The ASA score predicts infections, cardiovascular complications, and hospital readmissions after hip fracture - A nationwide cohort study

Risk factors and predictive models for postoperative surgical site infection in patients with massive hemorrhage

Background

This study aimed to identify risk factors associated with postoperative surgical site infection (SSI) in patients experiencing massive hemorrhage and develop a predictive model.

Methods

A retrospective analysis of 121 orthopedic surgery patients and experienced massive hemorrhage was conducted. According to postoperative SSI occurrence, the patients were divided into two groups: the infection group (n = 12) and the non-infection group (n = 109). Clinical data were collected, and a predictive model was developed using logistic regression analysis in patients with massive hemorrhage.

Results

Independent risk factors for postoperative SSI included ASA grade, urine volume, and type 2 diabetes. An area under the curve for the prediction of postoperative SSI based on the Receiver Operating Characteristic (ROC) curve for the risk score was 0.916.

Conclusions

Patients with a urine volume of ≥3.49 ml/kg/h, higher ASA grade, and type 2 diabetes are at an increased risk of developing postoperative SSI after experiencing massive hemorrhage.

Level of evidence

Level III.

Machine learning-based survival models for predicting rehospitalization of older hip fracture patients: a retrospective cohort study

PURPOSE

To evaluate machine learning-based survival model roles in predicting rehospitalization after hip fractures to improve reduce the burden on the healthcare system.

METHODS

This retrospective cohort study examined 718 patients with hip fractures hospitalized at the Daejeon Eulji Medical Center between January 2020 and June 2022. Demographic and clinical variables, and rehospitalization data were collected at 6 weeks and 3, 6, 12, and 24 months. Cox proportional hazards (CoxPH), random survival forest (RSF), gradient boosting (GB), and fast survival support vector machine (SVM) models were developed. Model performance was assessed using the concordance index (c-index), area under the curve (AUC), and Kaplan-Meier survival curves. Feature importance was analyzed using permutation importance, with the best model selected based on overall performance.

RESULTS

Hyperparameter tuning optimized the models. The GB model had the highest mean AUC of 0.868, followed by the RSF (0.785), SVM (0.763), and CoxPH (0.736) models. Feature importance analysis highlighted femoral neck T-score, age, body mass index, operation time, compression fracture, and total calcium as significant predictors. Feature selection improved the c-index for the RSF model from 0.742 to 0.874 and CoxPH model from 0.717 to 0.915; the GB and SVM models exhibited a c-index decline post-feature selection. The GB and RSF models predicted lower rehospitalization probabilities than Kaplan-Meier estimates; the CoxPH model's predictions were closely aligned with the observed data.

CONCLUSIONS

The effect of feature selection on model performance highlights the need for comprehensive variable selection and model evaluation strategies to improve predictive accuracy.

Predicting admission to and length of stay in intensive care units after general anesthesia: Time-dependent role of pre- and intraoperative data for clinical decision-making

BACKGROUND

Accurate prediction of intensive care unit (ICU) admission and length of stay (LOS) after major surgery is essential for optimizing patient outcomes and healthcare resources. Factors such as age, BMI, comorbidities, and perioperative complications significantly influence ICU admissions and LOS. Machine learning methods have been increasingly utilized to predict these outcomes, but their clinical utility beyond traditional metrics remains underexplored.

METHODS

This study examined a sub-cohort of 6043 patients who underwent general anesthesia at Seoul National University Hospital from August 2016 to June 2017. Various prediction models, including logistic regression and random forest, were developed for ICU admission and different LOS thresholds, e.g., a LOS of more than a week. Clinical utility was evaluated using decision curve analysis (DCA) across predefined risk preferences.

RESULTS

Among patients studied, 19.8 % were admitted to the ICU, with 1.4 % staying longer than a week. Prediction models demonstrated high discrimination (AUROC 0.93 to 0.96) and good calibration for ICU admission and short LOS. DCA revealed that intraoperative data provided the greatest decision-related benefit for predicting ICU admission, while preoperative data became more important for predicting longer LOS.

CONCLUSION

Intraoperative data are crucial for immediate postoperative decisions, while preoperative data are essential for extended LOS predictions. These findings highlight the need for a comprehensive risk assessment approach in perioperative care, utilizing both preoperative and intraoperative information to enhance clinical decision-making and resource allocation.

A quality improvement program to reduce surgical site infections after cardiac surgery: A 10-year cohort study

OBJECTIVES

To assess trends in surgical site infection (SSI) incidence in cardiosurgery following a quality improvement initiative in infection prevention and control (IP&C).

METHODS

This is a historical cohort study encompassing a 10-year surveillance period (2014-2023) in a cardiosurgical department in a multi-organ transplant center. The study encompassed three periods: a baseline period (Phase_1: January 2014-December 2018); an implementation phase covering quality improvement initiatives targeting various aspects of IP&C including organizational factors, pre-operative, intra-operative, post-operative measures, and post-hospitalization care (Phase_2: January 2019-June 2021); a post-implementation phase (Phase_3: July 2021-September 2023). A general linear mixed model was used to assess differences in SSI rates between distinct phases, adjusted for length of hospitalization, American Society of Anaesthesiologists (ASA) physical status classification, and Diagnostic-Related Groups (DRG) weight. The latter two were used as random effects. Results are reported as odds ratios [OR] with 95% confidence interval [CI].

RESULTS

All cardiac surgery patients were included (n = 5851). A total of 208 patients developed SSI (3.5 %). SSI incidence for phase_1, phase_2 and phase_3 were 4.5 %, 4.1 %, and 1.2 %, respectively. The mixed model regression analysis indicated that, compared with the reference period (Phase1), SSI risk did not drop during the implementation phase (OR 0.81, 95 % CI 0.59-1.13, P < 0.001 vs. reference period). A decrease in SSI risk was observed during the post-implementation phase (OR 0.19, 95 % CI 0.11-0.32) CONCLUSIONS: A quality improvement initiative encompassing measurements at all levels potentially impacting SSI risk was implemented over a 2.5 years period. While no risk reduction was observed during the implementation phase, a significant reduction in SSI risk took place in the post-implementation phase.

IMPLICATIONS FOR CLINICAL PRACTICE

This study suggests that considerable time may be required to achieve a substantial SSI risk reduction. We assume this may be attributed to the time required to achieve appropriate adherence with IP&C protocols.

Risk factors of postoperative complications and in-hospital mortality after hip fracture among patients older than 80 years old: a retrospective study

INDUCTION

The mortality and morbidity in hip fracture is a big healthcare burden. How to identify risk patients preoperatively is important. The aim of study was to evaluate the risk factors of postoperative complications and mortality in patients older than 80 years old after hip fracture surgery.

METHODS

Patients older than 80 years old with the diagnosis of hip fracture who had surgical treatment from February 2013 to June 2021 at a single center in China were included for analysis. The primary outcome were postoperative complications and in-hospital mortality. Binary logistic regression was used to confirm the relationship between preoperative factors and postoperative complications/mortality.

RESULTS

498 patients were included for analysis. 176 patients developed 265 episodes of complications and the incidence of postoperative complication was 35.3%. Postoperative pulmonary infection was the most common complication, followed by cardiovascular complications and postoperative delirium. And there were 10 postoperative in-hospital deaths (2.0%). Preoperative Charlson comorbidity index(CCI) was associated with postoperative complications (OR = 1.243, 95%CI 1.020-1.516, P = 0.031) and mortality (OR = 2.303, 95%CI 1.351-3.925, P = 0.002). However, American society of Anesthesiologists (ASA) score was not an independent risk factor for postoperative complication and mortality.

CONCLUSION

CCI was the risk factor of poor postoperative outcome for patients older than 80 years old after hip fracture surgery. And CCI can be used as the potential tool of risk stratification for this group of patients.

TRIAL REGISTRATION

This study had been registered in www.chictr.org.cn and the registration ID was ChiCTR2400085291 on June 4th 2024.

Examination of factors causing postoperative pneumonia in elderly hip fracture patients: A narrative review

With the increasing aging problem, the number of fractures in the elderly is also increasing, of which hip fractures are more common, known as "the last fracture of life." Postoperative pneumonia (POP) is a common complication of hip fracture, which greatly increases the mortality of patients. It is particularly important to clarify the factors of perioperative pneumonia for the prevention and treatment process. In this paper, the factors causing POP mainly include demographic factors, pre-injury comorbidities, blood index parameters, major clinical interventions and related mechanisms were reviewed, and the risk degree of the factors causing postoperative pneumonia was mainly discussed, and they were divided into independent factors and risk factors. The objective is to make the most accurate POP prevention measures for hip fracture patients according to the classification of independent factors and risk factors, and reduce the incidence of postoperative pneumonia.

Intracapsular and extracapsular fracture types and inpatient mortality in failed hemiarthroplasty

BACKGROUND

Increasing life expectancy has led to a rise in hip fractures and an associated increase in hemiarthroplasty procedures aimed at restoring mobility and preventing muscle loss. Despite the extensive literature on failed hemiarthroplasty, limited data address the influence of pre-operative fracture types-intracapsular versus extracapsular-on outcomes, including inpatient mortality. This study investigates the revisions of uncemented bipolar hemiarthroplasties concerning fracture type and identifies risk factors for inpatient mortality.

METHODS

This retrospective cohort study included 68 patients (16 males and 52 females) who underwent revision of uncemented bipolar hemiarthroplasties at a single institution between 2017 and 2024. Data on demographics, comorbidities, fracture type, surgical details and outcomes were analysed. Statistical analyses included t tests, chi-square tests and logistic regression, with significance set at p < 0.05.

RESULTS

Of 1,690 hemiarthroplasties performed, 68 required revision (revision rate: 4%). Revisions for extracapsular fractures were associated with a higher prevalence of diabetes mellitus (p = 0.01) and elevated Almelo Hip Fracture Score (AHFS; p = 0.01). The overall inpatient mortality rate was 19%, significantly higher in males (43.75%) than females (11.54%; p = 0.00). Deceased patients demonstrated higher AHFS and American Society of Anaesthesiologists scores but lower Parker Mobility Scores (p = 0.01). Prolonged intensive care unit (ICU) stays were also linked to increased mortality (p = 0.02). Logistic regression identified male sex as an independent predictor of mortality (odds ratio: 9.37; p < 0.05).

CONCLUSIONS

Pre-operative fracture type significantly influences revision outcomes in failed hemiarthroplasties. Moreover, extracapsular fractures are linked to diabetes mellitus and higher AHFS, whereas male sex, ICU stay duration and comorbidity scores predict inpatient mortality. These findings highlight the need for tailored perioperative care to mitigate risks.

TRIAL REGISTRATION

Not applicable.

Prevalence of complications in older adults after hip fracture surgery : a systematic review and meta-analysis

Aims

Older adults with hip fractures are at high risk of experiencing complications after surgery, but estimates of the rate of specific complications vary by study design and follow-up period. The aim of this systematic review was to determine the prevalence of complications in older adults after hip fracture surgery.

Methods

MEDLINE, Embase, CINAHL, and CENTRAL databases were searched from inception until 30 June 2023. Studies were included if they reported prevalence data of complications in an unselected, consecutive population of older adults (aged ≥ 60 years) undergoing hip fracture surgery.

Results

A total of 95 studies representing 2,521,300 patients were included. For surgery-specific complications, the 30-day prevalence of reoperation was 2.31%, surgical site infection 1.69%, and deep surgical site infection 0.98%; the 365-day prevalence of prosthesis dislocation was 1.11%, fixation failure 1.77%, and periprosthetic or peri-implant fracture 2.23%. For general complications, the 30-day prevalence of acute kidney injury was 1.21%, blood transfusion 25.55%, cerebrovascular accident 0.79%, lower respiratory tract infection 4.08%, myocardial infarction 1.98%, urinary tract infection 7.01%, and venous thromboembolism 2.15%.

Conclusion

Complications are prevalent in older adults who have had surgery for a hip fracture. Studies reporting complications after hip fracture surgery varied widely in terms of quality, and we advocate for the routine monitoring of complications in registries and clinical trials to improve the quality of evidence.

Correlation Analysis Between the Geriatric Nutritional Risk Index Hip Fracture in Male: Based on the National Health and Nutrition Examination Survey Database

Hip fractures (HFs) are common in elderly patients and are associated with high mortality rates and functional impairment. Malnutrition has been shown to negatively impact postoperative survival rates in HF patients. However, the relationship between the Geriatric Nutrition Risk Index (GNRI) and the risk of HF remains unclear. This study aims to evaluate the association between GNRI and HF risk, with a particular focus on the elderly male population.We conducted a cross-sectional study using data from the National Health and Nutrition Examination Survey (NHANES) for the periods 2007-2010, 2013-2014, and 2017-2018. Through multivariate regression analysis, we assessed the association between GNRI and HF and performed stratified and subgroup analyses to further explore this relationship. Additionally, we utilized restricted cubic splines (RCSs) to investigate the potential nonlinear relationship between GNRI and HF risk.The study found that gender significantly influenced the relationship between GNRI and HF (p for interaction = 0.002). In males, GNRI was significantly negatively associated with the risk of HF (OR < 1, p < 0.05). RCS analysis showed that the relationship between GNRI and HF risk in elderly males might be linearly negative. The critical threshold for GNRI was identified as 104.14, beyond which the risk of HF significantly decreased.This study demonstrates a linear negative correlation between GNRI and the risk of HF in elderly males, with a GNRI of 104.14 identified as the critical threshold for predicting the risk of hip fractures.

Correlation between admission hyperglycemia and postoperative pneumonia after hip fracture surgery: A propensity score-matched study

The association between admission hyperglycemia and postoperative pneumonia is unclear in hip fracture patients. We investigated the relationship between admission hyperglycemia and postoperative pneumonia after hip fracture surgery. This retrospective study analyzed data from 1,267 geriatric patients admitted for hip fractures. Patients were categorized into normoglycemic (< 6.10 mmol/L) and hyperglycemic (≥ 6.10 mmol/L) groups based on admission blood glucose levels. Multivariable logistic regression and propensity score matching (PSM) were used to control for potential confounding variables and estimate adjusted odds ratios and 95% confidence intervals for postoperative pneumonia (POP). We also examined the dose-dependent link between admission blood glucose and the likelihood of developing POP. Further analyses evaluated whether admission hyperglycemia has differing impacts on POP outcomes among hip fracture patients without diabetes (NDM) versus those with diabetes (DM). Additionally, subgroup analyses were conducted to assess the influence of other factors on the relationship between admission blood glucose and POP occurrence. Patients with admission hyperglycemia had significantly higher rates of POP compared to normoglycemic patients, both before (13.2% vs. 4.8%) and after (10.1% vs. 5.8%) PSM. Admission hyperglycemia is an independent risk factor of POP (OR = 2.64, 95% CI: 1.42-4.92, p = 0.002). The association persisted after PSM(OR = 2.90, 95% CI: 1.35-3.86, p = 0.016). Additionally, higher blood glucose levels correlated with a greater likelihood of developing POP. A dose-response relationship was observed between blood glucose levels and the risk of POP. Non-diabetic group patients with hyperglycemia were at higher risk of POP than diabetic group patients with hyperglycemia. Finally, the relationship between hyperglycemia and increased POP risk is modulated and influenced by the ASA classification of the patient. Admission hyperglycemia is an independent risk factor for POP after hip fracture surgery in the elderly. There is a dose-response relationship between admission blood glucose and the occurrence of POP, which is more significant in non-diabetic patients than diabetic patients.

Minimizing the Risk of Surgical Site Infection Following Hip Fracture Operation

Introduction: Hip fractures are the most common serious injury in the elderly, associated with disability, morbidity, and mortality. Surgical site infection (SSI) is a serious post-operative complication. This prospective cohort study outlines how our center made cumulative improvements in SSI incidence rates, reaching a 12-month average of 0.5%. Methods: All patients undergoing hip fracture operation between 2016 and 2021 were included. The primary outcome measure was confirmed SSI, according to the Public Health England definition. Results were compared with the baseline recordings by an independent SSI team in 2013. Demographic data were compared with National Hip Fracture Database records. Peri-operative infection control and wound management tactics introduced between 2014 and 2021 were collated to gain an overview care bundle. Results: Baseline recordings identified a 9.0% SSI rate in a three-month observation period. In our study, 3,138 hip fracture operative cases were completed between October 2016 and December 2021. There were 9 superficial and 32 deep infections identified, yielding an overall infection rate of 1.3%. However, when analyzing the 12-month average, there was consistent decline in SSI from the baseline 9.0% in 2013 to 0.5% in 2021 (p < 0.05). A peri-operative care bundle included pre-operative bleeding risk assessment. Intra-operatively, double preparation and draping is used for arthroplasty. Broad-spectrum antibiotic agents and tranexamic acid are administered. Meticulous hemostasis and watertight wound closure are observed. Anti-coagulated patients received negative pressure dressings. Post-operatively, a dedicated senior lead team provided daily inpatient review of patients, with urgent consultant review of all wound healing concerns. Conclusion: Patients with a hip fracture have numerous risk factors for SSI. A dedicated multi-focal tactic, adopted by a multi-disciplinary department, can yield substantial risk reduction. Each intervention is evidence based and contributes to cumulative improvement. By prioritizing infection prevention, we have minimized the need for complex infection management interventions and achieved an annual saving of £860,000 for our trust.

Updated systematic review and meta‑analysis for risk predictors of 30‑day unplanned readmission following gastric cancer surgery

Readmission to hospital is a common occurrence due to adverse post-operative events. The primary objective of the present study was to examine the possible risk predictors for 30-day unplanned readmissions after the surgical treatment of gastric cancer. The secondary aim was to determine the clinical characteristics that are associated with readmission. Studies that reported the risk factors and clinical characteristics of patients with gastric cancer who had an unplanned 30-day post-operative readmission were identified systematically from PubMed, Cochrane Central Register of Controlled Trials, Web of Science and Embase databases, with a final search date of March 30, 2024. A systematic review and meta-analysis were then performed to estimate the risk predictors and relevant clinical characteristics for readmission. A total of 16,154 patients from 12 studies were included in the present study, with 1,736 patients who were readmitted and 14,418 patients who were not readmitted. A higher proportion of patients with an age ≥70 years, cardiovascular comorbidity, Nutritional Risk Screening (NRS) 2002 score ≥3, respiratory diseases, male sex, American Society of Anesthesiologists score ≥3, combined multi-organ resection, greater depth of invasion (T3-4/T1-2), discharge to home with provision of care services, neoadjuvant therapy, post-operative complications or a blood transfusion were found in the readmission group compared with that in the non-readmission group. A meta-analysis was also performed to calculate risk predictors using the results of multivariate regression analyses from the original literature. This identified cardiovascular comorbidity, NRS 2002 score ≥3, pancreatectomy and post-operative complications as risk predictors for 30-day unplanned readmission following surgery for gastric cancer. Therefore, it is recommended that extra attention and support should be given to patients with these high-risk predictors during the perioperative period.

Fracture-related infections after osteosynthesis for hip fracture are associated with higher mortality: A retrospective single-center cohort study

BACKGROUND AND PURPOSE

 Fracture-related infections (FRIs) after osteosynthesis for hip fractures have not been thoroughly investigated. Our primary aim was to assess the association between FRIs and mortality after osteosynthesis for hip fracture. Secondary aims were to investigate the incidence, microbiology, and general epidemiological aspects of these FRIs.

METHODS

 This retrospective single-center study included 1,455 patients > 18 years old with non-pathological hip fractures treated with osteosynthesis between 2015 and 2019. Medical records were reviewed and FRIs were diagnosed based on current consensus criteria. The follow-up period was 2 years. Mortality was estimated using Kaplan-Meier survival analysis. Cox regression analyses were performed to investigate the potential association between FRIs, as a time-dependent variable, and increased mortality.

RESULTS

The median age for the entire cohort was 83 (interquartile range 75-89) years and 69% were females. At the 2-year follow-up mark, the crude mortality rate was 33% in the non-FRI group and 69% (11 of 16 patients) in the FRI group. Cox regression analysis assessing mortality risk revealed a hazard ratio of 3.5 (95% confidence interval [CI] 1.9-6.4) when adjusted for confounders. The incidence of FRI was 1.1% (16 of 1,455 patients). Staphylococcus aureus was the most common pathogen. Most FRI patients (94%) required at least 1 revision and 56% underwent ≥ 2 revision.

CONCLUSION

 We found an association between FRIs after hip fracture osteosynthesis and increased mortality, underscoring the critical need for FRI prevention measures in this frail patient group. The incidence and microbiological findings were consistent with previous studies.

Impact of the American Society of Anesthesiologists (ASA) classification on hip fracture surgery outcomes: insights from a retrospective analysis

BACKGROUND

The American Society of Anesthesiologists (ASA) classification is the most used system to assess patient health status before surgery, ranging from I to V levels. This study aims to explore the impact of different ASA risk classes (ASA II [mild risk] and ASA III [severe risk]) on clinical outcomes following hip fracture surgery, including all-cause mortality and postoperative complications.

METHODS

A retrospective analysis from 2019 to 2021 across three Jordanian centers was conducted. The study included patients aged 65 and above who underwent hip fracture repair surgeries. Preoperative measures, intraoperative management protocols, and postoperative care were collected. Clinical data were extracted from electronic medical records, including demographics, fracture type, intraoperative data, and postoperative outcomes.

RESULTS

The analysis included 1033 patients, with 501 (48.5%) in the mild anesthetic risk group (ASA I-II) and 532 (51.5%) in the severe anesthetic risk group (ASA III-V). The mean age was 73 years, with a higher prevalence of males in the severe risk group. Patients in the severe risk group had more comorbidities, higher ICU admissions (15.23% vs. 6.18%), longer hospital stays (median 7 vs. 6 days), and higher rates of postoperative thromboembolic complications (3.39% vs. 1.39%) compared to the mild risk group. Additionally, the severe risk group showed higher mortality rates both in-hospital mortality (3.38% vs. 1.39%) and all-cause mortality (16.92% vs. 10.36%). Multivariate analysis identified higher ASA score as independent risk factors for increased all-cause mortality (HR = 1.64 95%CI 1.51-2.34) and thromboembolic complications (OR = 2.85 95%CI 1.16-7). Length of hospital stay was significantly associated with higher ASA score (OR = 1.04 95%CI 0.96-1.11).

CONCLUSION

The study underscores the significant impact of anesthetic risk on the outcomes of hip fracture surgeries. Patients with higher ASA scores associated with severe systemic diseases may have at increased risk of adverse outcomes.

Predictors of Nonhome Discharge After Cervical Disc Replacement

STUDY DESIGN

Retrospective review of a national database.

OBJECTIVE

The aim of this study was to identify the factors that increase the risk of nonhome discharge after CDR.

SUMMARY OF BACKGROUND DATA

As spine surgeons continue to balance increasing surgical volume, identifying variables associated with patient discharge destination can help expedite postoperative placement and reduce unnecessary length of stay. However, no prior study has identified the variables predictive of nonhome patient discharge after cervical disc replacement (CDR).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients who underwent primary 1-level or 2-level CDR between 2011 and 2020. Multivariable Poisson regression with robust error variance was employed to identify the predictors for nonhome discharge destination following surgery.

RESULTS

A total of 7276 patients were included in this study, of which 94 (1.3%) patients were discharged to a nonhome destination. Multivariable regression revealed older age (OR: 1.076, P <0.001), Hispanic ethnicity (OR: 4.222, P =0.001), BMI (OR: 1.062, P =0.001), ASA class ≥3 (OR: 2.562, P =0.002), length of hospital stay (OR: 1.289, P <0.001), and prolonged operation time (OR: 1.007, P <0.001) as predictors of nonhome discharge after CDR. Outpatient surgery setting was found to be protective against nonhome discharge after CDR (OR: 0.243, P <0.001).

CONCLUSIONS

Age, Hispanic ethnicity, BMI, ASA class, prolonged hospital stay, and prolonged operation time are independent predictors of nonhome discharge after CDR. Outpatient surgery setting is protective against nonhome discharge. These findings can be utilized to preoperatively risk stratify expected discharge destination, anticipate patient discharge needs postoperatively, and expedite discharge in these patients to reduce health care costs associated with prolonged length of hospital stay.

LEVEL OF EVIDENCE

IV.

Predictive modeling for identifying infection risk following spinal surgery: Optimizing patient management

Infection is known to occur in a substantial proportion of patients following spinal surgery and predictive modeling may provide a useful means for identifying those at higher risk of complications and poor prognosis, which could help optimize pre- and postoperative management strategies. The outcome measure of the present study was to investigate the occurrence of all-cause infection during hospitalization following scoliosis surgery. To meet this aim, the present study retrospectively analyzed 370 patients who underwent surgery at the Second Affiliated Hospital, Zhejiang University School of Medicine (Hangzhou, China) between January 2016 and October 2022, and patients who either experienced or did not experience all-cause infection while in hospital were compared in terms of their clinicodemographic characteristics, surgical variables and laboratory test results. Logistic regression was subsequently applied to data from a subset of patients in order to build a model to predict infection, which was validated using another subset of patients. All-cause, in-hospital postoperative infections were found to have occurred in 66/370 patients (17.8%). The following variables were included in a predictive model: Sex, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), diabetes mellitus, hypertension, preoperative levels of white blood cells and preoperative C-reactive protein (CRP) and duration of surgery. The model exhibited an area under the curve of 0.776 against the internal validation set. In conclusion, dynamic nomograms based on sex, ASA classification, BMI, diabetes mellitus, hypertension, preoperative levels of white blood cells and CRP and duration of surgery may have the potential to be a clinically useful predictor of all-cause infection following scoliosis. The predictive model constructed in the present study may potentially facilitate the real-time visualization of risk factors associated with all-cause infection following surgical procedures.

Adverse events at the end of life of hospital patients with or without a condition relevant for palliative care: a nationwide retrospective record review study in the Netherlands

BACKGROUND

Patient safety is crucial for quality of care. Preventable adverse events (AEs) occur in 1 of 20 patients in the hospital, but it is unknown whether this is different for patients with a condition relevant for palliative care. The majority of the limited available research on this topic is only focused on patients already receiving palliative care, and do not make comparisons with other patients at the end-of-life. We identified and compared the prevalence, preventability, nature and causes of AEs in patients with and without a condition relevant for palliative care.

METHODS

A nationwide retrospective record review study was performed in 20 Dutch hospitals. A total of 2,998 records of patients who died in hospital in 2019 was included. Records were reviewed for AEs. We identified two subgroups: patients with (n = 2,370) or without (n = 248) a condition relevant for palliative care through the selection method of Etkind (2017). Descriptive analyses were performed to calculate prevalence, nature, causes and prevention strategies. T-tests were performed to calculate differences between subgroups.

RESULTS

We found no significant differences between subgroups regarding AE prevalence, this was 15.3% in patients with a condition relevant for palliative care, versus 12.0% in patients without a condition relevant for palliative care (p = 0.148). Potentially preventable AE prevalence was 4.3% versus 4.4% (p = 0.975). Potentially preventable death prevalence in both groups was 3.2% (p = 0.938). There were differences in the nature of AEs: in patients with a condition relevant for palliative care this was mostly related to medication (33.1%), and in patients without a condition relevant for palliative care to surgery (50.8%). In both subgroups in the majority of AEs a patient related cause was identified. For the potentially preventable AEs in both subgroups the two most important prevention strategies as suggested by the medical reviewers were reflection and evaluation and quality assurance.

DISCUSSION

Patient safety risks appeared to be equally prevalent in both subgroups. The nature of AEs does differ between subgroups: medication- versus surgery-related, indicating that tailored safety measures are needed. Recommendations for practice are to focus on reflecting on AEs, complemented with case evaluations.

Orthogeriatric Care Following Hip Fracture: Improving Post-Operative Outcomes in an Aged Population

INTRODUCTION

Hip fractures globally are associated with high levels of morbidity, mortality, and significant financial burden. This audit aimed to assess the impact of orthogeriatric liaison care on post-operative outcomes following surgical management of neck or femur fractures.

METHODS

Here, 258 patients who underwent hip fracture surgery over 1-year were included. Data were collected as an audit following the transition to an orthogeriatric liaison care model, involving regular orthogeriatric review (thrice weekly ward rounds, daily board rounds), superseding orthogeriatric review as requested. The audit is meant to assess the development of post-operative non-surgical site infection (NSSI) and mortality and duration of inpatient stay. Outcomes were compared to previous data from our hospital site in 2015/2016.

RESULTS

Patients with severe cognitive impairment and systemic disease (Abbreviated Mental Test Score (AMTS) < 7 and American Society of Anesthesiologists (ASA) grade ≥ 3) showed significantly elevated NSSI risk, consistent across the study periods. Both periods demonstrated an increased risk of NSSI associated with admission from nursing homes. Despite the 2021/2022 cohort being notably older, NSSI risk decreased from 40.6% to 37.2% after implementing the orthogeriatric care model. NSSI risk was notably reduced for severe cognitive impairment (51.6% vs. 71%), and the p-value was 0.025. Average hospital stay decreased post-intervention (2.4 days shorter), with a notable reduction for NSSI patients (3.4 days shorter). Overall mortality rates were similar, although mortality due to infection was significantly reduced in 2021/2022 (44.4% vs. 93.3%), and the p-value was 0.003.

CONCLUSION

The orthogeriatric liaison care model significantly decreased NSSI only in individuals with severe cognitive impairment and infection-associated mortality. This highlights the integral role of orthogeriatricians in the care of elderly hip fracture patients.

Characteristics of Postoperative Heart Failure in Older Hip Fractures Patients Combined with Coronary Heart Disease and Construction of a Prediction Model of Nomogram, a Retrospective Cohort Study

INTRODUCTION

Older patients combined with coronary heart disease (CHD) develop acute heart failure (AHF) after hip fracture surgery is common, and this study aimed to investigate the risk factors of postoperative AHF in older hip fracture patients and to construct a nomogram prediction model.

METHODS

We retrospectively collected older hip fracture patients with CHD who underwent hip fracture surgery at the Third Hospital of Hebei Medical University from January 2017 to December 2021. We divided them into a training set and a validation set. We collected the demographic data, laboratory indicators and imaging examination results. We identified risk factors for postoperative AHF and used R language software to establish a nomogram prediction model, plot ROC curves, calibration curves and DCA decision curves.

RESULTS

We retrospectively collected 1288 older hip fractures patients with CHD. After excluding 214 patients who did not meet the criteria, 1074 patients were included in our research and we divided them into the training set and the validation set. In the training set, a total of 346 (42.8%) patients developing postoperative AHF. Through univariate and multivariate logistic regression analysis, we identified the risk factors for postoperative AHF and constructed a nomogram prediction model. The AUC of the prediction model is 0.778. The correction curve shows that the model has good consistency. The decision curve analysis shows that the model has good clinical practicality.

CONCLUSION

There were 42.8% older patients combined with CHD develop postoperative AHF. Among them, fracture type, age, anemia at admission, combined with COPD, ASA ≥ 3, and preoperative waiting time >3 days are risk factors for postoperative AHF. We constructed a nomogram prediction model that can effectively predict the risk of postoperative AHF in older hip fracture patients combined with CHD.

Textbook outcome in urgent early cholecystectomy for acute calculous cholecystitis: results post hoc of the S.P.Ri.M.A.C.C study

INTRODUCTION

A textbook outcome patient is one in which the operative course passes uneventful, without complications, readmission or mortality. There is a lack of publications in terms of TO on acute cholecystitis.

OBJETIVE

The objective of this study is to analyze the achievement of TO in patients with urgent early cholecystectomy (UEC) for Acute Cholecystitis. and to identify which factors are related to achieving TO.

MATERIALS AND METHODS

This is a post hoc study of the SPRiMACC study. It´s a prospective multicenter observational study run by WSES. The criteria to define TO in urgent early cholecystectomy (TOUEC) were no 30-day mortality, no 30-day postoperative complications, no readmission within 30 days, and hospital stay ≤ 7 days (75th percentile), and full laparoscopic surgery. Patients who met all these conditions were taken as presenting a TOUEC.

OUTCOMES

1246 urgent early cholecystectomies for ACC were included. In all, 789 patients (63.3%) achieved all TOUEC parameters, while 457 (36.6%) failed to achieve one or more parameters and were considered non-TOUEC. The patients who achieved TOUEC were younger had significantly lower scores on all the risk scales analyzed. In the serological tests, TOUEC patients had lower values for in a lot of variables than non-TOUEC patients. The TOUEC group had lower rates of complicated cholecystitis. Considering operative time, a shorter duration was also associated with a higher probability of reaching TOUEC.

CONCLUSION

Knowledge of the factors that influence the TOUEC can allow us to improve our results in terms of textbook outcome.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Modified versus three-level technique of retroperitoneal laparoscopic adrenalectomy for all patients with adrenal lesions ≤ 6cm: a retrospective, case-controlled study

Objectives

The modified three-level technique for retroperitoneal laparoscopic adrenalectomy (RLA) has proven beneficial in the treatment of adrenal lesions in patients with BMI≥25 Kg/m2. This paper aims to summarize our institution's seven-year experience using this technique for all patients with Adrenal Lesions ≤ 6cm.

Patients and methods

Between January 2016 and December 2022. The patients underwent laparoscopic adrenal surgery were categorized into Zhang's technique (ZT) (Three-level Technique) group and modified technique (MT) group. The fundamental characteristics and perioperative data were analyzed, with statistical significance set at p<0.05.

Results

In total, 731 patients were stratified into two groups: ZT (n=448) and MT (n=283). Statistically significant distinctions were not detected between the two groups regarding sex, BMI, tumor location, tumor size, tumor type, or American Society of Anesthesiologists (ASA) score (p>0.05). The MT group demonstrated superior outcomes compared to the ZT group in terms of operative time, estimated blood loss, drainage volume, diet recovery time, complication rates, and postoperative hospitalization duration (p<0.05). 17 (4.34%) in the ZT group required unplanned adrenalectomy, while there was none in MT group (P<0.05).

Conclusion

MT retroperitoneal laparoscopic adrenalectomy has demonstrated its benefits in the treatment of adrenal lesions across all patients with adrenal lesions ≤ 6cm, serving as a valuable point of reference for the surgical management of adrenal diseases.

Patient summary

We have made modifications to the classic retroperitoneal laparoscopic adrenalectomy and achieved superior surgical outcomes, resulting in a procedure known as modified retroperitoneal laparoscopic adrenalectomy. This technique is suitable for both obese individuals and the general population with adrenal lesions ≤ 6cm.

Risk factors for urinary tract infection in geriatric hip fracture patients: a systematic review and meta-analysis

Background

Urinary tract infection (UTI) is a prevalent and consequential complication in hip fracture patients, leading to significant disability and heightened healthcare expenditures. Consequently, there is a critical need for a comprehensive systematic review to identify risk factors and establish early and effective preventive measures.

Methods

A comprehensive search was performed across the PubMed, Cochrane, Embase, Web of Science, and Scopus databases (up to August 31, 2023). Article screening, data extraction, and quality assessment were independently completed by two reviewers.

Results

Forty-four studies were eligible for inclusion, yielding an overall incidence rate of 11% (95% CI: 8%-14%). Our pooled analysis revealed 18 significant risk factors, including being female (OR = 2.23, 95% CI: 1.89-2.63), advanced age (MD = 1.35, 95% CI: 0.04-2.66), obesity (OR = 1.21, 95% CI: 1.11-1.31), catheterization (OR = 3.8, 95% CI: 2.29-6.32), blood transfusion (OR = 1.39, 95% CI: 1.21-1.58), American Society of Anesthesiologists ≥III (OR = 1.28, 95% CI: 1.18-1.40), general anesthesia (OR = 1.26, 95% CI: 1.11-1.43), intertrochanteric fracture (OR = 1.25, 95% CI: 1.01-1.54), hemiarthroplasty (OR = 1.43, 95% CI: 1.19-1.69), prolonged length of hospital stay (MD = 1.44, 95% CI: 0.66-2.23), delirium (OR = 2.66, 95% CI: 2.05-3.47), dementia (OR = 1.82, 95% CI: 1.62-2.06), Parkinson's disease (OR = 1.53, 95% CI: 1.46-1.61), diabetes (OR = 1.27, 95% CI: 1.13-1.43), hypertension (OR = 1.14, 95% CI: 1.03-1.26), congestive heart failure (OR = 1.35, 95% CI: 1.10-1.66), history of sepsis (OR = 7.13, 95% CI: 5.51-9.22), and chronic steroid use (OR = 1.29, 95% CI: 1.06-1.57).

Conclusion

Our study identifies numerous risk factors strongly associated with UTI, offering compelling evidence and actionable strategies for improving clinical prediction, enabling early intervention, and facilitating targeted UTI management.

Systematic review registration

identifier [CRD42023459600], https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=459600.

Any infection among patients with hip fracture: Predictive ability of Charlson, Elixhauser, Rx-Risk, and Nordic comorbidity indices

BACKGROUND

In studies on infection after hip fracture surgery, a common and serious complication, it remains unknown which comorbidity index is best for case-mix confounder adjustment. We evaluated the predictive ability of Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index (ECI), Rx-Risk Index (Rx-Risk), and Nordic Multimorbidity Index (NMI) for any infection up to 1 year from discharge after hip fracture surgery.

METHODS

Using Danish medical registries, we included 92,600 patients (mean age 83 years) surgically treated for hip fracture between 2004 and 2018. Comorbidity-index scores were calculated using prevalence of diagnosis codes, prescription codes, or both. Lookback periods of 1, 5, and 10 years were applied. Logistic regression was used to calculate c-index to assess discrimination of comorbidity indices individually and in combination with a base model of age and sex. Outcome was any infection (not only surgical site infection) in-hospital and 1 year after discharge.

RESULTS

At 10-year lookback period, the c-index for individual comorbidity indices for in-hospital infections varied from 0.53 to 0.56, similar to base model alone (0.56). The predictive ability of comorbidity indices in combination with base model varied from 0.56 to 0.57. Within 1 year after discharge, NMI in combination with base model had best predictive ability for infection (c-index = 0.62), followed by CCI and ECI (c-index = 0.60) and Rx-Risk (c-index = 0.58). Discrimination was similar for all lookback periods.

CONCLUSIONS

Comorbidity indices have low predictive ability for any infection up to 1 year after hip fracture surgery, similar to that of age and sex alone. For case-mix adjustment, evaluated comorbidity indices are of equal value.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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

TRIAL REGISTRATION

Registration number: INPLASY2022100091.

Modified Frailty Index predicts postoperative complications following adult-acquired buried penis surgery: A retrospective cohort study

BACKGROUND

Given that patients with morbid obesity are predisposed to frailty, we sought to determine whether the 5-Factor Modified Frailty Index (mFI-5) predicts postoperative complications following surgery for adult-acquired buried penis, and secondarily, to compare the mFI-5 to body mass index (BMI) and American Society of Anesthesiologists (ASA) status as preoperative risk stratification measures.

METHODS

We included all patients who underwent surgical management for adult-acquired buried penis at an academic Level I trauma center between 2015 and 2023. A manual chart review was performed to collect data on patient demographics, modified frailty index variables, intraoperative data, postoperative outcomes, and complications.

RESULTS

A total of 55 patients underwent surgical repair of adult-acquired buried penis, with 26 experiencing postoperative complications (47.3%). Univariable regression analyses revealed that the mFI-5 was a significant predictor of postoperative complications (odds ratio [OR] 3.40, 95% confidence interval [CI]: 1.56-7.42, p = .002), ongoing postoperative urinary problems (OR 2.03, 95% CI: 1.02-4.05, p = .045), patient dissatisfaction with outcomes (OR 3.29, 95% CI: 1.35-8.02, p = .009), and persistent postoperative symptoms (OR 2.42, 95% CI: 1.10-5.35, p = .029). There was no significant association between ASA classification and postoperative complications (OR 1.59, 95% CI:.544-4.63, p = .398). Multivariable analysis demonstrated that the mFI-5 was an independent predictor of postoperative complications (OR 5.34, 95% CI: 1.80-15.9, p = .003) when controlling for BMI and age.

CONCLUSION

The mFI-5 is an independent predictor of postoperative complications in patients undergoing surgical repair of adult-acquired buried penis. The simplicity of the index permits efficient preoperative risk stratification of adult-acquired buried penis patients and provides important counseling information that may not be reflected by age or BMI alone.

Lactate Dehydrogenase and Risk of Readmission with Gastric Cancer: A Propensity Score Matching Analysis

PURPOSE

Readmission is one of the measures of quality of care and potential costs. This study aimed to determine whether lactate dehydrogenase (LDH) is associated with an increased risk of 30-day readmission in gastric cancer.

METHODS

We performed a retrospective study of patients who underwent radical gastrectomy for gastric cancer at our institution between July 2014 and May 2018. Balanced cohorts were created by propensity score matching (PSM) with a 1:1 ratio to generate the elevated LDH (ELDH) group (n = 151) and the low LDH group (Control) (n = 302). To determine the incidence, causes, and risk factors of 30-day readmission, subgroup analyzes were performed and used to develop an efficient prediction model.

RESULTS

A total of 788 patients met the criteria to be included in the study. The cutoff value for serum LDH was 215.5. After PSM, a total of 302 patients were matched in pairs (ELDH group, n = 151, Control group, n = 151). ELDH levels had a higher risk of readmission (p = 0.005, Odds ratio 3.768, 95% confidence interval 1.493-9.510). The pre-match 30-day readmission rate was 7.2 percent, and common causes of post-match readmission included infection-related symptoms, gastrointestinal symptoms, and gastrointestinal bleeding.

CONCLUSIONS

Patients with preoperative ELDH levels, postoperative complications, and high preoperative American Society of Anesthesiologists Scores had a higher risk of readmission 30 days after 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.

Development of a prediction model for postoperative complications and economic burden analysis in older patients with hip fractures

Purpose

The high rates of disability and mortality due to postoperative complications of hip fractures in the elderly, especially the oldest-old individuals, have become an increasingly serious global public health concern. This study aimed to establish a nomogram prediction model and analyze the economic burden to guide clinical decision-making and improve patient prognosis.

Methods

Data of 514 patients aged over 80 years with hip fractures who received surgical treatment were retrospectively collected, and the patients were divided into training and validation cohorts. Independent risk factors for postoperative complications were identified based on logistic regression analysis, and a nomogram was constructed. The model was evaluated for its discrimination and consistency using receiver operating characteristic (ROC) curves and calibration curves, and for its clinical benefit using decision curve analysis (DCA). The economic burden was analyzed using propensity score matching (PSM).

Results

The American Society of Anesthesiologists (ASA) classification ≥Ⅲ, anemia, male sex, diabetes mellitus, and the number of comorbidities were found to be independent risk factors for postoperative complications in oldest-old patients with hip fracture (all P < 0.05). The areas under the curve (AUC) of the nomogram prediction model for the training and validation cohorts were 0.743 and 0.767, respectively, indicating reliable discrimination. The calibration curves and DCA showed that the model has good consistency and high benefits. The direct economic burden of postoperative complications for the patients was US$1045.10.

Conclusions

The nomogram model can accurately quantify the risk of postoperative complications among oldest-old patients with hip fractures and guide clinical professionals to implement early and targeted preventive treatment for high-risk patients.

Comorbidity and risk of infection among patients with hip fracture: a Danish population-based cohort study

Impact of comorbidity on infection risk among hip fracture patients is unclear. We found high incidence of infection. Comorbidity was an important risk factor for infection up to 1 year after surgery. Results indicates a need for additional investment in pre- and postoperative programs that assist patients with high comorbidity.

PURPOSE

Comorbidity level and incidence of infection have increased among older patients with hip fracture. The impact of comorbidity on infection risk is unclear. We conducted a cohort study examining the absolute and relative risks of infection in relation to comorbidity level among hip fracture patients.

METHODS

Utilizing Danish population-based medical registries, we identified 92,600 patients aged ≥ 65 years undergoing hip fracture surgery between 2004 and 2018. Comorbidity was categorized by Charlson comorbidity index scores (CCI): none (CCI = 0), moderate (CCI = 1-2), or severe (CCI ≥ 3). Primary outcome was any hospital-treated infection. Secondary outcomes were hospital-treated pneumonia, urinary tract infection, sepsis, reoperation due to surgical-site infection (SSI), and a composite of any hospital- or community-treated infection. We calculated cumulative incidence and hazard ratios (aHRs) adjusted for age, sex, and surgery year, including 95% confidence intervals (CIs).

RESULTS

Prevalence of moderate and severe comorbidity was 40% and 19%, respectively. Incidence of any hospital-treated infection increased with comorbidity level within 0-30 days (none 13% vs. severe 20%) and 0-365 days (none 22% vs. 37% severe). Patients with moderate and severe comorbidity, compared to no comorbidity, had aHRs of 1.3 (CI: 1.3-1.4) and 1.6 (CI: 1.5-1.7) within 0-30 days, and 1.4 (CI: 1.4-1.5) and 1.9 (CI: 1.9-2.0) within 0-365, respectively. Highest incidence was observed for any hospital- or community-treated infection (severe 72%) within 0-365 days. Highest aHR was observed for sepsis within 0-365 days (severe vs. none: 2.7 (CI: 2.4-2.9)).

CONCLUSION

Comorbidity is an important risk factor for infection up to 1 year after hip fracture surgery.

Associated Factors of Functional Ability in Older Persons Undergoing Hip Surgery Immediately Post-Hospital Discharge: A Prospective Study

BACKGROUND

hip fractures commonly have an impact on older adults' health. Surgical treatment aims to reduce pain and promote functional ability. However, developing adverse health outcomes or complications post-hip surgery may impede older patients' recovery to return to functional ability as pre-fracture. We aimed to examine the association of personal factors and adverse health outcomes during hospitalization and post-hospital discharge on the functional ability of older people undergoing hip surgery.

METHODS

a total of 120 older people with hip fractures who were scheduled for surgery at three tertiary hospitals and met the inclusion criteria were recruited for this study. Data were obtained at admission, before discharge, and during the two-week postoperative follow-up using the Demographic, Hip Dysfunction and Osteoarthritis Outcome Score, Joint Replacement, the Confusion Assessment Method (CAM) Thai version, and Health Outcome Questionnaires. Descriptive statistics and multiple logistic regression analyses were performed to analyze the data.

RESULTS

most participants were female, with a mean age of 78.10 years (range = 60-93; SD = 8.37). The most common adverse health outcome during hospitalization was urinary tract infection, followed by delirium, pneumonia, deep vein thrombosis, and surgical site infection. At two weeks immediately post-hospital discharge, 16 participants experienced unpleasant events, including delirium, urinary tract infection, surgical site infection, and pneumonia. The significant predictors of poor functional ability at two weeks immediately post-hospital discharge were old age (OR = 1.114, p = 0.001), subtrochanteric fracture (OR = 13.48, p = 0.008), and type of surgery (OR = 4.105, p = 0.049).

Analysis of Cardiac Events and the Subsequent Impact for Geriatric Patients Undergoing Hip Fracture Surgeries

Perioperative complications, particularly cardiac events, compromised surgical outcomes for geriatric patients. This retrospective study intended to investigate the occurrence and subsequent impact of cardiac events for geriatric patients undergoing hip fracture surgeries. We collected 607 patients undergoing hip fracture surgeries from January 2017 to December 2022 that received transthoracic echocardiography (TTE) pre-operatively to screen for cardiac abnormalities. Except for demographic characteristics, the researchers recorded fracture type, surgical method, American Society of Anesthesiologists (ASA) class, anesthesia type, perioperative cardiac events, and in-hospital mortality. Statistical analysis was performed using SPSS 22.0 statistics software. Throughout the whole course of the study, 16 postoperative cardiac events occurred. The cardiac events included ten arrhythmias, three acute myocardial infarctions, two heart failures, and one sudden death. Notably, 12 of 16 patients with cardiac events presented with abnormal findings on TTE, except 15 of them had a history of cardiac disease. This study disclosed 93.7% of cardiac events developed in patients with a history of cardiovascular disease. Among patients that experienced cardiac events, 75% of patients had abnormal echocardiographic findings. Pre-operative transthoracic echocardiography deserves a recommendation for geriatric patients with histories of cardiac diseases undergoing hip fracture surgeries to detect the risk of developing cardiac events earlier.

Development of a Frailty Index in the Irish Hip Fracture Database

INTRODUCTION

In older people, hip fracture can lead to adverse outcomes. Frailty, capturing biological age and vulnerability to stressors, can indicate those at higher risk. We derived a frailty index (FI) in the Irish Hip Fracture Database (IHFD) and explored associations with prolonged length of hospital stay (LOS ≥ 30 days), delirium, inpatient mortality and new nursing home admission. We assessed whether the FI predicted those outcomes independently of age, sex and pre-operative American Society of Anaesthesiology (ASA) score.

MATERIALS AND METHODS

A 21-item FI was constructed with 17 dichotomous co-morbidities, three 4-level ordinal pre-morbid functional variables (difficulty with indoor mobility, outdoor mobility, and shopping) and nursing home provenance (yes/no). The FI was computed as the proportion of items present and divided into tertiles (low, medium, high risk). Independent associations between FI and outcomes were explored with logistic regression, from which we extracted adjusted Odds Ratios (aOR) and Areas Under the Curve (AUC).

RESULTS

From 2017 to 2020, the IHFD included 14,615 hip fracture admissions, mean (SD) age 80.4 (8.8), 68.9% women. Complete FI data were available for 12,502 (85.5%). By FI tertile (low to high risk), prolonged LOS proportions were 5.9%, 16.1% and 23.1%; delirium 5.5%, 13.5% and 17.6%; inpatient mortality 0.6%, 3.3% and 10.1%; and new nursing home admission 2.2%, 5.9% and 11.3%. All associations were statistically significant (p < 0.001) independently of age and sex. AUC analyses showed that the FI score, added to age, sex, and ASA score, significantly improved the prediction of delirium and new nursing home admission (p < 0.05), and especially prolonged LOS and inpatient mortality (p < 0.001).

CONCLUSIONS

A 21-item FI in the IHFD was a significant predictor of outcomes and added value to traditional risk markers. The utility of a routinely derived FI to more effectively direct limited orthogeriatric resources requires prospective investigation.

Risk factors for perioperative acute heart failure in older hip fracture patients and establishment of a nomogram predictive model

AIM

This study aims to explore the risk factors for perioperative acute heart failure in older patients with hip fracture and establish a nomogram prediction model.

METHODS

The present study was a retrospective study. From January 2020 to December 2021, patients who underwent surgical treatment for hip fracture at the Third Hospital of Hebei Medical University were included. Heart failure was confirmed by discharge diagnosis or medical records. The samples were randomly divided into modeling and validation cohorts in a ratio of 7:3. Relevant demographic and clinic data of patients were collected. IBM SPSS Statistics 26.0 performed univariate and multivariate logistic regression analysis, to obtain the risk factors of acute heart failure. The R software was used to construct the nomogram prediction model.

RESULTS

A total of 751 older patients with hip fracture were enrolled in this study, of which 138 patients (18.37%, 138/751) developed acute heart failure. Heart failure was confirmed by discharge diagnosis or medical records. Respiratory disease (odd ratio 7.68; 95% confidence interval 3.82-15.43; value of P 0.001), history of heart disease (chronic heart failure excluded) (odd ratio 2.21, 95% confidence interval 1.18-4.12; value of P 0.010), ASA ≥ 3 (odd ratio 14.46, 95% confidence interval 7.78-26.87; value of P 0.001), and preoperative waiting time ≤ 2 days (odd ratio 3.32, 95% confidence interval 1.33-8.30; value of P 0.010) were independent risk factors of perioperative acute heart failure in older patients with hip fracture. The area under the curve (AUC) of the prediction model based on these factors was calculated to be 0.877 (95% confidence interval 0.836-0.918). The sensitivity and specificity were 82.8% and 80.9%, respectively, and the fitting degree of the model was good. In the internal validation group, the AUC was 0.910, and the 95% confidence interval was 0.869-0.950.

CONCLUSIONS

Several risk factors are identified for acute heart failure in older patients, based on which pragmatic nomogram prediction model is developed, facilitating detection of patients at risk early.

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

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

The Impact of Hip Fracture on Geriatric Care and Mortality Among Older Swedes: Mapping Care Trajectories and Their Determinants

In this study, we examined the impact of hip fractures on trajectories of home care, nursing home residence, and mortality among individuals aged 65 years or more and explored the impacts of living arrangements, cohabitation, frailty, and socioeconomic position on these trajectories. Based on a linkage of nationwide Swedish population registers, our study included 20,573 individuals with first hip fracture in 2014-2015. Care trajectories during the 2 years following the fracture were visualized and compared with those of 2 hip-fracture-free control groups drawn from the general population: age- and sex-matched controls and health-matched controls identified through propensity score matching. Multistate modeling was employed to identify sociodemographic and health-related factors associated with care trajectories among hip fracture patients. We found that hip fracture patients already had worse health than the general population before their fracture. However, when controlling for prefracture health, hip fractures still had a considerable impact on use of elder-care services and mortality. Comparisons with the health-matched controls suggest that hip fractures have an immediate, yet short-term, impact on care trajectories. Long-term care needs are largely attributable to poorer health profiles independent of the fracture itself. This emphasizes the importance of adequate comparison groups when examining the consequences of diseases which are often accompanied by other underlying health problems.

A Virtual Hybrid Care Hotel Model Supports the Recovery of Post-procedural Patients with Mild to Severe Systemic Diseases

BACKGROUND

Patients with mild to severe chronic systemic disease undergoing low-risk procedures are often hospitalized for observation. The Care Hotel is a novel virtual medicine hybrid model of care that offers patients a comfortable, out of hospital environment where they can receive both in-person and virtual care after a surgery or procedure. This study aimed to analyze if virtual hybrid post-procedure care in a hotel could be both conducted on and accepted by patients, even those with moderate to severe chronic diseases.

METHODS

This retrospective cohort study was conducted between July 23, 2020 and June 4, 2021 at Mayo Clinic in Florida, a 306-bed community academic hospital. We collected the sex, age, race, ethnicity, acceptance rate, ASA score, and primary procedure of patients using the Care Hotel.

RESULTS

Out of 392 patients, 272 (69.4%) opted for care in the program. Median patient age was 61.5 years, 59.56% were males, and 86.40% were white. We found that 50.37% had an ASA score of 2 and 43.4% had an ASA score of 3. Ten different surgical specialties were able to utilize the Care Hotel for care in 47 different procedure types. Urology had the most patients (n=70, 25.7%). Post-electrophysiologic procedures were the most common procedures (n=39, 14.3%).

CONCLUSION

Our virtual hybrid Care Hotel program was widely accepted by patients and could care for a multitude of post-operative procedures. Additionally, this novel program can care for patients with both mild and severe systemic diseases.