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Cohen C, Bélanger L, Turcotte M, Pereira F. Stressors and coping strategies in older people hospitalised for hip surgery following a fall: a multiple case study. BMC Nurs 2024; 23:653. [PMID: 39272183 PMCID: PMC11401280 DOI: 10.1186/s12912-024-02316-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 09/02/2024] [Indexed: 09/15/2024] Open
Abstract
BACKGROUND More than half of older persons admitted to an emergency department after a fall have a hip fracture and require surgery for a total hip replacement. This procedure has a high risk of postoperative complications and consequences for older persons, their informal caregivers, and the healthcare system. This study aimed to explore the perceptions of older persons, their informal caregivers and health professionals about intra-personal, inter-personal and extra-personal stressors arising from hip surgery following the fall of an older person hospitalised in orthopaedics, as well as the coping strategies used and the results obtained. METHODS A qualitative multiple case study. The sample consisted of eight cases. Each case consisted of one older person, their informal caregiver and the professionals involved in their care: a nurse, an orthopaedic surgeon and a physiotherapist. A total of 32 participants were recruited. Data were collected between August 2018 and February 2019 in a public hospital in French-speaking Switzerland. Intra- and inter-case analyses were performed. RESULTS Five topics emerged: two concerning stressors for older persons (the physical and psychological consequences of the fall and hospitalisation; the loss of relational and environmental markers and habits); two relating to the coping strategies used to face the stressors (being resilient and involved in their own care; partially meeting the older person's needs); and one regarding the results of the strategies used (reassurance through consideration of some of their needs). CONCLUSIONS Older persons hospitalised for hip surgery after a fall are confronted with various intra-, inter- and extra-personal stressors and have to explore, together with their informal caregivers, strategies to cope with the consequences of these stressors. Healthcare professionals should possess efficient intervention strategies to help identify and support older persons who experience various types of stressors during hospitalisation for hip surgery following a fall.
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Affiliation(s)
- Christine Cohen
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland, Avenue Vinet 30, Lausanne, 1004, Switzerland.
| | - Louise Bélanger
- Département des sciences infirmières, Université du Québec en Outaouais, Saint-Jérôme, QC, Canada
| | - Mathieu Turcotte
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland, Avenue Vinet 30, Lausanne, 1004, Switzerland
| | - Filipa Pereira
- School of Health Sciences, HES-SO Valais/Wallis, University of Applied Sciences and Arts, Western Switzerland, Sion, Switzerland
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Lee S, Kim S, Yi J. Shape phenotype of thigh fat and muscle and risk of major adverse cardiovascular events after fragility hip fracture. J Cachexia Sarcopenia Muscle 2024; 15:331-341. [PMID: 38129313 PMCID: PMC10834328 DOI: 10.1002/jcsm.13407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 10/18/2023] [Accepted: 11/15/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Although sarcopenia has been recognized as a predictor of mortality in elderly patients with hip fracture, the association of thigh fat and muscle with cardiovascular (CV) outcome remains unclear. We examined the impact of computed tomography (CT)-derived shape features of thigh fat and muscle on major adverse CV events (MACE) in elderly patients with hip fracture. METHODS We conducted a retrospective analysis of consecutive patients aged ≥65 years who presented with hip fracture confirmed on pelvic bone CT scan and underwent hip fracture surgery at our institution from April 2019 to December 2021. The cross-sectional area (CSA) and compactness (CM) of both the muscle and fat at the upper-thigh level were calculated from two-dimensional CT images using AVIEW Research (v1.1.38, Coreline Soft, Co. Ltd, Seoul, South Korea). The shape features of thigh fat and muscle were categorized into four groups based on the combination of CSA and CM: fat CSA (fat area [FA])/fat CM (FCM), muscle CSA (muscle area [MA])/muscle CM (MCM), FA/MCM and MA/FCM. In each of them, subjects were categorized into four subgroups: high CSA/high CM, high CSA/low CM, low CSA/high CM and low CSA/low CM. The primary outcome was MACE after 30 days of surgery, defined as a composite of all-cause death, acute myocardial infarction, stroke or hospitalization for heart failure. RESULTS Of 356 patients enrolled (median age, 82 years; 76.7% females), 72 (20.2%) had MACE over a median follow-up of 13.1 months (ranges 5.9-21.0 months). Patients with MACE had a significantly lower median FA (193.7 vs. 226.2 cm2 , P < 0.0001) and FCM (0.443 vs. 0.513, P = 0.001) compared with those without MACE, but no significant differences were found in MA, MCM and FA-MA ratio between the two groups. In a multivariate Cox regression analysis, low FA (<240.1 cm2 ) (adjusted hazard ratio [HR] 2.99, 95% confidence interval [CI] 1.39-6.44, P = 0.005) and low FCM (<0.477) (adjusted HR 2.00, 95% CI 1.10-3.63, P = 0.023) were associated with an increased risk of MACE. Among the shape phenotypes of thigh fat and muscle, the thigh fat phenotype of low FA/low FCM (adjusted HR 3.13, 95% CI 1.81-5.42, P < 0.0001 [reference, high FA/high FCM]) was found to be an independent predictor of MACE. CONCLUSIONS In elderly patients with fragility hip fracture, thigh CT-derived measures of FA and FCM may provide useful prognostic information for predicting adverse CV outcomes.
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Affiliation(s)
- Sheen‐Woo Lee
- Department of RadiologyEunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of KoreaSeoulSouth Korea
| | - Seung‐Chan Kim
- Department of Orthopedic SurgeryEunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of KoreaSeoulSouth Korea
| | - Jeong‐Eun Yi
- Division of Cardiology, Department of Internal MedicineEunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea1021 Tongil‐ro, Eunpyeong‐guSeoul03312South Korea
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Liu Y, Liu H, Zhang F. Development and Internal Validation of a Nomogram for Predicting Postoperative Cardiac Events in Elderly Hip Fracture Patients. Clin Interv Aging 2023; 18:2063-2078. [PMID: 38107187 PMCID: PMC10725632 DOI: 10.2147/cia.s435264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023] Open
Abstract
Purpose Postoperative cardiac events (PCEs) are among the main adverse events after hip fracture surgery in the elderly. Existing cardiac risk assessment tools have some limitations and are not specifically designed for elderly patients undergoing hip fracture surgery. This study aimed to develop and internally validate a nomogram for prediction of PCEs in these patients. Patients and Methods We performed a retrospective study of 992 patients aged ≥65 years undergoing hip fracture surgery in our hospital from July 2015 to December 2021. Patients' demographics and clinical data were collected. Least Absolute Shrinkage and Selection Operator (LASSO) regression was used to select predictors, and multivariate logistic regression was employed to construct a nomogram. Internal validation was performed by bootstrapping. The discriminatory ability of the model was determined by the area under the receiver operating characteristic curve (AUC). The calibration and clinical utility of the model were assessed. The predictive power and clinical benefit of the nomogram were compared with the Revised Cardiac Risk Index (RCRI). Results The nomogram was constructed including seven variables: general anesthesia, the American Society of Anesthesiologists (ASA) classification, history of heart failure, history of severe arrhythmia, history of coronary artery disease, preoperative platelet count, and serum creatinine. The nomogram had an excellent predictive ability (AUC = 0.875, 95% confidence interval [CI]: 0.828-0.918). Satisfactory calibration was shown by calibration plots and the Hosmer-Lemeshow goodness-of-fit test (P = 0.520). Clinical usefulness was confirmed by decision curve analysis and clinical impact curve. The predictive power and clinical utility of the nomogram were superior to RCRI. Conclusion We developed an easy-to-use nomogram for prediction of PCEs in elderly hip fracture patients. This prediction model could effectively identify patients at high risk of PCEs and may be useful for perioperative management optimization.
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Affiliation(s)
- Yuanmei Liu
- Department of Geriatrics, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
| | - Huilin Liu
- Department of Geriatrics, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
| | - Fuchun Zhang
- Department of Geriatrics, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
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Franco H, Wainwright C, Chernilo J, Tan ES, O'Callaghan W. Brain Natriuretic Peptide levels on hospital admission are a useful predictor of cardiac complications and mortality in geriatric patients with proximal femur fractures. J Orthop 2023; 36:82-87. [PMID: 36620093 PMCID: PMC9817089 DOI: 10.1016/j.jor.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/29/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022] Open
Abstract
Purpose Proximal femur fractures in geriatric patients are associated with increased morbidity and mortality. This study investigates Brain Natriuretic Peptide immunoassay levels taken at the time of hospital admission in predicting cardiac complications and mortality in geriatric patients with a proximal femur fracture. Methods A single-site prospective cohort study at a large tertiary care, level 1 trauma centre was conducted on all consecutive geriatric patients aged greater than 60 years who sustained a proximal femur fracture. Investigators collected Brain Natriuretic Peptide levels from venous blood samples on admission to the Emergency Department. The main outcome measurements were inpatient cardiovascular complications, and all-cause mortality at 30-day, 90-day, one-year, and nine-years. Results Over a one-year period, 112 patients were enrolled. The average age was 82.7 years, and the average follow up was 6 years and 6 months (range, 2 days to 9 years). No patients were lost to follow up. There were 44 new or exacerbations of pre-existing cardiac complications requiring management recorded in 30 (26.8%) patients. Mortality at 30 days was 9.8%, 90 days was 16.1%, and one year was 24.1%, with deceased patients having a statistically significant elevated Brain Natriuretic Peptide immunoassay on hospital admission. The Kaplan-Meier graph demonstrated a trend towards increasing Brain Natriuretic Peptide and adverse survivorship risk. The Charlson Comorbidity Index was statistically significant in predicting overall survival probability. Conclusion Brain Natriuretic Peptide immunoassay on hospital admission may be utilised to identify patients at risk of cardiac complications and mortality to guide further investigations, operative planning, the consent process, and post-operative monitoring.
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Affiliation(s)
- Helena Franco
- Cairns Base Hospital, Orthopaedic Department, Cairns, Queensland, Australia
- Bond University, Gold Coast, Queensland, Australia
| | - Chris Wainwright
- Mackay Hospital, Orthopaedic Department, Mackay, Queensland, Australia
| | - Jonathan Chernilo
- Gold Coast University Hospital, Orthopaedic Department, Gold Coast, Queensland, Australia
- Dr Luis Calvo MacKenna Children's Hospital, Orthopaedic Department, Providencia, Chile
| | - Ezekiel S.L. Tan
- Gold Coast University Hospital, Orthopaedic Department, Gold Coast, Queensland, Australia
| | - William O'Callaghan
- Cairns Base Hospital, Orthopaedic Department, Cairns, Queensland, Australia
- Gold Coast University Hospital, Orthopaedic Department, Gold Coast, Queensland, Australia
- The Orthopaedic Research Institute of Queensland (ORIQL), Pimlico, Queensland, Australia
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Pagotto V, Rodrigues de Lima B, Amorim de Souza Feitosa IA, da Cunha Guimarães LC, Ruiz Zimmer Cavalcante AM, da Silva Oliveira MD, Pires Nunes D. Risk factors for pneumonia in hospitalized older people with femoral fractures: Results from a Brazilian prospective cohort. Heart Lung 2022; 54:80-84. [PMID: 35358906 DOI: 10.1016/j.hrtlng.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/10/2022] [Accepted: 03/12/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pneumonia is a common complication in older people who are hospitalized to treat different fractures, which increases morbimortality in this population. OBJECTIVES Estimating the pneumonia incidence density in older people hospitalized to treat femoral fractures and identifying risk factors for this infection. METHODS Prospective cohort study whose data were collected from a population of older people who were being treated for femoral fractures at a hospital in the central region of Brazil between September 2016 and February 2017. The pneumonia diagnosis was based on radiography and clinical tests. Incidence density was estimated according to gender, age, Charlson comorbidity index, polypharmacy, chronic pulmonary disease, admission to the intensive care unit, surgical treatment, and nasoenteral tube feeding. Magnitude of the associations was estimated by multiple Poisson regression. RESULTS Among the 200 patients, the pneumonia incidence density was 13.04/1,000 person-days. For men and older people 80 years old or older, the pneumonia incidence density was 15.6/1,000 person-days and 18.3/1,000 person-days, respectively. After adjusting for age, gender, chronic pulmonary disease, and admission to the intensive care unit, use of nasoenteral tubes remained associated with occurrence of pneumonia in older people, and the risk of developing the infection was eight times higher in the population who received nasoenteral feeding than that calculated for the population that did not use the devices (p ≤ 0.001). CONCLUSION Using nasoenteral tubes during hospital stays increased the risk of developing pneumonia in hospitalized older people, which reinforces the need for continuous care monitoring regarding use of tubes to prevent complications.
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Affiliation(s)
- Valéria Pagotto
- Faculdade de Enfermagem, Programa de Pós-Gradução em Enfermagem, Universidade Federal de Goiás, Rua 227, Quadra 68, Setor Leste Universitário, Goiânia, Goiás 74605-080, Brazil
| | - Brunna Rodrigues de Lima
- Faculdade de Enfermagem, Programa de Pós-Gradução em Enfermagem, Universidade Federal de Goiás, Rua 227, Quadra 68, Setor Leste Universitário, Goiânia, Goiás 74605-080, Brazil
| | - Ione Almeida Amorim de Souza Feitosa
- Faculdade de Enfermagem, Programa de Pós-Gradução em Enfermagem, Universidade Federal de Goiás, Rua 227, Quadra 68, Setor Leste Universitário, Goiânia, Goiás 74605-080, Brazil
| | - Lara Cristina da Cunha Guimarães
- Faculdade de Enfermagem, Programa de Pós-Gradução em Enfermagem, Universidade Federal de Goiás, Rua 227, Quadra 68, Setor Leste Universitário, Goiânia, Goiás 74605-080, Brazil.
| | - Agueda Maria Ruiz Zimmer Cavalcante
- Faculdade de Enfermagem, Programa de Pós-Gradução em Enfermagem, Universidade Federal de Goiás, Rua 227, Quadra 68, Setor Leste Universitário, Goiânia, Goiás 74605-080, Brazil
| | - Michele Dias da Silva Oliveira
- Faculdade de Enfermagem, Programa de Pós-Gradução em Enfermagem, Universidade Federal de Goiás, Rua 227, Quadra 68, Setor Leste Universitário, Goiânia, Goiás 74605-080, Brazil
| | - Daniella Pires Nunes
- Faculdade de Enfermagem da Universidade Estadual de Campinas, Brazil. Pesquisadora do Estudo SABE - Saúde Bem-Estar e Envelhecimento
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Bae SJ, Kwon CH, Kim TY, Chang H, Kim BS, Kim SH, Kim HJ. Predictors and prognostic impact of post-operative atrial fibrillation in patients with hip fracture surgery. World J Clin Cases 2022; 10:3379-3388. [PMID: 35611197 PMCID: PMC9048557 DOI: 10.12998/wjcc.v10.i11.3379] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/18/2021] [Accepted: 02/27/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common arrhythmia developing in post-operative patients. Limited data are available regarding pre-operative risk factors and prognostic impact of post-operative AF (POAF) following hip fracture surgery (HFS) in Korean population.
AIM We aimed to investigate the incidence, predictors, and hospital prognosis of POAF in HFS patients.
METHODS This study included 245 patients without history of AF who underwent HFS between August 2014 and November 2016. POAF was defined as new-onset AF that occurred during hospitalization after HFS.
RESULTS Twenty patients (8.2%) experienced POAF after HFS. POAF developed on median post-operative day 2 (interquartile range, 1–3). Multivariable logistic regression analysis showed that age [odds ratio (OR), 1.111; 95% confidence interval (CI), 1.022–1.209], chronic obstructive pulmonary disease (COPD) (OR, 6.352; 95%CI, 1.561–25.841) and E/e’ ratio (OR, 1.174; 95%CI, 1.002–1.376) were significant predictors of POAF. Patients with POAF had a significantly higher intensive care unit admission rate (55.0% vs 14.7%, P < 0.001) and incidence of congestive heart failure (45.0% vs 10.7%, P < 0.001). In multivariable logistic regression analysis, POAF was significantly associated with increased incidence of congestive heart failure (OR, 4.856; 95%CI, 1.437–16.411) and intensive care unit admission (OR, 6.615; 95%CI, 2.112–20.718).
CONCLUSION POAF was frequently developed in elderly patients following HFS. Age, COPD and elevated E/e’ ratio were found as significant predictors of POAF in HFS patients. Patients with POAF significantly experienced intensive care unit admission and incident congestive heart failure during hospitalization.
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Affiliation(s)
- Seong Jun Bae
- Department of Internal Medicine, Konkuk University Medical Center, Seoul 05030, South Korea
| | - Chang Hee Kwon
- Department of Internal Medicine, Konkuk University Medical Center, Seoul 05030, South Korea
| | - Tae-Young Kim
- Department of Orthopaedic Surgery, Konkuk University Medical Center, Seoul 05030, South Korea
| | - Haseong Chang
- Department of Internal Medicine, Konkuk University Medical Center, Seoul 05030, South Korea
| | - Bum Sung Kim
- Department of Internal Medicine, Konkuk University Medical Center, Seoul 05030, South Korea
| | - Sung Hea Kim
- Department of Internal Medicine, Konkuk University Medical Center, Seoul 05030, South Korea
| | - Hyun-Joong Kim
- Department of Internal Medicine, Konkuk University Medical Center, Seoul 05030, South Korea
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Zhang X, Shen ZL, Duan XZ, Zhou QR, Fan JF, Shen J, Ji F, Tong DK. Postoperative Pneumonia in Geriatric Patients With a Hip Fracture: Incidence, Risk Factors and a Predictive Nomogram. Geriatr Orthop Surg Rehabil 2022; 13:21514593221083824. [PMID: 35340623 PMCID: PMC8949772 DOI: 10.1177/21514593221083824] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/03/2022] [Accepted: 02/08/2022] [Indexed: 11/20/2022] Open
Abstract
Objectives To evaluate the incidence and risk factors of postoperative pneumonia (POP) in geriatric patients with a hip fracture after surgery, to design a predictive nomogram, and to validate the accuracy of the nomogram. Design Retrospective study. Setting A tertiary hospital affiliated to a medical university. Patients/Participants We retrospectively studied 1285 surgical-treated geriatric patients with a hip fracture from April 2010 to April 2018. Intervention Surgical treatment was performed on the patients of this study. The procedure methods were classified as: total hip arthroplasty, hemiarthroplasty, percutaneous fixation, intramedullary nail fixation, and plate/screw fixation. Main Outcome Measurement The primary interest of end point of this study is the development of POP during the postoperative period. The postoperative period in this study was defined as the time from 24 hours after surgery to discharge. The diagnostic criteria for pneumonia were set according to the guidelines built by the Infectious Diseases Society of America and the American Thoracic Society (Guidelines for the Management of Adults with Hospital-Acquired, Ventilator-Associated, and Healthcare-Associated Pneumonia, 2005). Potential variables for developing POP were identified using logistic regression analyses initially and were further selected via the method of LASSO. Then the independent risk factors were identified by multivariable regression analyses. A predictive nomogram was built based on the multiple regression model, and the calibration abilities of the nomogram was measured by Harrel C-index, calibration plot and Hosmer–Lemeshow test, respectively. Decision curve analysis was carried out to assess the net benefit due to threshold probability and an on-line questionnaire survey was conducted among the clinicians to assess the applicability of the nomogram coherently. Results Of the 1285 patients, 70 (5.4%) developed POP. COPD, number of comorbidities, ASA classification >2, preoperative dependent functional status and cognitive impairment were identified as independent risk factors of POP. The nomogram built based on the results showed good accordance between the predicted probabilities and the observed frequency. The decision curve analysis confirmed the clinical utility of the nomogram when the threshold probabilities were between 5% and 65% due to the net benefit, while the results of on-line questionnaire among 200 clinicians showed that 91.5% of the participants had a mental threshold of intervention between 5-50%. Conclusion (1). COPD, number of comorbidities, ASA classification >2, preoperative dependent functional status and cognitive impairment are independent risk factors for POP. (2). The nomogram built in this study has a good accordance between the predictive risk and the observational incidence. The results of decision curve and questionnaire among clinicians show well applicability of the nomogram.
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Affiliation(s)
- Xin Zhang
- Department of Anesthesiology and Perioperative Medicine, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | | | - Xu-Zhou Duan
- Department of Orthopedics, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qi-Rong Zhou
- Department of Orthopedics, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jie-Fu Fan
- Naval Medical University, Shanghai, China
| | - Jie Shen
- Naval Medical University, Shanghai, China
| | - Fang Ji
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Da-Ke Tong
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Jiang Y, Luo Y, Li J, Jiang Y, Zhao J, Gu S, Li P, Zhang L, Yin P, Lyu H, Tang P. Chronic kidney disease and risk of postoperative cardiovascular events in elderly patients receiving hip fracture surgery. Injury 2022; 53:596-602. [PMID: 34974909 DOI: 10.1016/j.injury.2021.12.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/17/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The long-term risk of cardiovascular events caused by chronic kidney disease (CKD) is well described in the general population. Less is known concerning the risk of postoperative cardiovascular events in geriatric hip fracture patients with CKD. METHODS This study involved patients at least 65 years of age who received surgery for acute hip fracture between January 2000 and April 2016. We identified CKD patients with a baseline diagnosis of CKD or an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 at admission. Each CKD patient was matched, for age, gender, fracture type, and year of admission, with 4 control non-CKD patients. The primary endpoint was a compositepostoperative cardiovascular events, including pulmonary embolism, angina pectoris, myocardial infarction, heart failure, arrhythmia, stroke, and death. Conditional logistic regression was used to evaluate the association between CKD and the outcome after adjusting for potential confounders including age, gender, fracture type, body mass index, preexisting comorbidities, history of cardiovascular events, and the Charlson Comorbidity Index (CCI). RESULTS Three hundred and seventy-five CKD patients were matched with 1,438 non-CKD patients. The mean age of the CKD patients was 81.9 ± 7.0 (mean ± SD), 69.9% were females, and 59.2% had an intertrochanteric fracture. Compared to non-CKD patients, CKD patients had a higher proportion of preexisting comorbidities, including hypertension, coronary heart disease, heart failure, and type 2 diabetes (all p < 0.05). The risk of postoperative cardiovascular events was 125.3 per 1000 persons (95%CI, 91.8-158.8) in CKD patients and 64.7 per 1000 persons (95%CI, 52.0-77.4) in non-CKD patients. A 1.96-fold risk of cardiovascular events after hip fracture surgery was found in CKD patients than those without CKD (adjusted OR, 1.96; 95%CI, 1.23-3.12). CONCLUSION Patients with CKD were more likely to have cardiovascular events after hip fracture surgery than those without CKD. Appropriate preoperative cardiovascular risk assessment and corresponding preventive and therapeutic measures should be given to this vulnerable population to mitigate such complications.
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Affiliation(s)
- Yu Jiang
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China, 100853; Medical School of Chinese PLA, Beijing, China, 100853
| | - Yan Luo
- National Clinical Research Centre for Orthopaedics, Sports Medicine and Rehabilitation, Beijing, China, 100853
| | - Jia Li
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China, 100853
| | - Yuheng Jiang
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China, 100853
| | - Jingxin Zhao
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China, 100853
| | - Siqi Gu
- Medical School of Chinese PLA, Beijing, China, 100853
| | - Ping Li
- Department of Nephrology, State Key Laboratory of Kidney Disease, National Clinical Research Centre for Kidney Disease, Chinese PLA General Hospital, Beijing, China, 100853
| | - Licheng Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China, 100853
| | - Pengbin Yin
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China, 100853.
| | - Houchen Lyu
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China, 100853.
| | - Peifu Tang
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China, 100853
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Wahlsten LR, Zareini B, Smedegaard L, Gislason GH, Palm H, Brorson S. A medical history of arterial thrombosis is a strong predictor of post-operative myocardial infarction and stroke in patients with hip fractures-a nationwide cohort study. Age Ageing 2021; 50:1252-1260. [PMID: 33507243 DOI: 10.1093/ageing/afaa279] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Hip fractures lead to a substantial burden of disease and mortality among the elderly. Myocardial infarction (MI) and stroke are serious and overlooked complications, and their impact on mortality and morbidity may be underestimated. We investigated; 90-day absolute risk of stroke and MI following hip fracture surgery, and ii) anamnestic risk factors associated with elevated risk of postoperative MI and stroke. METHODS All Danish patients aged ≥60 undergoing first time hip fracture surgery in 2000-2017 were identified. Outcomes were MI or stroke 90 days after surgery. We performed gender-stratified cumulative incidence functions and multivariate Cox regression models adjusted for age and comorbidities. RESULTS 124,660 patients were included. Incidence of MI was 2.2% and 1.3%, and incidence of stroke was 3.5% and 2.5%, in men and women, respectively. The most important risk factor for MI and stroke was a previous event. Hazard ratio (HR) of MI associated with previous MI was 2.43 (95% Confidence Interval (CI) 2.02-2.92) in men and 2.65 (95% CI 2.23-3.16) in women, while the HR of stroke associated with previous stroke was 4.17 (95% CI 3.73-4.67) and 3.73 (95% CI 3.43-4.08), respectively. Other risk factors of MI were; sex, age, and a history of heart failure, hypertension, peripheral artery disease or diabetes. For postoperative stroke; sex age, and atrial fibrillation were important risk factors. CONCLUSION MI and stroke after hip fractures are overlooked and serious complications. Persons with elevated risk can be identified at admission, based on their medical history.
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Affiliation(s)
- Liv Riisager Wahlsten
- Department of Orthopaedics, Copenhagen University Hospital Herlev-Gentofte, Hellerup 2900, Denmark
| | - Bochra Zareini
- Department of Cardiology, Research 1, Copenhagen University Hospital Herlev-Gentofte, Hellerup 2900, Denmark
| | - Lærke Smedegaard
- Department of Cardiology, Research 1, Copenhagen University Hospital Herlev-Gentofte, Hellerup 2900, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Research 1, Copenhagen University Hospital Herlev-Gentofte, Hellerup 2900, Denmark
| | - Henrik Palm
- Department of Orthopaedics, Copenhagen University Hospital Bispebjerg, Copenhagen 2400, Denmark
| | - Stig Brorson
- Department of Orthopaedic Surgery, Zealand University Hospital, Køge 4600, Denmark
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Comparison of long-term outcomes after trans-catheter aortic valve implantation between patients primarily diagnosed by cardiac murmur and those diagnosed by other reasons. PLoS One 2021; 16:e0247588. [PMID: 33606827 PMCID: PMC7895360 DOI: 10.1371/journal.pone.0247588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/09/2021] [Indexed: 11/25/2022] Open
Abstract
Careful auscultation is the first step to diagnose aortic stenosis (AS). The aim of this study was to compare clinical outcomes following transcatheter aortic valve implantation (TAVI) between the patients primarily diagnosed by heart murmur and those diagnosed by other reasons. We retrospectively included 258 patients who underwent TAVI in our medical center, and divided those into the murmur group (n = 81) and the other-reason group (n = 177) according to the primary reason for AS diagnosis. The primary endpoint was the major adverse cardiovascular and cerebrovascular events (MACCE), which was defined as the composite of cardiovascular death, hospitalization due to acute decompensated heart failure, and disabling stroke. The murmur group included younger patients than the other-reason group (82.8 year-old vs. 84.0 year-old, P = 0.02). History of AF was more frequently observed in the other-reason group than in the murmur group (21.5% vs. 7.4%, P <0.01). STS score and logistic EuroSCORE were lower in the murmur group than in the other-reason group (STS: 4.7% vs. 7.2%, P <0.01, logistic EuroSCORE: 8.3% vs. 11.2%, P <0.01). The median follow-up period was 562 days. MACCE was more frequently observed in the other-reason group than in the murmur group (27.7% vs. 9.9%, Log Rank P <0.01). The multivariate COX hazard analysis revealed that the AS patients primarily diagnosed by heart murmur was inversely associated with MACCE (HR 0.38, 95%CI 0.17–0.86, P = 0.020). Among AS patients who underwent TAVI, the patients primarily diagnosed by heart murmur were significantly associated with favorable long-term clinical outcomes.
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11
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Briguglio M, Lombardi G, Sansoni V, Perego S, De Gennaro Colonna V, Stella D, Colombo C, Bonadies M, De Blasio G, Banfi G, Turiel M. Vitamin D, cardio-inflammation, and endothelial dysfunction in older adults after orthopedic surgery: Results from an open-label trial to ameliorate cardiac function. NUTR CLIN METAB 2020. [DOI: 10.1016/j.nupar.2020.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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12
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Li Z, Wei M, Lyu H, Huo K, Wang L, Zhang M, Su H. Fracture shortly before stroke in mice leads to hippocampus inflammation and long-lasting memory dysfunction. J Cereb Blood Flow Metab 2020; 40:446-455. [PMID: 30667320 PMCID: PMC7370615 DOI: 10.1177/0271678x19825785] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cognitive impairment occurs in stroke and hip fracture patients. In mice, bone fracture (BF) exacerbates stroke-related neuronal damage and sensorimotor dysfunction. We hypothesize that BF exacerbates post-stroke cognitive impairment. Adult mice were randomly assigned into BF, stroke, BF+stroke (BF 6 h before stroke), and control (sham operated) groups. Memory function was evaluated weekly for eight weeks by Y maze test and at eight weeks post-surgeries by novel object recognition (NOR) test. The neuronal damage and inflammation in hippocampus were analyzed three days and eight weeks after the surgeries. In Y maze test, BF+stroke mice started making fewer alternations than controls two weeks after the surgeries. Significant difference between BF+stroke and stroke groups started at five weeks post-injury and continued to the end of the experiment. In NOR test, BF+stroke group spent less time on novel objective than that of other groups. Cx3cr1+ cells and CD68+ cells accumulated in the stratum lacunosum moleculare (SLM) on the ipsilateral side of stroke injury in stroke and BF+stroke mice. BF+stroke mice had a higher ratio of ipsilateral/contralateral Cx3cr1+ cell-density than that of stroke mice. Therefore, BF shortly before stroke exacerbates hippocampal inflammation and causes long-lasting memory dysfunction.
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Affiliation(s)
- Zhengxi Li
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Meng Wei
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Haiyan Lyu
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Kang Huo
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Liang Wang
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Meng Zhang
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Hua Su
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
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Smeets SJM, van Wunnik BPW, Poeze M, Slooter GD, Verbruggen JPAM. Cardiac overscreening hip fracture patients. Arch Orthop Trauma Surg 2020; 140:33-41. [PMID: 31471640 PMCID: PMC6942037 DOI: 10.1007/s00402-019-03270-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND The aim of this study was to prospectively investigate the adherence to the American College of Cardiology (ACC) and the American Heart Association guidelines for perioperative assessment of patients with hip fracture in daily clinical practice and how this might affect outcome. METHODS This prospective cohort study from Maastricht University Medical Centre included 166 hip fracture patients within a 3-year inclusion period. The preoperative cardiac screening and adherence to the ACC/AHA guideline were analyzed. Cardiac risk was classified as low, intermediate and high risk. Secondary outcome measurements were delay to surgery, perioperative complications and in-hospital, 30-day, 1-year and 2-year mortality. RESULTS According to the ACC/AHA guideline, 87% of patients received correct preoperative cardiac screening. The most important reason for incorrect preoperative cardiac screening was overscreening (> 90%). Multivariate analysis showed that a cardiac consultation (p = 0.003) and overscreening (p = 0.02) as significant predictors for increased delay to surgery, while age, sex, previous cardiac history and preoperative mobility were not. High risk patients had in comparison with low risk patients a significantly higher relative risk ratio for in-hospital mortality (RR 6, 95% CI 2-17). Multivariate analysis showed that a previous cardiac history and increased delay to surgery were predictors for early mortality. High age and previous cardiac history were risk factors for late mortality. CONCLUSION Preoperative cardiac screening for hip fracture patients in adherence to the ACC/AHA guideline is associated with a diminished use of preoperative resources. Overscreening leads to greater delay to surgery, which poses a risk for perioperative complications and early mortality. LEVEL OF EVIDENCE II.
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Affiliation(s)
- S. J. M. Smeets
- Department of Surgery, Flevoziekenhuis, Hospitaalweg 1, 1315 RA Almere, The Netherlands
| | - B. P. W. van Wunnik
- Department of Surgery, Beatrixziekenhuis, Banneweg 57, 4204 AA Gorinchem, The Netherlands
| | - M. Poeze
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - G. D. Slooter
- Department of Surgery, Máxima Medical Center, De Run 4600, 5504 DB Veldhoven, The Netherlands
| | - J. P. A. M. Verbruggen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
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Gallardo P, Clavel O. FRACTURA DE CADERA Y GERIATRÍA, UNA UNIÓN NECESARIA. REVISTA MÉDICA CLÍNICA LAS CONDES 2020. [DOI: 10.1016/j.rmclc.2019.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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15
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Gundel O, Thygesen LC, Gögenur I, Ekeloef S. Postoperative mortality after a hip fracture over a 15-year period in Denmark: a national register study. Acta Orthop 2019; 91:58-62. [PMID: 31635502 PMCID: PMC7006693 DOI: 10.1080/17453674.2019.1680485] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - In Denmark, 44 per 10,000 persons over the age of 50 years suffered a hip fracture (HF) in 2011. We characterized the patients and identified risk factors associated with 30-day, 90-day, and 1-year postoperative mortality in Denmark from 2000 to 2014.Patients and methods - The study builds upon data from the Danish National Patients Register and the National Causes of Death Register including all acute hospitalized HF patients aged 18 years and above. Outcomes were 30-day, 90-day, and 1-year postoperative mortality. Mortality risk was analyzed with a univariable and multivariable Cox regression including predefined variables.Results - 113,721 acute hospitalized HF patients were admitted to Danish hospitals between 2000 and 2014. The 30-day mortality risk was 9.6%, 16% at 90 days, and 27% at 1 year after HF surgery. Mortality risk was similar from 2000 to 2014 while the median lengths of stay declined from 14 (IQR 8-25) to 8 (IQR 5-11) days. Male sex, increasing age, higher Charlson Comorbidity Index, per- and subtrochanteric fracture, and operation type other than total hip arthroplasty were independently associated with postoperative mortality.Interpretation - Short- and long-term mortality was high after hip fracture surgery and did not decline in Denmark from 2000 to 2014.
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Affiliation(s)
- Ossian Gundel
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Koege, Denmark; ,Correspondence: OG:
| | - Lau Caspar Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen K, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Koege, Denmark;
| | - Sarah Ekeloef
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Koege, Denmark;
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Cha YH, Lee YK, Koo KH, Wi C, Lee KH. Difference in Mortality Rate by Type of Anticoagulant in Elderly Patients with Cardiovascular Disease after Hip Fractures. Clin Orthop Surg 2019; 11:15-20. [PMID: 30838103 PMCID: PMC6389530 DOI: 10.4055/cios.2019.11.1.15] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 10/16/2018] [Indexed: 12/26/2022] Open
Abstract
Background The purpose of this study was to investigate the difference in mortalilty rate between cardiovascular disease (CVD) patients and non-CVD patients after hip fracture surgery performed in elderly patients. In addition, we compared the effect of CVD medication on mortality after hip fracture surgery. Methods Patients who underwent surgery for femoral intertrochanteric or neck fracture from January 2003 to December 2013 were enrolled in this study. After applying exclusion criteria, we categorized patients into group I (833 patients, non-CVD group) and group II (811 patients, CVD group). The CVD group was subcategorized as group IIa (332 patients, no medication), group IIb (381 patients, antiplatelet agents), and group IIc (98 patients, anticoagulation agents). Cumulative mortality rate at 30 days, 60 days, 3 months, and 1 year were compared between the groups. Results In the 1,644 patients, the cumulative mortality rate at 30 days, 60 days, 3 months, and 1 year was 0.1%, 0.5%, 0.7%, and 8.2%, respectively, in group I and 1.0%, 1.6%, 2.5%, and 8.8%, respectively, in group II (p = 0.02, p = 0.03. p = 0.01, and p = 0.72, respectively). In the 811 group II patients, the cumulative mortality rate at 30 days, 60 days, 3 months, and 1 year was 0.3%, 0.6%, 1.2%, and 6.6%, respectively, in group IIa; 0.8%, 1.6%, 2.1%, and 9.4%, respectively, in group IIb; and 4.1%, 5.1%, 8.2%, and 13.3%, respectively, in group IIc (p = 0.003, p = 0.01, p = 0.004, and p = 0.10, respectively). Conclusions CVD increases short-term mortality within 30 days, 60 days, and 3 months in elderly hip fracture patients. The use of anticoagulants in CVD patients increases the rate of surgical delay and short-term mortality within 30 days, 60 days, and 3 months.
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Affiliation(s)
- Yong-Han Cha
- Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Young-Kyun Lee
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyung-Hoi Koo
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Chankuk Wi
- Department of Orthopedic Surgery, National Medical Center, Seoul, Korea
| | - Kyung-Hag Lee
- Department of Orthopedic Surgery, National Medical Center, Seoul, Korea
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Abstract
INTRODUCTION The National Surgical Quality Improvement Project (NSQIP) and the Trauma Quality Improvement Project (TQIP) collect data on geriatric hip fractures (GHFs) that could be used to generate risk-adjusted metrics for care of these patients. We examined differences between GHFs reported by our own trauma center to the NSQIP and TQIP and those vetted through an internal GHF list. METHODS We reviewed charts of GHFs treated between January 1 and December 31, 2015, and compared patients in an internal GHF database and/or reported to the NSQIP and/or TQIP and determined differences between databases. RESULTS We identified 89 "true" GHFs, of which 96% were identified by our institutional database, 70% by NSQIP, and 9% by the TQIP. No differences were found in outcomes and total costs. The net revenue/patient in the NSQIP database was $24,373 more than those in the institutional database. CONCLUSION Caution should be taken when using NSQIP/TQIP databases to evaluate the care of GHFs. LEVEL OF EVIDENCE Level III.
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Abstract
A high proportion of patients with fragility fracture, mainly hip fracture, have a variable degree of comorbidity and show some degree of dependence in basic or more complex activities of daily living. Evaluating these patents following the geriatric concept of frailty, about one third of hip fracture patients may be categorised as frail with high risk of poor outcomes and prolonged length of stay, one third as not frail, and about one third with an intermediate condition. Due to the high vulnerability, combined with the hip fracture event and surgical repair procedures, a multidisciplinary approach that includes geriatric competencies becomes essential to improve short and long-term outcomes after hip fracture. A key element of an effective process of care is a true co-managed approach that applies quality standards and provides a fast-track pathway of care, minimises the time the patient spends in bed, and reduces postoperative complications by means of standardised procedures. The occurrence of a fragility fracture is the strongest risk factor for a subsequent fracture. Moreover, frail subjects have a further risk of fracture due to high risk of falls - related to loss of muscle mass, multiple illnesses, impaired balance and weakness. Thus, effective secondary prevention strategies are essential to reduce morbidity and mortality after hip fracture, and they are currently a standard task of orthogeriatric care. Fracture liaison services (FLS) are probably the most efficient way of addressing secondary prevention including the assessment of both bone health and falls risk. Therefore, the optimal management of frail patients with fragility fracture includes both orthogeriatric care and FLS, which are complementary to each other. Orthogeriatric collaboration is also powerful in influencing healthcare policy. British experience as well as that in Ireland, Australia and New Zealand, have shown that when two widely disparate specialisms say the same thing, they may achieve a fundamental shift in attitudes and behaviour of both managers and clinicians. Furthermore, a continuous real-time audit, at national level, is a powerful driver for change and better standards of care.
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Hickson LJ, Farah WH, Johnson RL, Thorsteinsdottir B, Ubl DS, Yuan BJ, Albright R, Rule AD, Habermann EB. Death and Postoperative Complications After Hip Fracture Repair: Dialysis Effect. Kidney Int Rep 2018; 3:1294-1303. [PMID: 30450456 PMCID: PMC6224855 DOI: 10.1016/j.ekir.2018.07.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 06/29/2018] [Accepted: 07/02/2018] [Indexed: 12/16/2022] Open
Abstract
Introduction It is unknown whether patients receiving dialysis have a higher morbidity and mortality risk after hip fracture repair conferred by their kidney failure or by the high comorbidity burden often present. Methods We examined associations of dialysis dependency with postoperative complications, death, and readmission in a matched cohort study of U.S. patients undergoing hip fracture repair, from January 2010 to December 2013, in the American College of Surgeons National Surgical Quality Improvement Program. Matching included sex, age, race, diabetes mellitus, operation year, primary surgery type, and anesthesia technique. Results Among 22,621 patients, 377 dialysis-dependent patients were matched to 1508 nondialysis patients. Median age was 78 years (interquartile range = 68−85) years, 56% were men, 70% were white, 43% had diabetes, and 47% underwent fracture fixation under mostly (80%) general anesthesia. Dialysis-dependent patients had higher physical status classification, had more heart failure and hypoalbuminemia, and were less often smokers. After adjustment, a greater risk of prolonged postoperative stays beyond 7 days (odds ratio [OR] = 1.43, 95% confidence interval [CI] = 1.09−1.89), higher in-hospital mortality (OR = 3.13, CI = 1.72−5.7), and 30-day death (OR = 2.29, CI = 1.51−3.48) but not 30-day readmission (P = 0.09) was observed with dialysis dependency. Adjusted analyses in the original cohort (n = 22,621) were similar: the dialysis group had greater risk of prolonged postoperative stay (OR = 1.77, CI = 1.42−2.21), in-hospital mortality (OR = 2.65, CI = 1.74−4.05), and 30-day death (OR = 2.03, CI = 1.48−2.80) and 30-day readmission (OR = 1.62, CI = 1.66−2.26). Conclusion Dialysis dependency is associated with an increased risk of death and postoperative complications after hip fracture repair. These findings have implications for case-mix adjustment and quality metrics.
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Affiliation(s)
- LaTonya J Hickson
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Geriatric Medicine and Gerontology, Mayo Clinic, Rochester, Minnesota, USA
| | - Wigdan H Farah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.,Evidence-based Practice Research Program, Knowledge Synthesis Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Rebecca L Johnson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Bjorg Thorsteinsdottir
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel S Ubl
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Brandon J Yuan
- Department of Orthopedic Trauma Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert Albright
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA
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Wei M, Lyu H, Huo K, Su H. Impact of Bone Fracture on Ischemic Stroke Recovery. Int J Mol Sci 2018; 19:ijms19051533. [PMID: 29786644 PMCID: PMC5983742 DOI: 10.3390/ijms19051533] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/17/2018] [Accepted: 05/18/2018] [Indexed: 01/21/2023] Open
Abstract
Stroke is one of the most devastating complications of bone fracture, occurring in up to 4% of patients after surgical repair for hip fracture. Bone fracture and ischemic stroke have many common risk factors. The impact of bone fracture on stroke recovery has not drawn much attention in the research field. Bone fracture could occur in stroke patients at different times during the recovery phase, which steepens the trajectory of cognitive decline, greatly affects the quality of life, and causes a heavy burden on healthcare resources. In this paper, we reviewed the growing information on the pathophysiological mechanisms by which bone fracture may affect ischemic stroke recovery process.
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Affiliation(s)
- Meng Wei
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA 94110, USA.
| | - Haiyian Lyu
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA 94110, USA.
| | - Kang Huo
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA 94110, USA.
| | - Hua Su
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA 94110, USA.
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Incidence, Risk Factors, and Clinical Implications of Pneumonia After Surgery for Geriatric Hip Fracture. J Arthroplasty 2018; 33:1552-1556.e1. [PMID: 29289445 DOI: 10.1016/j.arth.2017.11.068] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 11/25/2017] [Accepted: 11/29/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Little is known regarding the occurrence of pneumonia after hip fracture surgery. The purpose of this study is to determine the incidence, risk factors, and clinical implications of pneumonia after surgery for geriatric hip fracture. METHODS The American College of Surgeons National Surgical Quality Improvement Program was used to retrospectively study geriatric patients undergoing surgery for hip fracture during 2006-2014. Independent risk factors for developing pneumonia within 30 days of surgery were identified using multivariate regression. RESULTS Of the 29,377 patients meeting inclusion criteria, 13,736 (46.8%) underwent hemiarthroplasty, 9468 (32.2%) intramedullary fixation, 4294 (14.6%) plate and/or screw fixation, 1299 (4.4%) total joint arthroplasty, and 580 (2.0%) percutaneous fixation. In total 1191 patients developed pneumonia, an incidence of 4.1%. The strongest risk factors for pneumonia were male sex, older age (especially ≥90 years), low body mass index, and chronic obstructive pulmonary disease. Patients who developed pneumonia had a higher readmission rate (79.1% vs 8.2%, P < .001), a higher rate of sepsis (16.6% vs 1.7%, P < .001), and a higher mortality rate (29.2% vs 5.7%, P < .001). Among 1602 total mortalities, 348 (17.9%) occurred in patients with pneumonia. CONCLUSION Pneumonia is a serious complication after geriatric hip fracture surgery, which increases the readmission and mortality risks. Evidence-based pneumonia prevention programs should be implemented among high-risk patients-males, patients ≥90 years, body mass index <18.5 kg/m2, and/or patients with chronic obstructive pulmonary disease-to decrease morbidity and mortality.
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22
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Basques BA, McLynn RP, Lukasiewicz AM, Samuel AM, Bohl DD, Grauer JN. Missing data may lead to changes in hip fracture database studies: a study of the American College of Surgeons National Surgical Quality Improvement Program. Bone Joint J 2018; 100-B:226-232. [PMID: 29437066 DOI: 10.1302/0301-620x.100b2.bjj-2017-0791.r1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIMS The aims of this study were to characterize the frequency of missing data in the National Surgical Quality Improvement Program (NSQIP) database and to determine how missing data can influence the results of studies dealing with elderly patients with a fracture of the hip. PATIENTS AND METHODS Patients who underwent surgery for a fracture of the hip between 2005 and 2013 were identified from the NSQIP database and the percentage of missing data was noted for demographics, comorbidities and laboratory values. These variables were tested for association with 'any adverse event' using multivariate regressions based on common ways of handling missing data. RESULTS A total of 26 066 patients were identified. The rate of missing data was up to 77.9% for many variables. Multivariate regressions comparing three methods of handling missing data found different risk factors for postoperative adverse events. Only seven of 35 identified risk factors (20%) were common to all three analyses. CONCLUSION Missing data is an important issue in national database studies that researchers must consider when evaluating such investigations. Cite this article: Bone Joint J 2018;100-B:226-32.
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Affiliation(s)
- B A Basques
- Yale School of Medicine, 47 College Street, 2nd Floor, New Haven, Connecticut 06510, USA
| | - R P McLynn
- Yale School of Medicine, 47 College Street, 2nd Floor, New Haven, Connecticut 06510, USA
| | | | - A M Samuel
- Hospital for Special Surgery, 535 East 70th Street, New York, New York 10021, USA
| | - D D Bohl
- Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, Illinois 60612, USA
| | - J N Grauer
- Yale School of Medicine, 47 College Street, 2nd Floor, New Haven, Connecticut 06510, USA
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23
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Akinleye SD, Garofolo G, Culbertson MD, Homel P, Erez O. The Role of BMI in Hip Fracture Surgery. Geriatr Orthop Surg Rehabil 2018; 9:2151458517747414. [PMID: 29468090 PMCID: PMC5813852 DOI: 10.1177/2151458517747414] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 09/16/2017] [Accepted: 10/26/2017] [Indexed: 12/11/2022] Open
Abstract
Introduction: Obesity is an oft-cited cause of surgical morbidity and many institutions require extensive supplementary screening for obese patients prior to surgical intervention. However, in the elderly patients, obesity has been described as a protective factor. This article set out to examine the effect of body mass index (BMI) on outcomes and morbidity after hip fracture surgery. Methods: The National Surgical Quality Improvement Program database was queried for all patients undergoing 1 of 4 surgical procedures to manage hip fracture between 2008 and 2012. Patient demographics, BMI, and known factors that lead to poor surgical outcomes were included as putative predictors for complications that included infectious, cardiac, pulmonary, renal, and neurovascular events. Using χ2 tests, 30-day postoperative complication rates were compared between 4 patient groups stratified by BMI as low weight (BMI < 20), normal (BMI = 20-30), obese (BMI = 30-40), and morbidly obese (BMI > 40). Results: A total of 15 108 patients underwent surgery for hip fracture over the examined 5-year period. Of these, 18% were low weight (BMI < 20), 67% were normal weight (BMI = 20-30), 13% were obese (BMI = 30-40), and 2% were morbidly obese (BMI > 40). The low-weight and morbidly obese patients had both the highest mortality rates and the lowest superficial infection rates. There was a significant increase in blood transfusion rates that decreased linearly with increasing BMI. Deep surgical site infection and renal failure increased linearly with increasing BMI, however, these outcomes were confounded by comorbidities. Conclusion: This study demonstrates that patients at either extreme of the BMI spectrum, rather than solely the obese, are at greatest risk of major adverse events following hip fracture surgery. This runs contrary to the notion that obese hip fracture patients automatically require additional preoperative screening and perioperative services, as currently implemented in many institutions.
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Affiliation(s)
| | - Garret Garofolo
- Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | | | - Peter Homel
- Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Orry Erez
- Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
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Liu FL, Lin CS, Yeh CC, Shih CC, Cherng YG, Wu CH, Chen TL, Liao CC. Risk and outcomes of fracture in peripheral arterial disease patients: two nationwide cohort studies. Osteoporos Int 2017; 28:3123-3133. [PMID: 28821915 DOI: 10.1007/s00198-017-4192-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 08/07/2017] [Indexed: 12/19/2022]
Abstract
UNLABELLED Using national insurance claims data of Taiwan, we found that patients with peripheral arterial disease (PAD) had increased risk of fracture during the follow-up period of 2000-2013. History of PAD was also associated with adverse outcomes in hospitalized fracture patients. Prevention strategies were needed in this susceptible population. INTRODUCTION Limited information was available on the association between PAD and fracture. The purpose of this study is to evaluate fracture risk and post-fracture outcomes in patients with PAD. METHODS We identified 6647 adults aged ≥ 20 years with newly diagnosed PAD using the Taiwan National Health Insurance Research Database in 2000-2004. Comparison cohort consisted of 26,588 adults without PAD randomly selected with frequency matching in age and sex. Events of fracture were identified during the follow-up period from January 1, 2000 until December 31, 2013, to evaluate adjusted hazard ratios (HR) and 95% confidence interval (CI) of fracture associated with PAD. Another nested cohort study of 799,463 hospitalized fracture patients analyzed adjusted odds ratios (ORs) and 95% CIs of adverse events after fracture among patients with and without PAD in 2004-2013. RESULTS Incidences of fracture in people with and without PAD were 22.1 and 15.5 per 1000 person-years, respectively (P < .0001). Compared with control, the adjusted HR of fracture was 1.59 (95% CI, 1.48-1.69) for PAD patients. In the nested cohort study, patients with PAD had higher post-fracture mortality (OR = 1.16; 95% CI, 1.09-1.25) and various complications. PAD patients also had comparatively higher medical expenditure (2691 vs. 2232 USD, P < .0001) and longer hospital stay (10.6 vs. 9.0 days, P < 0.0001) during fracture admission. CONCLUSIONS Increased risk of fracture and post-fracture adverse outcomes were associated with PAD. This susceptible population needs care to prevent fracture and to minimize adverse outcomes after it occurs.
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Affiliation(s)
- F-L Liu
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - C-S Lin
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Medical University Hospital, 252 Wuxing St., Taipei, 110, Taiwan
- Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - C-C Yeh
- Department of Surgery, China Medical University Hospital, China Medical University, Taichung, Taiwan
- Department of Surgery, University of Illinois, Chicago, IL, USA
| | - C-C Shih
- School of Chinese Medicine for Post-Baccalaureate, I-Shou University, Kaohsiung, Taiwan
| | - Y-G Cherng
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - C-H Wu
- Department of Family Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - T-L Chen
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Medical University Hospital, 252 Wuxing St., Taipei, 110, Taiwan
- Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - C-C Liao
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
- Department of Anesthesiology, Taipei Medical University Hospital, 252 Wuxing St., Taipei, 110, Taiwan.
- Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan.
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan.
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Zhang J, Wang J, Wang X, Liu Z, Ren J, Sun T. Early surgery increases mitochondrial DNA release and lung injury in a model of elderly hip fracture and chronic obstructive pulmonary disease. Exp Ther Med 2017; 14:4541-4546. [PMID: 29067126 DOI: 10.3892/etm.2017.5044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 07/11/2017] [Indexed: 12/16/2022] Open
Abstract
Hip fractures are one of the most common injuries in elderly individuals and are associated with a high incidence of complications and mortality. Clinical guidelines recommend early reparative surgery within 24-48 h from hospital admission; however, it is currently unknown whether this principle of early surgery is applicable for patients with hip fracture and chronic obstructive pulmonary disease (COPD). To investigate the systemic inflammatory response and lung injury as a result early surgery in elderly patients with hip fracture and COPD, a COPD model was created, by daily exposure to cigarette smoke, and evaluated. Rats (5 months of age) were exposed to cigarette smoking for 37 weeks to create a COPD group. Rats not exposed to cigarette smoke formed the control group. All rats experienced hip fracture, which was subsequently treated with surgery at 24 h (early fixation; EF) or 72 h (late fixation; LF) after fracture, respectively. Serum mitochondrial DNA (mtDNA), tumor necrosis factor-α (TNF-α), interleukin (IL)-6 and IL-10 were measured at 2 and 24 h after surgery. Cytokine and myeloperoxidase (MPO) activity in the lung tissue were measured and assessed via bronchoalveolar lavage. The serum mtDNA, IL-6 and IL-10 levels in the control group and in the COPD group increased rapidly at 2 h and peaked at 24 h, while TNF-α levels peaked at 2 h and subsequently decreased. Rats that received EF in the COPD group demonstrated a significant increase of TNF-α (P<0.001 at 2 h), IL-6 (P<0.001 at 2 and 24 h), IL-10 (P=0.010 at 2 h and P=0.001 at 24 h) and mtDNA (P<0.001 at 24 h) compared with the rats that received LF. LF in experimental rats also significantly reduced the severity of MPO activity (P<0.001 and P=0.001) and permeability (P=0.009 and P=0.018) in pulmonary samples at 2 or 24 h, respectively, compared with EF. However, LF in the control group did not demonstrate a significant advantage at reducing MPO and permeability in serum and pulmonary samples. The present study indicated that early surgery increased mtDNA and cytokine release in a model of elderly hip fracture with COPD, and LF may reduce the severity of the inflammatory response and degree of permeability in pulmonary tissues.
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Affiliation(s)
- Jianzheng Zhang
- Department of Orthopedic Surgery, Beijing Army General Hospital, Beijing 100700, P.R. China
| | - Juan Wang
- Department of Orthopedic Surgery, Beijing Army General Hospital, Beijing 100700, P.R. China
| | - Xiaowei Wang
- Department of Orthopedic Surgery, Beijing Army General Hospital, Beijing 100700, P.R. China
| | - Zhi Liu
- Department of Orthopedic Surgery, Beijing Army General Hospital, Beijing 100700, P.R. China
| | - Jixin Ren
- Department of Orthopedic Surgery, Beijing Army General Hospital, Beijing 100700, P.R. China
| | - Tiansheng Sun
- Department of Orthopedic Surgery, Beijing Army General Hospital, Beijing 100700, P.R. China
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United States neurosurgery annual case type and complication trends between 2006 and 2013: An American College of Surgeons National Surgical Quality Improvement Program analysis. J Clin Neurosci 2016; 31:106-11. [DOI: 10.1016/j.jocn.2016.02.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 02/14/2016] [Indexed: 12/14/2022]
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Wang L, Kang S, Zou D, Zhan L, Li Z, Zhu W, Su H. Bone Fracture Pre-Ischemic Stroke Exacerbates Ischemic Cerebral Injury in Mice. PLoS One 2016; 11:e0153835. [PMID: 27089041 PMCID: PMC4835054 DOI: 10.1371/journal.pone.0153835] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 04/02/2016] [Indexed: 12/21/2022] Open
Abstract
Ischemic stroke is a devastating complication of bone fracture. Bone fracture shortly after stroke enhances stroke injury by augmenting inflammation. We hypothesize that bone fracture shortly before ischemic stroke also exacerbates ischemic cerebral injury. Tibia fracture was performed 6 or 24 hours before permanent middle cerebral artery occlusion (pMCAO) on C57BL/6J mice or Ccr2RFP/+Cx3cr1GFP/+ mice that have the RFP gene knocked into one allele of Ccr2 gene and GFP gene knocked into one allele of Cx3cr1 gene. Behavior was tested 3 days after pMCAO. Infarct volume, the number of CD68+ cells, apoptotic neurons, bone marrow-derived macrophages (RFP+), and microgila (GFP+) in the peri-infarct region were quantified. Compared to mice subjected to pMCAO only, bone fracture 6 or 24 hours before pMCAO increased behavioral deficits, the infarct volume, and the number of CD68+ cells and apoptotic neurons in the peri-infarct area. Both bone marrow-derived macrophages (CCR2+) and microglia (CX3CR1+) increased in the peri-infarct regions of mice subjected to bone fracture before pMCAO compared to stroke-only mice. The mice subjected to bone fracture 6 hours before pMCAO had more severe injury than mice that had bone fracture 24 hours before pMCAO. Our data showed that bone fracture shortly before stroke also increases neuroinflammation and exacerbates ischemic cerebral injury. Our findings suggest that inhibition of neuroinflammation or management of stroke risk factors before major bone surgery would be beneficial for patients who are likely to suffer from stroke.
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MESH Headings
- Animals
- Behavior, Animal
- Brain Injuries/etiology
- Brain Injuries/metabolism
- Brain Injuries/pathology
- Brain Ischemia/etiology
- Brain Ischemia/metabolism
- Brain Ischemia/pathology
- CX3C Chemokine Receptor 1
- Cytokines/metabolism
- Disease Models, Animal
- Enzyme-Linked Immunosorbent Assay
- Fractures, Bone/complications
- Fractures, Bone/metabolism
- Fractures, Bone/pathology
- Immunoenzyme Techniques
- Infarction, Middle Cerebral Artery/physiopathology
- Inflammation/etiology
- Inflammation/metabolism
- Inflammation/pathology
- Male
- Mice
- Mice, Inbred C57BL
- Mice, Knockout
- Mice, Transgenic
- Microglia/immunology
- Microglia/pathology
- Receptors, CCR2/physiology
- Receptors, Chemokine/physiology
- Stroke/etiology
- Stroke/metabolism
- Stroke/pathology
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Affiliation(s)
- Liang Wang
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, United States of America
- Department of Neurosurgery, Tianjin Fifth Center Hospital, Tianjin, China
| | - Shuai Kang
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, United States of America
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Dingquan Zou
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, United States of America
| | - Lei Zhan
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, United States of America
| | - Zhengxi Li
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, United States of America
- Department of Neurology, Shanghai Ninth People’s Hospital, Shanghai, China
| | - Wan Zhu
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, United States of America
| | - Hua Su
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
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