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.
Splenic injury accounts for 40% of all injuries after blunt abdominal trauma. Blunt splenic injury in hemodynamically unstable patients is preferably treated by splenectomy. Nowadays hemodynamically ...stable patients with low grade splenic injuries are mostly treated by non-operative management (NOM). However no consensus exists about the management of high grade splenic injuries in hemodynamically stable patients. Therefore the aim of this study was to analyze patients with high grade splenic injuries in our institution.
We retrospectively included all patients with a splenic injury presented to our level I trauma center during the 5-year period from January 1, 2012, until December 31, 2017. Baseline characteristics, data regarding complications and mortality were collected from the electronic patient registry. Patients were grouped based on splenic injury and the treatment they received.
A total of 123 patients were included, of which 93 (75.6%) were male with a median age of 31 (24-52) and a median injury severity score of 27 (17-34). High grade injuries (
= 28) consisted of 20 Grade IV injuries and 8 grade V injuries. Splenectomy was required in 15/28 (53.6%) patients, of whom all remained hemodynamically unstable after resuscitation, including all grade V injuries. A total of 13 patients with high grade injuries were treated with spleen preserving therapy. Seven of these patients received angio-embolization. One patient went for laparotomy and the spleen was treated with a hemostatic agent. Secondary hemorrhage was present in 3 of these patients (initial treatment: 1 embolization/ 2 observational), resulting in a success rate of 76.9%. There is no mortality seen in patient with high grade splenic injuries.
Non-operative treatment in high grade splenic injuries is a safe treatment modality in hemodynamically stable patients. Hemodynamic status and peroperative bleeding, not injury severity or splenic injury grade were the drivers for surgical management by splenectomy. This selected cohort of patients must be closely monitored to prevent adverse outcomes from secondary delayed bleeding in case of non-operative management.
Purpose
Most children with intra-abdominal injuries can be managed non-operatively. However, in Europe, there are many different healthcare systems for the treatment of pediatric trauma patients. ...Therefore, the aim of this study was to describe the management strategies and outcomes of all pediatric patients with blunt intra-abdominal injuries in our unique dedicated pediatric trauma center with a pediatric trauma surgeon.
Methods
We performed a retrospective, single-center, cohort study to investigate the management of pediatric patients with blunt abdominal trauma. From the National Trauma Registration database, we retrospectively identified pediatric (≤ 18 years) patients with blunt abdominal injuries admitted to the UMCU from January 2012 till January 2018.
Results
A total of 121 pediatric patients were included in the study. The median interquartile range (IQR) age of patients was 12 (8–16) years, and the median ISS was 16 (9–25). High-grade liver injuries were found in 12 patients. Three patients had a pancreas injury grade V. Furthermore, 2 (1.6%) patients had urethra injuries and 10 (8.2%) hollow viscus injuries were found. Eighteen (14.9%) patients required a laparotomy and 4 (3.3%) patients underwent angiographic embolization. In 6 (5.0%) patients, complications were found and in 4 (3.3%) children intervention was needed for their complication. No mortality was seen in patients treated non-operatively. One patient died in the operative management group.
Conclusions
In conclusion, it is safe to treat most children with blunt abdominal injuries non-operatively if monitoring is adequate. These decisions should be made by the clinicians operating on these children, who should be an integral part of the entire group of treating physicians. Surgical interventions are only needed in case of hemodynamic instability or specific injuries such as bowel perforation.
Background and purposeRecent research has highlighted non-operative management (NOM) as a viable alternative for frail older adults with hip fractures in the final phase of life. This study aims to ...guide Dutch physicians and hospitals nationwide in a standardised implementation of shared decision-making regarding surgery or NOM in selected frail older adults with a hip fracture.Methods and analysisThe patient population for implementation includes frail older adults aged ≥70 years with an acute proximal femoral fracture, nursing home care or a similar level of care elsewhere and at least one additional criterion (ie, malnutrition, severe mobility impairment or ASA≥4). The 2-year implementation study will be conducted in four phases. In phases 1 and 2, barriers and facilitators for implementation will be identified and an implementation protocol, educational materials and patient information will be developed. Phase 3 will involve an implementation pilot in 14 hospitals across the Netherlands. The protocol and educational material will be improved based on healthcare provider and patient experiences gathered through interviews. Phase 4 will focus on upscaling to nationwide implementation and the effect of the implementation on NOM rate will be measured using data from the Dutch Hip Fracture Audit.Ethics and disseminationThe study was exempted by the local Medical Research Ethics Committee (MEC-2023-0270, 10 May 2023) and Medical Ethics Committee United (W23.083, 26 April 2023). The study’s results will be submitted to an open access international peer-reviewed journal. Its protocols, tools and results will be presented at several national and international academic conferences of relevant orthogeriatric (scientific) associations.Trial registration numberNCT06079905.
Background
Severe postpartum hemorrhage (SPPH) is the leading cause of maternal mortality and morbidity worldwide. Platelet anomalies frequently occur during pregnancy. However, their role in the ...etiology of SPPH is largely unknown.
Objective
To study the relation between platelet parameters and SPPH.
Methods
This retrospective single‐center cohort included deliveries between 2009 and 2017. SPPH was defined as ≥1000 ml blood loss within 24 h after delivery. Platelet parameters were measured within 72 h before delivery. Multiple imputation was performed for missing data. Odds ratios were adjusted (aORs) for maternal age, multiple gestation, macrosomia, induction of labor, preeclampsia, and hemolysis, elevated liver enzymes, and low platelets syndrome.
Results
A total of 23 205 deliveries were included. Of the 2402 (10.4%) women with thrombocytopenia (<150 × 109/L), 10.3% developed SPPH, compared with 7.6% of women with a normal platelet count (aOR: 1.34, 95% CI: 1.14–1.59). Women with a platelet count of <50 × 109/L were most at risk (aOR of 2.24 1.01–4.94) compared with the reference group with normal platelet counts; the aOR was 1.22 (0.77–1.93) for the 50–99 × 109/L platelet count group and 1.31 (1.10–1.56) for the 100–149 × 109/L platelet count group. Plateletcrit was associated with SPPH (aOR 1.15 1.08–1.21 per 0.05% decrease), and, although rarely present, a platelet distribution width (PDW) ≥23% (n = 22) also increased the odds of SPPH (aOR 6.05 2.29–16.20).
Conclusion
Different degrees of thrombocytopenia were independently associated with the occurrence of SPPH. Despite their relation to SPPH, plateletcrit and a PDW of ≥23% have limited additional value in addition to platelet count.
Abstract Objectives: The aim of this study was to determine the variations in effect for predictors of mortality over time and risk of in-hospital complications in geriatric patients with a hip ...fracture. Many studies have investigated risk factors of short-term and long-term mortality separately. In current literature, little is known about the variations in effect of risk factors over time and no comparison with the general population is made. Methods: All patients with a hip fracture aged 70 years or older admitted to our hospital between January 1, 2016, and May 1, 2018, were included in this retrospective study. Patients who had undergone total hip arthroplasty (THA) were not included. The primary outcome was mortality after 1 year. Secondary outcomes were mortality after 30 days, 90 days, 2 years, and complications. Kaplan–Meier (KM) curves for risk factors were generated to visualize survival over time. Data were compared with data extracted from the national health records. Results: A total of 685 geriatric patients with hip fractures were included with a 1-year mortality of 27%. The adjusted odds ratios (AOR) found differed over time. Five risk factors for mortality were investigated in this study using KM curves: age, prefracture living situation, dementia, sex, and ASA classification. Conclusions: Over time, the variation of 5 risk factors for mortality were visualized in geriatric patients with a hip fracture: age, prefracture living situation, dementia, sex, and ASA classification. An elevated risk of mortality was discovered compared with the general population. The variation in effect observed in risk factors plays a vital role in prognosis. This insight will help guide accurate medical decision-making for a tailored treatment plan for geriatric patients with a hip fracture.
Hodgkin lymphoma (HL) occurs at young ages, with the highest incidence between 20 and 40 years. While cure rates have improved to 80%-90% over the past decades, survivors of HL are at substantial ...risk of late treatment-related complications, such as cardiovascular diseases, breast cancer, severe infections, and hypothyroidism. To reduce morbidity and mortality from late treatment effects, the Dutch Better care after lymphoma, Evaluation of long-term Treatment Effects and screening Recommendations (BETER) consortium developed a survivorship care program for 5-year survivors of HL that includes risk-based screening for and treatment of (risk factors for) late adverse events. Even though several cancer survivorship care programs have been established worldwide, there is a lack of knowledge about their effectiveness in clinical practice.
The Improving Nationwide Survivorship care Infrastructure and Guidelines after Hodgkin lymphoma Treatment (INSIGHT) study evaluates whether Dutch BETER survivorship care for survivors of HL decreases survivors' burden of disease from late adverse events after HL treatment and associated health care costs and improves their quality of life.
The INSIGHT study is a multicenter retrospective cohort study with a quasi-experimental design and prospective follow-up, embedded in the national BETER survivorship care infrastructure. The first BETER clinics started in 2013-2016 and several other centers started or will start BETER clinics in 2019-2024. This allows us to compare survivors who did and those who did not receive BETER survivorship care in the last decade. Survivors in the intervention group are matched to controls (n=450 per group) based on sex, age at diagnosis (±5 years), age in 2013 (±5 years), and treatment characteristics. The primary outcome is the burden of disease in disability-adjusted life years from cardiovascular disease, breast cancer, severe infections, and hypothyroidism. In a cost-effectiveness analysis, we will assess the cost of BETER survivorship care per averted or gained disability-adjusted life year and quality-adjusted life year. Secondary outcomes are BETER clinic attendance, adherence to screening guidelines, and knowledge and distress about late effects among survivors of HL. Study data are collected from a survivor survey, a general practitioner survey, medical records, and through linkages with national disease registries.
The study was funded in November 2020 and approved by the institutional review board of the Netherlands Cancer Institute in July 2021. We expect to finalize recruitment by October 2024, data collection by early 2025, and data analysis by May 2025.
INSIGHT is the first evaluation of a comprehensive survivorship program using real-world data; it will result in new information on the (cost-)effectiveness of survivorship care in survivors of HL in clinical practice. The results of this study will be used to improve the BETER program where necessary and contribute to more effective evidence-based long-term survivorship care for lymphoma survivors.
PRR1-10.2196/55601.
Bacterial infections are frequently seen in the emergency department (ED), but can be difficult to distinguish from viral infections and some non-infectious diseases. Common biomarkers such as ...c-reactive protein (CRP) and white blood cell (WBC) counts fail to aid in the differential diagnosis. Neutrophil CD64 (nCD64), an IgG receptor, is suggested to be more specific for bacterial infections. This study investigated if nCD64 can distinguish bacterial infections from other infectious and non-infectious diseases in the ED.
All COVID-19 suspected patients who visited the ED and for which a definitive diagnosis was made, were included. Blood was analyzed using an automated flow cytometer within 2 h after presentation. Patients were divided into a bacterial, viral, and non-infectious disease group. We determined the diagnostic value of nCD64 and compared this to those of CRP and WBC counts.
Of the 291 patients presented at the ED, 182 patients were included with a definitive diagnosis (bacterial infection n = 78; viral infection n = 64; non-infectious disease n = 40). ROC-curves were plotted, with AUCs of 0.71 95%CI: 0.64-0.79, 0.77 0.69-0.84 and 0.64 0.55-0.73 for nCD64, WBC counts and CRP, respectively. In the bacterial group, nCD64 MFI was significantly higher compared to the other groups (p < 0.01). A cut-off of 9.4 AU MFI for nCD64 corresponded with a positive predictive value of 1.00 (sensitivity of 0.27, a specificity of 1.00, and an NPV of 0.64). Furthermore, a diagnostic algorithm was constructed which can serve as an example of what a future biomarker prediction model could look like.
For patients in the ED presenting with a suspected infection, nCD64 measured with automatic flow cytometry, has a high specificity and positive predictive value for diagnosing a bacterial infection. However, a low nCD64 cannot rule out a bacterial infection. For future purposes, nCD64 should be combined with additional tests to form an algorithm that adequately diagnoses infectious diseases.
•Land use related to Dutch consumption was calculated in detail for the years 1990, 1995, 2000, 2005, 2010 and 2013.•Land use decreased during the 1990–2013 period due to increasing agricultural ...yields, despite growth in GDP and population.•Yields from import regions were used and global average yields; total land use amounted to 0.51 ha per capita using regional yields.•Most land use takes place abroad, mainly in the EU.•Wood, paper and animal products are the most important products.
Effects of Dutch consumption reach far beyond the country borders. The international consequences of consumption are related to imports of many commodities for consumptive needs. The goal of this study was to show the amount and distribution of land needed for Dutch national consumption, inside and outside the national borders. While this question has been investigated in general terms, the present study is motivated by the need to provide more accurate and precise product-level results that can be used in a practical way, for example to guide circular economy policy goals.
A model was developed to determine land use of 40 commodities, combining use- /supply-based consumption data with agricultural/forestry yields in the main regions of origin, plus land used for housing, recreation etc. The model thus calculates a land footprint that reflects actual occupied hectares. The model comprises the time series from 1990 to 2013.
The land used for the consumptive needs of Dutch people amounts to 8.6 million hectares in 2013, corresponding to 0.51 ha per capita. This is over two and a half times the land area of the Netherlands itself. Land use is primarily related to forestry and agriculture, with paper and meat as important land requiring products. During the 1990–2013 period total land use has decreased by 10%, despite a population increase of 13% and an increase in GDP by 54%. The main causes for this decrease are increased agricultural yields and a decrease in paper and wood consumption after 2010. For the years 1990 and 2013 a comparison was made between land use with actual region-specific yields and global average yields. This exercise showed that, for the year 2013, land use calculated using global average yields was almost twice as much as that calculated using regional yields. This means our commodities originate from regions with relatively productive lands. For the year 1990 the difference was even larger, indicating a converging trend in global yields. In 2013 most land for Dutch consumption was occupied within the EU (53%, of which 20% in the Netherlands) and South America (18%).
Hodgkin lymphoma (HL) survivors are at increased risk of cardiovascular disease (CVD) due to former lymphoma treatment. In 2013, cardiovascular screening for 5-year HL survivors according to national ...guidelines was implemented in Dutch survivorship clinics. We aim to assess the following: (1) adherence to screening guidelines and (2) the yield of (risk factors for) CVD in the screening program.
The study population consisted of 5-year HL survivors who received survivorship care at three University Medical Centers from 2013 to 2016 through 2021. Patient characteristics, cardiovascular screening procedures, and outcomes were collected from the medical records.
In 186 survivors eligible for cardiovascular screening (mean age 47.8 years, 60.8% female), the following diagnostics were performed: complete blood tests (81.0%, median frequency: yearly instead of advised 5-yearly evaluation), electrocardiogram (93.0%), echocardiography (94.6%). Fifty-five percent of survivors had at least one modifiable cardiovascular risk factor (i.e., current smoking, overweight, new/insufficiently controlled hypertension, dyslipidemia, or diabetes). Screening detected ≥ 1 CVD in 31.1% of survivors. Among survivors with available echocardiography report (n = 106), screening detected new aortic and/or mitral valve dysfunction(s) in 51.0% (with grades 3-4 in 4.9%) and impaired left ventricular ejection fraction in 10.3%.
Adherence to the screening guidelines in the Dutch HL survivorship care program was reasonable to good and a substantial number of actionable (risk factors for) CVD were diagnosed.
Our findings inform HL survivors at high risk of late cardiotoxicity about cardiovascular screening findings and demonstrate appropriate therapeutic actions after diagnosis of (risk factors for) CVD.
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