Introduction
This study aimed to evaluate the incidence of complications in elderly patients with a hip fracture following integrated orthogeriatric treatment. To discover factors that might be ...adjusted, in order to improve outcome in those patients, we examined the association between baseline patient characteristics and a complicated course.
Methods
We included patients aged 70 years and older with a hip fracture, who were treated at the Centre for Geriatric Traumatology (CvGT) at Ziekenhuisgroep Twente (ZGT) Almelo, the Netherlands between April 2011 and October 2013. Data registration was carried out using the clinical pathways of the CvGT database. Based on the American Society of Anesthesiologists (ASA) score, patients were divided into high-risk (HR, ASA 3 ≥,
n
= 341) and low-risk (LR, ASA 1–2,
n
= 111) groups and compared on their recovery. Multivariate logistic regression was used to identify risk factors for a complicated course.
Results
The analysis demonstrated that 49.6% (
n
= 224) of the patients experienced a complicated course with an in-hospital mortality rate of 3.8% (
n
= 17). In 57.5% (
n
= 196) of the HR patients, a complicated course was seen compared to 25.2% (
n
= 28) of the LR patients. The most common complications in both groups were the occurrence of delirium (HR 25.8% vs. LR 8.1%,
p
≤ 0.001), anemia (HR 19.4% vs. LR 6.3%,
p
= 0.001), catheter-associated urinary tract infections (CAUTIs) (HR 10.6% vs. LR 7.2%,
p
= 0.301) and pneumonia (HR 10.9% vs. LR 5.4%,
p
= 0.089). Independent risk factors for a complicated course were increasing age (OR 1.04, 95% CI 1.01–1.07,
p
= 0.023), delirium risk VMS Frailty score (OR 1.57, 95% CI 1.04–2.37,
p
= 0.031) and ASA score ≥3 (OR 3.62, 95% CI 2.22–5.91,
p
≤ 0.001).
Conclusions
After integrated orthogeriatric treatment, a complicated course was seen in 49.6% of the patients with a hip fracture. The in-hospital mortality rate was 3.8%. Important risk factors for a complicated course were increasing age, poor medical condition and delirium risk VMS Frailty score. Awareness of risk factors that affect the course during admission can be useful in optimizing care and outcomes. In the search for possible areas for improvement in care, targeted preventive measures to mitigate delirium, and healthcare-associated infections (HAIs), such as CAUTIs and pneumonia are important.
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.
Introduction
Dehydration is a major problem in the older population with traumatic hip fractures (THF). A preoperative hemodynamic preconditioning (PHP) protocol may help in achieving hemodynamic ...stability to ensure adequate perfusion and oxygenation using only clinical parameters to assess cardiovascular performance.
Materials and methods
A single-centre retrospective study in geriatric trauma patients was conducted in a Level 1 Trauma Centre in Switzerland. Patients over the age of 70 with THFs and with Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality (P-POSSUM) scores ≥ 5% who underwent surgical treatment between February 2015 and October 2017 were included. It was hypothesized that patients whose hemodynamic stability was optimised before surgery would have fewer complications and reduced mortality postoperatively. Primary outcomes were complications and mortality. Secondary outcomes were hospital length of stay (HLOS) and place of discharge.
Results
100 patients were included in the PHP group and 79 patients were included in the non-PHP group. The median age was 86.5 (82–90) in the PHP group and 86 (82–90) in the non-PHP group. Patients who had been treated according to the PHP protocol showed a significant reduction in mortality at 30 days (
p
= 0.02). The PHP group showed an 8.1 and 3.5% reduced mortality at 90 days and at 1 year, respectively. The PHP group showed an 11.7% reduction of patients with complicated courses. No significant differences were seen in HLOS and discharge disposition.
Conclusions
The PHP group showed a significant reduction in short-term mortality, a reduction in long-term mortality, and a reduction in the number of patients with complicated courses. The PHP protocol is a safe, strictly regulated, non-invasive fluid resuscitation protocol for the optimization of geriatric patients with a THF that requires minimal effort.
Level of evidence
Level III, therapeutic
•Surgical decision-making with geriatric patients is complex in acute surgical settings, and it is not always possible to make decisions as equals.•A shift in thinking from disease-oriented to a ...patient-goal oriented paradigm is required to provide better person-centred care for older patients.•Physicians must tailor the “sharedness” of decision-making to the needs of the patient and their family.•In this paper, we make recommendations to improve patient participation in decision-making in acute surgical settings.
Geriatric patients often present to the hospital in acute surgical settings. In these settings, shared decision-making as equal partners can be challenging. Surgeons should recognize that geriatric patients, and frail patients in particular, may sometimes benefit from de-escalation of care in a palliative setting rather than curative treatment. To provide more person-centred care, better strategies for improved shared decision-making need to be developed and implemented in clinical practice. A shift in thinking from a disease-oriented paradigm to a patient-goal-oriented paradigm is required to provide better person-centred care for older patients. We may greatly improve the collaboration with patients if we move parts of the decision-making process to the pre-acute phase. In the pre-acute phase appointing legal representatives, having goals of care conversations, and advance care planning can help give physicians an idea of what is important to the patient in acute settings.
When making decisions as equal partners is not possible, a greater degree of physician responsibility may be appropriate. Physicians should tailor the “sharedness” of the decision-making process to the needs of the patient and their family.
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.
Hyperimmunoglobulinaemia D and periodic fever syndrome (HIDS; MIM 260920) is a rare, apparently monogenic, autosomal recessive disorder characterized by recurrent episodes of fever accompanied with ...lymphadenopathy, abdominal distress, joint involvement and skin lesions. All patients have high serum IgD values (>100 U/ml) and HIDS `attacks' are associated with an intense acute phase reaction whose exact pathophysiology remains obscure. Two other hereditary febrile disorders have been described. Familial Mediterranean fever (MIM 249100) is an autosomal recessive disorder affecting mostly populations from the Mediterranean basin and is caused by mutations in the gene MEFV (refs 5,6). Familial Hibernian fever (MIM 142680), also known as autosomal dominant familial recurrent fever, is caused by missense mutations in the gene encoding type I tumour necrosis factor receptor. Here we perform a genomewide search to map the HIDS gene. Haplotype analysis placed the gene at 12q24 between D12S330 and D12S79. We identified the gene MVK, encoding mevalonate kinase (MK, ATP:mevalonate 5-phosphotransferase; EC 2.7.1.36), as a candidate gene. We characterized 3 missense mutations, a 92-bp loss stemming from a deletion or from exon skipping, and the absence of expression of one allele. Functional analysis demonstrated diminished MK activity in fibroblasts from HIDS patients. Our data establish MVK as the gene responsible for HIDS.
Summary
The AHFS
90
was developed for the prediction of early mortality in patients ≥ 90 years undergoing hip fracture surgery. The AHFS
90
has a good accuracy and in most risk categories a good ...calibration. In our study population, the AHFS
90
yielded a maximum prediction of early mortality of 64.5%.
Purpose
Identifying hip fracture patients with a high risk of early mortality after surgery could help make treatment decisions and information about the prognosis. This study aims to develop and validate a risk score for predicting early mortality in patients ≥ 90 years undergoing hip fracture surgery (AHFS
90
).
Methods
Patients ≥ 90 years, surgically treated for a hip fracture, were included. A selection of possible predictors for mortality was made. Missing data were subjected to multiple imputations using chained equations. Logistic regression was performed to develop the AHFS
90
, which was internally and externally validated. Calibration was assessed using a calibration plot and comparing observed and predicted risks.
Results
One hundred and two of the 922 patients (11.1%) died ≤ 30 days following hip fracture surgery. The AHFS
90
includes age, gender, dementia, living in a nursing home, ASA score, and hemoglobin level as predictors for early mortality. The AHFS
90
had good accuracy (area under the curve 0.72 for geographic cross validation). Predicted risks correspond with observed risks of early mortality in four risk categories. In two risk categories, the AHFS
90
overestimates the risk. In one risk category, no mortality was observed; therefore, no analysis was possible. The AHFS
90
had a maximal prediction of early mortality of 64.5% in this study population.
Conclusion
The AHFS
90
accurately predicts early mortality after hip fracture surgery in patients ≥ 90 years of age. Predicted risks correspond to observed risks in most risk categories. In our study population, the AHFS
90
yielded a maximum prediction of early mortality of 64.5%.
•The objective was to externally validate the U-HIP prediction model for in-hospital mortality in geriatric hip fracture patients.•In this large international cohort, the model showed a good ...discrimination and fair calibration.•This model is freely available online and can be used to predict the risk of mortality, identify high-risk patients, and aid clinical decision making.
Identification of high-risk hip fracture patients in an early stage is vital for guiding surgical management and shared decision making. To objective of this study was to perform an external international validation study of the U-HIP prediction model for in-hospital mortality in geriatric patients with a hip fracture undergoing surgery.
In this retrospective cohort study, data were used from The American College of Surgeons National Surgical Quality Improvement Program. Patients aged 70 years or above undergoing hip fracture surgery were included. The discrimination (c-statistic) and calibration of the model were investigated.
A total of 25,502 patients were included, of whom 618 (2.4%) died. The mean predicted probability of in-hospital mortality was 3.9% (range 0%-55%). The c-statistic of the model was 0.74 (95% CI 0.72–0.76), which was comparable to the c-statistic of 0.78 (95% CI 0.71–0.85) that was found in the development cohort. The calibration plot indicated that the model was slightly overfitted, with a calibration-in-the-large of 0.015 and a calibration slope of 0.780. Within the subgroup of patients aged between 70 and 85, however, the c-statistic was 0.78 (95% CI 0.75–0.81), with good calibration (calibration slope 0.934).
The U-HIP model for in-hospital mortality in geriatric hip fractures was externally validated in a large international cohort, and showed a good discrimination and fair calibration. This model is freely available online and can be used to predict the risk of mortality, identify high-risk patients and aid clinical decision making.
Objective
Clinical studies showing that non‐central nervous system cancer patients can develop cognitive impairment have primarily focused on patients with specific cancer types and intensive ...treatments. To better understand the course of cognitive function in the general population of cancer patients, we assessed cognitive trajectories of patients before and after cancer diagnosis in a population‐based setting.
Methods
Between 1989 and 2014, 2211 participants from the population‐based Rotterdam study had been diagnosed with cancer of whom 718 (32.5%) had undergone ≥1 cognitive assessment before and after diagnosis. Cognition was measured every 3 to 6 years using a neuropsychological battery. Linear mixed models were used to compare cognitive trajectories of patients before and after diagnosis with those of age‐matched cancer‐free controls (1:3).
Results
Median age at cancer diagnosis was 70.3 years and 47.1% were women. Most patients (68.1%) had received local treatment only. Cognitive trajectories of patients before and after cancer diagnosis were largely similar to those of controls. After diagnosis, the largest difference was found on a memory test (patients declined with 0.14 units per year on the Word Learning Test: delayed recall 95% CI = −0.35; 0.07 and controls with 0.09 units 95% CI = −0.18;‐0.00, p for difference = .59).
Conclusions
In this longitudinal cohort, cancer did not appear to alter the trajectory of change in cognitive test results over time from that seen in similar individuals without cancer, although most cancer patients did not receive systemic therapies. Future studies should focus on identifying subgroups of patients who are at high risk for developing cognitive impairment.
