Outcomes in older adults with stage 5 chronic kidney disease: comparison of peritoneal dialysis and conservative management

BACKGROUND

Data on the outcomes of older adults receiving peritoneal dialysis (PD), especially those who are dependent and have multiple comorbidities, are scarce.

METHODS

In a retrospective cohort study, we compared older adults (≥65 years) with stage 5 chronic kidney disease receiving PD (PD group) with those receiving conservative management (conservative group). Baseline characteristics (demographics and clinical, functional, socioeconomic, and laboratory parameters) were collected, and study outcomes (patient survival, emergency hospitalization, institutionalization, and palliative and end-of-life care) were compared between groups.

RESULTS

We included 199 eligible participants aged 65-90 years (mean ± standard deviation 73.8 ± 5.4 years; 157 in the PD group and 42 in the conservative group). The PD group had a longer survival (median [interquartile range]: 3.75 [2.49-5.25] vs 2.35 [1.13-3.71] years, p < .001), lower emergency hospitalization rates (1.63 [0.82-2.92] vs 3.51 [1.06-7.16] per person-year, p < .01) and hospital days (16.17 [6.29-43.32] vs 38.01 [6.75-76.56] days per person-year, p = .03), and no increased risk of institutionalization compared with the conservative group. Age (hazard ratio [HR] for 1-year increase 1.06, 95% confidence interval [CI] 1.02-1.10), modified Charlson's Comorbidity Index (HR 1.36, 95% CI 1.18-1.56), impairment in basic activities of daily living (HR 2.11, 95% CI 1.28-3.46), and emergency dialysis (HR 1.67, 95% CI 1.11-2.53) were independent predictors of mortality in the PD group.

CONCLUSION

PD is a viable treatment option in older adults with stage 5 chronic kidney disease. Age alone should not preclude dialysis. Comprehensive geriatric assessment can prognosticate and facilitate shared decision making to commence dialysis in older adults.

Characteristics and outcome of traumatic cardiac arrest at a level 1 trauma centre over 10 years in Sweden

BACKGROUND

Historically, resuscitation in traumatic cardiac arrest (TCA) has been deemed futile. However, recent literature reports improved but varying survival. Current European guidelines emphasise the addressing of reversible aetiologies in TCA and propose that a resuscitative thoracotomy may be performed within 15 min from last sign of life. To improve clinician understanding of which patients benefit from resuscitative efforts we aimed to describe the characteristics and 30-day survival for traumatic cardiac arrest at a Swedish trauma centre with a particular focus on resuscitative thoracotomy.

METHODS

Retrospective cohort study of adult patients (≥ 15 years) with TCA managed at Karolinska University Hospital Solna between 2011 and 2020. Trauma demographics, intra-arrest factors, lab values and procedures were compared between survivors and non-survivors.

RESULTS

Among the 284 included patients the median age was 38 years, 82.2% were male and 60.5% were previously healthy. Blunt trauma was the dominant injury in 64.8% and median Injury Severity Score (ISS) was 38. For patients with a documented arrest rhythm, asystole was recorded in 39.2%, pulseless electric activity in 24.8% and a shockable rhythm in 6.8%. Thirty patients (10.6%) survived to 30 days with a Glasgow Outcome Scale score of 3 (n = 23) or 4 (n = 7). The most common causes of death were haemorrhagic shock (50.0%) and traumatic brain injury (25.5%). Survivors had a lower ISS (P < 0.001), more often had reactive pupils (P < 0.001) and a shockable rhythm (P = 0.04). In the subset of prehospital TCA, survivors less frequently received adrenaline (epinephrine) (P < 0.001) and in lower amounts (P = 0.02). Of patients that underwent resuscitative thoracotomy (n = 101), survivors (n = 12) had a shorter median time from last sign of life to thoracotomy (P = 0.03), however in four of these survivors the time exceeded 15 min.

CONCLUSION

Survival after TCA is possible. Determining futility in TCA is difficult and this study demonstrates survivors outside of recent guidelines.

ARTHROSCOPIC PARTIAL MENISCECTOMY - SHORT-TERM CLINICAL OUTCOME IN AN ORTHOPAEDIC CENTER IN SOUTHWESTERN NIGERIA

BACKGROUND

Meniscal tears are one of the common causes of knee pain.

AIM

To evaluate the early clinical results of arthroscopic partial meniscectomy in the treatment of meniscal tears.

STUDY DESIGN

This was a prospective study in which consecutive patients presenting with meniscal injury, who met the inclusion criteria were recruited for the study.

SETTING

National Orthopaedic Hospital, Lagos.

METHODOLOGY

Biodemographic data and clinical findings were obtained. The visual analogue pain score and WOMET score were computed pre-operatively and at least 6-months post-operatively and these values compared using the Wilcoxon's signed rank. The level of significance was set at 0.05.

RESULTS

A total of 19 patients with 19 knees were included. Degenerative longitudinal tears were the commonest findings in 15 (79%), complex tears in 3 (16%) and radial tear in 1 (5%). The medial meniscus was more affected (52%) than lateral meniscus (48%). The red-white zone was involved in 12 (63%) cases and the white-white zone in 5 (37%). The median duration of follow up was 7 months while the median (IQR) WOMET score decreased from 59 (IQR =22) to 26.5(IQR=23), (Z= -3.409, P=001 ) and the visual analogue pain rating scale improved from 5 (IQR=1.5) to 3 (IQR=2.5) (Z= -3.346, P=001 ).

CONCLUSION

Arthroscopic partial meniscectomy offers a good short term clinical outcome for patients with knee pain secondary to meniscal injury.

Review of treatment modalities and clinical outcome of giant saccular posterior inferior cerebellar artery aneurysms

INTRODUCTION

Giant posterior inferior cerebellar artery (PICA) aneurysms are rare lesions carrying significant morbidity due to mass effect and present therapeutic challenges due to proximity to critical neurovascular structures.

MATERIALS AND METHODS

A systematic literature review through the PubMed and Scopus databases was performed according to the PRISMA guidelines to identify cases of giant PICA aneurysms treated either microsurgically or by endovascular means. Patients' demographics, aneurysm size, preoperative and postoperative neurologic status, clinical outcomes as well as follow-up information were retrieved.

RESULTS

Data from 24 studies including 24 patients was obtained. Mean patient age was 53.42 years, with a male-to-female ratio of approximately 1:2. Mean maximum aneurysm diameter was 33.43 mm. A favorable outcome (mRS 0-2) was reported on 66.7% of endovascular and 84.2% of microsurgical cases. Death rate was 0% for endovascular and 5.3% for open cases. The PICA was sacrificed in 33% of the patients without lasting morbidity. 87.5% of the aneurysms were partially thrombosed, 41.7% were debulked due to mass effect and 20.8% required a revascularization procedure.

CONCLUSIONS

Giant PICA aneurysms are amenable to both microsurgery and endovascular treatment. The latter may require PICA sacrifice which may be safely attempted in distal aneurysms. Proximal aneurysms which cannot be safely embolized or ones with significant mass effect may benefit from microsurgical occlusion and may require debulking and/or PICA bypass.

CLINICAL CHARACTERISTICS AND OUTCOME OF PATIENTS WITH UPPER GASTROINTESTINAL BLEEDING AT THE EMERGENCY DEPARTMENT OF A TERTIARY HOSPITAL IN NIGERIA

BACKGROUND

Upper gastrointestinal bleeding is a potentially life threatening condition with multiple causes. There is scarcity of health data depicting the clinical characteristics of the condition in African countries. This study was designed to describe the demographic, clinical characteristics and outcome of the patients who presented to our Emergency Department.

METHOD

The records of cohort of all patients admitted with upper gastrointestinal tract bleeding from 1 January 2011 to 31 December 2012 were retrospectively reviewed from admission to discharge or death.

RESULTS

There were 169 patients with median age of 44.0 years (range 13-89); 25 (15.0%) of them were known peptic ulcer disease patients. Most (69.2%) of the patients were males. The most common presenting symptom was haematemesis (34.9%) followed by melaena (16.6%). There was a history of NSAIDs use in 16.8% and alcohol ingestion in 12%. Upper Gastrointestinal Endoscopy was performed in 6.8% cases. Twenty-three (13.6%) patients died. There was association between mortality and diastolic blood pressure; more deaths (1/7; 14.3%) occurred in those with diastolic blood pressure > 90mmHg compared with ≤90mmHg (5/70; 7.1%) (P = 0.002). There were more deaths among patients who did not receive blood transfusion (4/40; 10.0%) compared with those who had blood transfusion (2/37; 5.4%) (P=0.008).

CONCLUSION

The common presentations were haematemesis and melaena, mainly in middle aged men with mortality in one out of seven patients. The high mortality may be due to co-morbidities and poor support services.

Spanish Research Network on Drugs in Hospital Emergency Departments - the REDUrHE registry: general analysis and comparisons between weekend and weekday poisonings

OBJECTIVES

To describe the sociodemographic characteristics, drug use patterns, and the severity of drug overdoses treated in hospital emergency departments according to the registry of the Spanish Research Network on Drugs in Hospital Emergency Departments (REDUrHE project), and to identify differences between patterns on weekdays and weekends/national holidays.

MATERIAL AND METHODS

Eleven hospitals participated in the REDUrHE project, studying consecutive patients with symptoms of drug overdose over a 24-month period. The drugs implicated were extracted from clinical records or toxicology reports. An overdose was considered severe if management required intubation, cardiopulmonary resuscitation, or admission to the intensive care unit, or if in-hospital death occurred (composite event). Each of these variables was also analyzed by itself.

RESULTS

A total of 4526 patients were studied (2218 [49%] on weekends/holidays; 2308 [51%] on workdays). The mean (SD) age was 33 (11) years, and 75.5% were men. The most commonly used drugs were cocaine (47.8%), paciencannabis (44.4%), amphetamine derivatives (25.5%), benzodiazepines (8.8%), and opioids (7.3%). Patients treated on weekends/holidays were younger (32.1 vs 33.1 years on weekdays, P = .006), and they were more often taken to the hospital in an ambulance (60.5% vs 57.3%, P = .035). Hospitals in large cities (Barcelona and Madrid) saw more patients on weekends/holidays (55.8%). Major tourist destinations (the Balearic and Canary Islands) saw fewer patients on weekends/holidays (44.7%, P .001). Alcohol was ingested along with a drug by 58.2%; this combination was more common on weekends/holidays (in 63.3% vs 52.9% on weekdays, P .001), and 39.4% used more than 1 drug. Use of more than 1 drug was less common on weekends (in 37.6% vs 41.2%, P = .013). Opioid emergencies were also less frequent on weekends (6.0% vs 8.6%, P = .001), when gamma-hydroxybutyrate (GHB) overdoses were more common (5.8% vs 3.6%, P .001). Severity indicators were present (the composite event) more often on weekends (in 3.6% vs 2.2%, P = .006). Likewise, weekends saw more intubations (in 2.3% vs 1.0%, P = .001) and intensive care unit admissions (2.4% vs 1.6%, P = .047). Twelve patients (0.3%) died; mortality was similar on weekends (0.2%) and weekdays (0.3%) (P = .826). After adjusting for age, sex, combined use of alcohol, and type of drug, the risk of the severe-event composite was greater on weekends (odds ratio, 1.569; 95% CI, 1.088-2.263).

CONCLUSION

Weekend and holiday emergencies due to drug overdoses are more frequent in large city hospitals. Weekend emergencies share certain distinctive characteristics: patients are younger, alcohol more often is ingested with drugs but multiple-drug combinations are less common, and GHB is used more often while opioids are used less often. Severe poisonings occur more often on weekends and holidays.

Impact of perioperative hemoglobin-related parameters on clinical outcomes in patients with spinal metastases: identifying key markers for blood management

PURPOSE

Patients with spinal metastases undergoing surgical treatment face challenges related to preoperative anemia, intraoperative blood loss, and frailty, emphasizing the significance of perioperative blood management. This retrospective analysis aimed to assess the correlation between hemoglobin-related parameters and outcomes, identifying key markers to aid in blood management.

METHODS

A retrospective review was performed to identify patients who underwent surgical treatment for spinal metastases. Hb-related parameters, including baseline Hb, postoperative nadir Hb, predischarge Hb, postoperative nadir Hb drift, and predischarge Hb drift (both in absolute values and percentages) were subjected to univariate and multivariate analyses. These analyses were conducted in conjunction with other established variables to identify independent markers predicting patient outcomes. The outcomes of interest were postoperative short-term (6-week) mortality, long-term (1-year) mortality, and postoperative 30-day morbidity.

RESULTS

A total of 289 patients were included. Our study demonstrated that predischarge Hb (OR 0.62, 95% CI 0.44-0.88, P = 0.007) was an independent prognostic factor of short-term mortality, while baseline Hb (OR 0.76, 95% CI 0.66-0.88, P < 0.001) was identified as an independent prognostic factor of long-term mortality. Additionally, nadir Hb drift (OR 0.82, 95% CI 0.70-0.97, P = 0.023) was found to be an independent prognostic factor for postoperative 30-day morbidity.

CONCLUSIONS

This study demonstrated that predischarge Hb, baseline Hb, and nadir Hb drift are prognostic factors for outcomes. These findings provide a foundation for precise blood management strategies. It is crucial to consider Hb-related parameters appropriately, and prospective intervention studies addressing these markers should be conducted in the future.

A 2-year review of stroke admissions and short term out-come predictors in a teaching hospital, Southeast, Nigeria

Background

Stroke is a common neurological disorder with a huge global burden in terms of mortality and morbidity. Epidemiological evidence has shown that modifiable risk factors are responsible for more than 90% of all strokes. Stroke outcome in hospitalized patients is influenced by several variables, such as socio-demographic factors, stroke subtype, and admission severity. The interaction between stroke outcomes and these parameters is often complex. The study is aimed to profile hospitalized stroke patients and determine outcome predictors.

Methodology

A descriptive retrospective study of 100 patients hospitalized for acute stroke. Their medical records were reviewed for demographic and clinical variables and relevant data were retrieved and analysed using appropriate statistical methods.

Results

Of the 100 acute stroke patients studied, 36% were men and 64% were women. The mean age was 65.16±15.72. About 78%had ischemic stroke while 21% had haemorrhagic strokes. The commonest risk factor was hypertension (71.2%). On multivariate analysis, stroke subtype and admission duration were significantly linked to stroke outcome.

Conclusion

Ischemic stroke comprises more than two-thirds of stroke admissions, with hypertension being the most common risk factor and stroke case fatality of 23%. Stroke subtype and admission duration significantly predicted stroke outcomes. The need to step up measures aimed at improving acute stroke care in hospitalized patients is imperative as this will hopefully improve overall outcomes in resource constraint settings such as Nigeria.