Thirty-day mortality following surgical management of hip fractures during the COVID-19 pandemic: findings from a prospective multi-centre UK study

PURPOSE

Thirty-day mortality of patients with hip fracture is well researched and predictive; validated scoring tools have been developed (Nottingham Hip Fracture Score, NHFS). COVID-19 has significantly greater mortality in the elderly and comorbid patients which includes hip fracture patients. Non-operative treatment is not appropriate due to significantly higher mortality, and therefore, these patients are often exposed to COVID-19 in the peri-operative period. What is unclear is the effect of concomitant COVID-19 infection in these patients.

METHODS

A multicentre prospective study across ten sites in the United Kingdom (responsible for 7% of hip fracture patients per annum in the UK). Demographic and background information were collected by independent chart review. Data on surgical factors included American Society of Anesthesiologists (ASA) score, time to theatre, Nottingham Hip fracture score (NHFS) and classification of fracture were also collected between 1st March 2020 and 30th April 2020 with a matched cohort from the same period in 2019.

RESULTS

Actual and expected 30-day mortality was found to be significantly higher than expected for 2020 COVID-19 positive patients (RR 3.00 95% CI 1.57-5.75, p < 0.001), with 30 observed deaths compared against the 10 expected from NHFS risk stratification.

CONCLUSION

COVID-19 infection appears to be an independent risk factor for increased mortality in hip fracture patients. Whilst non-operative management of these fractures is not suggested due to the documented increased risks and mortality, this study provides evidence to the emerging literature of the severity of COVID-19 infection in surgical patients and the potential impact of COVID-19 on elective surgical patients in the peri-operative period.

Role of CMV-serostatus and CX3CR1 on lymphocyte kinetics and left ventricular remodelling in patients with acute myocardial infarction

Background

Patients with latent cytomegalovirus (CMV) infection have higher rates of adverse cardiovascular outcomes, but the reasons for this remain elusive. CMV-induced changes to T-lymphocyte populations, with a proliferation of CMV-specific, CX3CR1+ effector memory cells, may contribute. Effector T-cells are associated with cardiovascular mortality in CMV positive patients, and ischaemia-reperfusion injury after ST-elevation myocardial infarction (STEMI) and primary percutaneous coronary intervention (pPCI).

Purpose

To investigate the effect of CMV status on lymphocyte kinetics and cardiac MRI (cMRI) parameters in 52 STEMI patients receiving pPCI, and examine the prognostic relevance of pre-reperfusion lymphocyte count in a large cohort.

Methods

We retrospectively analysed the association between pre-reperfusion lymphocyte count, troponin, and long-term survival in 4874 consecutive STEMI patients. Using flow cytometry, we analysed lymphocyte kinetics in 52 STEMI patients, of known CMV status, during and after pPCI. We assessed the impact of CMV status on infarct size, left-ventricular (LV) function and microvascular obstruction with cMRI in the first week after reperfusion in 101 patients. Repeat cMRI at 12 weeks, to assess LV remodelling, was obtained in 48 patients.

Results

Pre-reperfusion lymphopenia is an independent predictor of mortality over 7.5 years (hazard ratio for lowest vs highest quartile: 2.0; 95% CI 1.7–2.4; p&lt;0.001), and is associated with higher admission troponins (p&lt;0.001 for lowest vs second-lowest quartile), suggesting lymphocyte count falls prior to reperfusion in response to myocardial injury. CMV positive patients had more cytotoxic T-cells, strongly expressing the fractalkine receptor, CX3CR1. In CMV positive patients these cells fell dramatically by 90 minutes post-reperfusion, and dropped more sharply in patients with extensive microvascular obstruction on cMRI (p≤0.05 in all effector subsets). CX3CR1 expression was lower at 90 minutes post-reperfusion than at 24 hours (return to physiological expression) in all effector T-cell subsets. All subsets lost a similar proportion of their 24-hour value, but consistently lost a larger proportion in CMV positive patients (−27% in CMV+, −18% in CMV−; p=0.007). CX3CR1 expression falls in the presence of fractalkine, and we hypothesise that membrane-bound fractalkine is induced more strongly in CMV positive patients, as soluble fractalkine levels were similar. At 12 weeks, LV remodeling was worse in CMV positive patients (change in end-diastolic volume: +10.7ml vs −6.1ml; p=0.02).

Conclusions

Lymphopenia occurs prior to reperfusion in STEMI, and predicts long-term mortality. Effector T-cells drop substantially after reperfusion only in CMV positive patients, likely mediated by CX3CR1-fractalkine interaction, and this is associated with adverse cMRI findings. Remodeling is worse in CMV positive patients at 12 weeks post-STEMI.

Lymphocytes, troponin and survival

Funding Acknowledgement

Type of funding source: Public Institution(s)

Interferon-gamma inducible protein IP-10 and left ventricular remodelling post-acute myocardial infarction: a longitudinal cardiovascular magnetic resonance imaging substudy of CAPRI clinical trial

Background

Adverse left ventricular (LV) remodelling is associated with development of heart failure and poor outcomes in patients with acute myocardial infarction (AMI). Understanding the immunomodulatory mechanisms of LV remodelling is an essential step for the development of novel therapies. Interferon-γ-inducible protein-10 (IP-10)/CXCL10 is a chemokine involved in the recruitment of activated T cells into sites of tissue inflammation. Although IP-10 was reported to reduce adverse LV remodeling in a preclinical myocardial infarction model, its role in LV remodeling in humans with AMI remains unknown.

Purpose

To determine the clinical predictive value of serum IP-10 in LV remodeling in patients with ST-segment elevation myocardial infarction (STEMI).

Methods

This is a substudy of the double-blind, randomised controlled trial “Evaluating the effectiveness of intravenous ciclosporin on reducing reperfusion injury in patients undergoing primary percutaneous coronary intervention” (CAPRI; ClinicalTrials.gov registry number NCT02390674), which enrolled 52 acute STEMI patients. LV remodeling was assessed by cardiovascular magnetic resonance (CMR) imaging and was defined as the 12-week vs. the 3-day post-myocardial infarction change of the left ventricular ejection fraction (ΔLVEF), LV end-diastolic volume (ΔEDV) or LV end-systolic volume (ΔESV). Serum IP-10 was measured before and 5min, 15min, 30min, 90min and 24h after reperfusion by ELISA. Linear regression analysis was used to determine the independent association of IP-10 with the endpoints of the study.

Results

Serum IP-10 concentration peaked at 30min after reperfusion followed by a 2-fold decrease at the 24h post reperfusion compared to pre-reperfusion levels (P&lt;0.001 for all). Comparison of the 12-week CMR to the baseline CMR imaging revealed that baseline pre-reperfusion as well as 5min, 15min, 30min and 90min, but not 24h, post-reperfusion IP-10 serum levels associated with increased LVEF and decreased ESV at 12-weeks (range correlation coefficient r=[0.35–0.41], P&lt;0.05 with ΔLVEF and r=[−0.33 to −0.44], P&lt;0.05 with ΔESV) indicating that the increase of IP-10 at the acute phase of myocardial infarction confers a cardioprotective role. Multivariable linear regression analysis for ΔLVEF showed that in a model including baseline pre-reperfusion or 5min or 15min or 30min or 90min post-reperfusion IP-10 and age, gender, traditional risk factors (arterial hypertension, body-mass index, hyperlipoproteinemia, diabetes mellitus, smoking, family history of CAD), infarct location, admission high-sensitivity troponin T, door-to-balloon time and ciclosporin treatment, only IP-10 was the independent determinant of ΔLVEF.

Conclusions

Increased serum IP-10 levels early after reperfusion are associated with reverse LV remodeling in patients with STEMI undergoing primary PCI. The clinical application of IP-10 as a novel biomarker of LV remodeling post-AMI should be further explored and validated.

Funding Acknowledgement

Type of funding source: None

PROMs in total knee replacement: analysis of negative outcomes

INTRODUCTION

NHS England uses the Oxford Knee Score (OKS) as part of patient-reported outcome measures (PROMs) to evaluate 'health gains' following total knee replacement. Policy makers use this to guide healthcare funding and resource allocation. Our study aims to undertake a qualitative and quantitative analysis of OKS among patients who experienced a negative outcome after a total knee replacement at our centre.

MATERIALS AND METHODS

Between April 2017-March 2018, 19 of 189 (10%) patients had a worsened OKS at our centre. We retrospectively and prospectively reviewed 14 of these patients. Structured telephone interviews with a repeat OKS were carried out in September 2019 (18-29 months post-operation).

RESULTS

Eight patients were female and the total age range was 57-95, mean average 75.6 (SD 9.9 years). Of 48 (higher scores meaning better outcomes), the average preoperative OKS was 24.2 and the average postoperative OKS at 6 months was 19.4 (decrease of 20%). The average postoperative OKS at 18-29 months was 35.6 (an increase of 83.5% from 6 months).

DISCUSSION

The OKS was developed and validated over 20 years ago in Oxford. In our study, four patients asked for clarification of questions 4, 6 and 10 owing to ambiguous language. All 14 patients who had negative OKS outcomes had positive outcomes when retested after 18 months, depicting 'health gains' not conveyed in PROMs analysis.

CONCLUSION

The OKS needs to be revalidated on current patient groups for accurate and reliable data. Further prospective studies should be undertaken on larger cohorts to understand the recovery course and whether PROMs should be carried out later.

Atrial fibrillation and non-ischaemic cardiomyopathy in the peripartum period

A 31-year-old primiparous woman with a history of bigeminy as a teenager developed atrial fibrillation with rapid ventricular response during elective caesarean section. Initial postoperative medical management was undertaken on the maternal high dependency unit and involved the administration of beta-blockers and digoxin. On postoperative day 1 the patient was transferred to the coronary care unit where she subsequently required synchronised direct current cardioversion to restore sinus rhythm. The patient remained on the coronary care unit for 5 days before discharge. Magnetic resonance imaging undertaken 6 weeks postpartum showed non-ischaemic cardiomyopathy. In this report, we discuss tachycardia-induced and peripartum cardiomyopathies, along with their potential underlying pathologies, incidence and associated morbidity. We describe potential pharmacological therapies including beta-blockers and angiotensin-converting enzyme inhibitors, as well as the implications of such medications for breastfeeding mothers. Patients presenting with palpitations in the antenatal period should receive prompt investigation including electrocardiography with ambulatory monitoring considered for those with persistent symptoms. Anyone with a proven cardiac arrhythmia should undergo echocardiography. This report illustrates the importance of the investigation of the symptoms of arrhythmia during pregnancy and emphasises the role of multidisciplinary working in the management of obstetric patients with complex medical comorbidity.

Subnanosecond phase transition dynamics in laser-shocked iron

Iron is one of the most studied chemical elements due to its sociotechnological and planetary importance; hence, understanding its structural transition dynamics is of vital interest. By combining a short pulse optical laser and an ultrashort free electron laser pulse, we have observed the subnanosecond structural dynamics of iron from high-quality x-ray diffraction data measured at 50-ps intervals up to 2500 ps. We unequivocally identify a three-wave structure during the initial compression and a two-wave structure during the decaying shock, involving all of the known structural types of iron (α-, γ-, and ε-phase). In the final stage, negative lattice pressures are generated by the propagation of rarefaction waves, leading to the formation of expanded phases and the recovery of γ-phase. Our observations demonstrate the unique capability of measuring the atomistic evolution during the entire lattice compression and release processes at unprecedented time and strain rate.

Excess leukocytosis (leukemoid reaction) associated with feline non-flea, non-food hypersensitivity dermatitis in a young cat

A one and a half-year-old, male, castrated, domestic short-haired cat was presented with a six‑month history of depression, anorexia, skin lesions, excessive itching and systemic lymphadenopathy. Complete blood count revealed severe leukocytosis (114,700 cells/μl), and peripheral blood films were characterized by marked lymphocytosis. Lymph nodes examinations and bone marrow aspirate were not suggestive of neoplastic changes. Histopathologic examination of skin lesions revealed allergic dermatitis. Based on the anamnesis and histopathologic features, non-flea, non-food hypersensitivity dermatitis (NFNFHD) was diagnosed. Treatment was initiated with prednisolone and cyclosporine. During the treatment, the cat fully recovered from the skin lesions. Leukocytosis was reduced to 18,940/μl six months after initiation of medication. To the authors’ knowledge, this is the first report describing a case of a leukemoid reaction secondary to feline NFNFHD.

P2444Comparison of 3D and 2D echocardiography-derived indices of left ventricular function and structure to predict long-term mortality in the general population: Southall And Brent Revisited (SABRE) study

Background

Three-dimensional echocardiography (3DE) may have advantages over two-dimensional echocardiography (2DE) for the assessment of left ventricular (LV) function and structure. However, studies comparing 3DE and 2DE-derived indices in relation to mortality are limited, particularly in the general population.

Purpose

We examined associations between 2DE and 3DE-derived LV ejection fractions (LVEF) and volumes for all-cause mortality in a population-based sample.

Methods

A total of 899 individuals (age, 69.6±6.1 years; 77.5%male) from the SABRE study, a UK-based tri-ethnic community cohort, underwent a comprehensive transthoracic echocardiography examination. 2D LVEF and volumes were calculated, and full-volume 3D LV datasets acquired over 4 sub-volumes were obtained using a matrix-array transducer and were analysed offline using Qlab advanced, v7.0. The associations between both 2D- and 3D-derived LVEF (≥55% vs. <55%), body surface area indexed end-diastolic volume (iEDV) and end-systolic volume (iESV), and all-cause mortality were determined using Cox proportional hazards models. Survival curves were constructed using the Kaplan-Meier method.

Results

Of the 899 individuals, 118 (13.1%) died over a median follow-up period of 8 years to 2018. Kaplan Meier survival estimates (Figure 1 illustrates LVEF) and Cox regression revealed that 2D and 3D LVEF, iEDV and iESV were associated with increased risk of all-cause mortality (LVEF (≥55% vs. <55%), 3DE: HR=0.53 (0.35, 0.80); 2DE: HR=0.51 (0.34, 0.75), iEDV (per 1SD increment), 3DE: HR=1.20 (1.0, 1.41); 2DE: HR=1.19 (1.0–1.41), iESV (per 1SD increment), 3DE: HR=1.27 (1.1, 1.52), 2DE: HR=1.32 (1.15, 0.1.51)). However, 3DE associations tended to be stronger in models adjusted for classical risk factors including age, sex, ethnicity, systolic blood pressure, cholesterol:HDL ratio, body mass index, antihypertensive medications, diabetes, and smoking (LVEF (≥55% vs. <55%), 3DE: HR=0.59 (0.39, 0.90); 2DE: HR=0.69 (0.46, 1.0), iEDV (per 1SD increment), 3DE: HR=1.20 (1.0, 1.41); 2DE: HR=1.10 (0.93, 1.31), iESV (per 1SD increment), 3DE: HR=1.27 (1.1, 1.52), 2DE: HR=1.20 (1.04, 0.1.39)).

Figure 1. Kaplan-Meier curves.

Conclusions

In this population-based study, both 2DE and 3DE-derived indices of LV structure and function were associated with all-cause mortality independently of classical risk factors, with some indication that strengths of association were greater for 3DE-derived indices.

Acknowledgement/Funding

SABRE is funded by BHF, Diabetes UK, the MRC and the Wellcome Trust. LA holds a scholarship grant from Imam Abdulrahman Bin Faisal University, SA

6070Association of blood pressure measures with brain structure and function: the Southall and Brent REvisited (SABRE) study

Background

In our rapidly ageing society, dementia and neurocognitive decline are significant global public health problems. Blood pressure (BP), an established cardiovascular risk factor, has been extensively studied with respect to brain structure and function; however, findings across the literature differ depending on the BP component in consideration, and the use of brachial rather than central BP.

Purpose

We set out to assess associations between detailed measures of brain structure and function with comprehensive measures of central and peripheral BP. Furthermore, we performed comprehensive mediation analyses on the associations to investigate potential micro and macro vascular mediatory pathways.

Methods

A community-based sample of 1438 individuals (69.7±6.2 years) from a tri-ethnic cohort. underwent vascular, cognitive and MRI based structural brain measures. BP measures included central (cSBP (Pulsecor)) and peripheral systolic BP (pSBP), diastolic BP (DBP), brachial (bPP) and central pulse pressure (cPP), and mean arterial pressure (MAP). Cognitive assessments comprised tests which explored global/overall function (CSID), executive function and memory. For brain structure, hippocampal brain volume was our key measure. Potential macro- and microvascular mediators included: arterial stiffness (cfPWV), carotid intima-media thickness, retinopathy, white matter hyperintensities and infarcts. Multivariable regression analyses were used to assess associations of BP components with cognitive function scores and brain volumes, adjusted for age, sex and ethnicity as well as macro- and microvascular risk factors. Multiple imputation was performed to account for missing data.

Results

After adjusting for age, sex and ethnicity, both cSBP and pSBP were negatively associated with memory (data are β±SE (z-score) −0.014±0.006, p=0.04), while DBP was positively associated with hippocampal volume (0.006±0.003, p=0.03). cPP was negatively associated with memory (−0.020±0.009, p=0.03), executive function (−0.018±0.006, p=0.002) and hippocampal volume (−0.007±0.003, p=0.005), while bPP was negatively associated with CSID (−0.008±0.004, p=0.04), memory (−0.020±0.008, p=0.02), executive function (−0.016±0.005, p=0.002) and hippocampal volume (−0.006±0.002, p=0.007). There was a stronger association between both PP measures and brain structure and function than with the other BP components, especially MAP. There was little difference in association between cPP and bPP measures with brain structure and function. Furthermore, these associations do not appear to be mediated by either macro- or microvascular disease.

Conclusion

These results suggest that there is a direct association between increased PP and a decline in brain structure and function. This implies that older patients with suboptimal PP control may be at increased risk of developing cognitive impairment and that measuring PP offers mechanistic information above and beyond conventional BP measures.

Acknowledgement/Funding

Wellcome Trust, British Heart Foundation