2010 January 15

Hip fractures after falls in hospital: a retrospective observational cohort study.

Jan 152010

Hip fractures after falls in hospital: a retrospective observational cohort study.

Injury. 2009 Feb;40(2):201-4

Authors: Johal KS, Boulton C, Moran CG

OBJECTIVES: To compare the prevalence and characteristics of hip fractures sustained after inpatient falls (hospital subgroup) to those presenting with a fall in the community (control group). DESIGN: Retrospective observational cohort study. SETTING: University teaching hospital. PARTICIPANTS: 5879 hip fractures occurred over an 8-year period, 327 of these took place after a fall as a hospital inpatient. OUTCOME MEASURES: Comparison of 30-day and 1 year mortality, co-morbidities, length of post-fracture hospital stay, specific complication rates and cognitive function between the hospital and control group. Other specific data on those falling in hospital was also collected. RESULTS: There were significantly higher rates (p<0.001) of cerebrovascular, chronic obstructive airways and renal disease, diabetes, malignancy and polypharmacy in patients suffering falls in hospital. Mini-mental test scores (MTS) were also significantly reduced in this subgroup (p<0.001). 30-day and 1 year mortality rates were 9% and 26%, respectively in the control group and almost double this in the hospital subgroup, being 18% and 47%, respectively (30 days, 95% CI 2.00 (1.54-2.60): p<0.001; 1 year, 95% CI 2.04 (1.73-2.40): p<0.001). There was no statistical difference between post-operative complications or length of stay post-fracture. 55% of falls in hospital took place on medical/geriatric wards with an additional 14% occurring on psychiatric units. DISCUSSION: Patients suffering hip fractures after falls in hospital are frailer with impaired cognitive function and have more co-morbidities than those suffering a fracture in the community. These patients have increased mortality, with almost 50% dead within 1 year of the fall. The majority of hip fractures after falls occur in medical or geriatric wards, but the highest risk group appears to be elderly patients on psychiatric wards. Therefore, falls risk assessment and falls prevention schemes in hospital elderly patients are of paramount importance.

PMID: 19100542 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Influence of the timing of surgery on mortality and activity of hip fracture in elderly patients.

J Orthop Sci Start a Discussion »

Jan 152010

Influence of the timing of surgery on mortality and activity of hip fracture in elderly patients.

J Orthop Sci. 2009 Sep;14(5):566-73

Authors: Yonezawa T, Yamazaki K, Atsumi T, Obara S

BACKGROUND: Existing reports describe the decline of the mortality rate by conducting surgery for hip fractures within 24 h; however, the theory is still controversial. We have compared the perioperative mortality rate, improvement of mobility, and duration of hospital stay for early surgery (within 24 h) and delayed surgery (beyond 24 h) between two groups. METHODS: We studied 536 cases of proximal femoral fracture in patients >60 years who were treated between September 2003 and December 2006. There were 91 men and 445 women, who had a total of 257 femoral neck fractures and 279 trochanteric fractures. In all, 270 patients were operated on within 24 h after injury and were defined as the early group; 266 patients were treated surgically more than 24 hours after injury and were defined as the delayed group. Based on admission laboratory tests, co-morbidity, dementia, preoperative mobility, and residential environment before injury, we compared the duration of hospital stay, mobility at discharge, and mortality rates between the early group and the delayed group. RESULTS: There was no significant difference in duration of hospital stay between the two groups. Improvement of mobility was 52% in the early group and 41% in the delayed group, with the difference being significant (P < 0.05). Inpatient mortality rate was 5.6% in the early group and 2.6% in the delayed group, but the difference was not significant. In the early group, men with co-morbidity, dementia, and abnormal laboratory values upon admission showed a significantly higher mortality rate. CONCLUSIONS: Early surgery was useful for improving mobility, but it showed a higher mortality rate in patients with a compromised somatic condition at the time of the injury. For independent patients with a stabilized somatic condition, surgery should be performed within 24 h. For unstable cases, we believe it is better to provide early surgery after stabilizing the patient's condition to the greatest possible extent.

PMID: 19802668 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Nosocomial bacterial meningitis.

N Engl J Med Start a Discussion »

Jan 152010

Nosocomial bacterial meningitis.

N Engl J Med. 2010 Jan 14;362(2):146-54

Authors: van de Beek D, Drake JM, Tunkel AR

PMID: 20071704 [PubMed - in process]

Link to Article at PubMed

Preoperative biliary drainage for cancer of the head of the pancreas.

N Engl J Med Start a Discussion »

Jan 152010

Preoperative biliary drainage for cancer of the head of the pancreas.

N Engl J Med. 2010 Jan 14;362(2):129-37

Authors: van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, Gerritsen JJ, Greve JW, Gerhards MF, de Hingh IH, Klinkenbijl JH, Nio CY, de Castro SM, Busch OR, van Gulik TM, Bossuyt PM, Gouma DJ

BACKGROUND: The benefits of preoperative biliary drainage, which was introduced to improve the postoperative outcome in patients with obstructive jaundice caused by a tumor of the pancreatic head, are unclear. METHODS: In this multicenter, randomized trial, we compared preoperative biliary drainage with surgery alone for patients with cancer of the pancreatic head. Patients with obstructive jaundice and a bilirubin level of 40 to 250 micromol per liter (2.3 to 14.6 mg per deciliter) were randomly assigned to undergo either preoperative biliary drainage for 4 to 6 weeks, followed by surgery, or surgery alone within 1 week after diagnosis. Preoperative biliary drainage was attempted primarily with the placement of an endoprosthesis by means of endoscopic retrograde cholangiopancreatography. The primary outcome was the rate of serious complications within 120 days after randomization. RESULTS: We enrolled 202 patients; 96 were assigned to undergo early surgery and 106 to undergo preoperative biliary drainage; 6 patients were excluded from the analysis. The rates of serious complications were 39% (37 patients) in the early-surgery group and 74% (75 patients) in the biliary-drainage group (relative risk in the early-surgery group, 0.54; 95% confidence interval [CI], 0.41 to 0.71; P<0.001). Preoperative biliary drainage was successful in 96 patients (94%) after one or more attempts, with complications in 47 patients (46%). Surgery-related complications occurred in 35 patients (37%) in the early-surgery group and in 48 patients (47%) in the biliary-drainage group (relative risk, 0.79; 95% CI, 0.57 to 1.11; P=0.14). Mortality and the length of hospital stay did not differ significantly between the two groups. CONCLUSIONS: Routine preoperative biliary drainage in patients undergoing surgery for cancer of the pancreatic head increases the rate of complications. (Current Controlled Trials number, ISRCTN31939699.)

PMID: 20071702 [PubMed - in process]

Link to Article at PubMed

Tick bites and skin rashes.

Curr Opin Infect Dis Start a Discussion »

Jan 152010

Tick bites and skin rashes.

Curr Opin Infect Dis. 2010 Jan 11;

Authors: Elston DM

PURPOSE OF REVIEW: Fever and a rash following a tick bite can signify a true medical emergency. Ticks are important vectors of disease worldwide, including Rocky Mountain spotted fever, Lyme disease, and Congo-Crimean hemorrhagic fever. This paper will review the major ticks of medical importance and the diseases they transmit, including important emerging pathogens. RECENT FINDINGS: Rocky Mountain spotted fever continues to be the most lethal tick-borne illness in the United States and is emerging as an important disease in South America. Other important emerging diseases include human anaplasmosis, southern tick associated rash illness, human monocytic ehrlichiosis, and a variety of rickettsial fevers including those caused by Rickettsia parkeri and Rickettsia amblyommii. SUMMARY: Most tick-borne illnesses respond readily to doxycycline therapy. In the case of Rocky Mountain spotted fever, therapy should be started when the disease is suspected and should never be delayed for confirmatory tests. Accurate identification of tick vectors can help establish a diagnosis and can help guide preventive measures to reduce the burden of disease.

PMID: 20071986 [PubMed - as supplied by publisher]

Link to Article at PubMed

The impact of prolonged continuous wakefulness on resident clinical performance in the intensive care unit: A patient simulator study.

Crit Care Med Start a Discussion »

Jan 152010

The impact of prolonged continuous wakefulness on resident clinical performance in the intensive care unit: A patient simulator study.

Crit Care Med. 2010 Jan 9;

Authors: Sharpe R, Koval V, Ronco JJ, Qayumi K, Dodek P, Wong H, Shepherd J, Fitzgerald JM, Ayas NT

OBJECTIVE:: To evaluate the impact of prolonged continuous wakefulness on resident performance under controlled experimental conditions. DESIGN:: Experimental within-subjects comparison. SETTING:: High-fidelity patient simulator. PARTICIPANTS:: Twelve residents in an Internal Medicine Program at various stages of training (range, 1-35 mos). MEASUREMENTS:: Performance was studied during 26 hrs of continuous wakefulness at four time points (8:00-10:00 am, 2:00-4:00 pm, 2:00-4:00 am, and 8:00-10:00 am the next day) using high-fidelity patient simulation. At each session, residents managed eight simulated dysrhythmias according to advanced cardiac life support protocols (advanced cardiac life support scenarios) and then managed a simulated critically ill patient (e.g., patient with meningitis) to test more complicated clinical decision-making (complex scenario). The frequency of previously defined major medical errors (i.e., action or inaction that likely would have resulted in significant harm in a real patient) was assessed by a scorer blinded to the time of the session. For each complex scenario, a global score between 0 and 100 was also given for overall performance. The impact of wakefulness on performance was assessed by using longitudinal mixed-effects models. RESULTS:: For the complex scenarios, the mean number of errors increased from 0.92 +/- 0.90 in the first session to 1.58 +/- 0.79 in the fourth session (p = .09), and mean global score decreased from 56.8 +/- 14.6 to 49.6 +/- 12.6 (p = .02). For the advanced cardiac life support scenarios, the mean number of major errors committed in the advanced cardiac life support scenarios decreased during the study period (p = .01). However, essentially all of the improvement occurred between the first and second time points, suggesting that a substantial learning effect accounted for the findings. CONCLUSIONS:: During prolonged continuous wakefulness of medical residents, clinical performance in the management of a simulated critically ill patient deteriorates. The practice of scheduling residents for extended work shifts (>24 hrs) should be reconsidered.

PMID: 20068462 [PubMed - as supplied by publisher]

Link to Article at PubMed

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