displacement resulted in relatively larger measurement values compared to speckle tracking echocardiography, with a mean difference of absolute values of -3.33 and -7.41 for the left ventricular base and mid-cavity, respectively.
Obviating the limitations of echocardiography, inward displacement was found to highly correlate with speckle tracking echocardiographic strain to evaluate regional segmental left ventricular function. Significant improvements in basal and mid-cavity left ventricular contractility were demonstrated in ischemic HFrEF patients following left ventricular reconstruction of large antero-apical scars, consistent with the concept of reverse left ventricular remodeling at a distance. Inward displacement holds significant promise in the HFrEF population being evaluated pre- and post-left ventriculoplasty procedures.
Quality indicators are used to measure quality of care and enable benchmarking. An overview of all existing hip fracture quality indicators is lacking. The primary aim was to identify quality ...indicators for hip fracture care reported in literature, hip fracture audits, and guidelines. The secondary aim was to compose a set of methodologically sound quality indicators for the evaluation of hip fracture care in clinical practice. A literature search according to the PRISMA guidelines and an internet search were performed to identify hip fracture quality indicators. The indicators were subdivided into process, structure, and outcome indicators. The methodological quality of the indicators was judged using the Appraisal of Indicators through Research and Evaluation (AIRE) instrument. For structure and process indicators, the construct validity was assessed. Sixteen publications, nine audits and five guidelines were included. In total, 97 unique quality indicators were found: 9 structure, 63 process, and 25 outcome indicators. Since detailed methodological information about the indicators was lacking, the AIRE instrument could not be applied. Seven indicators correlated with an outcome measure. A set of nine quality indicators was extracted from the literature, audits, and guidelines. Many quality indicators are described and used. Not all of them correlate with outcomes of care and have been assessed methodologically. As methodological evidence is lacking, we recommend the extracted set of nine indicators to be used as the starting point for further clinical research. Future research should focus on assessing the clinimetric properties of the existing quality indicators.
Regional functional left ventricular (LV) assessment using current imaging techniques remains limited. Inward displacement (InD) has been developed as a novel technique to assess regional LV function ...via measurement of the regional displacement of the LV endocardial border across each of the 17 LV segments. Currently, normal ranges for InD are not available for clinical use. The aim of this study was to validate the normal reference limits of InD in healthy adults across all LV segments.
InD was analyzed in 120 healthy subjects with a normal LV ejection fraction, using the three standard long-axis views obtained during cardiac MRI that quantified the degree of inward endocardial wall motion towards the true LV center of contraction. For all LV segments, InD was measured in mm and expressed as a percentage of the theoretical degree of maximal segment contraction towards the true LV centerline. The arithmetic average InD was obtained for each of the 17 segments. The LV was divided into three regions, obtaining average InD at the LV base (segments 1-6), mid-cavity (segments 7-12) and apex (segments 13-17).
Average InD was 33.4 ± 4.3%. InD was higher in basal and mid-cavity LV segments (32.8 ± 4.1% and 38.1 ± 5.8%) compared to apical LV segments (28.6 ± 7.7%). Interobserver variability correlations for InD were strong (R = 0.80,
< 0.0001).
We provide clinically meaningful reference ranges for InD in subjects with normal LV function, which will emerge as an important screening and assessment imaging tool for a range of HFrEF therapies.
Late-life depression may differ from early-life depression in its phenomenology.
To investigate the effect of age on the phenomenology of major depression.
A systematic search was conducted in ...PubMed, Embase and PsycINFO for all studies examining the relation between age and phenomenology of major depression according to RDC, DSM and ICD criteria. Studies were included only if the age groups were compared at the single-item level using the 17-, 21- or 24-item versions of the Hamilton Rating Scale for Depression; a meta-analysis was done for each item of the 17-item scale.
Eleven papers met the inclusion criteria. Older depressed adults, compared with younger depressed adults, demonstrated more agitation, hypochondriasis and general as well as gastrointestinal somatic symptoms, but less guilt and loss of sexual interest.
The phenomenology of late-life depression differs only in part from that of early-life depression. Major depression in older people may have a more somatic presentation, whereas feelings of guilt and loss of sexual function may be more prevalent in younger people.
Radiation-resistant advanced silicon carbide (SiC/SiC) composites have been developed as a promising candidate of the high-temperature operating advanced fusion reactor. With the completion of the ...‘proof-of-principle’ phase in development of ‘nuclear-grade’ SiC/SiC composites, the R&D on SiC/SiC composites is shifting toward the more pragmatic phase, i.e., industrialization of component manufactures and data-basing. In this paper, recent advances and issues in (1) development of component fabrication technology including joining and functional coating, e.g., a tungsten overcoat as a plasma facing barrier, (2) recent updates in characterization of non-irradiated properties, e.g., strength anisotropy and chemical compatibility with solid lithium-based ceramics and lead-lithium liquid metal breeders, and (3) irradiation effects are specifically reviewed. Importantly high-temperature neutron irradiation effects on microstructural evolution, thermal and electrical conductivities and mechanical properties including the fiber/matrix interfacial strength are specified under various irradiation conditions, indicating seemingly very minor influence on the composite performance in the design temperature range.
Summary
To improve the quality of care and reduce the healthcare costs of elderly patients with a hip fracture, surgeons and geriatricians collaborated intensively due to the special needs of these ...patients. After treatment at the Centre for Geriatric Traumatology (CvGT), we found a significant decrease in the 1-year mortality rate in frail elderly patients compared to the historical control patients who were treated with standard care.
Introduction
The study aimed to evaluate the effect of an orthogeriatric treatment model on elderly patients with a hip fracture on the 1-year mortality rate and identify associated risk factors.
Methods
This study included patients, aged 70 years and older, who were admitted with a hip fracture and treated in accordance with the integrated orthogeriatric treatment model of the CvGT at the Hospital Group Twente (ZGT) between April 2008 and October 2013. Data registration was carried out by several disciplines using the clinical pathways of the CvGT database. A multivariate logistic regression analysis was used to identify independent risk factors for 1-year mortality. The outcome measures for the 850 patients were compared with those of 535 historical control patients who were managed under standard care between October 2002 and March 2008.
Results
The analysis demonstrated that the 1-year mortality rate was 23.2 % (
n
= 197) in the CvGT group compared to 35.1 % (
n
= 188) in the historical control group (
p
< 0.001). Independent risk factors for 1-year mortality were male gender (odds ratio (OR) 1.68), increasing age (OR 1.06), higher American Society of Anesthesiologists (ASA) score (ASA 3 OR 2.43, ASA 4–5 OR 7.05), higher Charlson Comorbidity Index (CCI) (CCI 1–2 OR 1.46, CCI 3–4 OR 1.59, CCI 5 OR 2.71), malnutrition (OR 2.01), physical limitations in activities of daily living (OR 2.35), and decreasing Barthel Index (BI) (OR 0.96).
Conclusion
After integrated orthogeriatric treatment, a significant decrease was seen in the 1-year mortality rate in the frail elderly patients with a hip fracture compared to the historical control patients who were treated with standard care. The most important risk factors for 1-year mortality were male gender, increasing age, malnutrition, physical limitations, increasing BI, and medical conditions. Awareness of risk factors that affect the 1-year mortality can be useful in optimizing care and outcomes. Orthogeriatric treatment should be standard for elderly patients with hip fractures due to the multidimensional needs of these patients.
PDF
