The Neutrophil to Lymphocyte Ratio on Admission and Short-Term Outcomes in Orthogeriatric Patients

Prediction of Osteoporotic Hip Fracture Outcome: Comparative Accuracy of 27 Immune-Inflammatory-Metabolic Markers and Related Conceptual Issues

Objectives: This study, based on the concept of immuno-inflammatory-metabolic (IIM) dysregulation, investigated and compared the prognostic impact of 27 indices at admission for prediction of postoperative myocardial injury (PMI) and/or hospital death in hip fracture (HF) patients. Methods: In consecutive HF patient (n = 1273, mean age 82.9 ± 8.7 years, 73.5% females) demographics, medical history, laboratory parameters, and outcomes were recorded prospectively. Multiple logistic regression and receiver-operating characteristic analyses (the area under the curve, AUC) were used to establish the predictive role for each biomarker. Results: Among 27 IIM biomarkers, 10 indices were significantly associated with development of PMI and 16 were indicative of a fatal outcome; in the subset of patients aged >80 years with ischaemic heart disease (IHD, the highest risk group: 90.2% of all deaths), the corresponding figures were 26 and 20. In the latter group, the five strongest preoperative predictors for PMI were anaemia (AUC 0.7879), monocyte/eosinophil ratio > 13.0 (AUC 0.7814), neutrophil/lymphocyte ratio > 7.5 (AUC 0.7784), eosinophil count < 1.1 × 109/L (AUC 0.7780), and neutrophil/albumin × 10 > 2.4 (AUC 0.7732); additionally, sensitivity was 83.1-75.4% and specificity was 82.1-75.0%. The highest predictors of in-hospital death were platelet/lymphocyte ratio > 280.0 (AUC 0.8390), lymphocyte/monocyte ratio < 1.1 (AUC 0.8375), albumin < 33 g/L (AUC 0.7889), red cell distribution width > 14.5% (AUC 0.7739), and anaemia (AUC 0.7604), sensitivity 88.2% and above, and specificity 85.1-79.3%. Internal validation confirmed the predictive value of the models. Conclusions: Comparison of 27 IIM indices in HF patients identified several simple, widely available, and inexpensive parameters highly predictive for PMI and/or in-hospital death. The applicability of IIM biomarkers to diagnose and predict risks for chronic diseases, including OP/OF, in the preclinical stages is discussed.

Relationship between the clinical outcomes and the systemic inflammatory response index and systemic immune inflammation index after total knee arthroplasty

BACKGROUND

Periprosthetic joint infection (PJI) is an extremely damaging complication that can occur after total knee arthroplasty (TKA). There is no study in the literature investigating the relationship between systemic inflammatory response index (SIRI) and systemic inflammation immune index (SII) values and prognosis and infection in patients who have undergone TKA. The aim of the study was to determine the relationship between the inflammatory index values and the rate of PJI in patients who had previously had TKA.

METHODS

A total of 187 patients who underwent TKA between 2015 and 2023 years were retrospectively analyzed.

RESULTS

The median value of the postoperative SII index was 1862.3 (1146.6-2630.4) in the infected group, while it was 1058.2 (605.0-1762.8) in the non-infected group (p < 0.001). In the infected group, the median value of preoperative SIRI was observed as 2.3 (1.7-3.5), while in the non-infected group it was 0.9 (0.7-1.5) (p < 0.001). The cutoff value for postoperative SIRI was observed to be 2.19, with a sensitivity value of 95%, a specificity value of 46%, the AUC value observed was 65%. The cutoff value for the postoperative SII index was observed to be 1058.96, with a sensitivity value of 100%, a specificity value of 50%.

CONCLUSIONS

Our study has associated the inflammatory markers SIRI, SII, neutrophil lymphocyte ratio, and platelet lymphocyte ratio with PJI, which are easy and inexpensive to obtain. There is no widely recognized serum biomarker that can be used alone with good sensitivity and specificity. This study contributes to finding the gold standard inflammatory marker for diagnosing PJI.

Combined Systemic Immune-inflammatory Index (SII) and Geriatric Nutritional Risk Index (GNRI) predict survival in elderly patients with hip fractures: a retrospective study

PURPOSE

The Systemic Immune-inflammatory Index (SII) and Geriatric Nutritional Risk Index (GNRI) have undergone comprehensive examination and validation in forecasting the outcomes of diverse medical conditions. Nevertheless, the correlation between the combined use of GNRI and SII metrics and hip fractures has yet to be elucidated. This study aimed to determine whether the amalgamation of SII and GNRI scores constitutes an independent prognostic factor for elderly patients with hip fractures.

METHODS

We conducted a retrospective analysis of elderly patients admitted to our facility with hip fractures, encompassing both femoral neck and intertrochanteric fractures. Demographic information, experimental parameters, and postoperative complications were systematically recorded. The Geriatric Nutritional Risk Index (GNRI) and Systemic Immunoinflammatory Index (SII) were meticulously computed. Receiver operating characteristic (ROC) curves were generated, and optimal cutoff values for each parameter were determined. Subsequently, a multivariate Cox regression analysis was employed to assess the predictive utility of the SII-GNRI score in relation to 1-year postoperative mortality among elderly patients with hip fractures.

RESULTS

In a study involving 597 patients, 90 of whom experienced mortality within 1 year, it was observed that the SII-GNRI score in the group of patients who passed away was significantly higher compared to the group that survived. Following a multifactorial adjustment, it was established that a high SII-GNRI score served as an independent predictor of 1-year all-cause mortality in older patients with hip fractures. In addition to the SII-GNRI score, factors such as length of hospital stay, CCI > 2, and blood transfusion were also identified as independent risk factors for survival. Notably, the incidence of postoperative complications in patients with high SII-GNRI scores was significantly greater than in patients with low scores.

CONCLUSION

The SII-GNRI score proves valuable in predicting the 1-year survival rate for elderly patients with hip fractures who have undergone surgery.

Development and Internal Validation of a Nomogram for Predicting Postoperative Cardiac Events in Elderly Hip Fracture Patients

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.

Study of the link between hemotopoietic and skeletal systems in patients attending a referral center for osteoporosis

PURPOSE

To investigate the link between hematopoietic and skeletal tissues in patients with fragility fractures.

METHODS

We retrospectively analyzed the medical records of women older than 40 years who attended the Bone Disease Unit of "Sapienza" University of Rome for their first visit for osteoporosis from January 2020 to June 2022.

RESULTS

Fragility fractures were found in 61.8% of the sample. In particular, vertebral fractures in 35.5%, femoral fractures in 6.3%, Colles fractures in 16.5% and non-vertebral non-hip in 42.5%. Fractured patients were significantly older compared to non-fractured, had lower mean values of lumbar spine (p = 0.01), and femoral neck BMD (p = 0.007). A red blood cell distribution width (RDW) value higher than 15% was observed four times more in those with fractures compared to non-fractured patients (8.9% vs 2%, p = 0.01) and was associated with vertebral fracture after adjusting for age, BMI, menopause, nutritional status, smoking, osteoporosis and anemia (OR = 4.1, 95% CI 1.6-11.4, p = 0.003). Hematocrit was negatively associated with hip fracture also adjusting for age, BMI, menopause, nutritional status, smoking, osteoporosis (p = 0.025).

CONCLUSION

Our study demonstrates that RDW values were significantly associated with vertebral fracture and hematocrit with hip fracture. Since both parameters are included in the initial evaluation of patients with suspected bone fragility, our results should push doctors to look at these values with no incremental cost for national health services.

Can nutritional and inflammatory indices predict 90-day mortality in fragility hip fracture patients?

INTRODUCTION

Hip fractures in the elderly are related to increased mortality. The identification of patients at risk is essential. Several nutritional and inflammatory parameters were investigated in an effort to find a prognostic indicator for mortality following fragility hip fractures (FHF) surgery. We aim to evaluate their utility and compare between the different factors.

METHODS

A retrospective cohort study of patients 65 years and older, who underwent surgery following fragility hip fractures between January 2012 and June 2020, was conducted. Patients who died within 90 days were matched at a 1:1 ratio with surviving controls, based on age, gender, fracture type, and comorbidities. Nutritional and inflammatory indices, including serum albumin, protein energy malnutrition (PEM), albumin-to-globulin ratio (AGR), prognostic nutritional index (PNI), the systemic immune-inflammation index (SII), platelet-to-lymphocyte ratio (PLR), and the neutrophile-to-lymphocyte ratio (NLR), were compared between groups.

RESULTS

304 patients were included, 152 in each group. Patients' demographics were similar. Among all indices evaluated, only the PLR significantly differed between the study groups (236.9 ± 193.5 for the study group vs. 186.6 ± 119.3 for the control group (p = 0.007). In patients who survived the initial hospitalization, the PEM was also found to be correlated with 90 days mortality.

DISCUSSION

The PLR was found to be correlated with mortality risk following FHF surgery. As it can be easily calculated from accessible blood tests, we recommend its' routine assessment as a screening tool for personalized management of patients at high risk for mortality.

The Value of Preoperative Systemic Immune-Inflammation Index as a Predictor of Prolonged Hospital Stay in Orthopedic Surgery: A Retrospective Study

Purpose

Many risk factors, such as the duration of surgery and higher ASA scores, are associated with longer hospitalization in patients undergoing orthopedic surgery. However, no studies have evaluated the relationship between the preoperative systemic immune-inflammation index (SII) and length of hospital stay in orthopedic surgical patients. Therefore, this study aimed to investigate whether the SII is associated with the length of hospital stay in orthopedic surgery in adults.

Patients and Methods

This was a retrospective cohort study, and data were extracted from electronic health records. Patients were included if they were older than 18 years and had undergone orthopedic surgery between [2016-2021]. The patients were divided into two groups according to the median duration of hospitalization and according to SII cut-off value (high-SII group: ≥799.86, low-SII group: <799.86). Univariate and multivariate linear regression analyses were used to identify the association between SII and length of hospitalization.

Results

A total of 196 patients who underwent orthopedic surgery were included, and 62 were hospitalized for >21 days. There were significant differences in terms of ASA score (P = 0.041). Patients who required a longer hospitalization of >21 days had significantly lower hemoglobin level (P < 0.001), higher duration of surgery (P = 0.015), and increased requirement of ICU admission (P < 0.001). The optimal cut-off value for preoperative SII of 799.86 stratified the patients into high-SII and low-SII groups. Patients in high-SII group had higher median LOHS (22 days) compared to low-SII group (17 days; P = 0.006). In the multivariable linear regression analysis, the SII was significantly related to the length of hospital stay (β = 0.246, 95% confidence interval [CI] 0.000-0.005, P = 0.031).

Conclusion

A high-SII value is associated with an increased risk of longer hospitalization after orthopedic surgery.

The Role of Neutrophil to Lymphocyte Ratio in the Assessment and Rehabilitation of Knee Osteoarthritis Patients

Osteoarthritis (OA) is considered to be a real problem for many people. The last decade is characterized through an increased interest in using a non-specific, simply and readily available marker of inflammation-neutrophil to lymphocyte ratio (NLR)-to predict various chronic diseases (gastrointestinal and colorectal cancers, lung cancer, cardiovascular events, sarcoidosis, arthritis). The aim of our study is to establish the correlation between NLR and other parameters of clinical and functional status in KOA patients and to compare the NLR values before and after rehabilitation program. 90 patients, aged 40 to 82 years, diagnosed with mild (8 patients), moderate (70 patients) and severe (12 patients) KOA, in accordance with Kellgren and Lawrence score. Statistical assessment showed different values for the erythrocyte sedimentation (ESR) rate at 1-hour, Visual Analogue Scale (VAS), and Lequesne index in the studied group. NLR regression was significant for ESR at 1 and 2 hours. As an independent diagnostic marker, NLR has limited value, however it can be considered an inexpensive additional biomarker for the diagnosis of KOA and for monitoring the rehabilitation program.

Nutritional and Inflammatory Indices and the Risk of Surgical Site Infection After Fragility Hip Fractures: Can Routine Blood Test Point to Patients at Risk?

Background: Surgical site infection (SSI) after fragility hip fracture (FHF) surgery is associated with increased morbidity and mortality. We aim to utilize several established nutritional and inflammatory indices to characterize patients at risk. Patients and Methods: A retrospective cohort study of patients 65 years and older, who underwent surgery following FHFs between January 2012 and June 2020. Those patients who presented with post-operative infection in the year after surgery were compared with patients who did not. The primary outcomes were serum albumin, protein energy malnutrition (PEM), albumin to globulin ratio, prognostic nutritional index (PNI), the systemic immune inflammation index, platelet to lymphocyte ratio, neutrophil to lymphocyte ratio, and body mass index. Results: A total of 1,546 patients, ages 82.4 ± 7.7, were included; 55 of whom presented with SSI. Demographics and comorbidities were similar. Anticoagulation treatment was more prevalent in the infected group (32.7% vs. 13.9%, p < 0.001) as were intra-capsular fractures (60% vs. 42.9%, respectively; p = 0.012). Of all indices estimated, only the PNI and the PEM were found to differ significantly (44.7 ± 9.6 and 26.1% vs. 49.4 ± 17.3 and 13.6% for the study and control groups respectively; p = 0.002 and 0.027). A logistic regression model was calculated to evaluate the contribution of fracture type and anticoagulation treatment as possible confounders. Both indices were found to be significant for infection after regression odds ratio, 2.25 for PEM; (95% confidence interval [CI], 1.089-4.344) and odds ratio, 0.97 for PNI (95% CI, 0.937-0.996). Conclusions: The PNI and the PEM were found to correlate with infection risk after FHF surgery. As both can be easily calculated from an accessible blood test, we recommend their routine use as a screening tool for tailored management of patients at risk for SSI.

Risk Factors of the 2-Year Mortality after Bipolar Hemiarthroplasty for Displaced Femoral Neck Fracture

Purpose

This study investigates the relationship between preoperative neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-C-reactive protein ratio (LCR), albumin, and 2-year mortality in elderly patients having hemiarthroplasty for displaced femoral neck fracture (FNF).

Materials and Methods

We retrospectively reviewed 284 elderly patients who underwent hemiarthroplasty for Garden type IV FNF from September 2014 to September 2020. Using the receiver operating characteristic curve, optimal cutoff values for LCR, NLR, and albumin were established, and patients were categorized as low or high. Associations with 2-year mortality were evaluated through univariate and multivariate Cox regression analyses.

Results

Of the 284 patients, 124 patients (45.9%) died within 2 years post-surgery. The optimal cutoff values were: LCR at 7.758 (specificity 58.5%, sensitivity 25.0%), NLR at 3.854 (specificity 39.2%, sensitivity 40.0%), and albumin at 3.750 (specificity 65.9%, sensitivity 21.9%). Patients with low LCR (<7.758), high NLR (≥3.854), and low albumin (<3.750) had a statistically significant reduced survival time compared to their counterparts.

Conclusion

Lower preoperative LCR and albumin levels, along with higher NLR, effectively predict 2-year mortality and 30-day post-surgery complications in elderly patients with Garden type IV FNF undergoing hemiarthroplasty.

The Role of Combined Inflammatory Biomarkers in the Diagnosis of High- and Low-Virulence FRI Among High-Risk Lower Extremity Fractures

Objective

The aim of this study is to evaluate the diagnostic accuracy of infection-related biomarkers in high-risk lower limb injury patients with fracture-related infection (FRI) caused by high-/low-virulence microorganisms.

Methods

This study was a retrospective analysis of patients with high-risk lower extremity fractures (including tibial plateau, calcaneus, and Pilon fractures) who underwent open reduction internal fixation (ORIF) surgery from January 2017 to February 2022. Peripheral blood samples were collected within 24 hours of admission, and the following information was evaluated: gender, age, BMI, smoking, comorbidities, injury information, surgical details, values for serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), as well as neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR).

Results

A total of 576 patients receiving lower extremity fracture surgery were included in this study. Fifty-one patients (8.85%) were identified as FRI, and 28 (54.9%) of these 51 cases were further classified as high-virulence group. The median levels of CRP, ESR, NLR, and MLR were significantly higher in the FRI group than in the non-FRI group (p < 0.01). Similarly, the marginally significantly higher levels of CRP and NLR presented in the high-virulence group, compared to the low-virulence group (p < 0.1). The AUC areas of CRP, NLR, and CRP+NLR were 0.826, 0.650, and 0.873, respectively. We calculated the optimal cut-off points for CRP+NLR as diagnostic markers of high-virulent infection was 0.377.

Conclusion

This study showed the incidence of FRI in high-risk lower extremity fractures was 8.9%, and identified preoperative serum biomarkers, including CRP, ESR, NLR, and PLR, as useful tools for assisting in the diagnosis of infection. Additionally, the combination of CRP with NLR played a discriminating clinical role in postoperative infections caused by different virulence.

Level of Evidence

Clinical study.

Relationship Between Pre- and Post-Operative C-Reactive Protein (CRP), Neutrophil-to-Lymphocyte Ratio (NLR), and Platelet-to-Lymphocyte Ratio (PLR) With Post-Operative Pain After Total Hip and Knee Arthroplasty: An Observational Study

BACKGROUND

Anesthetic technique and postoperative pain management are crucial for total joint arthroplasty (TJA) patients. The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP) are new, simple, and cost-effective predictors for prognosis. The predictive value of NLR as an inflammatory marker can predict post-operative pain caused by inflammatory pathways secondary to surgical trauma. CRP is also the most sensitive and specific biomarker of inflammation whereas PLR was also recently considered a possible marker for inflammation which may further contribute to pain and sequelae. Thus, anesthetists can make decisions about the amount, time, and type of analgesic to use based on preoperative values of these parameters to provide maximum postoperative pain control and facilitate early rehabilitation. Thus, the current study was conducted to determine the relationship between CRP, NLR, and PLR levels and the intensity of pain in patients following total hip arthroplasty (THA) and total knee arthroplasty (TKA).

MATERIALS AND METHODS

A total of 105 patients scheduled for THA and TKA fulfilling the study's inclusion criteria were enrolled. Inclusion criteria of the study were all the patients giving written consent, ASA Grade I-III, patients between 18 and 90 years who were scheduled for elective lower extremity TJA, and all the patients who remained admitted until stitches were removed. Patients were given intrathecal 15 mg hyperbaric bupivacaine via 25G atraumatic spinal needle in the L3-L4 interspace. The recorded data were demographic characteristics, preexisting comorbidities, number of blood transfusions, and operation time, postoperative analgesics given, duration of hospital stay, time of mobility, pain scoring as per visual analog scale (VAS) scoring system with an aim to establish a relationship between pre- and post-operative (Days 3 & 5) CRP, NLR, and PLR with post-operative pain after THA and TKA.

RESULT

The present study demonstrated a significant correlation (p < 0.002) between preoperative and postoperative NLR with pain after TJA whereas PLR and CRP did not show any significant relationship with post-operative pain after THA and TKA. A significantly higher NLR ratio was observed for patients on all the periods of observation (pre-op., Day 3, and Day 5). Pre-op. and Day 5 NLR of patients who required transfusion were significantly higher than those who did not require transfusion and patients with higher NLR values could be mobilized significantly later and had significantly higher duration of hospital stay. The correlation of CRP levels and PLR levels at different time intervals did not show a significant correlation with Day 3 and Day 5 pain scores.

CONCLUSION

The present study demonstrated a significant correlation between preoperative and postoperative NLR with pain after TJA.

Predictability of Neutrophil to Lymphocyte Ratio in preoperative elderly hip fracture patients for post-operative short-term complications: a retrospective study

PURPOSE

Neutrophil to Lymphocyte Ratio (NLR) is a simple biomarker of systemic inflammatory response. We investigated predictability of NLR for early adverse outcome after surgery for hip fracture in elderly population.

METHODS

We reviewed a total of 971 elderly patients with hip fracture who underwent emergency surgery between January 2017 and July 2020 in the Department of Orthopaedics Surgery at the Wollongong Hospital. After considering exclusion criteria, data from a total of 834 patients included in our study. Socio-demographic data, NLR in admission, updated Charlson comorbidity index (uCCI), biochemical markers, mortality rate and 15 short term post-operative complications were collected to determine predictability of NLR for post-operative complications and mortality.

RESULTS

After hip surgery, Hospital in-patient case fatality rate was 3.7% (31). In addition, 63.1% (511) of the patients had at least one complication or more. Logistic regression demonstrated that raised NLR (P-value < 0.001, OR 1.05) and uCCI≥4 (P-Value < 0.001, OR 1.75) are associated with post-operative complications. Moreover, decreased haemoglobin was associated with adverse effects (P-value < 0.001, OR 0.97). No association was found for any of these variables with in-patient mortality except for albumin (P-value: 0.03). In addition, despite significant association, ROC analyses showed a low predictability for each of the above variables including NLR (AUC 0.59) for post-operative complications.

CONCLUSIONS

Despite significant association, NLR was unable to prognosticate early adverse outcomes. However, it can be considered as a risk factor in admission for postoperative complications in combination with other risk factors and clinical context.

Biomarkers as predictors of inpatient mortality in fractured neck of femur patients

INTRODUCTION

Hip fractures are common and it is estimated to cost the National Health Service (NHS) around £2 billion/year. The majority of these patients are elderly and they require careful perioperative management as morbidity and mortality are high. This study aims to look at routinely gathered biomarker data and baseline demographics to evaluate if they may be used to predict inpatient mortality.

PATIENTS AND METHODS

The study included 2158 patients from a single Centre over a 5-year period.

INCLUSION CRITERIA

age>60, confirmed fractured neck of femur on radiological imaging.

EXCLUSION CRITERIA

pathological fractures, patients treated non-operatively, missing data. Univariate followed by multivariate analysis was conducted to identify the independent predictors of inpatient mortality.

RESULTS

The variables found to be independent predictors of inpatient mortality were: age > 85, sex (male), albumin < 35, lymphocytes < 1, American Society of Anesthesiologist (ASA) grade > 3. For the final derived multivariate logistic regression model, a receiver operator characteristic (ROC) curve was constructed to assess the ability of the included variables to predict inpatient mortality. The area under the curve was 0.794 which together with sensitivity of 63.2% and a specificity of 79.1% at a cut value of 0.1.

CONCLUSION

This paper supports research previously conducted in this field, showing the prognostic value of both biomarker (albumin and lymphocytes), and non-biomarker data (ASA grade, age and gender) in predicting mortality in patients who have sustained a hip fracture.

Proximal Femur Fractures in the Elderly-A Novel Modality to Predict Mortality: The Neutrophil-to-Lymphocyte Ratio

Background: The assessment and identification of elderly patients with proximal femur fractures (PFF) who are at high risk of postoperative mortality may influence the treatment decision-making process. The purpose of this study was to determine whether the neutrophil-to-lymphocyte ratio (NLR) could be used to predict postoperative mortality in the elderly population. Methods: A four-year retrospective cohort study of electronic medical records was conducted at a single tertiary care hospital between 2015 and 2018. Data from 1551 patients aged 65 years and older who underwent surgical treatment for PFF were collected and analyzed. The data included complete blood counts at admission, demographic information, underlying illnesses, type of surgery, and postoperative mortality and complications during the first year of follow-up. A survival analysis model was utilized. Results: The mean age was 90.76 ± 1.88 years, 1066 (68.7%) women. Forty-four (2.8%) patients experienced postoperative infection. A higher NLR0 was independently associated with higher all-cause mortality rates in patients who underwent surgical treatment for PFF (p = 0.041). Moreover, the mean NLR0 value was higher when the death occurred earlier after surgery (p < 0.001). Conclusions: When combined with other clinical and laboratory findings, NLR0 levels may serve as a potentially valuable, inexpensive, and reliable prognostic biomarker to improve risk stratification for elderly patients who are candidates for PFF surgery. Furthermore, with additional research, we could potentially develop a treatment algorithm to identify patients at high risk of postoperative mortality.

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.

Comparison of Prognostic Value of 10 Biochemical Indices at Admission for Prediction Postoperative Myocardial Injury and Hospital Mortality in Patients with Osteoporotic Hip Fracture

Aim: To evaluate the prognostic impact at admission of 10 biochemical indices for prediction postoperative myocardial injury (PMI) and/or hospital death in hip fracture (HF) patients. Methods: In 1273 consecutive patients with HF (mean age 82.9 ± 8.7 years, 73.5% women), clinical and laboratory parameters were collected prospectively, and outcomes were recorded. Multiple logistic regression and receiver-operating characteristic analyses (the area under the curve, AUC) were preformed, the number needed to predict (NNP) outcome was calculated. Results: Age ≥ 80 years and IHD were the most prominent clinical factors associated with both PMI (with cardiac troponin I rise) and in-hospital death. PMI occurred in 555 (43.6%) patients and contributed to 80.3% (49/61) of all deaths (mortality rate 8.8% vs. 1.9% in non-PMI patients). The most accurate biochemical predictive markers were parathyroid hormone > 6.8 pmol/L, urea > 7.5 mmol/L, 25(OH)vitamin D < 25 nmol/L, albumin < 33 g/L, and ratios gamma-glutamyl transferase (GGT) to alanine aminotransferase > 2.5, urea/albumin ≥ 2.0 and GGT/albumin ≥ 7.0; the AUC for developing PMI ranged between 0.782 and 0.742 (NNP: 1.84−2.13), the AUC for fatal outcome ranged from 0.803 to 0.722, (NNP: 3.77−9.52). Conclusions: In HF patients, easily accessible biochemical indices at admission substantially improve prediction of hospital outcomes, especially in the aged >80 years with IHD.

Synovial Fluid and Serum Neutrophil-to-Lymphocyte Ratio: Novel Biomarkers for the Diagnosis and Prognosis of Native Septic Arthritis in Adults

BACKGROUND

Septic arthritis (SA) is a musculoskeletal emergency for which prompt diagnosis and treatment are critical. However, traditional diagnostic criteria of a synovial fluid (SF) white blood-cell count (WBC) of >50,000 cells/mm 3 or >90% polymorphonuclear leukocytes (%PMN) are not particularly sensitive or specific for the diagnosis of SA. Furthermore, prognostic markers are lacking. The purposes of this study were to assess the discriminative ability of the SF neutrophil-to-lymphocyte ratio (NLR) in the diagnosis of SA and of the serum NLR in the prognosis of SA.

METHODS

A multi-institution, retrospective study of 598 patients with native shoulder, hip, or knee SA in 2000 to 2018 was conducted. SF-NLR was calculated from the arthrocentesis cell count with differential. Receiver operating characteristic curves were analyzed, and the optimal threshold of SF-NLR for SA diagnosis was determined using the Youden index. Results were compared with traditional SF diagnostic criteria. Similar analyses assessed the association of serum NLR with 90-day treatment failure and mortality for the subset of patients with confirmed hip or knee SA and with serum complete blood-cell counts with differentials (n = 235). Results were compared with traditional serum prognostic markers (WBC, C-reactive protein [CRP], and erythrocyte sedimentation rate [ESR]).

RESULTS

The SF-NLR (area under the receiver operating characteristic curve [AUC], 0.85 [95% confidence interval (CI), 0.82 to 0.88]) was significantly more accurate for an SA diagnosis than SF-WBC (AUC, 0.80 [95% CI, 0.76 to 0.83]; p = 0.002) and SF-%PMN (AUC, 0.81 [95% CI, 0.77 to 0.84]; p = 0.01). The optimal threshold of SF-NLR was 25 (78% sensitivity and 81% specificity), compared with >50,000 cells/mm 3 for SF-WBC (56% sensitivity and 80% specificity) and >90% for SF-%PMN (65% sensitivity and 78% specificity). Elevated serum NLR was independently associated with 90-day treatment failure (odds ratio [OR], 7.04 [95% CI, 3.78 to 13.14]; p < 0.001) and mortality (OR, 7.33 [95% CI, 2.00 to 26.92]; p = 0.003); elevated serum WBC and CRP were also associated with treatment failure, and WBC, CRP, and ESR were not associated with mortality.

CONCLUSIONS

This study provides compelling data on the superior diagnostic and prognostic ability of serum NLR and SF-NLR for SA compared with current clinical standards. Given that this biomarker requires no additional cost or time to return than current laboratory tests already being performed, pending validation, it can readily be used to aid clinicians in the diagnosis and prognostication of SA.

LEVEL OF EVIDENCE

Diagnostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Associations of Neutrophil-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio and Monocyte-to-Lymphocyte Ratio with Osteoporosis and Incident Vertebral Fracture in Postmenopausal Women with Rheumatoid Arthritis: A Single-Center Retrospective Cohort Study

Background and Objectives: We investigated whether nutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphoycte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR) are associated with the presence of osteoporosis (OP) and vertebral fractures in patients with rheumatoid arthritis (RA). Materials and Methods: This retrospective cohort study included 413 postmenopausal patients with RA and 200 healthy controls who underwent dual-energy X-ray absorptiometry (DEXA) between January 2005 and December 2017. DEXA examination data were defined as the index date, and all laboratory values were measured within one month from the index date. OP was defined as a T-score < −2.5, and incident vertebral fractures were defined as the first occurrence of non-traumatic fractures after the index date. NLR, PLR, and MLR measures were dichotomized by a median split (low vs. high). Results: The median NLR, PLR, and MLR in RA patients were significantly higher than those in controls. The frequencies of OP of the lumbar spine, hip, and either site in postmenopausal patients with RA were 24.7%, 15.5%, and 32%, respectively, and were significantly higher than those in controls. After adjusting for confounding factors, a high baseline NLR was significantly associated with OP at either site (OR = 1.61, p = 0.041). In addition, high baseline NLR (OR = 2.11, p = 0.025) and PLR (OR = 2.3, p = 0.011) were related with the presence OP at hip. During the follow-up period, 53 (12.8%) patients with RA developed vertebral fractures incidentally. In multivariable Cox regression models, a high baseline NLR (HR = 4.72, p < 0.001), PLR (HR = 1.96, p = 0.024), and MLR (HR = 2.64, p = 0.002) were independently associated with a higher risk of incidental vertebral fractures. Conclusions: Our data suggest that NLR, PLR, and MLR can be used as potential markers of systemic bone loss among individuals with RA.

Can C-reactive protein-based biomarkers be used as predictive of 30-day mortality in elderly hip fractures?A retrospective study

BACKGROUND

C-reactive protein-to-lymphocyte ratio (CLR), C-reactive protein/albumin (CRP/ALB), and CRP are prognostic factors for outcome and survival in oncology and digestive surgery. CLR has not been studied for the prediction of mortality in hip fracture. The aim of this study is to investigate whether there is an association between pre-operative CLR, CRP/ALB, and CRP levels in patients with hip fracture and patient survival.

METHODS

The medical reports of the patients who underwent surgery with a diagnosis of hip fracture in our hospital between January 2016 and December 2019 were retrospectively reviewed. The patients were divided into two groups (Group E: Those who died within 1 month and Group S: Those who died after the 1st month or those who survived). A total of 19 parameters, namely, included ' blood parameters including hemoglobin, C-reactive protein, albumin, lymphocytes, neutrophils, monocytes, platelets, PLR, NLR, LMR, CLR CRP/ALB ratios, gender, American Society of Anesthesiologists, Charlson Comorbidity Index, delirium, infections, repeated surgeries, and type of anesthesia were evaluated preoperatively and on the post-operative 2nd and 5th days and 1 month.

RESULTS

A total of 165 patients with the mean age of 83.09±8.52 years who met the inclusion criteria were studied. The pre-op-erative means of CRP, neutrophil count, CLR ratio, and CRP/ALB ratio were statistically significantly higher in Group E than in Group S (p=0.016, p=0.023, p=0.035, and p=0.044, respectively). The univariate regression analysis showed that age, pre-operative Hb level, CRP, and CRP/ALB ratio were significant predictors of the 1-month mortality (ß=-0.335, p=0.049; ß=0.411, p=0.028; ß=3.632, p=0.007; and ß=-3.280, p=0.008; respectively). When we performed the ROC curve analysis, the CRP/ALB ratio had the highest AUC, with the highest sensitivity and specificity. The cutoff value of CRP/ALB ratio was found to be 12.42.

CONCLUSION

We found that the pre-operative CRP/ALB ratio is an important parameter for predicting the first 30-day mortality in elderly patients with intertrochanteric femur fractures. For this reason, we recommend that CRP and albumin be checked in prepa-ration for routine pre-operative anesthesia.

Standard and Newly Defined Prognostic Factors Affecting Early Mortality After Hip Fractures

Purpose: Early mortality rate in geriatric patients after hip fractures remains very high. Determining the prognostic factors is crucial for decreasing early mortality. This study aimed to evaluate the prognostic risk factors affecting early mortality after hip fracture in the elderly.

Methods: Medical records of 335 patients with age 70 years or older who sustained hip fractures which were treated by hemiarthroplasty or proximal femoral nailing between May 2017 and May 2019 were reviewed. Neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) were investigated for validity as the new prognostic markers. The other variables included age, gender, type of surgery, type of implant, type of anesthesia, American Society of Anesthesiologists (ASA) score, presence of comorbidities, delirium, length of hospital stay, time delay to surgery, number of erythrocyte transfusions, and laboratory data were assessed for 30-day, 90-day, and one-year mortality. Univariate analysis and logistic regression analysis were used to determine the associated mortality.

Results: Thirty-day mortality rate was 10.4% and was associated with being aged ≥90 years (p-value: 0.013, odds ratio {OR}: 0.13) and ASA score of 4 (p-value: 0.019, OR: 0.22). Ninety-day mortality rate was 21.5% and was associated with age (p-value: 0.002), being aged 80-89 years (p-value: 0.032, OR: 0.43), being aged ≥90 years (p-value: 0.001, OR: 0.13), general anesthesia (p-value: 0.016, OR: 0.41), preoperative high NLR level (p-value: 0.028, OR: 1.05), high blood urea nitrogen (BUN) level (p-value: 0.049, OR:1.02). One year mortality rate was 33.7% and independent significant prognostic risk factors were determined as being aged ≥90 years (p-value: 0.003, OR: 0.23), length of hospital stay (p-value: 0.003, OR: 1.04), and preoperative serum albumin level (p-value: 0.037, OR: 0.6). The other evaluated risk factors were not independently found to be associated with all early mortality time.

Conclusion: Patients at or over 90 years old were at risk for all early mortality time points. NLR which is a new and cheap biomarker can be used as a prognostic risk factor for 90-day mortality. The variable of PLR was not found valuable for early mortality.

Association between Neutrophil Levels on Admission and All-Cause Mortality in Geriatric Patients with Hip Fractures: A Prospective Cohort Study of 2,589 Patients

OBJECTIVE

To evaluate the association between neutrophil levels and all-cause mortality in geriatric hip fractures.

METHODS

Elderly patients with hip fractures were screened between January 2015 and September 2019. Demographic and clinical characteristics of the patients were collected. Linear and nonlinear multivariate Cox regression models were used to identify the association between neutrophil levels and mortality. Analyses were performed using Empower Stats and R software.

RESULTS

A total of 2,589 patients were included in this study. The mean follow-up period was 38.95 months. During the study period, 875 (33.80%) patients died due to various causes. Linear multivariate Cox regression models showed that neutrophil levels were associated with mortality after adjusting for confounding factors, when neutrophil concentration increased by 1∗10⁹/L, the mortality risk increased by 3% (HR = 1.03, 95% CI: 1.00-1.06, and P=0210). Neutrophil concentration was used as a categorical variable; we only found statistically significant differences when neutrophil levels were high (HR = 1.27, 95% CI:1.05-1.52, and P=0.0122). In addition, the results are stable in P for trend and propensity score matching sensitivity analysis.

CONCLUSIONS

Neutrophil levels are associated with mortality in geriatric hip fractures and could be considered a predictor of death risk in the long-term. This study is registered with the Chinese Clinical Trial Registry (ChiCTR) as number ChiCTR2200057323.

Risk prediction model for deep surgical site infection (DSSI) following open reduction and internal fixation of displaced intra-articular calcaneal fracture

Deep surgical site infection (DSSI) is a serious complication affecting the surgical outcome of displaced intra‐articular calcaneal fracture, and a risk prediction model based on the identifiable risk factors will provide great clinical value in prevention and prompt interventions. This study retrospectively identified patients operated for calcaneal fracture between January 2014 and December 2019, with a follow‐up ≥1 year. The data were extracted from electronic medical records, with regard to demographics, comorbidities, injury, surgery and laboratory biomarkers at admission. Univariate and multivariate logistics regression analyses were used to identify the independent factors for DSSI, thereby the risk prediction model was developed. Among 900 patients included, 2.7% developed a DSSI. The multivariate analyses identified five factors independently associated with DSSI, including current smoking (OR, 2.8; 95% confidence interval [CI], 1.3‐6.4; P = .021), BMI ≥ 26.4 kg/m² (OR, 3.1; 95% CI, 1.6‐8.4; P = .003), ASA ≥II (OR, 1.3; 95% CI, 1.0‐5.1; P = .043), incision level of II (OR, 3.8; 95% CI, 1.3‐12.6; P = .018) and NLR ≥6.4 (OR, 3.2; 95% CI, 1.3‐7.5; P = .008). A score of 14 as the optimal cut‐off value was corresponding to sensitivity of 0.542 and specificity of 0.872 (area, 0.766; P < .001); ≥14 was associated with 8.1‐times increased risk of DSSI; a score of 7 was corresponding sensitivity of 100% and 10 corresponding to sensitivity of 0.875. The risk prediction model exhibited excellent performance in distinguishing the risk of DSSI and could be considered in practice for improvement of wound management, but its validity requires to be verified by better‐design studies.

A Case of Bordetella bronchiseptica Bacteremia in a Patient With COVID-19: Brief Report

Bordetella bronchiseptica is a gram-negative coccobacillus that colonizes the respiratory system of mammals such as dogs, cats, rabbits and others and might cause upper respiratory tract infections. Although it can be rarely pathogenic in humans, there are several case reports describing infections in humans. We describe the case of a patient without prolonged immunosuppression or underlying diseases, with bacteremia from Bordetella bronchiseptica, while being treated in a tertiary hospital for COVID-19 infection.

Association of Platelets and White Blood Cells Subtypes with Trauma Patients' Mortality Outcome in the Intensive Care Unit

Background: White blood cell (WBC) subtypes have been suggested to reflect patients’ immune-inflammatory status. Furthermore, the derived ratio of platelets and WBC subtypes, including monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR), is proposed to be associated with patient outcome. Therefore, this study aimed to identify the association of platelets and white blood cells subtypes with the mortality outcome of trauma patients in the intensive care unit (ICU). Method: The medical information from 2854 adult trauma patients admitted to the ICU between 1 January 2009 and 31 December 2019 were retrospectively retrieved from the Trauma Registry System and classified into two groups: the survivors group (n = 2524) and the death group (n = 330). The levels of monocytes, neutrophils, lymphocytes, platelets, and blood-drawn laboratory data detected upon patient arrival to the emergency room and the derived MLR, NLR, and PLR were calculated. Multivariate logistic regression analysis was used to determine the independent effects of univariate predictive variables on mortality occurrence. Result: The results revealed the patients who died had significantly lower platelet counts (175,842 ± 61,713 vs. 206,890 ± 69,006/μL, p < 0.001) but higher levels of lymphocytes (2458 ± 1940 vs. 1971 ± 1453/μL, p < 0.001) than the surviving patients. However, monocyte and neutrophil levels were not significantly different between the death and survivor groups. Moreover, dead patients had a significantly lower PLR than survivors (124.3 ± 110.3 vs. 150.6 ± 106.5, p < 0.001). However, there was no significant difference in MLR or NLR between the dead patients and the survivors. Multivariate logistic regression revealed that male gender, old age, pre-existing hypertension, coronary artery disease and end-stage renal disease, lower Glasgow Coma Scale (GCS), higher Injury Severity Score (ISS), higher level of lymphocytes and lower level of red blood cells and platelets, longer activated partial thromboplastin time (aPTT), and lower level of PLR were independent risk factors associated with higher odds of trauma patient mortality outcome in the ICU. Conclusion: This study revealed that a higher lymphocyte count, lower platelet count, and a lower PLR were associated with higher risk of death in ICU trauma patients.

Association Between High-Sensitivity Troponin T on Admission and Organ Dysfunction During Hospitalization in Patients Aged 80 Years and Older with Hip Fracture: A Single-Centered Prospective Cohort Study

Background

Prognostic evaluation of elderly patients with hip fracture is an issue that has been highly concerned by clinicians. Only a few studies have focused on organ dysfunction after hip fracture in the elderly. This study aimed to investigate the association between high-sensitivity troponin T (hs-TnT) at admission and organ dysfunction during hospitalization in elderly patients with hip fracture.

Methods

We enrolled 168 patients with hip fracture who were aged 80 years and older at Geriatric Orthopaedic Center of Sichuan Provincial Orthopedic Hospital between January 2020 and August 2020. Baseline characteristics, perioperative information, and short-term clinical outcomes were analyzed.

Results

Of the 208 patients admitted during the study period, 168 met the inclusion criteria; of these, 91 (54.2%) had higher hs-TnT than the 99th percentile in the normal population. After adjustment for confounders, elevated hs-TnT was independently associated with multiple organ dysfunction syndrome in the elderly (MODSE) (adjusted OR, 5.76; 95% CI, 1.74–19.10; P = 0.004), heart dysfunction (adjusted OR, 7.48; 95% CI, 2.17–25.82; P = 0.001), MODS severity score > 3 (adjusted OR, 5.22; 95% CI, 1.32–20.60; P = 0.018), and length of hospital stay > 14 days (adjusted OR, 2.38; 95% CI, 1.05–5.36; P = 0.037).

Conclusion

Increased hs-TnT on admission is an independent risk factor for MODSE after hip fracture in patients aged 80 years and older. Effective measures should be applied to avoid progression of MODSE from pre-failure stage to failure stage.

Systemic immune-inflammation index independently predicts poor survival of older adults with hip fracture: a prospective cohort study

Background

The systemic immune-inflammation index (SII), based on peripheral platelet, neutrophil and lymphocyte counts, has been proven to be a promising prognostic indicator in various diseases. Hip fracture is a common injury among the older adults, and has become a global public health problem with high mortality and disability rates. However, the relationship between SII and the prognosis of hip fracture is not yet well-known. The aim of the this study was to explore the predictive value of SII in older adults with hip fracture undergoing surgery.

Methods

This was a prospective cohort study performed from January 2014 to December 2018 at a orthopaedic center, China. The SII was calculated as platelet×neutrophil/lymphocyte counts. Univariable and multivariable Cox proportional hazard models were used to assess the association between SII and all-cause mortality.

Results

A total of 290 older adults with hip fracture were included, and the mean (SD) age was 77.6 (8.6) years, and 189 (65.2%) were female. The median (IQR) SII was 759.4 (519.0–1128.7) × 10⁹/L. After a median follow-up time of 33.4 months, 13 (4.5%), 26 (9.0%) and 54 (18.6%) patients died within the 30-day, 1-year and last follow-up, respectively. Multivariable Cox analysis revealed that each increase of 100 units of SII was associated with a 8% increased hazard of death at 1-year follow-up (HR = 1.08, 95% CI: 1.01–1.17, p = 0.033), and 9% increased hazard of death at last follow-up (HR = 1.09, 95% CI: 1.03–1.15, p = 0.003).

Conclusions

SII is associated with poor all-cause mortality in older adults with hip fracture undergoing surgery, and deserves further investigation and application in clinical practice.

Admission neutrophil-to-lymphocyte ratio and monocyte-to-lymphocyte ratio to predict 30-day and 1-year mortality in geriatric hip fractures

INTRODUCTION

Elderly patients with hip fractures exhibit a high incidence of mortality and morbidity. The aim of this study was to evaluate the factors that may predict mortality in patients with geriatric hip fracture.

METHODS

Included in this retrospective study were 241 patients who were admitted to the hospital with hip fractures between May 2017 and March 2019. The effect of the modified 5-item frailty index (mFI-5) on 30-day and 1-year mortality was evaluated. In addition, admission neutrophil-to-lymphocyte ratios (NLRs) and monocyte-to-lymphocyte ratios (MLRs) were also examined.

RESULTS

The mFI-5 was not found to be a statistically significant predictive indicator for 30-day and 1-year mortality (P = 0.485 and P = 0.484, respectively). Chronic obstructive pulmonary disease or current pneumonia was found to increase mortality by 2.702 times (P = 0.002). The 30-day mortality rates of patients aged ≥80 years were significantly higher than those aged 65-79 years (P < 0.05). However, there was no statistical difference in the mortality rates between the age groups after 30 days postoperatively (P = 0.114). Admission NLRs and MLRs were significantly higher in the 30-day and 1-year mortality groups. The cut-off values of the admission NLRs and MLRs for 30-day mortality were calculated as 6.55 and 0.65, respectively, while the same cut-off values for 1-year mortality were calculated as 6.55 and 0.635, respectively.

CONCLUSIONS

Admission NLRs and MLRs are useful hematological data for the prediction of 30-day and 1-year mortality in geriatric hip fracture 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.

Neutrophil to lymphocyte ratio and fracture severity in young and middle-aged patients with tibial plateau fractures

PURPOSE

The neutrophil-to-lymphocyte ratio (NLR) has recently been found to be closely associated with the severity of trauma. This study aimed to analyze the correlation between the imaging severity of isolated tibial plateau fractures (TPFs) and the NLR in the blood.

METHODS

A total of 223 patients with isolated TPFs were enrolled in this retrospective study over five years. The data at hospital admission were extracted from an electronic database. Schatzker classification was performed according to the imaging data by two experienced orthopaedic surgeons. All patients were divided into two groups: group 1 included patients with mild-to-moderate fractures (Schatzker types I-IV), and group 2 included patients with severe fractures (Schatzker types V-VI). The NLR levels at hospital admission were statistically compared between the two groups.

RESULTS

The blood NLR, hemoglobin level, red blood cell count, neutrophil count, platelet count, time from injury to admission, total protein, and Na⁺ levels were significantly different among the two groups. According to the receiver operating characteristic (ROC) curve, the cutoff for the NLR was 5.8. ROC curve analysis showed that the sensitivity of an NLR ≥ 5.8 to predict severe TPFs was 53.4%, and the specificity was 70.7%. In the multivariate analysis, NLR ≥ 5.8 and haemoglobin < lower limit appeared to be independent predictors of severe TPFs.

CONCLUSIONS

Our study is the first to demonstrate that the NLR level appears to be a useful biomarker for predicting the severity of isolated TPFs in young and middle-aged adults.

Association Between Preoperative Metformin Exposure and Postoperative Outcomes in Adults With Type 2 Diabetes

Importance

Adults with comorbidity have less physiological reserve and an increased rate of postoperative mortality and readmission after the stress of a major surgical intervention.

Objective

To assess postoperative mortality and readmission among individuals with diabetes with or without preoperative prescriptions for metformin.

Design, Setting, and Participants

This cohort study obtained data from the electronic health record of a multicenter, single health care system in Pennsylvania. Included were adults with diabetes who underwent a major operation with hospital admission from January 1, 2010, to January 1, 2016, at 15 community and academic hospitals within the system. Individuals without a clinical indication for metformin therapy were excluded. Follow-up continued until December 18, 2018.

Exposures

Preoperative metformin exposure was defined as 1 or more prescriptions for metformin in the 180 days before the surgical procedure.

Main Outcomes and Measures

All-cause postoperative mortality, hospital readmission within 90 days of discharge, and preoperative inflammation measured by the neutrophil to leukocyte ratio were compared between those with and without preoperative prescriptions for metformin. The corresponding absolute risk reduction (ARR) and adjusted hazard ratio (HR) with 95% CI were calculated in a propensity score-matched cohort.

Results

Among the 10 088 individuals with diabetes who underwent a major surgical intervention, 5962 (59%) had preoperative metformin prescriptions. A total of 5460 patients were propensity score-matched, among whom the mean (SD) age was 67.7 (12.2) years, and 2866 (53%) were women. In the propensity score-matched cohort, preoperative metformin prescriptions were associated with a reduced hazard for 90-day mortality (adjusted HR, 0.72 [95% CI, 0.55-0.95]; ARR, 1.28% [95% CI, 0.26-2.31]) and hazard of readmission, with mortality as a competing risk at both 30 days (ARR, 2.09% [95% CI, 0.35-3.82]; sub-HR, 0.84 [95% CI, 0.72-0.98]) and 90 days (ARR, 2.78% [95% CI, 0.62-4.95]; sub-HR, 0.86 [95% CI, 0.77-0.97]). Preoperative inflammation was reduced in those with metformin prescriptions compared with those without (mean neutrophil to leukocyte ratio, 4.5 [95% CI, 4.3-4.6] vs 5.0 [95% CI, 4.8-5.3]; P < .001). E-value analysis suggested robustness to unmeasured confounding.

Conclusions and Relevance

This study found an association between metformin prescriptions provided to individuals with type 2 diabetes before a major surgical procedure and reduced risk-adjusted mortality and readmission after the operation. This association warrants further investigation.

Defining the Term "Elderly" in the Field of Surgery: A Retrospective Study Regarding the Changes in the Immunoinflammatory Indices During the Immediate Perioperative Period of the Elective Uncomplicated Laparoscopic Cholecystectomy

BACKGROUNDS

The term "elderly" seems to have been used as "vulnerable to various stresses" but not well defined. To define the "elderly", we investigated whether the increased age causes unfavorable changes in several immunoinflammatory indices that indicate the increased vulnerability in the surgical field.

PATIENTS AND METHODS

One-hundred forty-two patients undergoing an elective-uncomplicated laparoscopic cholecystectomy (within 60 min and without intraoperative-cholangiography, bile spillage, or open conversion) were retrospectively investigated. Before surgery, immediately after surgery, and on postoperative day (POD)1, whether the patient age correlated the following variables was examined: neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio, platelet-to-lymphocyte ratio, lymphocyte-to-C-reactive-protein ratio (LCR), C-reactive-protein-to-albumin ratio (CAR), and others.

RESULTS

The immunoinflammatory indices most unfavorably changed on POD1. The age correlated neither lymphocyte-to-monocyte ratio nor platelet-to-lymphocyte ratio on POD1, when NLR, LCR, and CAR showed the significant correlation with the age. Multiple regression analyses determined the following variables as the independent determinants of these 3 indices on POD1: age, intraoperative minimum body temperature ≥35.5°C (IntMinBT ≥35.5°C), maximum heart rate during POD0-1 (MaxHR) for NLR; age and IntMinBT ≥ 35.5°C for LCR; and age and MaxHR for CAR. The threshold of "elderly" was determined as 102-year-old for NLR, 94-year-old for LCR, and 97-year-old for CAR.

CONCLUSIONS

The increased age causes the unfavorable changes in early postoperative immunoinflammatory indices after the uncomplicated laparoscopic cholecystectomy. Thus, the term "elderly" can be rephrased by the term "vulnerable to various surgical stresses." The thresholds for "elderly" defined herein seem impractical. Namely, the increased vulnerability caused by the aging seems modified by the individual surgical procedures.

Postoperative Elevations of Neutrophil-to-lymphocyte and Platelet-to-lymphocyte Ratios Predict Postoperative Pulmonary Complications in Non-small Cell Lung Cancer Patients: A Retrospective Cohort Study

The neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) are found to increase in patients who develop postoperative complications (PCs). The aim of the present study was to explore the association of the perioperative changes of NLR (ΔNLR) and PLR (ΔPLR) with PCs in non-small cell lung cancer (NSCLC). Clinical data of 509 patients, who were diagnosed with NSCLC and underwent thoracoscopic radical resection between January 1, 2014 and July 31, 2016 at the Department of Thoracic Surgery, West China Hospital, were reviewed. Patients were divided into PC and non-PC groups, and clinical characteristics including ΔNLR and ΔPLR were compared between them. The optimal cut-off values of ΔNLR and ΔPLR were determined by receiver operating characteristics (ROC) curves and patients were assigned to high ΔNLR/ΔPLR and low ΔNLR/ΔPLR groups in terms of the cut-off values. Clinicopathologic characteristics and the incidence of different PCs were compared between the dichotomized groups. Univariate and multivariate logistic regression analyses were performed to identify the independent risk factors for PCs. The results showed that the ΔNLR and ΔPLR in the PC group were signifcantly higher than those in the non-PC group (P<0.001 for both). The optimal cutoff values of ΔNLR and ΔPLR were 6.6 and 49, respectively. Patients with ΔNLR>6.6 or ΔPLR>49 were more likely to experience postoperative pulmonary complications (PPCs) (P<0.001 for both). Multivariate logistic regression analysis demonstrated that smoking [odds ratio (OR): 2.450, 95% confdence interval (95% CI): 1.084-5.535, P=0.031)], tumor size (OR: 1.225, 95% CI: 1.047-1.433, P=0.011), ΔNLR>6.6 (OR: 2.453, 95% CI: 1.224-4.914, P=0.011) and ΔPLR>49 (OR: 2.231, 95% CI: 1.182-4.212, P=0.013) were predictive of PPCs. In conclusion, the ΔNLR and ΔPLR may act as novel predictors for PPCs in NSCLC patients undergoing thoracoscopic radical lung resection, and patients with ΔNLR>6.6 or ΔPLR>49 should be treated more actively to prevent or reduce PPCs.

Prognostic value of laboratory values in older patients with cervical spine fractures

OBJECTIVES

To understand the prognostic value of laboratory markers at presentation on post-treatment survival of patients 50 and older following cervical spine fracture.

PATIENTS AND METHODS

We obtained clinical data on patients 50 and older treated for cervical spine fracture in a single healthcare system (2006-2016). Our primary outcome consisted of 1-year mortality, with mortality within 3-months of presentation considered secondarily. Our primary predictors included serum glucose, serum creatinine, platelet-lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) at presentation. We used multivariable logistic regression to adjust for confounding from sociodemographic and clinical characteristics. Point estimates and 95 % confidence intervals (CI) from the final model were refined using Bayesian regression techniques.

RESULTS

We included 1781 patients in this analysis, with an average age of 75.3 (SD 12.0). The mortality rate at 3-months was 12 % and 17 % at 1-year. In multivariable testing, neither elevated PLR or NLR were significant predictors of 1-year mortality. Elevated serum creatinine was associated with increased mortality at 1-year (OR 1.89; 95 % CI 1.30, 2.74), as was hyperglycemia (OR 1.50; 95 % CI 1.06, 2.13). Elevated serum creatinine remained influential (OR 1.64; 95 % CI 1.06, 2.54) on mortality at 3-months.

CONCLUSIONS

This is the first study to evaluate laboratory values at presentation in conjunction with survival following cervical fractures. The results can be used to help forecast natural history and in expectation management. They may also help formulate treatment plans, especially when the need for surgical intervention is not clearly defined.

Platelet/lymphocyte ratio is an independent predictor for osteoporosis

Objectives:

To investigate the intercourse between the platelet/lymphocyte (P/L) and neutrophil/lymphocyte ratio (N/L), and vitamin D (Vit-D) levels in low bone mineral density (BMD) of women.

Methods:

Two hundred fifty-two postmenopausal female outpatients who were admitted to the obstetrics and gynecology and physical therapy clinics between July 2016 and December 2017 were retrospectively analyzed. The patients were grouped in relation to their T-score (normal [n=92], osteopenia [n=112], and PMO [n=48]). The serum levels of P/L, N/L, Vit-D, BMD and complete blood count of the patients were retrospectively examined.

Results:

The median P/L was significantly higher and Vit-D levels were significantly lower in the PMO group (130.75 [52.89-385] versus 123.05 [54-232.5], p=0.02 and 15.4 [4-34] versus 20.1 [4-47], p=0.003). While BMD and P/L were negatively correlated, a positive correlation between BMD and Vit-D was found. Vitamin D levels were negatively correlated with P/L (p<0.001) and N/L (p=0.04). Older age (≥65 years), Vit-D deficiency and P/L values >125.06 were found as independent prognostic factors for PMO in regression analysis.

Conclusion:

Higher P/L seems to be a quite simple marker to help predict postmenopausal PMO. As seen in our study, having low levels of Vit-D is crucial for PMO.

IS THERE A RELATIONSHIP BETWEEN PARATHYROID HORMONE AND NEUTROPHIL LYMPHOCYTE RATIO OR PLATELET LYMPHOCYTE RATIO?

Context

Neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) are recent prognostic markers associated with inflammation in many diseases such as chronic kidney disease (CKD), malignancies, myocardial infarction.

Objective

In this study, we investigated the relationship between NLR-PLR and parathyroid hormone (PTH) and vitamin D in patients with high PTH levels.

Design

The patients with high PTH levels in Nephrology and Endocrinolgy Outpatient clinics were evaluated retrospectively.

Subjects and methods

The medical records of the patients were examined and clinical data, including demographic details, clinical and laboratory findings, treatment and follow-up data were obtained. NLR and PLR were calculated. Serum creatinine, calcium, phosphorus, magnesium, lipid levels, calcium phosphorus product, PTH and vitamin D values were investigated. The relationship between NLR-PLR and laboratory parameters, GFR (MDRD-GFR), PTH and vitamin D were investigated.

Results

48 male and 253 female patients were enrolled in this study. The mean age was 57.57±13.28. NLR correlated negatively with albumin, hemoglobin, vitamin D, calcium and cholesterol and it positively correlated with creatinine and PTH. Multiple regression analysis showed that main determinants of NLR were PTH, albumin, LDL-cholesterol, hemoglobin and gender.

Conclusions

In this study NLR and PLR correlated negatively with hemoglobin and cholesterol. Positive correlation between NLR and creatinine could be explained by increased degrees of inflammation associated with more pronounced degrees of renal dysfunction. The impact of PTH on NLR was independent of GFR. In multiple regression model this suggests that PTH could be a pro-inflammatory parameter independent of the degree of renal dysfunction.

Prediction of postoperative mortality in elderly patient with hip fractures: a single-centre, retrospective cohort study

Background

Elderly patients are at high risk for postoperative complications and increased mortality after hip fracture (HF) surgery due to frailty and co-morbidities. The prediction of postoperative outcome could be used for clinical decision making. A reliable score to predict postoperative mortality after HF surgery in this sub-population remains unavailable.

Methods

A single-centre retrospective cohort study was performed in 782 patients who were operated on for HF. Receiver Operating Characteristic (ROC)-curves were used to analyse the performance of gender, age, neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) at admission (D₀) as prognostic factors, alone or combined with the PreOperative Score to predict PostOperative Mortality (POSPOM) in univariate and multivariate linear regression models.

Results

No correlation between gender, age, NLR D₀ or CRP D₀ and postoperative, intra-hospital mortality was found. The Area Under the ROC-curve (AUC) for age, male gender, NLR and CRP were 0.61 [95% confidence interval (CI) = 0.45–0.61], 0.56 [95% CI = 0.42–0.56], 0.47 [95% CI = 0.29–0.47] and 0.49 [95% CI = 0.31–0.49] respectively. Combination with the POSPOM score did not increase its discriminative capacity as neither age (AUC = 0.69, 95% CI = 0.54–0.69), gender (AUC = 0.72, 95% CI = 0.58–0.72), NLR D₀ (AUC = 0.71, 95% CI = 0.56–0.71), nor the CRP D₀ (AUC = 0.71, 95% CI = 0.58–0.71) improved the POSPOM performance.

Conclusions

Neither age, gender, NLR D₀ nor CRP D₀ are suitable parameters to predict postoperative, intra-hospital mortality in elderly patients undergoing surgery for HF.

Parathyroidectomy decreases neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios

BACKGROUND

Systemic inflammation has been implicated in complications and heightened mortality of patients with secondary hyperparathyroidism. The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are widely available surrogate markers of inflammation. This study sought to delineate the changes in NLR and PLR after parathyroidectomy.

METHODS

A total of 213 patients undergoing initial parathyroidectomy from 2010 to 2015 for secondary hyperparathyroidism were identified from a prospectively maintained clinical database. Among 183 patients free of persistent or recurrent disease, follow-up NLR and PLR were available for analysis in 85 patients.

RESULTS

In the whole study population, the baseline NLR was positively correlated with male sex, total white blood cell count, height, serum phosphorus, and calcium-phosphorus product levels. The baseline PLR was positively correlated with platelet count, serum phosphorus, and calcium-phosphorus product levels and negatively associated with patient age. Postoperative parathyroid hormone levels were positively correlated with NLR and PLR at follow-up. For patients who had successful parathyroidectomy, there was a decrease in NLR (P = 0.0006), PLR (P = 0.0003), and platelet count (P = 0.033), whereas hemoglobin significantly increased (P = 0.0002) after surgery. Those with persistent or recurrent hyperparathyroidism had no change in NLR, PLR, hemoglobin, total white blood cell, or platelet count.

CONCLUSIONS

Successful parathyroidectomy is associated with a decrease in NLR and PLR. The modulatory effects of parathyroidectomy on systemic inflammation may partially explain the benefits of surgery in secondary hyperparathyroidism.

Neutrophil-to-lymphocyte ratio shows faster changing kinetics than C-reactive protein after total hip and knee arthroplasty

Background

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) induce inflammatory reactions, which can be described by changes in the neuroendocrine, cellular, protein, and cytokine systems. The aim of this study was to document the normal distribution pattern of the neutrophil-to-lymphocyte ratio (NLR) after THA and TKA and to compare it with postoperative C-reactive protein (CRP) patterns.

Methods

Changes in serum CRP levels, neutrophil count, and lymphocyte count were measured before and during the first 5 postoperative days in a prospective study performed on 387 patients undergoing total hip or knee arthroplasty.

Results

Mean CRP levels in patients undergoing THA were 7.7 mg/L, 184.8 mg/L, and 115.9 mg/L, respectively, at Days 0, 3 and 5. The mean NLR of patients undergoing THA was 2.9, 3.6, and 2.7, respectively, at Days 0, 3, and 5. Mean CRP levels in patients undergoing TKA were 7.8 mg/L, 192.6 mg/L, and 108.6 mg/L, respectively, at Days 0, 3 and 5. The mean NLR of patients undergoing TKA was 2.8, 3.4, and 2.6, respectively, at Days 0, 3, and 5. When comparing the preoperative value and the Day 3 value, CRP levels increased more than the NLR (almost a 24-fold increase in mean CRP values vs. a 1.2-fold increase in mean NLR values). In both groups, the NLR returned to preoperative values by the 5th postoperative day.

Conclusions

The present study demonstrated a significant elevation in CRP levels and the NLR following THA and TKA. In both groups, the NLR showed a faster kinetics pattern than CRP levels in response to surgical trauma.The translational potential of this article: We describe results of the use of the NLR, as compared to a routinely used marker, CRP, as advantageous in clinical setting due to faster dynamics of change. Integrating the NLR in clinical practice seems easy and without extra cost.