Risk factors and prognostic implications of aspiration pneumonia in older hip fracture patients: A multicenter retrospective analysis

Dietary patterns and micronutrients in respiratory infections including COVID-19: a narrative review

BACKGROUND

COVID-19 is a pandemic caused by nCoV-2019, a new beta-coronavirus from Wuhan, China, that mainly affects the respiratory system and can be modulated by nutrition.

METHODS

This review aims to summarize the current literature on the association between dietary intake and serum levels of micronutrients, malnutrition, and dietary patterns and respiratory infections, including flu, pneumonia, and acute respiratory syndrome, with a focus on COVID-19. We searched for relevant articles in various databases and selected those that met our inclusion criteria.

RESULTS

Some studies suggest that dietary patterns, malnutrition, and certain nutrients such as vitamins D, E, A, iron, zinc, selenium, magnesium, omega-3 fatty acids, and fiber may have a significant role in preventing respiratory diseases, alleviating symptoms, and lowering mortality rates. However, the evidence is not consistent and conclusive, and more research is needed to clarify the mechanisms and the optimal doses of these dietary components. The impact of omega-3 and fiber on respiratory diseases has been mainly studied in children and adults, respectively, and few studies have examined the effect of dietary components on COVID-19 prevention, with a greater focus on vitamin D.

CONCLUSION

This review highlights the potential of nutrition as a modifiable factor in the prevention and management of respiratory infections and suggests some directions for future research. However, it also acknowledges the limitations of the existing literature, such as the heterogeneity of the study designs, populations, interventions, and outcomes, and the difficulty of isolating the effects of single nutrients from the complex interactions of the whole diet.

Postoperative pneumonia after femoral fracture surgery: an in-depth retrospective analysis

BACKGROUND

Femoral fractures significantly contribute to disability, predominantly in the elderly. Despite this, data on postoperative pneumonia following femoral fracture surgeries remains sparse. Our study sought to explore the incidence and impact of postoperative pneumonia on outcomes following such surgeries.

METHODS

A retrospective study analyzed femoral fracture patients hospitalized from 2016 to 2022. We scrutinized postoperative outcomes, including pneumonia, hospital stay duration, intensive care unit (ICU) admissions, and in-hospital mortality. We established stringent diagnostic criteria for postoperative pneumonia, incorporating both clinical signs and radiological evidence, excluding patients with prior infections or those discharged within 24 h post-surgery. Statistical analyses involved Chi-square and t-tests, linear regression, and logestic regression using SPSS.

RESULTS

Out of 636 patients, 10.8% were diagnosed with postoperative pneumonia. The average age was 79.55 ± 8.57 years, with a male prevalence of 47.8%. Common comorbidities were hypertension (78.3%), diabetes (60.9%), and cardiovascular diseases (40.6%). Surgical interventions were categorized as intramedullary nailing (40.6%), partial hip replacement (37.7%), and dynamic hip screw (21.7%). Postoperative pneumonia was associated with older age (AOR = 1.053, 95% CI 1.020 to 1.087, p = 0.002), ICU admission (AOR = 2.283, 95% CI 1.256 to 4.148, p = 0.007), and longer length of hospital stay (AOR = 1.079, 95% CI 1.030 to 1.130, p = 0.001). The presence of pneumonia was associated with a 2.621-day increase in hospitalization after adjusting for other variables (p < 0.001, 95% CI: 1.454 to 3.789).

CONCLUSION

This study accentuates the clinical significance of postoperative pneumonia in femoral fracture patients, with a noted incidence of 10.8%. A notable association with older age, prolonged hospital stays, and ICU admissions was observed, underscoring the necessity of addressing this complication to improve patient outcomes and healthcare resource allocation.

Evaluating Pain Management from Peripheral Nerve Block for Geriatric Patients following Bipolar Hemiarthroplasty for Displaced Femoral-Neck Fracture

INTRODUCTION

The purpose of this study was to evaluate peripheral nerve block (PNB) effectiveness in postoperative pain management and surgical outcomes for displaced femoral-neck fracture in geriatric patients (>70 years) who underwent bipolar hemiarthroplasty (BHA).

METHODS

From January 2017 to December 2021, 231 geriatric patients with displaced femoral-neck fracture who consecutively underwent BHA were retrospectively reviewed. Patients were divided into two groups: the patient-controlled analgesia (PCA) group (n = 132) who received only intravenous (IV) PCA for postoperative pain management, and all others who received PNB with IV PCA (PNB+PCA) such as femoral nerve block or fascia iliaca compartment block after surgery (n = 99). Primary outcomes were postoperative visual analog scale (VAS) at rest and during activity at 6, 24, and 48 h postoperatively. Secondary outcomes were postoperative complications, changes in hemoglobin, length of hospital stay, and total morphine usage after surgery.

RESULTS

Postoperative resting VAS at 6 h and 48 h was significantly lower in the PNB+PCA group compared with the PCA group (p = 0.075, p = 0.0318, respectively). However, there was no significant difference in either resting VAS at 24 h or active VAS. Complications of pneumonia and delirium until 1 month postoperative were significantly lower in the PNB + PCA group than the PCA group (p = 0.0022, p = 0.0055, respectively).

CONCLUSION

PNB with IV PCA seems to have a beneficial effect on geriatric femoral-neck patients who underwent BHA with postoperative analgesia for reducing postoperative resting pain and complications, especially pneumonia and delirium.

Risk factors for hospital-acquired pneumonia in hip fracture patients: A systematic review and meta-analysis

BACKGROUND

This study aimed to comprehensively assess the prevalence and risk factors for Hospital-acquired pneumonia (HAP) in hip fracture patients by meta-analysis.

METHODS

Systematically searched 4 English databases and 4 Chinese databases from inception until October 20, 2022. All studies involving risk factors of HAP in patients with hip fractures will be considered. Newcastle-Ottawa Scale was used to evaluate the quality of the included studies. The results were presented through Review Manager 5.4 with the pooled odds ratio (OR) and 95% confidence interval.

RESULTS

Of 35 articles included in this study, the incidence of HAP was 8.9%. 43 risk factors for HAP were initially included, 23 were eventually involved in the meta-analysis, and 21 risk factors were significant. Among them, the 4 most frequently mentioned risk factors were as follows: Advanced age (OR 1.07, 95% CI 1.05-1.10), chronic obstructive pulmonary disease (COPD) (OR 3.44, 95% CI 2.83-4.19), time from injury to operation (OR 1.09, 95% CI 1.07-1.12), time from injury to operation ≥ 48 hours (OR 3.59, 95% CI 2.88-4.48), and hypoalbuminemia < 3.5g/dL (OR 2.68, 95% CI 2.15-3.36).

DISCUSSION

Hip fracture patients diagnosed with COPD have a 3.44 times higher risk of HAP compared to the general hip fracture patients. The risk of HAP also increases with age, with patients over 70 having a 2.34-fold higher risk and those over 80 having a 2.98-fold higher risk. These findings highlight the need for tailored preventive measures and timely interventions in vulnerable patient populations. Additionally, hip fracture patients who wait more than 48 hours for surgery have a 3.59-fold higher incidence of HAP. This emphasizes the importance of swift surgical intervention to minimize HAP risk. However, there are limitations to consider in this study, such as heterogeneity in selected studies, inclusion of only factors identified through multivariate logistic regression, and the focus on non-randomized controlled trial studies.

Risk factors for hospital-acquired pneumonia in hip fracture patients: a systematic review and meta-analysis

OBJECTIVE

This study aimed to systematically assess the incidence and risk factors for hospital-acquired pneumonia (HAP) in hip fracture patients by meta-analysis.

METHODS

Systematically searched four English databases (PubMed, EMBASE, The Cochrane Library, and Web Of Science) and four Chinese databases (CNKI, CQVIP, Sinomed, and WAN FANG) from inception until 20 November 2023. All studies involving risk factors of HAP in patients with hip fractures were considered. Newcastle-Ottawa Scale was used to evaluate the quality of the included studies. The results were presented with the pooled odds ratio (OR) and 95% confidence interval (95% CI).

RESULTS

Of 35 articles (337,818 patients) included in this study, the incidence of HAP was 89 per 1000 cases. Twenty-three risk factors were eventually involved in the meta-analysis, and 21 risk factors were significant. Our study has identified four significant risk factors (advanced age, preoperative time, COPD, and hypoalbuminemia) associated with HAP, as follows: Advanced age as a continuous variable (OR 1.07, 95% CI 1.05-1.10), Advanced age > 70 years (OR 2.34, 95% CI 1.77-3.09), Advanced age > 80 years (OR 2.98, 95% CI 2.06-4.31), Chronic obstructive pulmonary disease (COPD) (OR 3.44, 95% CI 2.83-4.19), Time from injury to operation as a continuous variable (OR 1.09, 95% CI 1.07-1.12), Time from injury to operation ≥48 h (OR 3.59, 95% CI 2.88-4.48), Hypoalbuminemia < 3.0 g/dL (OR 3.03, 95% CI 1.93-4.73), and Hypoalbuminemia < 3.5 g/dL (OR 2.68, 95% CI 2.15-3.36). However, it is important to note that all the studies included in our research were retrospective in nature, which introduces certain limitations to the level of evidence and the ability to establish causal inferences.

DISCUSSION

Patients who have suffered hip fractures are at an increased risk of developing postoperative hospital-acquired pneumonia, which can lead to prolonged hospital stays and adverse clinical outcomes. Consequently, the identification of these risk factors offers novel insights and methodologies for healthcare professionals in terms of both prevention and treatment.

TRIAL REGISTRATION

Registration number: INPLASY2022100091.

Relationship between preoperative red blood cell distribution width and postoperative pneumonia in elderly patients with hip fracture: a retrospective cohort study

OBJECTIVE

The relationship between the preoperative red blood cell distribution width and postoperative pneumonia in elderly patients with hip fractures remains unclear. This study investigated whether the preoperative red blood cell distribution width was associated with postoperative pneumonia in elderly patients with hip fractures.

METHODS

Clinical data of patients with hip fractures in the Department of orthopedics of a hospital from January 2012 to December 2021 were retrospectively analyzed. A generalized additive model was used to identify both linear and nonlinear relationships between red blood cell distribution width and postoperative pneumonia. A two-piecewise linear regression model was used to calculate the saturation effect. Subgroup analyses were performed using stratified logistic regression.

RESULTS

This study included a total of 1444 patients. The incidence of postoperative pneumonia was 6.30% (91/1444), the mean age of the patients was 77.55 ± 8.75 years, and 73.06% of them (1055/1444) were female. After full adjustment for covariates, the preoperative red blood cell distribution width showed a nonlinear relationship with postoperative pneumonia. The two-piecewise regression model showed an inflection point at 14.3%. On the left side of the inflection point, the incidence of postoperative pneumonia increased by 61% for every 1% increase in red blood cell distribution width (OR: 1.61, 95% CI 1.13-2.31, P = 0.0089). The effect size was not statistically significant on the right side of the inflection point (OR: 0.83, 95% CI 0.61-1.12, P = 0.2171).

CONCLUSION

The relationship between preoperative red blood cell distribution width and incidence or postoperative pneumonia was nonlinear in elderly patients with hip fractures. The incidence of postoperative pneumonia was positively correlated with red blood cell distribution width when it was < 14.3%. A saturation effect was observed when the red blood cell distribution width reached 14.3%.

What are Risk Factors of Postoperative Pneumonia in Geriatric Individuals after Hip Fracture Surgery: A Systematic Review and Meta-Analysis

Postoperative pneumonia (POP) is a common postoperative complication. Negative consequences associated with POP included prolonged hospital length of stay, more frequent intensive care unit (ICU) stays, and a higher rate of sepsis, readmission, and mortality. This meta-analysis aimed to assess the incidence and risk factors associated with POP after hip fracture surgery in elderly patients. PubMed, Web of Science, and Cochrane Library were searched (up to March 31, 2022). All studies on the risk factors for POP after hip fracture surgery in elderly patients, published in English, were reviewed. The qualities of the included studies were assessed using the Newcastle-Ottawa Scale. Data were pooled, and a meta-analysis was performed. Ten studies, including 12,084 geriatric patients undergoing hip fracture surgery, were included. Of these 12,084 patients, POP occurred in 809 patients. The results indicated that age (mean difference [MD] = 4.95, 95% confidence interval [CI]: 3.22-6.69), male (odds ratio [OR] = 1.41, 95% CI: 1.02-1.93), the American Society of Anaesthesiologists classification ≥3 (OR = 3.48, 95% CI: 1.87-6.47), dependent functional status (OR = 5.23, 95% CI: 2.18-12.54, P = 0.0002), smoking (OR = 1.33, 95% CI: 1.07-1.65), chronic obstructive pulmonary disease (OR = 3.76, 95% CI: 2.07-6.81), diabetes mellitus (OR = 1.19, 95% CI: 1.01-1.40), coronary heart disease (OR = 1.74, 95% CI: 1.23-2.46), arrhythmia (OR = 1.47, 95% CI: 1.01-2.14), cerebrovascular disease (OR = 1.88, 95% CI: 1.56-2.27), dementia (OR = 2.36, 95% CI: 1.04-5.36), chronic renal failure (OR = 1.85, 95% CI: 1.29-2.67), hip arthroplasty (OR = 1.30, 95% CI: 1.08-1.56), delayed surgery (OR = 6.40, 95% CI: 3.00-13.68), preoperative creatinine (MD = 5.32, 95% CI: 0.55-10.08), and preoperative serum albumin (MD = -3.01, 95% CI: -4.21 - -1.80) were risk factors for POP. Related prophylactic measures should be provided in geriatric patients with the above-mentioned risk factors to prevent POP after hip fracture surgery.

Low lymphocyte-to-C-reactive protein ratio relates to high 1-year mortality in elderly patients undergoing hemiarthroplasty for displaced femoral neck facture

OBJECTIVE

Lymphocyte-to-C-reactive protein (CRP) ratio (LCR) is a novel biomarker for predicting poor prognosis in many diseases. This study aims to analyze the association between preoperative LCR and 1-year mortality in elderly patients with displaced FNF undergoing hemiarthroplasty.

METHODS

Between May 2017 and May 2019, a retrospective study including 364 elderly patients undergoing hemiarthroplasty for displaced FNF was performed. LCR was defined as the ratio of preoperative lymphocyte count to CRP level. The optimal cutoff value of LCR was determined by receiver operating characteristic curve, and all patients were categorized into low-LCR group and high-LCR group accordingly. The relationship between LCR and 1-year mortality was evaluated by using univariate and multivariate Cox regression analysis. Furthermore, the complications within 30 days after surgery, length of hospital stay, and perioperative red blood cell transfusion were also analyzed stratified by LCR.

RESULTS

A total of 47 patients (12.9%) died within 1-year follow-up after surgery. The optimal cutoff value for LCR was 30,560 (specificity 76.6% and sensitivity 63.4%). Low-LCR (≤ 30,560) group had a higher mortality rate than high-LCR group (23.53% vs. 5.21%, P < 0.001). In multivariate analysis, low LCR, hypoalbuminemia, and Age-Adjusted Charlson Comorbidity Index ≥ 6 were identified as independent predictors for 1-year mortality. Moreover, low level of LCR was associated with high rate of total complications (19.6% vs. 11.4%, P = 0.029), perioperative transfusions (37.9% vs. 27.0%, P = 0.027), and longer hospital stay (7.84 ± 2.40 vs. 7.30 ± 2.32, P = 0.031).

CONCLUSIONS

The low level of preoperative LCR can effectively predict 1-year mortality and 30-day total complications after surgery in elderly patients with displaced FNF undergoing hemiarthroplasty.

Risk Factors for Postoperative Pneumonia in the Elderly Following Hip Fracture Surgery: A Systematic Review and Meta-Analysis

Introduction: Pneumonia is a serious complication following hip fracture surgery in older people. However, the prevalence and risk factors of postoperative pneumonia (POP) are not well-established. This study identified pre- and peri-operative factors associated with the development of POP following hip fracture surgery. Methods: We searched the Cochrane library, PubMed, and Embase databases for relevant articles published up to June 2021. Studies involving older patients who underwent hip fracture surgery were considered if they detailed the demographic or surgical characteristics of the participants. For all analyses, the pooled odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated. Results: A total of 24 studies (288819 participants) were included. The overall prevalence of POP following hip fracture surgery was 5.0%. There were 36 risk factors for POP, and the meta-analysis included the five most common: delayed surgery (OR: 1.84, 95% CI: 1.29-2.63), low serum albumin (OR: 2.34, 95% CI: .82-6.73), chronic respiratory diseases (OR: 2.42, 95% CI: 1.82-3.24), increased age (OR: 1.25, 95% CI:1.11-1.40), and male sex (OR: 2.22, 95% CI: 2.00-2.47). Conclusions: The prevalence of POP was 5.0% following hip fracture surgery in the elderly. Older age, male sex, chronic respiratory diseases, delayed surgery, and low serum albumin were significant risk factors. Clinicians treating hip fracture patients must remain be aware of these risk factors.

Relationship Between Preoperative Hypoalbuminemia and Postoperative Pneumonia Following Geriatric Hip Fracture Surgery: A Propensity-Score Matched and Conditional Logistic Regression Analysis

Background

Pneumonia is a devastating complication following geriatric hip fracture surgery, and preoperative hypoalbuminemia may be a potentially modifiable factor leading to improved outcome. This study aimed to quantify the relationship between preoperative hypoalbuminemia and postoperative pneumonia.

Methods

We retrospectively reviewed the medical records of elderly patients (≥60 years) who underwent surgeries for hip fracture in a tertiary referral center between 2016 and 2020. According to the preoperative serum albumin level, they were divided into two groups: <35 g/ L and ≥35 g/ L. To reduce potential confounding, propensity score matching (PSM) in a 1:1 ratio was performed, with the caliper value set as 0.002; and further conditional logistic regression analysis was used to control the other potential confounders to determine the association strength.

Results

Among 3,147 eligible patients included, PSM yielded 1,318 matched patients, with 659 in each respective group, suggesting significantly improved balance in most variables (standardized mean deviation improvement range, 20.7% to 99.1%), except for basophil count. The conditional logistic regression analysis, adjusted for PS and other intra- or post-operative variables, showed 6.18-fold (relative ratio, 6.18; 95% CI, 3.15–11.98; P<0.001) increased risk of postoperative pneumonia associated with preoperative hypoalbuminemia.

Conclusion

Preoperative hypoalbuminemia was identified to be independently and highly associated with development of postoperative pneumonia in elderly patients undergoing hip fracture surgeries. However, whether the patients who had such condition may benefit from preoperative targeted nutritional support needs to be clarified by more prospective studies.

What do hip fracture patients die from?

Hip fractures in the elderly are associated with an increased mortality rate, even if they are operated within the recommended time window. However, the causes of mortality vary considerably depending on the postoperative period and the patients' comorbidities. In the 30-day postoperative period, the most common causes of death are acute processes such as bacterial and aspiration pneumonia followed by myocardial infarction, cancer, gastrointestinal hemorrhage, stroke, pulmonary embolism, and acute renal failure. In the 6-month and 1-year postoperative period, chronic processes appear to be the most important causes of death, as well as decompensation of patients' chronic diseases. To enhance the literature, we performed this literature review to summarize and discuss the causes of mortality of elderly hip fracture patients depending on the postoperative period that they occur, and possibly to address the question what do hip fracture patients die from? Our aim was to perform an interesting and concise paper that the curious reader will find interesting and informative.

Early Detection of Pneumonia with the Help of Dementia in Geriatric Hip Fracture Patients

Objective

To investigate the role of dementia in pneumonia among geriatric patients with hip fracture and further develop an algorithm for stratifying risk of developing postoperative pneumonia.

Methods

The algorithm was developed after retrospectively analyzing 1344 hip fracture patients in the National Clinical Research Center for Orthopedics, Sports Medicine, and Rehabilitation from 1992 to 2012. Twenty‐eight variables were analyzed for evaluating the ability to predict postoperative pneumonia. The validation of the algorithm was performed in the MIMIC‐III database after enrolling 235 patients.

Results

One thousand five hundred and seventy‐nine patients were enrolled, 4.69% patients had postoperative pneumonia in our hospital, and 17.02% suffered pneumonia in the MIMIC‐III database. Dementia patients had more postoperative pneumonia (12.68% vs 4.24%, P = 0.0075), as compared with patients without dementia. The algorithm included nine predictors: dementia, age, coronary heart disease, the American Society of Anesthesiologists score, surgical method, mechanical ventilation, anemia, hypoproteinemia, and high creatinine. Internal validation showed the algorithm with dementia could improve predictive performance, while external validation found the algorithm with or without dementia both had similar and good predictive ability.

Conclusions

The algorithm has the potential to be a pragmatic risk prediction tool to calculate risk of pneumonia in clinical practice and it may also be applicable in critically ill hip fracture patients with dementia.

Postoperative Pneumonia and Aspiration Pneumonia Following Elderly Hip Fractures

OBJECTIVES

The present study aimed to investigate the incidence of and risk factors for postoperative pneumonia and aspiration pneumonia after hip fracture surgery.

DESIGN

Retrospective cohort study from 2005 to 2021.

SETTING

Asan Medical Center in Seoul, Republic of Korea.

PARTICIPANTS

A total 1,208 patients aged ≥ 65 years who underwent hip fracture surgery.

MEASUREMENTS

Postoperative pneumonia was defined as cases with new infiltration on chest x-ray or chest computed tomography (CT) after surgery or confirmed by a pulmonologist's consultation and diagnosis. Aspiration pneumonia was defined as: 1) radiologic findings of hospital-acquired pneumonia on chest radiographs or CT, medical record of aspiration pneumonia confirmed by a pulmonologist's consultation, and history of vomiting or aspiration, or 2) gravity-dependent opacity on chest CT when the history of vomiting or aspiration is ambiguous. Patient demographics, past medical history, pre-injury Koval score, Charlson Comorbidity Index (CCI), blood test results, length of hospital stay, and in-hospital mortality were evaluated. A comparison analysis and binary logistic regression were performed to identify the incidence and risk factors for postoperative pneumonia and aspiration pneumonia.

RESULTS

Postoperative pneumonia was diagnosed in 47 patients (3.9%), including 20 with aspiration pneumonia (1.7%). In the multivariate analysis, postoperative delirium (odds ratio [OR], 3.42; P < 0.001), American Society of Anesthesiologists (ASA) scores ≥ 3 (OR, 2.11; P = 0.021), and CCI (OR, 1.21; P = 0.013) were significant risk factors for postoperative pneumonia. Male sex (OR, 3.01; P = 0.017), postoperative delirium (OR, 3.16; P = 0.014), and preoperative serum albumin levels < 3.5 g/dL (OR, 7.00; P = 0.010) were significant risk factors for aspiration pneumonia.

CONCLUSION

ASA classification ≥ 3, higher CCI, and postoperative delirium were the risk factors for postoperative pneumonia. Male sex, postoperative delirium, and lower preoperative serum albumin level were the risk factors for aspiration pneumonia. Thus, physicians should pay attention to patients with the risk factors.

Partial pressure of oxygen level at admission as a predictor of postoperative pneumonia after hip fracture surgery in a geriatric population: a retrospective cohort study

OBJECTIVE

To identify whether the partial pressure of oxygen in arterial blood (PaO₂) level at admission is an independent risk factor as a prognostic biomarker to predict postoperative pneumonia (POP) in the geriatric population who have undergone hip fracture surgical repair at our hospital.

DESIGN

A retrospective cohort study.

SETTING

This is a retrospective chart review of POP after hip fracture surgery in China.

PARTICIPANTS

In training cohort, patients aged ≥65 years who had hip fracture surgery between 1 January 2018 and 30 November 2019. In the validation cohort, a series of patients who underwent hip fracture surgery between 1 January 2020 and 28 February 2020.

INTERVENTIONS

Receiver operating characteristic (ROC) analysis was used to obtain the area under the ROC curve (AUC) and cut-off values of PaO₂ to predict POP. A binomial logistic regression model was used to identify potential risk factors for POP by analysing demographic distribution factors, laboratory results, preoperative comorbidities and surgical factors. Then the regression model was validated using an independent cohort.

RESULTS

In the training cohort, ROC curves were generated to compare the predictive performance of PaO₂ for the occurrence of POP, and the area under the receiver operating characteristic curve (AUC) was 0.653 (95% CI 0.577 to 0.729, p<0.0001), with sensitivity and specificity values of 60.0% and 63.8%, respectively. The cut-off value of the PaO₂ for POP was 72.5 mm Hg. Binary logistic regression analysis revealed that hypoxaemia (PaO₂ <72.5 mm Hg) at hospital admission (OR=3.000, 95% CI 1.629 to 5.528; p<0.0001) was independent risk factors associated with POP after hip fracture surgery. In the validation cohort, PaO₂ had a predictive effect for POP (AUC 0.71, 95% CI 0.541 to 0.891).

CONCLUSIONS

The current study revealed that the PaO₂ level at hospital admission is a simple and widely available biomarker predictor of POP after hip fracture surgery in elderly patients.

High platelet-to-lymphocyte ratio predicts poor survival of elderly patients with hip fracture

Purpose

The platelet-to-lymphocyte ratio (PLR) has been extensively studied in various diseases. However, the relationship between PLR and hip fracture remains unknown. The aim of this study was to evaluate whether PLR would be an independent prognostic factor in elderly hip fracture patients.

Methods

Between January 2014 and December 2018, a retrospective cohort study was conducted in a orthopaedic centre, China. A total of 460 hip fracture patients were included. PLR was calculated as the ratio of platelet to lymphocyte counts and divided into high PLR group (≥ 189) and low PLR group (< 189) by using the receiver operating characteristic (ROC) curve. The relationship between PLR and one year all-cause mortality rate was assessed by univariate and multivariate Cox proportional hazard models. Further subgroup analysis stratified by different clinical and biological characteristics was performed to make the results more accurate.

Results

After a median follow-up of 32.0 months (range, 12.0–75.4), 92 patients (mortality rate: 20.0%) died within one year. PLR was significantly higher in dead patients compared with alive patients (p < 0.05), and high PLR group also had a high mortality rate (32.21% vs. 14.15%, p < 0.001). After multivariate adjustment, high PLR remained an independent predictor for one year all-cause mortality (adjusted hazard ratio (HR) 1.56, 95% confidence interval (CI) 1.02–2.41, p = 0.041). Moreover, advanced age (HR 1.05, 95% CI 1.01–1.08), male (HR 1.62, 95% CI 1.06–2.45), CCI ≥ 2 (HR 2.83, 95% CI 1.64–4.89), conservative treatment (HR 5.94, 95% CI 3.71–9.73), low haemoglobin level (HR 1.02, 95% CI 1.01–1.04), and low albumin level (HR 1.07, 95% CI 1.02–1.13) were independent risk factors for survival. Furthermore, subgroup analysis results were consistent with the main findings in most stratified groups.

Conclusion

This study highlights that high PLR (≥ 189) is associated with increased one year all-cause mortality in elderly hip fracture patients. As PLR is a simple indicator that can be calculated from the blood routine test, it can be easily performed in usual clinical practice.

A Nomogram for Prediction of Postoperative Pneumonia Risk in Elderly Hip Fracture Patients

Purpose

Pneumonia is one of the common complications of hip fracture. This study aimed to evaluate the risk factors and apply a nomogram to predict postoperative pneumonia in elderly hip fracture patients.

Materials and Methods

From August 2014 to October 2019, 1113 hip fracture patients who were older than 65 years and underwent surgical treatment in our hospital were subjects of this study. Univariate and multivariate Cox analyses were used to identify independent risk factors. A predictive nomogram model was built, and the discrimination and calibration were determined by receiver operating characteristic and calibration plot.

Results

A total of 166 patients developed pneumonia after operation (14.91%, pneumonia group) while the remaining 947 patients did not (85.09%, non-pneumonia group). According to the results, body mass index (OR, 0.76, 95% CI, 0.70 to 0.84, P<0.001), serum albumin (OR, 0.86, 95% CI, 0.79 to 0.93, P<0.001), c-reactive protein (OR, 1.01, 95% CI, 1.00 to 1.92, P=0.011), functional status (OR, 2.94, 95% CI, 1.69 to 5.10, P<0.001) and time to surgery (OR, 4.56, 95% CI, 2.64 to 7.88, P<0.001) were identified as independent risk factors of pneumonia. The area under the curve value for postoperative pneumonia risk was 0.905, and the P-value of the Hosmer-Lemeshow calibration test was 0.529.

Conclusion

Our nomogram model can be used to predict the risk of pneumonia in elderly hip fractures after surgery and provide clinicians with guidance for better perioperative intervention to improve prognosis and reduce mortality.

Care complexity individual factors associated with adverse events and in-hospital mortality

Introduction

Measuring the impact of care complexity on health outcomes, based on psychosocial, biological and environmental circumstances, is important in order to detect predictors of early deterioration of inpatients. We aimed to identify care complexity individual factors associated with selected adverse events and in-hospital mortality.

Methods

A multicenter, case-control study was carried out at eight public hospitals in Catalonia, Spain, from January 1, 2016 to December 31, 2017. All adult patients admitted to a ward or a step-down unit were evaluated. Patients were divided into the following groups based on the presence or absence of three adverse events (pressure ulcers, falls or aspiration pneumonia) and in-hospital mortality. The 28 care complexity individual factors were classified in five domains (developmental, mental-cognitive, psycho-emotional, sociocultural and comorbidity/complications). Adverse events and complexity factors were retrospectively reviewed by consulting patients’ electronic health records. Multivariate logistic analysis was performed to identify factors associated with an adverse event and in-hospital mortality.

Results

A total of 183,677 adult admissions were studied. Of these, 3,973 (2.2%) patients experienced an adverse event during hospitalization (1,673 [0.9%] pressure ulcers; 1,217 [0.7%] falls and 1,236 [0.7%] aspiration pneumonia). In-hospital mortality was recorded in 3,996 patients (2.2%). After adjustment for potential confounders, the risk factors independently associated with both adverse events and in-hospital mortality were: mental status impairments, impaired adaptation, lack of caregiver support, old age, major chronic disease, hemodynamic instability, communication disorders, urinary or fecal incontinence, vascular fragility, extreme weight, uncontrolled pain, male sex, length of stay and admission to a medical ward. High-tech hospital admission was associated with an increased risk of adverse events and a reduced risk of in-hospital mortality. The area under the ROC curve for both outcomes was > 0.75 (95% IC: 0.78–0.83).

Conclusions

Several care complexity individual factors were associated with adverse events and in-hospital mortality. Prior identification of complexity factors may have an important effect on the early detection of acute deterioration and on the prevention of poor outcomes.

A clinical pathway for pre-operative screening of COVID-19 and its influence on clinical outcome in patients with traumatic fractures

PURPOSE

Coronavirus disease 2019 (COVID-19) has become a worldwide pandemic. The toughest issue traumatic orthopaedic surgeons are faced with is how to maintain a balance between adequate COVID-19 screening and timely surgery. In this study, we described our experience with pre-operative COVID-19 screening in patients with traumatic fractures. Furthermore, we analysed the clinical results of fracture patients undergoing confined or emergency surgery during the COVID-19 outbreak.

METHODS

This was a case series study. Patients with traumatic fractures who were admitted to our hospital for surgery were enrolled in this study during the COVID-19 outbreak from March to April 2020. All patients were enrolled and managed using the standardized clinical pathway we designed for preoperative COVID-19 screening. Clinical, laboratory and outcome data were analysed.

RESULTS

The average surgery waiting time from injury to surgery was 8.7 ± 3.4 days. The average waiting time from admission to surgery was 5.3 ± 2.8 days. These average waiting times were increased by 4.1 days and 2.0 days, respectively, compared with 2019 data. Cardiovascular complications, venous thromboembolism and pneumonia occurred in one, two and one patient, respectively. Three and two patients developed pre-operative and postoperative fevers, respectively.

CONCLUSIONS

We introduced a novel clinical pathway for pre-operatively screening of COVID-19 in traumatic orthopaedic patients. The delay in surgery caused by COVID-19 screening was minimized to a point at which reasonable and acceptable clinical outcomes were achieved. Doctors should pay more attention to perioperative complications, such as cardiovascular complications, venous thromboembolism, pneumonia and fever.

Association of Sarcopenic Dysphagia with Underlying Sarcopenia Following Hip Fracture Surgery in Older Women

This study aimed to investigate the association between the development of dysphagia in patients with underlying sarcopenia and the prevalence of sarcopenic dysphagia in older patients following surgical treatment for hip fracture. Older female patients with hip fractures (n = 89) were studied. The data of skeletal muscle mass, hand-grip strength, and nutritional status were examined. The development of dysphagia postoperatively was graded using the Food Oral Intake Scale by a certified nurse in dysphagia nursing. The patients’ mean age was 85.9 ± 6.5 years. The prevalence of sarcopenia was 76.4% at baseline. Of the 89 patients, 11 (12.3%) and 12 (13.5%) had dysphagia by day 7 of hospitalization and at discharge, respectively. All patients who developed dysphagia had underlying sarcopenia. Lower skeletal muscle mass index (SMI) (<4.7 kg/m²) and grip strength (<8 kg) at baseline indicated a higher incidence of dysphagia on day 7 (p = 0.003 and Phi = 0.391) and at discharge (p = 0.001 and Phi = 0.448). Dysphagia developed after hip fracture surgery could be sarcopenic dysphagia, and worsening sarcopenia was a risk factor for dysphagia following hip fracture surgery. Clinicians and medical coworkers should become more aware of the risks of sarcopenic dysphagia. Early detection and preventive interventions for dysphagia should be emphasized.

Effect of Pneumonia on All-cause Mortality after Elderly Hip Fracture: a Korean Nationwide Cohort Study

BACKGROUND

The purposes of this study were 1) to investigate the incidence of pneumonia during hospitalization in elderly hip fracture patients, 2) to evaluate the effect of pneumonia on 30 day to 1 year mortality and 3) to analyze the impact of age and gender on the mortality rate in the pneumonia patients using a nationwide cohort of Korea.

METHODS

The Korean National Health Insurance Service (NHIS) database included approximately 5.5 million Korean enrollees > 60 years of age. A total of 588,147 participants were randomly selected for senior cohort using 10% simple random sampling. We identified senile (> 65 years old) patients who underwent hip fracture surgery from January 2005 to December 2014 and those who developed pneumonia during hospitalization from the NHIS-Senior cohort. The index date of hip fracture occurrence was defined as the date of admission to the acute care hospital. The last date of follow-up was defined as the date of death or 31 December 2015, whichever came first. A multivariable-adjusted Cox proportional hazards model was used to investigate the effects of pneumonia on all-cause mortality.

RESULTS

During the enrollment period, a total of 14,736 patients, who were older than 65 years, underwent hip fracture surgeries. Among them, 1,629 patients (11.05%) developed pneumonia during the hospitalization. The pneumonia incidence was 16.39% (601/3,666) in men patients and 9.29% (1,028/10,042) in women patients. Compared to 13,107 non-pneumonia patients, adjusted relative risk (aRR) of death in pneumonia patients was 2.69 (95% confidence interval [CI], 2.14-3.38; P < 0.001) within postoperative 30-day, 3.40 (95% CI, 3.01-3.83; P < 0.001) within postoperative 90-day, 2.86 (95% CI, 2.61-3.15; P < 0.001) within postoperative 180-day and 2.31 (95% CI, 2.14-2.50; P < 0.001) within postoperative 1-year. According to patient's age, the aRR of death in pneumonia patients was 5.75 (95% CI, 2.89-11.43) in adults aged < 70 years, 5.14 (95% CI, 4.08-6.46) in those aged 70-79 years, 3.29 (95% CI, 2.81-3.86) in those aged 80-89 years and 2.02 (95% CI, 1.52-2.69) in those aged ≥ 90 years. The aRR was 3.63 (95% CI, 3.01-4.38) in men pneumonia patients, and 3.27 (95% CI, 2.80-3.83) in women pneumonia patients.

CONCLUSION

The prevalence of pneumonia in elderly hip fracture patients was 11.05%. Men had higher incidence (16.39%) than women (9.29%). Compared to non-pneumonia patients, the pneumonia patients had higher 30-day to 1-year mortalities with aRR of 2.31 to 3.40. They had increased mortality in all age groups older than 65 years with aRR of 1.52 to 4.08. Both genders of pneumonia patients had higher risk of mortality (aRR, 3.63 in men and 3.27 in women) compared to non-pneumonia patients.

The prevalence, risk factors and prognostic implications of dysphagia in elderly patients undergoing hip fracture surgery in Korea

Background

Dysphagia is prevalent in geriatric patients, such as elderly hip fracture patients, and is associated with a poor prognosis. This study investigated (1) the prevalence of dysphagia based on clinical screening and a video-fluoroscopic swallowing study (VFSS), (2) the risk factors of dysphagia, and (3) the prognostic implications of dysphagia in elderly patients (≥ 65 years) undergoing hip fracture surgery.

Methods

In this retrospective study, data from 393 female and 153 male patients ≥65 years of age who underwent surgery for a hip fracture between 2015 and 2018 were analysed. Patients who were considered at high risk of dysphagia after screening underwent a VFSS. To identify risk factors of dysphagia, demographic factors, the American Society of Anesthesiologists classification, past medical history, known risk factors of dysphagia, and factors associated with surgery were analysed using a binary logistic regression model. Odds ratios (ORs) of dysphagia for having poor prognosis including postoperative pneumonia, intensive care unit (ICU) admission, and death within 6 months after surgery were obtained by logistic regression. The association of postoperative pneumonia with poor prognosis was also analysed.

Results

Dysphagia was seen in 5.3% of hip fracture patients. In multivariate regression analysis, a serum albumin level < 3.5 g/dL was identified as a risk factor for dysphagia (OR [95%CI] = 3.13 [1.40, 7.01]). Dysphagia was identified as a risk factor for postoperative pneumonia in regression analysis after adjustment (OR [95%CI] = 3.12 [1.05, 9.27]). Postoperative pneumonia was significantly associated with ICU admission (OR [95% CI] = 4.56 [1.85, 11.28]) and death within 6 months after surgery (OR [95% CI] = 2.56 [1.03, 6.33]).

Conclusions

Dysphagia in elderly hip fracture surgery patients was associated with postoperative pneumonia, a risk factor for poor outcomes including ICU admission and death within 6 months after surgery. A serum albumin level < 3.5 g/dL was identified as a risk factor for dysphagia. Therefore, diagnostic testing should be performed to detect dysphagia, especially in patients with a low serum albumin level. Finally, particular care should be taken to prevent postoperative complications in patients with dysphagia.

Effect of Nutritional Intervention Programs on Nutritional Status and Readmission Rate in Malnourished Older Adults with Pneumonia: A Randomized Control Trial

Pneumonia leads to changes in body composition and weakness due to the malnourished condition. In addition, patient family caregivers always have a lack of nutritional information, and they do not know how to manage patients’ nutritional intake during hospitalization and after discharge. Most intervention studies aim to provide nutritional support for older patients. However, whether long-term nutritional intervention by dietitians and caregivers from patients’ families exert clinical effects—particularly in malnourished pneumonia—on nutritional status and readmission rate at each interventional phase, from hospitalization to postdischarge, remains unclear. To investigate the effects of an individualized nutritional intervention program (iNIP) on nutritional status and readmission rate in older adults with pneumonia during hospitalization and three and six months after discharge. Eighty-two malnourished older adults with a primary diagnosis of pneumonia participated. Patients were randomly allocated to either a nutrition intervention (NI) group or a standard care (SC) group. Participants in the NI group received an iNIP according to energy and protein intake requirements in addition to dietary advice based on face-to-face interviews with their family caregivers during hospitalization. After discharge, phone calls were adopted for prescribing iNIPs. Anthropometry (i.e., body mass index, limb circumference, and subcutaneous fat thickness), blood parameters (i.e., albumin and total lymphocyte count), hospital stay, Mini-Nutritional Assessment-Short Form (MNA-SF) score, target daily calorie intake, total calorie intake adherence rate, and three-major-nutrient intakes were assessed during hospitalization and three and six months after discharge. Both groups received regular follow-up through phone calls. Furthermore, the rate of readmission resulting from pneumonia was recorded after discharge. During hospital stay, the NI group showed significant increases in daily calorie intake, total calorie intake adherence rate, and protein intake compared with the SC group (p < 0.05); however, no significant difference was found in anthropometry, blood biochemical values, MNA-SF scores, and hospital stay. At three and six months after discharge, the NI group showed significantly higher daily calorie intake and MNA-SF scores (8.2 vs. 6.5 scores at three months; 9.3 vs. 7.6 scores at six months) than did the SC group (p < 0.05). After adjusting for sex, the readmission rate for pneumonia significantly decreased by 77% in the NI group compared with that in the SC group (p = 0.03, OR: 0.228, 95% CI: 0.06–0.87). A six-month iNIP under dietitian and patient family nutritional support for malnourished older adults with pneumonia can significantly improve their nutritional status and reduce the readmission rate.

Delay in surgery, risk of hospital-treated infections and the prognostic impact of comorbidity in hip fracture patients. A Danish nationwide cohort study, 2005-2016

Purpose: We examined the association between delay in surgery and hospital-treated infections in hip fracture patients with and without known comorbidities.

Patients and methods: All hip fracture patients aged ≥65 years registered in the Danish Multidisciplinary Hip Fracture Registry from 2005 to 2016 were included (n=72,520). Delay in surgery was defined as the time in hours from admission to surgery and was divided into 3 groups (12, 24 and 48 hrs). The outcomes were hospital-treated pneumonia, urinary tract infection and reoperation due to infection 0–30 days after surgery. As a measure of comorbidity, we used the Charlson Comorbidity Index (CCI): none (no registered comorbidities prior to the fracture), medium (1–2 points) and high (≥3 points).

Results: Overall, there was an association between a delay of 12 hrs and pneumonia. A delay of 12 hrs was associated with an increased risk of pneumonia in patients with no comorbidities (adjusted hazard ratio (HR) 1.20, confidence interval (CI) 1.03–1.40) and a delay of 24 hrs was associated with an increased risk of pneumonia in patients with a medium level of comorbidity (HR 1.12, CI (1.02–1.23)). Overall, delay was associated with reoperation due to infection, particularly among patients with comorbidities, although the confidence intervals of some of the estimates were wide. A delay of 48 hrs was associated with an increased risk of reoperation due to infection in patients with a high level of comorbidity (HR 2.36, CI 1.19–4.69).

Conclusion: Delay in surgery was associated with an increased risk of hospital-treated pneumonia and reoperations due to infection within 30 days of surgery. The number of postoperative hospital-treated infections within 30 days may be reduced by continuously targeting pre-, per- and postoperative optimization not only for patients with high level of comorbidity but also for hip fracture patients without known comorbidities prior to surgery.