Prognostic Value of Serum Procalcitonin After Orthopedic Surgery in the Elderly Population

Plasma procalcitonin kinetics in healthy dogs and dogs undergoing tibial plateau leveling osteotomy

BACKGROUND

Procalcitonin (PCT) is a well-established biomarker for bacterial infection in human patients.

OBJECTIVES

We aimed to analyze the kinetics of plasma PCT (pPCT) in healthy dogs and dogs with canine cranial cruciate ligament (CCL) rupture undergoing tibial plateau leveling osteotomy (TPLO).

METHODS

This prospective, longitudinal study included 15 healthy dogs and 25 dogs undergoing TPLO. Hematology, pPCT, and C-reactive protein (CRP) were assessed on 3 consecutive days in healthy dogs and 1 day preoperatively and days 1, 2, 10, and 56 postoperatively. Inter- and intraindividual variability of pPCT were assessed in healthy dogs. Median pPCT concentrations of dogs with CCL rupture preoperatively were compared with healthy controls, and median pPCT concentrations, as well as percentage change post anesthesia, arthroscopy, and TPLO, were compared with baseline. For the correlation analysis, the Spearman rank correlation test was used.

RESULTS

Inter- and intraindividual variabilities of pPCT in healthy dogs were 36% and 15%, respectively. Median baseline pPCT concentrations were not significantly different between healthy dogs (118.9 pg/mL; IQR: 75.3-157.3 pg/mL) and dogs undergoing TPLO (95.9 pg/mL; IQR: 63.8-117.0 pg/mL). Plasma PCT concentrations were significantly lower immediately post- than preoperatively (P < 0.001). CRP, WBC, and neutrophil concentrations increased significantly on post-OP day 2 and had normalized by day 10.

CONCLUSIONS

These results indicate that CCL rupture, as well as anesthesia, arthroscopy, and TPLO combined, are not associated with increased pPCT concentrations in dogs with uncomplicated recovery. Considering the high intraindividual variability, individual serial measurements rather than a population-based reference interval should be considered.

Hip Fracture Leads to Transitory Immune Imprint in Older Patients

Background: Hip fracture (HF) is common in the geriatric population and is associated with a poor vital and functional prognosis which could be impacted by immunological changes. The objective here is to decipher immune changes occurring in the 1st days following HF and determine how phenotype, function, and regulation of innate and adaptive compartments adapt during acute stress event.

Methods: We included HF patients, aged over 75 years. For each patient, blood samples were taken at five different timepoints: four in the perioperative period (day 0 to hospital discharge) and one at long term (6–12 months). Phenotypical and functional analysis were performed longitudinally on fresh blood or cryopreserved PBMCs. Clinical data were prospectively collected.

Results: One-hundred HF patients and 60 age-matched controls were included. Innate compartment exhibits pro-inflammatory phenotypes (hyperleukocytosis, increase of CD14+ CD16+ proportion and CCR2 expression), maintaining its ability to produce pro-inflammatory cytokines. Adaptive compartment extends toward a transitory immunosuppressive profile (leucopenia) associated with an active T-cell proliferation. Furthermore, increases of LAG-3 and PD-1 and a decrease of 2-B4 expression are observed on T-cells, reinforcing their transitory suppressive status. Of note, these immune changes are transitory and sequential but may participate to a regulation loop necessary for homeostatic immune control at long term.

Conclusion: HF is associated with several transitory immunological changes including pro-inflammatory phenotype in innate compartment and immunosuppressive profile in adaptive compartment. A comprehensive assessment of immune mechanisms implicated in the patient's prognosis after HF could pave the way to develop new immune therapeutics strategies.

Attributable Mortality of Hip Fracture in Older Patients: A Retrospective Observational Study

Hip fracture (HF) in older patients is associated with a high six-month mortality rate. Several clinical conditions may affect outcome, including baseline characteristics, co-existing acute illnesses, perioperative factors, and postoperative complications. Our primary objective was to estimate the respective effect of these four domains on six-month mortality after HF. A retrospective observational study using a monocentric cohort of older patients was conducted. All patients ≥ 70 years old admitted to the emergency department for HF and hospitalized in our perioperative geriatric care unit from June 2009 to September 2018 were included. Among 1015 included patients, five (0.5%) were lost to follow-up, and 1010 were retained in the final analysis (mean age 86 ± 6 years). The six-month mortality rate was 14.8%. The six-month attributable mortality estimates were as follows: baseline characteristics (including age, gender, comorbidities, autonomy, type of fracture): 62.4%; co-existing acute illnesses (including acute events present before surgery that could result from the fracture or cause it): 0% (not significantly associated with six-month mortality); perioperative factors (including blood transfusion and delayed surgery): 12.3%; severe postoperative complications: 11.9%. Baseline characteristics explained less than two-thirds of the six-month mortality after HF. Optimizing patients care by improving management of perioperative factors and thus decreasing postoperative complications, could reduce by a maximum of one quarter of the six-month mortality rate after HF.

The Effects of Initial Procalcitonin Levels on Mortality Rates in Geriatric Patients Undergoing Surgery

Introduction

The aim of the current study is to investigate the relationship between mortality rate in geriatric patients undergoing surgery with preoperative serum levels of procalcitonin, C-reactive protein, and erythrocyte sedimentation rate.

Methods

This was a single-center retrospective study, including three groups with 101 patients, who are older than 65 years of age. A retrospective investigation was carried out from the laboratory information system for all groups from January to December 2018. Group 1 included patients who had surgery and then mortality within 30 days after surgery. Group 2 included hospitalized patients who had surgery and no mortality within 30 days after surgery. Group 3 included outpatient patients, who had suspicion for a bacterial infection and then no surgery or no mortality within 30 days.

Results

When three group comparisons were made for procalcitonin, C-reactive protein, and erythrocyte sedimentation rate values, the p-value of one-way analysis of variance (ANOVA) was higher than 0.05 for procalcitonin and lower than 0.05 for C-reactive protein and erythrocyte sedimentation rate, suggesting that one or more groups were significantly different. When post-hoc multiple comparison methods were applied, there were statistically significant differences between Groups 1 and 3 for C-reactive protein and erythrocyte sedimentation rate.

Conclusions

Procalcitonin levels do not predict mortality following surgery. C-reactive protein and erythrocyte sedimentation rate are more useful biomarkers predicting mortality in geriatric patients undergoing surgery.

Association between Cognitive Status before Surgery and Outcomes in Elderly Patients with Hip Fracture in a Dedicated Orthogeriatric Care Pathway

BACKGROUND

Dementia is associated with a worse prognosis of hip fracture, but the impact of a dedicated geriatric care pathway on the prognosis of these patients has not been evaluated.

OBJECTIVE

According to the cognitive status before surgery, our main objective was to compare mortality rate at 6 months; secondary outcomes were to compare in-hospital complications, the risk of new institutionalization, and the ability to walk at 6 months.

METHODS

Between 2009 and 2015, all patients (>70 years) admitted after hip fracture surgery into a dedicated unit of peri-operative geriatric care were included: patients with dementia (DP), without dementia (NDP), and with cognitive status not determined (CSND). Data are expressed as hazard ratio (HR) for multivariate cox analysis or odds ratio (OR) for multivariate logistic regression analysis and their 95% confidence interval (CI).

RESULTS

We included 650 patients (86±6 years): 168 DP, 400 NDP, and 82 CSND. After adjustment for age, sex, comorbidities, polypharmacy, pre-fracture autonomy, time-to-surgery, and delirium, there were no significant differences for 6-month mortality (DP versus NDP: HR = 0.7[0.4-1.2], DP versus CSND: HR = 0.6[0.3-1.4], CSND versus NDP: HR = 0.8[0.4-1.7]); but DP and CSND were more likely to be newly institutionalized after 6 months compared to NDP (OR DP = 2.6[1.4-4.9], p = 0.003, OR CSND = 2.9[1.4-6.1], p = 0.004). 92% of population was walking after 6 months (63% with assistance): no difference was found between the three groups.

CONCLUSION

In a dedicated geriatric care pathway, DP and CSND undergoing hip surgery have the same 6-month mortality and walking ability as NDP.

Elevated Neopterin Levels Predict Early Death in Older Hip-fracture Patients

Our society faces a major challenge concerning management of the health and socio-economic burden caused by acute physical stress in the older population (+ 75 years). In particular, hip-fracture surgery (HFS) represents a major health care preoccupation, affecting 1.6 million patients worldwide, resulting in a significant drop in life quality and autonomy. The trauma is associated with 20–30% one-year mortality in the elderly. In the present study, we aim to identify factors, which influence and/or predict the outcome of elderly hip- fracture patients (HFP) post-surgery.

Our objective was to identify biomarkers with a prognostic capacity of one-year mortality. We employed an observational cohort of HFP (n = 60) followed-up longitudinally during the first year post fracture. Clinical and biological data (n = 136), collected at arrival to hospital, were then compared to healthy controls (n = 42) and analyzed using a regularized logistic regression model with lasso penalty followed by 10-fold cross-validation of variables.

We show that plasmatic neopterin levels, a molecule released by IFN-γ-activated macrophages, is predictive of mortality in HFP (ROC-AUC = 0.859). Moreover, neopterin measured at arrival to the hospital correlated negatively with the time of survival after HFS.

Neopterin therefore represents a biomarker, which enables better follow-up of patients at risk of early death.

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Neopterin level, measured at arrival to hospital, is a robust predictive marker of one-year mortality in HFPs.

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Neopterin concentration correlated negatively with the time of survival after hip fracture surgery.

The growing incidence of hip fractures, due to demographically aging populations, represent an important burden for health care systems and for injured patients in terms of hospitalization, rehabilitation, needs for long-term care, change in autonomy and mortality. Hip fractures are associated with high rates of adverse outcome, but previous studies have not discovered methods to identify patients at high risk of pernicious clinical outcome or death. Here, we show that innate immune activation post hip fracture in older adults is associated with pernicious clinical outcome.