股骨颈骨折术后股骨头坏死率及相关危险因素的Meta分析

目的: 研究2000年以后的成人股骨颈骨折患者内固定术后股骨头坏死发生率及相关危险因素以识别股骨头坏死高危人群。方法: 检索PubMed、Medline、The Cochrane Library、中国知网、万方和维普数据库,收集2000年1月1日至2020年7月1日期间有关股骨颈骨折术后股骨头坏死及其危险因素的全部研究,根据入选和排除标准剔除不符合要求的研究。使用Endnote X9和Excel 2019进行文献提取、管理以及数据录入,利用R Studio 3.6.5软件进行Meta分析。通过亚组分析、敏感性分析和发表偏倚检测来研究异质性来源及评估结果的可靠性。结果: 共纳入16篇文献,包括5 521例股骨颈骨折患者。Meta分析结果显示成人股骨颈骨折内固定术后股骨头坏死发生率为14.5%[95%CI(0.126-0.165)]。骨折移位情况[OR=0.27,95%CI(0.21-0.35)]和复位质量[OR=0.15,95%CI(0.09-0.27)]是股骨头坏死相关危险因素。亚组率分析结果显示:非移位型骨折坏死率为6.2%[95%CI(0.051-0.077)],移位型骨折坏死率为20.4%[95%CI(0.166-0.249)];骨折复位良好坏死率为8.3%[95%CI(0.072-0.095)],骨折复位不良坏死率为35.5%[95%CI(0.233-0.500)]。纳入的文献一致性较好,不存在发表偏倚。结论: 2000年以后的成人股骨颈骨折内固定术后股骨头总坏死率有所下降,而移位型骨折和复位质量不良的患者坏死率仍处于较高水平。由于各原始文献对受伤至手术时间间隔的划分不一致,没有对该指标进行分析。     

个体化预测老年髋部骨折患者术后谵妄风险

[目的]通过分析老年髋部骨折患者术后谵妄的相关危险因素,建立并验证个体化预测老年髋部骨折术后谵妄风险的列线图模型。[方法]纳入2013年1月～2018年3月于淄博市中心医院行手术治疗的老年髋部骨折患者257例,收集临床资料。应用单因素及多因素Logistic回归模型,分析老年髋部骨折患者术后谵妄的独立危险因素。应用R软件构建预测老年髋部骨折患者术后谵妄风险的列线图模型,并进行验证。[结果]多因素Logistic回归分析显示,年龄(OR=1.143,95%CI:1.076～1.214)、2型糖尿病(OR=4.591,95%CI:2.14～9.846)、ASA评分III级(OR=4.262,95%CI:1.600～11.352)、ASA评分IV级(OR=5.396,95%CI:1.868～15.583)、全身麻醉(OR=1.281,95%CI:1.066～1.540)及手术时间(OR=1.018,95%CI:1.001～1.035)是老年髋部骨折患者术后谵妄的独立危险因素(P0.05)。对列线图模型进行验证,ROC曲线显示该模型预测老年髋部骨折患者术后谵妄风险的曲线下面积为0.818(95%CI:0.752～0.885);校准曲线为斜率接近于1的直线,Hosmer-Lemeshow拟合优度检验(x~2=8.760,P=0.363)均显示该模型预测老年髋部骨折患者术后谵妄风险具有良好准确度。[结论]本研究基于年龄、2型糖尿病、ASA分级、麻醉方式及手术时间这5项老年髋部骨折患者术后谵妄的独立危险因素,构建的预测老年髋部骨折患者术后谵妄风险的列线图模型,具有良好的区分度与准确度,可为临床个体化防治老年髋部骨折患者术后谵妄提供科学指导。     

2013—2022年我国术后谵妄研究热点及趋势的可视化分析

目的 基于可视化知识图谱分析2013—2022年我国术后谵妄的研究热点与发展趋势。
方法 检索2013—2022年我国在中国知网（CNKI）、万方和维普（VIP）数据库中发表的术后谵妄相关中文文献及在Web of Science核心合集中发表的英文文献，采用CiteSpace软件进行可视化分析。
结果 本研究共纳入中文文献928篇、英文文献502篇。我国术后谵妄相关研究年度发文量整体呈上升趋势，中文文献年均增长率为13.4%，英文文献为41.1%。研究团队间联系较弱，未形成核心作者群；中文与英文文献中心性超过0.1的共同高频关键词为“老年患者”“危险因素”和“髋部骨折”，关键词数量最多的聚类为“白细胞介素-6”。
结论 我国术后谵妄领域研究团队间合作有待加强，近十年的研究热点为有关术后谵妄的危险因素和生物标志物的分析。     

中国人固定正畸矫治后牙齿脱矿情况的系统评价和Meta分析

目的：系统评价中国人固定矫治后牙齿的脱矿情况。方法：计算机检索PubMed、EMbase、The?Cochrane?Library、CNKI、CBM、WanFang?Data和VIP数据库中关于中国人固定矫治后牙齿脱矿情况的横断面研究,检索时限从建库-2021年12月。经过两名研究者的筛选和方法学评估后,纳入的文献采用Stata?16.0软件进行Meta分析。结果：最终纳入25篇文献,共2355例患者,总牙数为29662颗。Meta分析结果显示,固定矫治结束后患者的脱矿发病率为51%[95%CI(46%,57%)];男性和女性脱矿发病率分别为49%[95%CI(38%,59%)]和51%[95%CI(37%,65%)],不同性别脱矿发病情况的比值比（OR）值为0.94[95%CI(0.73,1.21),P=0.66];牙齿的脱矿率为13%[95%CI(12%,14%)],上颌和下颌牙脱矿率分别为16%[95%CI(13%,18%)]和11%[95%CI(10%,12%)];不同牙位脱矿率：上侧切牙>上中切牙>上尖牙>下前磨牙>下侧切牙=下尖牙>下中切牙=上...     

加味逍遥散在预防老年髋部骨折患者术后谵妄的临床研究

目的：研究疏肝解郁健脾补血降低高龄髋部骨折患者谵妄发生的疗效。方法：将2014年12月至2018年6月收治的180例髋部骨折的老年患者按照入院顺序分为治疗组及安慰剂组：治疗组患者90例,服用加味逍遥散,其中男32例,女58例;年龄（72.12±4.92）岁;股骨转子骨折67例,股骨颈骨折23例;35例行动力髋螺钉固定,31例行髓内固定,24例行人工髋关节置换。安慰剂组患者90例,服用安慰剂,其中男37例,女53例;年龄（72.91±5.43）岁;股骨转子骨折69例,股骨颈骨折21例;其中37例动力髋螺钉固定,30例髓内固定,23例人工髋关节置换。观察比较两组患者年龄、性别、损伤部位、术中出血量、术后引流量、手术时间、麻醉时间、术后疼痛评分、术后血红蛋白、术后C-反应蛋白、谵妄严重程度评分及谵妄发生。结果：所有患者随访至谵妄恢复正常,治疗组中术后谵妄12例（13.33%）;安慰剂组术后谵妄39例（43.33%）,治疗组明显优于安慰剂组;两组监测指标对比：术后疼痛评分（P=0.002）、术后血红蛋白（P=0.012）,术后C-反应蛋白（P=0.042）,两组比较差异有统计学意义。结论：加味逍遥散通过其疏肝解郁、健脾补血之效,达到降低术后疼痛、炎症刺激及补充血容量的目的,能够明显降低术后谵妄的发生率。     

经导管主动脉瓣置换术治疗主动脉瓣关闭不全有效性及安全性的系统评价与Meta分析

目的 评估经导管主动脉瓣置换术治疗主动脉瓣关闭不全的有效性及安全性。方法 计算机检索PubMed、EMbase、The Cochrane Library、Web of Science、中国知网、万方和维普数据库，检索时限均从建库至2021年8月。由2名研究员按照纳入与排除标准独立筛选文献、提取资料和评价纳入研究的质量，然后，采用Stata 16.0软件进行Meta分析。根据使用瓣膜的种类、研究类型进行亚组分析。结果 最终纳入25篇文献，其中12篇文献为队列研究、13篇文献为单臂研究，共4 370例患者。Meta分析结果显示：成功率为87%[95%CI(0.81,0.92)]。亚组分析，新一代瓣膜的成功率为93%[95%CI(0.89,0.96)]，早一代瓣膜的成功率为66%[95%CI(0.56,0.75)]。此外术后30 d死亡率为7%[95%CI(0.05,0.10)]，术后30 d心源性死亡率为4%[95%CI(0.01,0.07)]，术后起搏器植入率为10%[95%CI(0.08,0.13)]，中转开胸率为2%[95%CI(0.01,0.04)]，术后中度及重度瓣膜反流率为6%...     

胫骨平台骨折术后并发症的Meta分析

目的统计胫骨平台骨折术后并发症的发生率,探索对应的防治措施。方法计算机检索Medline、Embase、中国生物医学文献数据库、万方数据库和中国知网等,检索文献发表时间为2001年1月至2014年5月,获取胫骨平台骨折术后并发症发生率的相关文献。通过R软件Meta软件包中的Metaprop函数进行统计分析,记录胫骨平台骨折术后常见并发症的发生率。结果共纳入24篇文献,其中前瞻性研究9篇,回顾性分析15篇。常见并发症包括感染、深静脉血栓形成、复位不良、关节僵直、关节炎,其发生率分别为6.3%[95%CI(0.04;0.09)]、2.5%[95%CI(0.02;0.04)]、9.3%[95%CI(0.06;0.14)]、4.4%[95%CI(0.03;0.08)]、10.2%[95%CI(0.07;0.15)]。结论感染、深静脉血栓形成、复位不良、关节僵直及关节炎等胫骨平台骨折术后常见并发症的发生率较高,对患者预后影响显著,围手术期需积极采取预防措施以降低手术风险。     

神经阻滞预防性镇痛对髋部骨折患者围术期镇痛影响的Meta分析

目的 系统评价神经阻滞预防性镇痛对髋部骨折患者围术期镇痛效果及安全性的影响。
方法 检索Cochrane、Pubmed、Embase、万方、维普、中国知网，收集髋部骨折后使用神经阻滞对患者行创伤后早期疼痛管理的随机对照试验（RCT），检索时间为建库至2023年3月。根据Cochrane指导手册独立筛选文献、提取资料并评价纳入研究的偏倚风险，采用RevMan 5.3软件进行Meta分析。
结果 共纳入13篇RCT，共计患者1 241例，神经阻滞组603例，对照组638例。与对照组比较，神经阻滞（或给药）后24 h运动时VAS疼痛评分明显降低（MD=-2.16分，95%CI -4.04～-0.28分，P＜0.05），恶心呕吐发生率明显降低（OR=0.33，95%CI 0.20～0.52，P＜0.05）。两组补救镇痛率、神经阻滞（或给药）后30 min内HR和MAP差异无统计学意义。
结论 神经阻滞预防性镇痛可降低髋部骨折患者神经阻滞后VAS疼痛评分和恶心呕吐发生率，但对补救镇痛率、神经阻滞后30 min内HR和MAP无明显影响。     

老年髋部骨折患者术后谵妄的危险因素及护理对策

<正>随着世界人口老龄化的不断加剧,骨质疏松患者逐年增加。老年骨质疏松骨折中,髋部骨折约占50%以上[1-3]。谵妄是老年髋部骨折患者术后最为常见的并发症之一。比较不同手术部位术后谵妄的发生率,排在前三位的分别为,髋部骨折(35%~65%)、腹主动脉瘤(33%~54%)、冠状动脉搭桥手术(37%~52%),可见髋部骨折患者术后谵妄发生率最高[4]。且随着住院时间的延长,其死亡率呈上升趋势,为4%~17%[5-7],因此,     

腔内治疗逆行撕裂Stanford A型主动脉夹层:Meta分析

目的 采用Meta分析评价腔内治疗逆行撕裂Stanford A型主动脉夹层（RAAD）的效果。方法 检索万方数据库、中国知网及PubMed、Embase、Cochrane library数据库,获得有关腔内治疗RAAD的文献。依据纳入标准筛选文献,采用R软件对文献进行Meta分析,综合评价腔内治疗RAAD围手术期并发症、死亡率及预后。结果 最终纳入11篇文献、共224例RAAD患者。Meta分析结果显示,腔内治疗RAAD围手术期内漏发生率10.22%[95% CI（0.02,0.18）],神经系统并发症发生率0.75%[95% CI（0.00,0.03）],围手术期死亡率1.22%[95% CI（0.00,0.03）]。随访期间6例死亡[0.60%,95% CI（0.00,0.03）],其中5例死因为非主动脉相关性;8例再次接受手术干预[0.89%,95% CI（0.00,0.03）]。结论 腔内治疗RAAD安全、有效。     

Is preoperative balloon aortic valvuloplasty of interest for severe aortic stenosis in hip fracture surgery?

PurposeIn elderly patients, the discovery and management of a severe aortic stenosis (AS) prior to emergency non-cardiac surgery is a frequent and controversial issue. The objective of this study was to evaluate preoperative balloon aortic valvuloplasty (BAV) for severe AS in hip fracture surgery.MethodsWe conducted an observational, monocentric, retrospective study from 2011 to 2018. Survival (30-day, 90-day and 180-day mortality) and the occurrence of perioperative complications were analyzed and compared between control (i.e. no BAV prior to surgery) and preoperative BAV groups in patients with hip fracture surgery and a formal transthoracic echocardiographic diagnosis of severe AS (aortic valve area < 1 cm²). Patients' allocation to the intervention and control groups was after a discussion between cardiologist, anesthesiologist and the surgeon.ResultsAmong the 8506 patients who underwent hip fracture surgery, 29 patients in the control group and 30 patients in the BAV group were finally included. Kaplan-Meier survival analysis demonstrated a significant decrease in mortality in the BAV group (p=0.014) despite an increase in median time to operation of about 48 hours (p<0.0001). Multivariate analysis (stepwise logistic regression) showed that postoperative delirium (OR [95%CI]: 17.5 [1.8-168]; p=0.013) and postoperative acute congestive heart failure (OR [95%CI]: 59.4 [5.0-711.1]; p=0.0013) were predictive factors of 30-day mortality with an area under ROC curve of 0.90 (95%CI: 0.80-0.97; p<0.0001).Conclusionspreoperative BAV for severe AS could reduce the mortality of hip fracture patients despite an increase in time to operation. This improved survival could be linked to the decrease in cardiologic and neurologic adverse events. A larger prospective randomized study is necessary before generalizing our results.     

Timing of surgery for hip fractures in the elderly: A retrospective cohort study

IntroductionAlthough early surgery for elderly patients with hip fracture is recommended in existing clinical guidelines, the results of previous studies are inconsistent. The aim of this study was to compare postoperative outcomes of early and delayed surgery for elderly patients with hip fracture.Materials and MethodsIn this retrospective study using a national inpatient database in Japan, patients aged 65 years or older who underwent surgery for hip fracture between July 2010 and March 2014 were included. Early surgery was defined as surgery on the day or the next day of admission. Assessed outcomes included death within 30 days and hospital-acquired pneumonia.ResultsIn this cohort, 47,073 (22.5%) patients underwent surgery for hip fractures within two days of admission (early surgery group) and 161,805 (77.5%) underwent surgery for hip fractures thereafter (delayed surgery group). Early surgery was significantly associated with lower odds for hospital-acquired pneumonia (odds ratio, 0.42; 95% confidence interval, 0.25–0.69) and pressure ulcers (odds ratio, 0.56, 95%CI: 0.33–0.96, p = 0.035), but was not associated with 30-day mortality (odds ratio, 0.96; 95% confidence interval, 0.49–1.86) or pulmonary embolism (odds ratio, 1.62, 95%CI: 0.58–4.52, p = 0.357).ConclusionsThese results support current guidelines, which recommend early surgery for elderly hip fractures patients.     

ICU髋部骨折患者术后谵妄的回顾性分析

目的：研究重症监护病房（ICU）髋部骨折患者术詹谵妄的发生率、临床特点及相关危险因素。方法：279例髋部骨折手术患者,67例术后转入ICU。用ICU意识紊乱评估方法（CAM-ICU）进行监测,有7项因素被选作谵妄的危险因素予以分析：骨折前痴呆史．合并血管危险因素．贫血．低蛋白血症、脱水、电解质紊乱、低氧血症。结果：19例（28．4％）患者在手术后7d内发生谵妻。单因素分析具有统计学意义的变量有既往痴呆史（OR=3．16,95％Cl 1.24～8,15）、术后脱水（OR=3．64,95％cl 1．02～7．44）．合并三个及以上的血管危险因素（OR=3．76,95％cl 1．38～10;53）;多因素回归分析显示具有统计学意义的相关因素有既往痴呆病史（RR=3．06。P=0．014）,合并三个及以上的血管危险因素（RR=3．74,P=O．021）。结论：ICU髓部骨折患者手术后谵妄发生率较高,采用CAM-ICU牟亩助诊断和观察．能提高诊断率．骨折前痴呆史、合并三个及以上的血管危险因素是发生手术后谵妄的危险因素。     

The hip fracture surgery in elderly patients (HIPELD) study to evaluate xenon anaesthesia for the prevention of postoperative delirium: a multicentre,randomized clinical trial

Background

Postoperative delirium occurs frequently in elderly hip fracture surgery patients and is associated with poorer overall outcomes. Because xenon anaesthesia has neuroprotective properties, we evaluated its effect on the incidence of delirium and other outcomes after hip fracture surgery.

The association of preoperative delirium with postoperative outcomes following hip surgery in the elderly

Study objectiveTo determine the association of preoperative delirium with postoperative outcomes following hip surgery in the elderly.DesignRetrospective cohort study.SettingPostoperative recovery.Patients8466 patients all of whom were 65 years of age or older undergoing surgical repair of a femoral fracture. Of the total population studied, 1075 had preoperative delirium. Of those with preoperative delirium, 746 were ASA class 3 or below and 327 were ASA class 4 or above. Of the 7391 patients without preoperative delirium, 5773 were ASA class 3 or below and 1605 were ASA class 4 or above. The remainder in each group was of unknown ASA class.InterventionsWe used multivariable logistic regression to explore the association of preoperative delirium with 30-day postoperative outcomes. The odds ratio (OR) with associated 95% confidence interval (CI) was reported for each covariate.Measurements.Data was collected regarding the incidence of postoperative outcomes including: delirium, pulmonary complications, extended hospital stay, infection, renal complications, vascular complications, cardiac complications, transfusion necessity, readmission, and mortality.Main Results.After adjusting for potential confounders, the odds of postoperative delirium (OR 9.38, 95% CI 7.94–11.14), pulmonary complications (OR 1.83, 95% CI 1.4–2.36), extended hospital stay (OR 1.47, 95% CI 1.26–1.72), readmission (OR 1.27, 95% CI 1.01–1.59) and mortality (OR 1.92, 95% CI 1.54–2.39) were all significantly higher in patients with preoperative delirium compared to those without.ConclusionsAfter controlling for potential confounding variables, we showed that preoperative delirium was associated with postoperative delirium, pulmonary complications, extended hospital stay, hospital readmission, and mortality. Given the lack of studies on preoperative delirium and its postoperative outcomes, our data provides a strong starting point for further investigations as well as the development and implementation of targeted risk-reduction programs.     

骨替代物加强内固定与单纯内固定治疗老年股骨近端骨折疗效的Meta分析

目的 :系统评价骨替代物加强内固定与单纯内固定治疗老年股骨近端骨折的临床疗效。方法 :采用主题词和自由词(或主题词和关键词)结合的方法,通过计算机检索Pubmed、考克兰数据库(Cochrane databases)、中国知网数据库(CNKI),检索起止时间为从建库至2015年8月。收集骨替代物加强内固定与单纯内固定治疗老年股骨近端骨折的随机对照研究和准随机对照研究。选择术后再移位、再手术率、并发症(感染和骨折不连)、功能结果、生活质量评分和肌肉力量作为结局指标。计数资料采用风险差异及95%可信区间,计量资料采用均数差和95%可信区间。当同一计量资料在不同的研究中被不同标准评估时,采用其标准均值差及95%可信区间。按照考克兰协作网推荐的方法进行系统评价。结果:共纳入11项研究677例患者。Meta分析结果显示:骨替代物加强内固定组术后较少发生再移位[SMD=-0.75,95%CI(-1.03,-0.47)],并可获得更好的功能[SMD=0.40,95%CI(0.20,-0.59)]。两组患者再手术率[RD=0.02,95%CI(-0.05,-0.09)]、术后1周疼痛[SMD=-1.79,95%CI(-13.55,-9.96)]、术后6~8周疼痛[SMD=-7.24,95%CI(-20.07,-5.59)]、术后12周疼痛[MD=-0.32,95%CI(-4.19,-3.55)],肌力[MD=1.25,95%CI(-6.98,-9.48)]、骨折不愈合[RD=0.02,95%CI(-0.01,-0.05)]、术后感染[MD=0.01,95%CI(-0.03,-0.04)]等方面比较无明显差异。结论:与单纯内固定治疗相比,采用骨替代物加强内固定治疗老年股骨近端骨折术后较少发生再移位,且可获得较好的功能恢复。     

微创与传统全髋关节置换术临床疗效对比的系统评价

目的 :系统评价微创全髋关节置换术与传统全髋关节置换术治疗髋关节疾病的疗效。方法 :计算机检索Pub Med、Cochrane Library、EMbase、Web of Science、中国生物医学文献数据库(CBM)、中国期刊全文数据库(CNKI)、万方期刊全文数据库(Wanfang Data)的微创全髋关节置换术与传统全髋关节置换术治疗髋关节疾病的随机对照试验,时间为建库至2014年6月。按照纳入与排除标准独立筛选文献、提取资料,按Cochrane Handbook 5.0推荐的"偏倚风险评估"工具对纳入研究进行方法学质量评价,采用Rev Man 5.3软件进行Meta分析。比较两组术后3个月Harris髋关节评分、术后1年Harris髋关节评分、术后6周WOMAC评分、术后6周Oxford评分、术后8 h红细胞压积、术后48 h红细胞压积及血红蛋白量、术后髋内翻及髋关节脱位发生率和股骨偏心距增加值。结果 :共纳入13个随机对照试验,共1 213例患者(1 284髋),其中微创全髋关节置换术631髋,传统全髋关节置换术653髋。Meta分析结果显示:术后3个月Harris髋关节评分[MD=8.37,95%CI(6.02,10.72)],术后48 h红细胞压积[MD=0.02,95%CI(0.01,0.03)],术后48 h血红蛋白量[MD=0.50,95%CI(0.16,0.85)],改善股骨偏心距[MD=0.30,95%CI(0.04,0.56)]方面传统全髋关节置换术优于微创全髋关节置换术,差异有统计学意义;术后1年Harris髋关节评分[MD=3.26,95%CI(-3.25,9.76)],术后6周WOMAC评分[MD=-0.53,95%CI(-3.67,2.60)],术后6周Oxford评分[MD=1.34,95%CI(-3.46,6.13)],术后8 h红细胞压积[MD=-0.01,95%CI(-0.02,0.00)],髋内翻发生率[RR=0.82,95%CI(0.45,1.52)],髋关节脱位发生率[RR=1.40,95%CI(0.48,4.12)]方面两组差异无统计学意义。结论 :传统全髋关节置换术可带来更小的创伤和失血,其术后早期疗效优于微创全髋关节置换术;两种术式在术后并发症发生率方面并无差异。     

Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis

Study objectiveTo determine the effect of cognitive impairment (CI) and dementia on adverse outcomes in older surgical patients.DesignA systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). Various databases were searched from their inception dates to March 8, 2021.SettingPreoperative assessment.PatientsOlder patients (≥ 60 years) undergoing non-cardiac surgery.MeasurementsOutcomes included postoperative delirium, mortality, discharge to assisted care, 30-day readmissions, postoperative complications, and length of hospital stay. Effect sizes were calculated as Odds Ratio (OR) and Mean Difference (MD) based on random effect model analysis. The quality of included studies was assessed using the Cochrane Risk Bias Tool for RCTs and Newcastle-Ottawa Scale for observational cohort studies.ResultsFifty-three studies (196,491 patients) were included. Preoperative CI was associated with a significant risk of delirium in older patients after non-cardiac surgery (25.1% vs. 10.3%; OR: 3.84; 95%CI: 2.35, 6.26; I²: 76%; p < 0.00001). Cognitive impairment (26.2% vs. 13.2%; OR: 2.28; 95%CI: 1.39, 3.74; I²: 73%; p = 0.001) and dementia (41.6% vs. 25.5%; OR: 1.96; 95%CI: 1.34, 2.88; I²: 99%; p = 0.0006) significantly increased risk for 1-year mortality. In patients with CI, there was an increased risk of discharge to assisted care (44.7% vs. 38.3%; OR 1.74; 95%CI: 1.05, 2.89, p = 0.03), 30-day readmissions (14.3% vs. 10.8%; OR: 1.36; 95%CI: 1.00, 1.84, p = 0.05), and postoperative complications (40.7% vs. 18.8%; OR: 1.85; 95%CI: 1.37, 2.49; p < 0.0001).ConclusionsPreoperative CI in older surgical patients significantly increases risk of delirium, 1-year mortality, discharge to assisted care, 30-day readmission, and postoperative complications. Dementia increases the risk of 1-year mortality. Cognitive screening in the preoperative assessment for older surgical patients may be helpful for risk stratification so that appropriate management can be implemented to mitigate adverse postoperative outcomes.     

Intraoperative hypotension is not associated with postoperative cognitive dysfunction in elderly patients undergoing general anesthesia for surgery: results of a randomized controlled pilot trial

Study objectiveTo assess the effect of different intraoperative blood pressure targets on the development of POCD and test the feasibility of a larger trial.DesignRandomized controlled pilot trial.SettingPerioperative care in a tertiary care teaching hospital with outpatient follow-up.PatientsOne hundred one patients aged ≥75 years with ASA physical status <4, undergoing elective, non-cardiac surgery under general anesthesia and 33 age-matched healthy controls.InterventionsRandomization to a personalized intraoperative blood pressure target, mean arterial pressure (MAP) ≥ 90% of preoperative values (Target group), or to a more liberal intraoperative blood pressure management (No-Target group). Strategies to reach intraoperative blood pressure target were at discretion of anesthesiologists.MeasurementsAn experienced neuropsychologist performed a validated battery of neurocognitive tests preoperatively and 3 months after surgery. Incidence of POCD at three months and postoperative delirium were assessed. Intraoperative time spent with MAP ≥ 90% of preoperative values, recruitment and drop-out rate at 3 months were feasibility outcomes.Main resultsThe Target group spent a higher percentage of intraoperative time with MAP ≥90% of preoperative values (65 ± 25% vs. 49 ± 28%, p < 0.01). Incidence of POCD (11% vs. 7%, relative risk 1.52; 95% CI, 0.41 to 6.3; p = 0.56) and delirium (6% vs. 14%, relative risk, 0.44; 95% CI, 0.12 to 1.60; p = 0.21) did not differ between groups. No correlation was found between intraoperative hypotension and postoperative cognitive performance (p = 0.75) or delirium (p = 0.19). Recruitment rate was of 6 patients/month (95% confidential interval (CI), 5 to 7) and drop-out rate at 3 months was 24% (95% CI, 14 to 33%).ConclusionsIntraoperative hypotension did not correlate with postoperative cognitive dysfunction or delirium occurrence in elderly patients undergoing general anesthesia for non-cardiac surgery.A multicenter randomized controlled trial is needed in order to confirm the effect of intraoperative blood pressure on the development of POCD.Trial registration numberNCT02428062 www.clinicaltrials.gov.     

Effect of hip fracture surgery within 24 hours on short-term mobility

BackgroundHip fracture constitutes a high-mortality injury in elderly patients. In addition, caregiver burden is also a relevant issue, as patients after hip fracture surgery lose ambulation and require support in the perioperative period and after discharge. Early surgery is recommended to improve mortality. However the positive effect of early surgery on the short-term postoperative ambulatory function is unknown. The objective of this study was to determine whether a shorter waiting time for hip fracture surgery improves short-term postoperative mobility in elderly patients. We used the cumulated ambulation score (CAS), a feasible function scoring system using low-demand activities, to measure short-term postoperative mobility.MethodsIn this retrospective, observational study of 175 hip fracture patients at a single hospital, the patients were divided based on the waiting period for surgery (within 24 hours of arrival, early group; after 24 hours of arrival, delayed group). The primary outcome was postoperative mobility, assessed using the CAS. Multivariable linear regression analysis with adjustment for covariates, age, sex, mobility before injury, comorbidity, presence of dementia and type of fracture. As a subgroup analysis, cognitive function and the interaction between the surgical waiting time and the presence of dementia were considered.ResultsThe early group had a significantly better CAS (adjusted beta = 1.36; 95% confidence interval [95% CI]: 0.24–2.48, p = 0.02) than the delayed group. Significant CAS improvement was observed among cognitively intact patients (adjusted beta = 2.66; 95% CI: 0.62–4.69, p = 0.01), but not among those with dementia (adjusted beta = 0.43; 95% CI: ?0.93 to 1.79, p = 0.53). However, the interaction between the surgical waiting time and the presence of dementia in the entire population did not reach statistical significance (p for interaction = 0.15).ConclusionsHip fracture surgery within 24 hours could improve the recovery of postoperative ambulatory function faster. The postoperative caregiver burden would be reduced by early surgery.