Risk Factors for 30-Days Mortality After Proximal Femoral Fracture Surgery, a Cohort Study

Purpose

The primary objective of this study was to identify new risk factors and to confirm previously reported risk factors associated with 30-day mortality after hip fracture surgery.

Patients and methods

A prospective hip fracture database was used to obtain data. In total, 3523 patients who underwent hip fracture surgery between 2011 and 2021 were included. Univariable and multivariable logistic regression was used to screen and identify candidate risk factors. Twenty-seven baseline factors and 16 peri-operative factors were included in the univariable analysis and 28 of those factors were included in multivariable analysis.

Results

8.6% of the patients who underwent hip fracture surgery died within 30 days after surgery. Prognostic factors associated with 30-day mortality after hip fracture surgery were as follows: age 90-100 years (OR = 4.7, 95% CI: 1.07-19.98, p = 0.041) and above 100 years (OR = 11.3, 95% CI: 1.28-100.26, p = 0.029), male gender (OR = 2.6, 95% CI: 1.97-3.33, p < 0.001), American Society of Anesthesiologists (ASA) 3 and ASA 4 (OR = 2.1, 95% CI: 1.44-3.14, p < 0.001), medical history of dementia (OR = 1.7, 95% CI: 1.25-2.36, p = 0.001), decreased albumin level (OR = 0.94, 95% CI: 0.92-0.97, p < 0.001), decreased glomerular filtration rate (GFR) (OR = 0.98, 95% CI: 0.98-0.99, p < 0.001), residential status of nursing home (OR = 2.1, 95% CI: 1.44-2.87, p < 0.001), higher Katz Index of Independence in Activities of Daily Living (KATZ-ADL) score (OR = 1.1, 95% CI: 1.01-1.16, p=0.018) and postoperative pneumonia (OR = 2.4, 95% CI: 1.72-3.38, p < 0.001).

Conclusion

A high mortality rate in patients after acute hip fracture surgery is known. Factors that are associated with an increased mortality are age above 90 years, male gender, ASA 3 and ASA 4, medical history of dementia, decreased albumin, decreased GFR, residential status of nursing home, higher KATZ-ADL score and postoperative pneumonia.

The Ratio Between the Infrarenal and Suprarenal Aortic Diameter Is a Predictor of Durable Proximal Seal After Endovascular Aneurysm Repair

OBJECTIVES

The aim of this study was to assess whether the ratio of the mean infrarenal neck diameter to the suprarenal aortic diameter is a predictor for a durable proximal seal after endovascular aneurysm repair (EVAR).

METHODS

A total of 439 patients who underwent elective EVAR between 2004 and 2018 in a single vascular referral center met our inclusion criteria. Ratios were calculated by dividing the mean infrarenal neck diameter by 4 different suprarenal aortic diameters. Patients who developed a late type 1A endoleak (n=20) or proximal neck dilatation mandating revision (n=8) were compared with the 411 patients without long-term proximal seal complications.

RESULTS

Patients who developed a late type 1A endoleak had more frequently hypertension, a shorter infrarenal neck length, and a larger mean infrarenal neck diameter. The ratio of the mean infrarenal neck diameter to all 4 suprarenal aortic diameters was higher in the late type 1A endoleak group compared with the group without a late type 1A endoleak. Least absolute shrinkage and selection operator (LASSO) logistic regression identified a combination of 6 variables as the best combination to predict a late type 1A endoleak: presence of hypertension, increased mean infrarenal neck diameter, decreased aneurysm neck length, larger ratio of the mean infrarenal neck diameter to the aortic diameter proximal to the superior mesenteric artery (SMA), larger ratio of the mean infrarenal neck diameter to the aortic diameter proximal to the upper renal artery, and increased β-angle. Of these, based on both the univariate area under the curve (AUC) and optimal LASSO model restricted to a single predictor, the ratio of the mean infrarenal neck diameter to the aortic diameter proximal to the SMA (AUC, 0.770; cutoff value, 0.997) was considered the best prognostic variable.

CONCLUSION

The ratio of the mean infrarenal neck diameter to the aortic diameter proximal to the SMA is a good predictor for a late type 1A endoleak. Patients with mean infrarenal neck diameter larger than the diameter proximal to the SMA (ratio >1) are at risk for a late type 1A endoleak.

CLINICAL IMPACT

In this single-center, retrospective cohort study, we found that the ratio of the mean infrarenal neck diameter to the aortic diameter proximal to the SMA is a good predictor for a late type 1A endoleak. We conclude that the suprarenal diameter must be taken into account before assessing endovascular aortic aneurysm repair eligibility. Patients with a ratio >1 may not be the best candidates for a durable result after EVAR and may be better off with fenestrated EVAR or open repair.

A trial-based economic evaluation of the CaFaSpA referral strategy for axial spondyloarthritis

OBJECTIVE

To assess the cost-utility from healthcare and societal perspectives of the digital CaFaSpA referral strategy (CS) for axial spondyloarthritis (axSpA) in primary care patients with chronic low back pain (CLBP).

METHOD

A cluster randomized controlled trial was performed in the Netherlands. General practice units were randomized into CS or usual care (UC). Economic evaluation was performed from the healthcare and societal perspectives within a 12-month time horizon. Outcome measures encompassed disability [Roland-Morris Disability Questionnaire (RMDQ)] and health-related quality of life (EQ-5D-3L). Direct medical (iMTA Medical Consumption Questionnaire) and indirect costs (iMTA Productivity Cost Questionnaire), including productivity loss, were evaluated. Incremental cost-utility ratios (ICURs) were calculated.

RESULTS

The study included 90 GP clusters with 563 patients (CS: n = 260; UC: n = 303) (mean ± sd age 36.3 ± 7.5 years; 66% female). After 12 months, no minimal important differences in outcomes were observed for RMDQ (-0.21, 95%CI -1.52 to 1.13) or EQ-5D (-0.02, 95%CI -0.08 to 0.05). However, total costs were significantly lower in the CS group owing to lower productivity loss costs. The ICUR for RMDQ was €18,059 per point decrease and €220,457 per quality-adjusted life year increase.

CONCLUSIONS

Digital referral did not decrease the overall healthcare status of patients after 1 year of follow-up and appears to be more cost-effective than UC. Therefore, CS can be used as an appropriate primary care referral model for CLBP patients at risk for axSpA. This will accelerate timely provision of care by the right caregiver.

PROMISE: effect of protein supplementation on fat-free mass preservation after bariatric surgery, a randomized double-blind placebo-controlled trial

INTRODUCTION

Protein malnutrition after bariatric surgery is a severe complication and leads to significant morbidity. Previous studies have shown that protein intake and physical activity are the most important factors in the preservation of fat-free mass during weight loss. Low protein intake is very common in patients undergoing bariatric surgery despite dietary counseling. Protein powder supplements might help patients to achieve the protein intake recommendations after bariatric surgery and could therefore contribute to preserve fat-free mass. This double-blind randomized placebo-controlled intervention study aims to assess the effect of a daily consumed clear protein powder shake during the first 6 months after bariatric surgery on fat-free mass loss in the first 12 months after laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS AND ANALYSIS

Inclusion will take place at the outpatient clinic of the bariatric expertise center for obesity of the Maasstad Hospital. Patients will be randomly assigned to either the intervention or control group before surgery. The intervention group will receive a clear protein powder shake of 200 ml containing 20 g of whey protein dissolved in water which should be taken daily during the first 6 months after LRYGB on top of their normal postoperative diet. The control group will receive an isocaloric, clear, placebo shake containing maltodextrine. Postoperative rehabilitation and physiotherapeutical guidance will be standardized and similar in both groups. Also, both groups will receive the same dietary advice from specialized dieticians. The main study parameter is the percentage of fat-free mass loss 6 months after surgery, assessed by multi-frequency bioelectrical impedance analysis (MF-BIA).

ETHICS AND DISSEMINATION

The protocol, version 2 (February 20, 2022) has been approved by the Medical Research Ethics Committees United (MEC-U) (NL 80414.100.22). The results of this study will be submitted to peer-reviewed journals.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05570474. Registered on October 5, 2022.

A Ratio Between Infrarenal and Suprarenal Aortic Diameters Corrects for Absolute Aortic Diameter Variations due to Patients' Sex and Body Size

OBJECTIVES

Aortic diameters may differ significantly between patients with different gender and body size. The aim of this study was to relate absolute aortic diameters to age, sex, height, and weight of the patients and to correct for these factors by calculating the ratio between the infrarenal and the suprarenal aortic diameters.

METHODS

A total of 458 patients who underwent elective endovascular aneurysm repair (EVAR) between 2004 and 2018 were included. The aortic anatomy in this group of elective EVAR patients was compared with a control group of 75 patients without an abdominal aortic aneurysm (AAA). The aortic diameter was measured at 4 suprarenal points and 4 infrarenal points. Ratios were calculated by dividing the mean infrarenal neck diameter by 4 suprarenal measurements.

RESULTS

Patients in the aneurysm group had significantly larger suprarenal and infrarenal aortic diameters. The ratios between the mean infrarenal neck diameter and all 4 suprarenal measurements were larger in the AAA group than in the control group. In both groups, there was a significant correlation between the mean infrarenal neck diameter and sex, height, weight, and body surface area (BSA). However, in both groups, all 4 ratios between the mean infrarenal neck diameter and suprarenal aortic diameters were not correlated with age, sex, height, weight, or BSA, except for the ratio between the mean infrarenal neck diameter and the aortic diameter measurement proximal to the upper renal artery, which was correlated to weight and BSA in the control group.

CONCLUSION

The mean infrarenal neck diameter is correlated with sex, height, weight, and BSA. However, when the suprarenal aortic diameter was used as an internal control for the mean infrarenal neck diameter, we were able to correct for these variations in aortic diameters due to sex and body size. The clinical relevance of this ratio in patients treated by EVAR has yet to be assessed in future research.

CLINICAL IMPACT

In the assessment for EVAR suitability the absolute diameter of the aneurysm neck is taken into account. We believe that using absolute diameters is not the appropriate way to assess this suitability, but that patient characteristics such as age, gender and body size, should be factored into this assessment. In this paper, we show that suprarenal and infrarenal aortic diameters are both significantly increased in patients with an aneurysm compared with patients without an aneurysm. Besides, we found that mean infrarenal aortic diameter is correlated with sex, height, weight, and body surface area. Finally, we propose a new ratio system, using suprarenal diameters as an internal control, to correct for aortic diameter variations due to sex and body size.

Arthroscopic synovectomy versus intra-articular injection of corticosteroids for the management of refractory psoriatic or rheumatoid arthritis of the wrist: study protocol for a randomized controlled trial (ARCTIC trial)

BACKGROUND

Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are inflammatory diseases that often affect the wrist and, when affected, can lead to impaired wrist function and progressive joint destruction if inadequately treated. Standard care consists primarily of disease-modifying anti-rheumatic drugs (DMARDs), often supported by systemic corticosteroids or intra-articular corticosteroid injections (IACSI). IACSI, despite their use worldwide, show poor response in a substantial group of patients. Arthroscopic synovectomy of the wrist is the surgical removal of synovitis with the goal to relieve pain and improve wrist function. The primary objective of this study is to evaluate wrist function following arthroscopic synovectomy compared to IACSI in therapy-resistant patients with rheumatoid or psoriatic arthritis. Secondary objectives include radiologic progress, disease activity, health-related quality of life, work participation and cost-effectiveness during a 1-year follow-up.

METHODS

This protocol describes a prospective, randomized controlled trial. RA and PsA patients are eligible with prominent wrist synovitis objectified by a rheumatologist, not responding to at least 3 months of conventional DMARDs and naïve to biological DMARDs. For 90% power, an expected loss to follow-up of 5%, an expected difference in mean Patient-Rated Wrist Evaluation score (PRWE, range 0-100) of 11 and α = 0.05, a total sample size of 80 patients will be sufficient to detect an effect size. Patients are randomized in a 1:1 ratio for arthroscopic synovectomy with deposition of corticosteroids or for IACSI. Removed synovial tissue will be stored for an ancillary study on disease profiling. The primary outcome is wrist function, measured with the PRWE score after 3 months. Secondary outcomes include wrist mobility and grip strength, pain scores, DAS28, EQ-5D-5L, disease progression on ultrasound and radiographs, complications and secondary treatment. Additionally, a cost-effectiveness analysis will be performed, based on healthcare costs (iMCQ questionnaire) and productivity loss (iPCQ questionnaire). Follow-up will be scheduled at 3, 6 and 12 months. Patient burden is minimized by combining study visits with regular follow-ups.

DISCUSSION

Persistent wrist arthritis continues to be a problem for patients with rheumatic joint disease leading to disability. This is the first randomized controlled trial to evaluate the effect, safety and feasibility of arthroscopic synovectomy of the wrist in these patients compared to IACSI.

TRIAL REGISTRATION

Dutch trial registry (CCMO), NL74744.100.20. Registered on 30 November 2020.

CLINICALTRIALS

gov NCT04755127. Registered after the start of inclusion on 15 February 2021.

Impact of triage by a rheumatologist on appropriateness of referrals from primary to secondary care: a cluster randomized trial

OBJECTIVE

The quality of referrals is often criticized, and the effectiveness of improvement efforts remains uncertain. We assessed the impact of a rheumatologist triaging patients in primary care on the appropriateness of referrals to secondary care, healthcare utilization, and patient experience and outcomes.

METHOD

A cluster randomized controlled trial was conducted with patients experiencing musculoskeletal complaints. Intervention practices deployed an experienced rheumatologist triaging patients through in-person review. Usual care was performed in control practices, where practitioners referred patients based on their own judgement. The primary outcome was the proportion of inflammatory rheumatic diseases (IRDs) diagnosed by rheumatologists in referred patients. Healthcare utilization (iMTA Medical Consumption Questionnaire), quality of life (EuroQol 5 Dimensions), and experience of care (Consumer Quality Index) were determined after 3 months of follow-up. Data were analysed according to the intention-to-treat principle.

RESULTS

In total, 544 participants were included [mean age 51.4 (range 18-87) years; 24% were men]. Of all referred patients, 51% had an IRD in the intervention group versus 21% in the control group (p = 0.035). After 3 months of follow-up, patients from the triage intervention showed lower healthcare utilization (p = 0.006) and higher quality of life (p = 0.011), without a decline in experienced quality of care (p = 0.712), compared to controls.

CONCLUSION

Triage by a rheumatologist in primary care provides appropriate care and adequate experience of care, leading to a higher quality of life. Long-term evidence is needed to assess the value on cost-effectiveness before implementing this strategy nationwide.

Clinical outcomes of tranexamic acid in acute hip hemiarthroplasties in frail geriatric patients

BACKGROUND

Tranexamic acid (TXA) has shown to significantly reduce perioperative blood loss in elective orthopedic joint replacement surgery but is yet not implemented in acute hip fracture surgery for elderly patients who are particularly vulnerable to perioperative blood loss and postoperative anemia. Aim of this study is to answer the following questions: 1. Does TXA reduce bleeding associated complications in elderly patients? 2. Does TXA induce thromboembolic complications in elderly patients?

HYPOTHESIS

TXA reduces perioperative blood loss and associated complications in acute hip fracture surgery in geriatric patients.

PATIENTS AND METHODS

In this observational cohort study with prospectively enrolled patients over 65 years of age who received an acute hip hemiarthroplasty, the primary outcome was blood loss, also described as Δ hemoglobin. Secondary outcomes were bleeding associated complications as hematomas. Also, the occurrence of thromboembolic events and mortality were examined.

RESULTS

In total 864 geriatric patients were included of which 235 received TXA and 629 did not. Multivariable analysis showed reduced Δ hemoglobin loss [-0.24 (-0.39; -0.09), p=0.002] and hematomas (OR 0.44 (0.21; 0.91), p=0.026). Pulmonary embolism were diagnosed more frequently after administration of TXA (2% versus 0.3%, p=0.008), without an association with increased 30-day mortality rate (6% versus 8%, p=0.3).

DISCUSSION

TXA reduced perioperative blood loss and associated complications. However, adverse effects of TXA as pulmonary embolisms were found more frequently without effecting postoperative mortality rates. More research is needed to assess adverse effects of intravenous TXA and topical TXA as an alternative for systemic TXA to prevent systemic adverse effects.

LEVEL OF EVIDENCE

III, Observational cohort study.

Renal function after withdrawal of lithium

OBJECTIVES

Patients on chronic lithium therapy sometimes develop chronic kidney disease. For clinical decision-making, it is important to know whether discontinuation of lithium can lead to improvement of renal function. We studied the trajectory of renal function in a population previously on chronic lithium therapy.

METHODS

From a large database of patients on chronic lithium therapy, we selected a group of patients who stopped using lithium and whose creatinine values at least half a year after lithium withdrawal were available. We measured the slope of renal function (eGFR) before and after discontinuation of lithium. We compared the subgroup of patients with improvement of the renal function with those who showed further deterioration of the eGFR.

RESULTS

eGFR slope significantly improved after discontinuation of lithium. Of patients with chronic kidney disease stage 3 or more (eGFR<60 ml/min), the vast majority showed an increase of eGFR or a decrease in the rate of decline after lithium withdrawal. The group of patients with further deterioration of the renal function had a mean eGFR of 32 ml/min, which was significantly lower than the patients with an improvement of the kidney function.

CONCLUSIONS

Discontinuation of lithium leads in the majority of patients to improvement in renal function or at least less rapid deterioration.

A stable aneurysm sac after endovascular aneurysm repair as a predictor for mortality, an in-depth analysis

OBJECTIVES

The aim of this study was to compare the long-term survival in patients with a stable aneurysmal sac and those with aneurysmal sac regression after endovascular aneurysm repair (EVAR) and to identify independent risk factors for aneurysmal sac regression and mortality after EVAR.

METHODS

We reviewed all patients who underwent EVAR between 2005 and 2018 with a computed tomography angiography available at 1-year follow-up. Aneurysm sac regression was defined as a diameter decrease of more than 10%. We used a multivariable regression to identify independent risk factors for sac regression. Kaplan-Meier analysis and Cox regression were done to test differences in 5-year mortality between a stable sac and sac regression.

RESULTS

The inclusion criteria were met by 325 patients, 185 in the sac regression group and 140 in the stable sac group. Multivariable logistic regression analysis showed that treatment for a ruptured aneurysm was an independent risk factor for aneurysmal sac regression (hazard ratio [HR], 0.26; 95% confidence interval [CI], 0.07-0.96). Age (HR, 1.05; 95% CI, 1.01-1.09), ischemic heart disease (HR, 1.94; 95% CI, 1.13-3.31), neck thrombus (HR, 2.72; 95% CI, 1.07-6.95), and a type II endoleak (HR, 19.21; 95% CI, 7.32-50.40) were independent risk factors for a stable aneurysm sac diameter. Multivariable Cox regression showed a significantly increased risk of mortality for patients with a stable aneurysm sac after EVAR (odds ratio, 2.25; 95% CI, 1.36-3.72). There was no significant difference in cause of death between the two groups.

CONCLUSION

A stable aneurysm sac after EVAR is associated with increased mortality. Age, ischemic heart disease, neck thrombus, and a type II endoleak are independent risk factors for a stable sac. However, a well-founded explanation for this finding is still lacking. Future research should be focussed on aggressive treatment of type II endoleaks and inflammatory processes as potential pathophysiological mechanisms.

Validation of the Nottingham Hip Fracture Score (NHFS) in Patients with Hip Fracture: A Prospective Cohort Study in the Netherlands

Introduction

The Nottingham Hip Fracture Score (NHFS) was developed to predict 30-day mortality for patients with hip fracture. This study aimed to validate the NHFS in a cohort with sufficient statistical power.

Methods

Data were extracted from a prospective hip-fracture database (FAMMI). Patients were included between January 1, 2018 and January 11, 2021. All consecutively admitted patients ≥18 years of age with a hip fracture (ie, femoral neck fracture, intertrochanteric fracture, and subtrochanteric fracture) were included. Mann–Whitney’s U values were calculated to find potential miscalibration of the NHFS formula. Discrimination evaluation was performed using the concordance statistic as an equivalent to area under the receiver-operating curve.

Results

In total, 2,458 patients were included. Mean age was 80±12 years, and 66% were women (n=1,631). Median NHFS was 5 (4–6) and overall 30-day mortality 7.9% (n=195). Overall goodness of fit was tested with Pearson’s ?² (11.8, df 10; P=0.297). No statistically significant signs of miscalibration were found (Mann–Whitney U, P=0.08). Discrimination was tested with area under the receiver- operating curve, which was 72.1% (95% CI 68.7%–75.4%). However, observed 30-day mortality in our population of hip-fracture patients was slightly higher than the NHFS prediction.

Conclusion

The NHFS seemed to predict 30-day mortality with reasonable accuracy for patients with a hip fracture in a population within the Netherlands.

Antithrombotics in Patients With a Femoral Neck Fracture: Evaluating Daily Practice in an Observational Cohort Study

Introduction

Geriatric hip fracture patients are characterized by frailty due to multiple comorbidities, such as cardiovascular disease, in which the use of antithrombotics is frequent. The aim of this study is to assess the effect of antithrombotics on perioperative care and patient outcomes after hip hemiarthroplasty following current guidelines.

Materials and Methods

This observational cohort study included all consecutively admitted patients with a femoral neck fracture requiring hip hemiarthroplasty between January 1^st 2010, and May 16^th 2016, in two level II trauma teaching hospitals. Patients with multiple trauma injuries were excluded.

Results

In total, n = 907 patients (68% female (n = 615), median age 84 years) were included of which n = 142 used a vitamin K antagonist (VKA) and n = 213 used antiplatelet (AP) therapy. Both were associated with more packed cell supplementation (.4 ± 1.1 units and .3 ± .8 units vs .2 ± .6 units, P < .001 and P = .03, respectively). VKA was associated with more hematomas compared no antithrombotics (23% vs 11%, P = .001). VKA had a longer time to surgery compared to no antithrombotics and AP (24 hours vs 19 and 20 hours, P < .001 and P < .001, respectively) and longer admission duration (9 days vs 7 days P < .001. There were no differences in 30 day mortality nor in 1-year mortality rates.

Discussion

All modifiable causes for deep SSI, such as hematomas, should be prevented in acute hip fracture surgery. Since antithrombotics are associated with hematomas, an optimal handling in perioperative setting is necessary.

Conclusion

VKA was associated with longer time to surgery, more hematomas, and longer admission duration. VKA and AP were associated with more packed cell supplementation.

Drain versus no drain after hip hemi-arthroplasty for femoral neck fractures; differences in clinical outcomes

PURPOSE

The routine use of surgical drains in elective hip arthroplasty has been abandoned. Also in acute hip arthroplasty for femoral neck fractures drain use reduces. Question is, whether this is justified in geriatric patients, where the incidence of anticoagulation use is high. Therefore, the aim of this study is to compare the clinical outcomes in patients with and without the use of a wound drain after hip hemiarthroplasty.

METHODS

Data were extracted from a prospective hip fracture database and completed by retrospective review of the hospital records at two level II trauma centers between January 1st 2010 and May 16th 2016. Patients with a femoral neck fracture requiring hip hemiarthroplasty were included in the study.

RESULTS

This study cohort included 900 patients (68% female), with a median age of 83.5 (IQR 78-88), of which 544 (60%) had a wound drain. Patients with a wound drain needed more days to be ready for discharged (10.0 days (SD ± 43.3), P =  < 0.001) compared to patients without a drain (5.3 days (SD ± 4.2). With a drain more hemoglobin loss was found, 2.66 g/dL versus 2.4 g/dL (P = 0.008) and also more packed cells were supplemented, 0.29 versus 0.13 (P = 0.0016). Wound drain placement showed a statistically significant inverse relation with post-operative hematoma; odds ratio (OR 0.61, 95% CI 0.39; 0.94, P = 0.024), but no reduced risk of post-operative deep surgical site infection, (OR 1.09, 95% CI 0.43; 2.72, P = 0.862).

CONCLUSION

Surgical drain placement was not associated with a reduced risk of post-operative deep surgical site infections, nor one-year mortality. However, a decreased risk of post-operative wound hematoma was observed. Furthermore, patients with a drain needed more days to be ready for discharge, show more hemoglobin loss and need more packed cell supplementation during admission.

The impact of a disease flare during tapering of DMARDs on the lives of rheumatoid arthritis patients

OBJECTIVES

To determine the impact of a disease flare on patient reported outcome measures (PROMs) in rheumatoid arthritis (RA) patients, who are tapering treatment.

METHODS

Data were used from the TARA trial; a multicenter, randomized controlled trial in which RA patients, with a well-controlled disease (DAS≤2.4 and SJC≤1) for at least 6 months, gradually tapered their DMARDs. PROMs of patients with a flare (DAS>2.4 and/or SJC>1) were compared every three months before and after a flare with their own norm values. Linear Mixed Models were used to investigate whether a disease flare influenced functional ability (HAQ-DI), fatigue (BRAF-MDQ), quality of life (EQ-5D and SF36), anxiety and depression (HADS), morning stiffness, general health (GH) and worker productivity, and if so, the duration was determined. For unemployment and sick leave we used descriptive statistics.

RESULTS

A flare negatively influenced GH, morning stiffness, HAQ-DI, EQ-5D, BRAF-MDQ, and the SF36 physical component scale and this effect lasted >3 months. Except for the HAQ-DI, effect sizes exceeded the minimum clinically important differences (MCIDs). For the physical outcomes effects lasted >6 months. Worker productivity was not significantly affected by a flare.

CONCLUSION

A disease flare influenced patients' lives, the largest effect was seen in the physical outcomes, and lasted 6 months. Although on a group level effect sizes for the separate PROMs were not always significant or larger than specific MCIDs, a disease flare can still be of great importance for individual patients.

Delirium after hip hemiarthroplasty for proximal femoral fractures in elderly patients: risk factors and clinical outcomes

Background

The primary aim of the present study was to verify the potential risk factors for developing a delirium after hip fracture surgery. The secondary aim of this study was to examine the related clinical outcomes after a delirium developed post-hip fracture surgery.

Patients and methods

Data were extracted from a prospective hip fracture database and completed by retrospective review of the hospital records. A total of 463 patients undergoing hip fracture (hip hemiarthroplasty) surgery in a level II trauma teaching hospital between January 2011 and May 2016 were included. Delirium was measured using the Delirium Observation Screening Scale, the confusion assessment method, and an observatory judgment by geriatric medicine specialists.

Results

The results showed that 26% of the patients (n=121) developed a delirium during hospital stay with a median duration during admission of 5 days (IQR 3–7). The multivariable model showed that the development of delirium was significantly explained by dementia (OR 2.75, P=0.001), age (OR 1.06, P=0.005), and an infection during admission (pneumonia, deep surgical site infection, or urinary tract infection) (OR 1.23, P=0.046). After 1 year of follow-up, patients who developed delirium after hip fracture surgery were significantly more discharged to (semi-independent) nursing homes (P<0.001) and had a significantly higher mortality rate (P<0.001) compared to patients without delirium after hip fracture surgery.

Conclusions

The results showed that 26% of the patients undergoing hip fracture surgery developed a delirium. The risk factors including age, dementia, and infection during admission significantly predicted the development of the delirium. No association was confirmed between delirium and time of admission or time to surgery. The development of delirium after hip fracture surgery was subsequently found to be a significant predictor of admission to a nursing home and mortality after 1 year.

Fatigue in early, intensively treated and tight-controlled rheumatoid arthritis patients is frequent and persistent: a prospective study

Fatigue has a large impact on quality of life and is still unmanageable for many patients. Study aims were describe (1) the prevalence and pattern of fatigue over time in patients with early rheumatoid arthritis under a treat-to-target strategy and (2) identify predictive factors for worsening and recovering of fatigue over time. Data from the tREACH study were used, comparing different treatment strategies with fatigue as secondary objective. Patient outcomes on fatigue, quality of life, depression, and coping were obtained every 6 months and clinically assessed every 3 months. Prediction of fatigue at 12 months was investigated with an ROC curve. Analysis was stratified into non-fatigue and fatigue at baseline. Logistic regression was used for the evolution of fatigue in relation with the covariates over time. Almost half of all patients (n = 246) had high fatigue levels at baseline, decreasing slightly over time. At 12 months, 43% of patients were fatigued; while 23% of the initially fatigued patients showed lower levels of fatigue, the fatigue level had increased in 15% of the initially non-fatigued patients. The strongest predictor of fatigue was the previous fatigue levels (AUC 0.89). Higher score on the depression scale and coping with limitations was associated with developing fatigue over time in the initially non-fatigued group. Despite a strict treat-to-target strategy, fatigue remained an overall problem during the first year of treatment, and was mainly predicted by its baseline status. In subgroups, a small additional effect of depression was seen. Monitoring fatigue and depression may be important in managing fatigue.

Effects of psychosocial factors on monitoring treatment effect in newly diagnosed rheumatoid arthritis patients over time: response data from the tREACH study

OBJECTIVES

To investigate whether, apart from effects of patient- and disease-related factors, psychosocial factors have additional effects on disease activity; and which factors are most influential during the first year of treatment in early rheumatoid arthritis (RA).

METHOD

The study assessed 15 month follow-up data from patients in tREACH, a randomized clinical trial comparing initial triple disease-modifying anti-rheumatic drug therapy to methotrexate monotherapy, with glucocorticoid bridging in both groups. Patients were evaluated every 3 months and treated to target. Associations between Disease Activity Score (DAS) at 3, 9, and 15 months and psychosocial factors (anxiety, depression, fatigue, and coping with pain) at the previous visit were assessed by multivariable linear regression correcting for demographic, clinical, and treatment-related factors.

RESULTS

At 3, 9, and 15 months of follow-up, 265, 251, and 162 patients, respectively, were available for analysis. Baseline anxiety and coping with pain were associated with DAS at 3 months; coping with pain at 6 months was associated with DAS at 9 months, and fatigue at 12 months with DAS at 15 months. Psychosocial factors were moderately correlated. Effects on DAS were mainly due to tender joint count and global health.

CONCLUSION

Psychosocial factors have additional effects on DAS throughout the first year of treatment in early RA. A change was observed from anxiety and coping with pain at baseline being associated with subsequent DAS towards fatigue being associated with subsequent DAS at 12 months. Owing to the explorative nature of this study, more research is needed to confirm this pattern.

Factors affecting the rate of surgical site infection in patients after hemiarthroplasty of the hip following a fracture of the neck of the femur

AIMS

Surgical site infection can be a devastating complication of hemiarthroplasty of the hip, when performed in elderly patients with a displaced fracture of the femoral neck. It results in a prolonged stay in hospital, a poor outcome and increased costs. Many studies have identified risk and prognostic factors for deep infection. However, most have combined the rates of infection following total hip arthroplasty and internal fixation as well as hemiarthroplasty, despite the fact that they are different entities. The aim of this study was to clarify the risk and prognostic factors causing deep infection after hemiarthroplasty alone.

PATIENTS AND METHODS

Data were extracted from a prospective hip fracture database and completed by retrospective review of the hospital records. A total of 916 patients undergoing a hemiarthroplasty in two level II trauma teaching hospitals between 01 January 2011 and 01 May 2016 were included. We analysed the potential peri-operative risk factors with univariable and multivariable logistic regression analysis.

RESULTS

A total of 92 patients (10%) had a surgical site infection, and 44 (4.9%) developed a deep infection. After univariable analyses, the multivariable model showed that the level of experience of the surgeon measured by the number of hemiarthroplasties performed per year was a significant prognostic factor (odds ratio (OR) 0.93, p = 0.042) for the development of an infection. Secondly, the development of a haematoma (OR 9.6, p < 0.001), a re-operation (OR 4.7, p = 0.004) and an operating time of < 45 mins (OR 5.1, p = 0.002) or > 90 mins (OR 2.7, p = 0.034) were also significant factors.

CONCLUSION

There was a significant association between the experience of the surgeon and the rate of deep infection. Secondly, a haematoma, a re-operation and both shorter and longer operating times were associated with an increased risk of deep infection after hemiarthroplasty. No association was found between deep infection and the anatomical approach, the time when surgery was undertaken and the use of a drain. Cite this article: Bone Joint J 2017;99-B:1088-94.