An in-hospital mortality equation for mechanically ventilated patients in intensive care units

Objective

To develop an equation model of in-hospital mortality for mechanically ventilated patients in adult intensive care using administrative data for the purpose of retrospective performance comparison among intensive care units (ICUs).

Design

Two models were developed using the split-half method, in which one test dataset and two validation datasets were used to develop and validate the prediction model, respectively. Nine candidate variables (demographics: age; gender; clinical factors hospital admission course; primary diagnosis; reason for ICU entry; Charlson score; number of organ failures; procedures and therapies administered at any time during ICU admission: renal replacement therapy; pressors/vasoconstrictors) were used for developing the equation model.

Setting

In acute-care teaching hospitals in Japan: 282 ICUs in 2008, 310 ICUs in 2009, and 364 ICUs in 2010.

Participants

Mechanically ventilated adult patients discharged from an ICU from July 1 to December 31 in 2008, 2009, and 2010. Main Outcome Measures: The test dataset consisted of 5,807 patients in 2008, and the validation datasets consisted of 10,610 patients in 2009 and 7,576 patients in 2010. Two models were developed: Model 1 (using independent variables of demographics and clinical factors), Model 2 (using procedures and therapies administered at any time during ICU admission in addition to the variables in Model 1). Using the test dataset, 8 variables (except for gender) were included in multiple logistic regression analysis with in-hospital mortality as the dependent variable, and the mortality prediction equation was constructed. Coefficients from the equation were then tested in the validation model.

Results

Hosmer–Lemeshow χ ² are values for the test dataset in Model 1 and Model 2, and were 11.9 (P = 0.15) and 15.6 (P = 0.05), respectively; C-statistics for the test dataset in Model 1and Model 2 were 0.70 and 0.78, respectively. In-hospital mortality prediction for the validation datasets showed low and moderate accuracy in Model 1 and Model 2, respectively.

Conclusions

Model 2 may potentially serve as an alternative model for predicting mortality in mechanically ventilated patients, who have so far required physiological data for the accurate prediction of outcomes. Model 2 may facilitate the comparative evaluation of in-hospital mortality in multicenter analyses based on administrative data for mechanically ventilated patients.     

Serum Albumin as a Significant Prognostic Factor for Patients with Gastric Carcinoma

Background

The definition of prognostic factors in gastric carcinoma (GC) remains controversial. The potential of serum albumin as a prognostic factor for GC is emphasized because the technique to measure it is simple as well as being cheap and widely available. Our aim was to define the prognostic role of serum albumin in GC.

Methods

A cohort treated from January 1987 to December 2002 was studied. Relevant clinical, pathological and therapeutic variables were recorded. Kaplan–Meier and Cox’s methods were used to define prognostic factors associated with cancer-related survival.

Results

One thousand and twenty-three patients were included. Serum albumin did impact survival, showing a dose-response effect. This effect was present after adjustment for other prognostic factors, including Tumor-Node-Metastasis (TNM) stage, surgical resection and type of lymphadenectomy. In multivariate analysis, TNM stage [Stage Ia and Ib Hazard Ratio [HR] 1, Stage II HR 1.6 (95% confidence interval [CI], 0.56–4.7), Stage IIIa HR 4.4 (95% CI 1.7–11.3), Stage IIIb HR 5.6 (95% CI 2.6–17.2), Stage IV HR 6.8 (95% CI 2.7–17.5), high albumin HR 1, medium albumin HR 1.2 (95% CI 0.8–1.7), low albumin HR 1.2 (95% CI 0.8–1.8), very low albumin HR 1.8 (95% CI 1.3–2.6), D2 dissection HR 1, D1 dissection HR 1.9 (95% CI 1.3–2.97), and no resection HR 3.7 (95% CI 2.4–5.7)] were the most significant prognostic factors associated to survival (model P = 0.00001).

Conclusion

Pretherapeutic serum albumin level is a significant prognostic factor, which should be evaluated along with other well-defined prognostic factors in decisions concerning therapy for GC.     

A pilot study of the pleth variability index as an indicator of volume-responsive hypotension in newborn infants during surgery

Purpose

The aim of this pilot study was to evaluate the diagnostic value of pleth variability index (PVI) to predict fluid responsiveness in newborn infants during surgery.

Methods

PVI was continuously recorded in 29 mechanically ventilated newborn infants during surgery, and episodes of clinically indicated volume expansion (VE) (≥10 ml/kg in ≤15 min) administration were evaluated. The upper limit of the reference range for PVI in mechanically ventilated newborns was defined by the 95th percentile of all PVI values from hemodynamically stable infants.

Results

The upper limit of the reference range of PVI was 18 %. One hundred and three VEs were evaluated in 58 sufficient VE size (SVES) episodes and 16 insufficient initial VE size (IVES) episodes requiring repeated VE; all but one fulfilled criteria of volume-responsive hypotension (VRH). The median (interquartile range) PVI value during arterial hypotension in the 73 episodes with VRH was 23 % (20–25 %); postvolume PVI was 16 % (13–18 %). In 63 of 73 VRH episodes, during-hypotension PVI values were >18 % (86 % sensitivity for VRH). The median intermediate PVI, measured between VE in IVES episodes, was significantly higher than post-VE PVI in SVES episodes [18 % (16–21 % vs. 16 % (13–18 %].

Conclusion

This preliminary evaluation shows that PVI may indicate VRH in newborn infants during surgery.     

Patientenverfügung aus der Sicht des chirurgischen Patienten

Background

Progressive health care implies progress also in physician/patient interaction, especially with regard to moribund patients and their relatives. Advance health care directives emerged from the desire to influence medical treatment even in borderline situations. In spite of the present political and public discussions in Germany, advance directives are rarely of much importance in everyday surgical practice. By means of questionnaires, this study aimed at the frequency of advance directives among the patients of a surgical hospital and at related influencing factors.

Methods

Between August 2007 and January 2008, 450 patients at our hospital were interviewed, prior to scheduled surgery, on the topic of advance health care directives by means of anonymous questionnaires. In addition to questions about the existence of or the intention to draw up advance directives, the study focussed particularly on the relationship between patient and attending physician. Patient-specific and sociodemographic data were collected as well.

Results

Of the patients interviewed, 16.7% stated they had drawn up advance directives, while 21.3% did not know about the possibility of drawing up such a document. A mere 9.7% of the patients interviewed saw no need for such directives, whereas the majority (65.3%) considered it an option. Among the factors influencing the drawing up of advance directives, age and prior experience with severe disease figured significantly. Of the patients interviewed, 64.8% wished for more information on the topic of advance health care directives and health care proxies. The wish was expressed by 80.1% of patients that the attending surgeon mention the topic prior to surgery.

Conclusions

Although the proportion of patients that draw up advance health care directives continues to be less than one fifth, surgical patients have a great need for information regarding the topic. Surgical hospital personnel should also set themselves to this task.     

Critical care services in Ontario: a survey-based assessment of current and future resource needs

Purpose

In response to the challenges of an aging population and decreasing workforce, the provision of critical care services has been a target for quality and efficiency improvement efforts. Reliable data on available critical care resources is a necessary first step in informing these efforts. We sought to describe the availability of critical care resources, forecast the future requirement for the highest-level critical care beds and to determine the physician management models in critical care units in Ontario, Canada.

Methods

In June 2006, self-administered questionnaires were mailed to the Chief Executive Officers of all acute care hospitals, identified through the Ontario government’s hospital database. The questionnaire solicited information on the number and type of critical care units, number of beds, technological resources and management of each unit.

Results

Responses were obtained from 174 (100%) hospitals, with 126 (73%) reporting one or more critical care units. We identified 213 critical care units in the province, representing 1789 critical care beds. Over half (59%) of these beds provided mechanical ventilation on a regular basis, representing a capacity of 14.9 critical care and 8.7 mechanically ventilated beds per 100,000 population. Sixty-three percent of units with capacity for mechanical ventilation involved an intensivist in admission and coordination of care. Based on current utilization, the demand for mechanically ventilated beds by 2026 is forecast to increase by 57% over levels available in 2006. Assuming 80% bed utilization, it is estimated that an additional 810 ventilated beds will be needed by 2026.

Conclusion

Current utilization suggests a substantial increase in the need for the highest-level critical care beds over the next two decades. Our findings also indicate that non-intensivists direct care decisions in a large number of responding units. Unless major investments are made, significant improvements in efficiency will be required to maintain future access to these services.     

Severity of Acute Respiratory Distress Syndrome in haematology patients: long‐term impact and early predictive factors

Severe forms of acute respiratory distress syndrome in patients with haematological diseases expose clinicians to specific medical and ethical considerations. We prospectively followed 143 patients with haematological malignancies, and whose lungs were mechanically ventilated for more than 24 h, over a 5‐y period. We sought to identify prognostic factors of long‐term outcome, and in particular to evaluate the impact of the severity of acute respiratory distress syndrome in these patients. A secondary objective was to identify the early (first 48 h from ICU admission) predictive factors for acute respiratory distress syndrome severity. An evolutive haematological disease (HR 1.71; 95% CI 1.13–2.58), moderate to severe acute respiratory distress syndrome (HR 1.81; 95% CI 1.13–2.69) and need for renal replacement therapy (HR 2.24; 95% CI 1.52–3.31) were associated with long‐term mortality. Resolution of neutropaenia during ICU stay (HR 0.63; 95% CI 0.42–0.94) and early microbiological documentation (HR 0.62; 95% CI 0.42–0.91) were associated with survival. The extent of pulmonary infiltration observed on the first chest X‐ray and the diagnosis of invasive fungal infection were the most relevant early predictive factors of the severity of acute respiratory distress syndrome.     

Notärztliche Einschätzung der klinischen Weiterversorgung von Notfallpatienten

Introduction

Prehospital assessment of illness and injury severity with the National Advisory Committee for Aeronautics (NACA) score and hospital pre-arrival notification of a patient who is likely to need intensive care unit (ICU) or intermediate care unit (IMC) admission are both common in Germany’s physician-staffed emergency medical services (EMS) system.

Aim

This study aimed at comparing the prehospital evaluation of severity of disease or injuries by EMS physicians and the subsequent clinical treatment in unselected emergency department (ED) patients.

Material and methods

This study involved a prospective observational analysis of patients transported to the ED of an academic level I hospital escorted by an EMS physician over a period of 6 months (February–July 2011). The physician’s qualification and the patient’s NACA score were documented and the EMS physician was asked to predict whether the patient would need hospital admission and, if so, to the general ward, IMC or ICU. After the ED treatment, discharge or admission, outcome and length of hospital and ICU or IMC stay were documented.

Results

A total of 378 mostly non-trauma patients (88?%) treated by experienced EMS physicians could be enrolled. The number of patients discharged from the ED decreased, while the number of patients admitted to the ICU increased with higher NACA scores. Prehospital prediction of discharge or admission, IMC or ICU treatment by EMS physicians was accurate in 47?% of the patients. In 40?% of patients a lower level of care was sufficient while 12?% needed treatment on a higher level of care than that predicted by EMS physicians. Of the patients 39?% who were predicted to be discharged after ED treatment, were admitted to hospital and 48?% of patients predicted to be admitted to the IMC were admitted to the general ward. Patients predicted to be admitted to the ICU were admitted to the ICU in 75?%. Higher NACA scores were associated with increased mortality and a longer hospital IMC or ICU length of stay, but significant differences were only found between patients with NACA V versus VI scores or patients predicted to be treated on the IMC versus the ICU.

Conclusions

Prehospital NACA scores indicate the need for inpatient treatment, but neither hospital discharge or admission nor need of IMC or ICU admission after initial ED treatment could be sufficiently predicted by EMS physicians. Thus, hospital prenotification in order to predispose IMC or ICU capacities does not seem to be useful in cases where an ED can reassess admitted EMS patients.     

Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)

Objective

Since 2001 the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), a method for the diagnosis of delirium, has been available for the Anglo American area which can also be applied to mechanically ventilated patients. This study was conducted to answer the following questions: 1. Can a German version of the CAM-ICU be applied to patients after cardiac surgery? 2. What is the prevalence rate of postoperative delirium after cardiac surgery diagnosed by the CAM-ICU? 3. Do patients with and without the diagnosis delirium differ in the clinical variables usually associated with this disorder in cardiac surgery?

Methods

A total of 194 patients undergoing cardiac surgery served as the analysis sample (85.5% of the total group). The CAM-ICU was carried out every day for 5 days after the operation. Sociodemographic and clinical variables were collected to examine the validity of CAM-ICU. Postoperative complaints were assessed by the Anaesthesiological Questionnaire for Patients (ANP).

Results

Postoperatively, the CAM-ICU could be applied to almost all patients without any problems. The prevalence rate of delirium was 28.4% and 85.5% of the delirium diagnosed was a hypoactive subtype when diagnosed for the first time. Patients with delirium diagnosed by CAM-ICU were older (p<0.001), had a lower educational level (p<0.05), longer anaesthesia time and operation time (p<0.05), a longer postoperative ICU stay (p<0.001), were mechanically ventilated for a longer time postoperatively (p<0.001), more often reintubated (p<0.01) and had higher leucocytes postoperatively (p<0.10). More patients with delirium had the lowest postoperatively measured oxygen saturation below 95% (p<0.01).

Conclusion

The CAM-ICU is an economic method for the assessment of delirium which can easily be learned. It can be applied to patients after cardiac surgery without any problems.     

Breathing movements of the chest and upper abdomen in mechanically ventilated paralyzed patients

Aim

Assessment of breathing on clinical examination requires visualization of “chest” wall movement. However, in mechanically ventilated paralyzed patients, chest expansion is smaller than that of the abdomen. The aim of this study was to determine chest and upper abdominal movements in mechanically ventilated patients under general anesthesia.

Methods

The subjects were 68 patients scheduled for general anesthesia. Chest and upper abdominal wall movements were measured using laser light at tidal volumes (VT) of 6, 10, and 15 mL/kg. The subjects were divided into the Lean group [body mass index (BMI) < 18.5 kg/m²], Normal group (BMI 18.5–24.9 kg/m²), and Obese group (BMI ≥ 25 kg/m²), and the relationships between chest and upper abdominal wall excursions and BMI at each VT were investigated.

Results

At VT of 10 mL/kg in all subjects, chest and upper abdominal wall excursions were 4.4 and 9.4 mm, respectively. The same pattern (upper abdominal wall excursions were twice as much as those of the chest wall) was noted in all groups and all VTs.

Conclusion

Upper abdominal wall excursions were significantly larger than those of the chest wall in mechanically ventilated paralyzed patients, regardless of BMI. Assessment of breathing by clinical examination should avoid emphasis on “chest” wall movement alone, and instead include upper abdominal wall movement.     

Comparison between lumbar and thoracic epidural morphine for severe isolated blunt chest wall trauma: a randomized open-label trial

Purpose

The aim of this randomized, parallel-arm, open-label trial was to compare lumbar versus thoracic epidural morphine for severe isolated blunt chest wall injury as regards the incidence of pulmonary complications and pain control.

Methods

Fifty-five patients who sustained severe isolated blunt chest wall trauma were randomized using a computer-generated list to receive epidural morphine injection every 24 h through an epidural catheter inserted into the lumbar (n = 28) or thoracic (n = 27) region. Need for mechanical ventilation, incidence of pneumonia, arterial blood gas values, and pulmonary function tests were compared in both groups. Pain scores, supplemental analgesic consumption, length of intensive care unit (ICU) stay, and occurrence of epidural morphine-related side effects were compared as well. Primary outcome measures were need for mechanical ventilation and incidence of pneumonia.

Results

Five (17.9 %) patients in the lumbar group were mechanically ventilated, compared with six (22.2 %) in the thoracic group (hazard ratio 1.35; 95 % CI 0.41–4.4; P = 0.611). Seven (25 %) patients in the lumbar group developed pneumonia versus six (22.2 %) in the thoracic group (hazard ratio 0.97; 95 % CI 0.33–2.9; P = 0.96). Both groups were comparable as regards the duration of mechanical ventilation (P = 0.141) and length of ICU stay (P = 0.227). Pain scores, supplemental analgesic consumption, pulmonary function, and occurrence of epidural morphine-related side effects were, likewise, comparable (P > 0.05).

Conclusion

Lumbar and thoracic epidural morphine administered as once-daily injection to patients with severe isolated blunt chest wall trauma were comparable in terms of pain control, incidence of pulmonary complications, and occurrence of epidural morphine-related side effects.     

Ventilatory strategies in septic patients

Background

Mortality in intensive care unit (ICU) patients is affected by multiple variables. The possible impact of the mode of ventilation has not yet been clarified; therefore, a secondary analysis of the “epidemiology of sepsis in Germany” study was performed. The aims were (1) to describe the ventilation strategies currently applied in clinical practice, (2) to analyze the association of the different modes of ventilation with mortality and (3) to investigate whether the ratio between arterial partial pressure of oxygen and inspired fraction of oxygen (PF ratio) and/or other respiratory variables are associated with mortality in septic patients needing ventilatory support.

Methods

A total of 454 ICUs in 310 randomly selected hospitals participated in this national prospective observational 1-day point prevalence of sepsis study including 415 patients with severe sepsis or septic shock according to the American College of Chest Physicians/Society of Critical Care Medicine criteria.

Results

Of the 415 patients, 331 required ventilatory support. Pressure controlled ventilation (PCV) was the most frequently used ventilatory mode (70.6 %) followed by assisted ventilation (AV 21.7 %) and volume controlled ventilation (VCV 7.7 %). Hospital mortality did not differ significantly among patients ventilated with PCV (57 %), VCV (71 %) or AV (51 %, p?=?0.23). A PF ratio equal or less than 300 mmHg was found in 83.2 % of invasively ventilated patients (n?=?316). In AV patients there was a clear trend to a higher PF ratio (204?±?70 mmHg) than in controlled ventilated patients (PCV 179?±?74 mmHg, VCV 175?±?75 mmHg, p?=?0.0551). Multiple regression analysis identified the tidal volume to pressure ratio (tidal volume divided by peak inspiratory airway pressure, odds ratio OR?=?0.94, 95 % confidence interval 95% CI?=?0.89–0.99), acute renal failure (OR?=?2.15, 95% CI?=?1.01–4.55) and acute physiology and chronic health evaluation (APACHE) II score (OR?=?1.09, 95% CI?=?1.03–1.15) but not the PF ratio (univariate analysis OR?=?0.998, 95 % CI?=?0.995–1.001) as independent risk factors for in-hospital mortality.

Conclusions

This representative survey revealed that severe sepsis or septic shock was frequently associated with acute lung injury. Different ventilatory modes did not affect mortality. The tidal volume to inspiratory pressure ratio but not the PF ratio was independently associated with mortality.     

Evaluation of a “do not resuscitate” policy in intensive care

The decision to withhold cardiopulmonary resuscitation from a patient within an intensive care unit (ICU) may be a difficult but appropriate one for which there are few guidelines. We describe the formulation of a Do Not Resuscitate (DNR) policy in our multidisciplinary ICU. To evaluate the effect of implementation of the DNR policy on physician practice and on communication among physicians, nurses, patients and their families, we interviewed physicians and nurses caring for patients designated DNR before (n = 8) and after (n = 17) implementation of the DNR policy. We found that DNR orders in the ICU were not infrequent (2-3 per week). All patients designated DNR were either irreversibly ill or not responsive to maximal therapy, and 22 of 25 were not competent. The DNR order was not accompanied by withdrawal of other therapy in 50% of cases and one patient recovered and was discharged from hospital. The implementation of the DNR policy encouraged greater physician consultation with other physicians, patients and their families. Although there were differences in perception of communication between physicians and nurses, we believe that the DNR policy influenced physician practice and enhanced overall communication in the ICU.     

Impact of positive surgical margins and their locations after radical prostatectomy: comparison of biochemical recurrence according to risk stratification and surgical modality

Purpose

We investigated the influence of positive surgical margins (PSMs) and their locations on biochemical recurrence (BCR) according to risk stratification and surgical modality.

Methods

A total of 1,874 post-radical-prostatectomy (RP) patients of pT2–T3a between 2000 and 2010 at three tertiary centers, and who did not receive neoadjuvant/adjuvant therapy, were included in this study. Patients were stratified according to BCR risk: low risk (PSA <10, pT2a-b, and pGS ≤6), intermediate risk (PSA 10–20 and/or pT2c and/or pGS 7), and high risk (PSA >20 or pT3a or pGS 8–10). The median follow-up was 43 months.

Results

PSMs were a significant predictor of BCR in both the intermediate- and high-risk-disease groups (P = .001, HR 2.1, 95 % CI 1.3–3.4; P < .001, HR 2.8, 95 % CI 2.0–4.1). Positive apical margin was a significant risk factor for BCR in high-risk disease (P = .003, HR 2.0, 95 % CI 1.2–3.3), but not in intermediate-risk disease (P = .06, HR 1.7, 95 % CI 0.9–3.1). Positive bladder neck margin was a significant risk factor for BCR in both intermediate- and high-risk disease (P < .001, HR 5.4, 95 % CI 2.1–13.8; P = .001, HR 4.5, 95 % CI 1.8–11.4). In subgroup analyses, robotic RP provided comparable BCR-free survival regardless of risk stratification. Patients with PSMs showed similar BCR-free survival between open and robotic RP (log-rank, P = .897).

Conclusions

Post-RP PSMs were a significantly independent predictor of disease progression in high-risk disease as well as intermediate-risk disease. Both positive apical and bladder neck margins are also significant risk factors of BCR in high-risk disease. Patients with PSMs showed similar BCR-free survival between open and robotic surgery.     

Clinical Outcomes After Unplanned Extubation in a Surgical Intensive Care Population

Background

Clinical outcome after unplanned extubation (UE) in patients admitted to the surgical intensive care unit (SICU) has not been fully investigated. In this study we assessed in-hospital mortality of patients with UE and determined whether UE is a predictor of in-hospital mortality. Finally, we sought to identify predictors of reintubation after UE in mechanically ventilated patients in the SICU.

Methods

Medical charts of patients (n = 4,407) admitted to the SICU between October 2007 and December 2011 were reviewed retrospectively.

Results

Eighty-five episodes of UE occurred in 81 patients. Patients with UE required emergency surgery more frequently and had higher ICU and hospital mortality rates, reintubation rate, and APACHE II scores and longer mechanical ventilation (MV) and ICU stay than patients without UE (P < 0.05 for all associations). Multivariate analysis revealed that reintubation (odds ratio [95 % confidence interval]: 4.14 [2.58–6.67]; P < 0.001), APACHE II scores (1.14 [1.12–1.17]; P < 0.001), emergency surgery (1.73 [1.18–2.53]; P = 0.005), and chronic neurologic disease (2.11 [1.30–3.41]; P = 0.002) were associated with hospital mortality. Reintubation was necessary in 17 patients. On multivariate analysis, a score on the Richmond Agitation–Sedation Scale (RASS, 0.48 [0.31–0.76]; P = 0.001), PaO₂/FiO₂ ratio (0.99 [0.99–1.00]; P = 0.048), and MV duration before UE (1.46 [1.08–1.98]; P = 0.014) were independently associated with reintubation after UE.

Conclusions

Our results indicated that although patients with UE had high in-hospital mortality, UE was not directly associated with in-hospital mortality. Reintubation, chronic neurologic disease, emergency operation, and higher APACHE II score were related to increased in-hospital mortality. A low RASS score, a low PaO₂/FiO₂ ratio, and long MV duration before UE were related to reintubation after UE.     

Perphenazine decreases vomiting by children after tonsillectomy

Purpose

To test the hypothesis that perphenazine decreases the incidence of vomiting by children after tonsillectomy.

Methods

Healthy children (n = 260) aged 2–12 yr undergoing elective tonsillectomy on a day care surgical basis were studied in this randomised, stratified, blocked, double-blind investigation. General Anaesthesia was induced intravenously with propofol or by inhalation with halothane and N₂O. Perphenazine 70 μg·kg^?1 up to 5 mg or placebo iv was administered before surgery. Management of perioperative fluids, emesis and pain were all standardised.

Results

The groups were similar with respect to demographic data. There was less vomiting after perphenazine during the first 24 hr after surgery 42% (95% CI = 34%–50%) vs 57% (95% CI = 48%–66%, placebo), P < 0.01. On the day of surgery, both in and out-of hospital emesis were decreased by perphenazine. The perphenazine treated patients required fewer rescue antiemetics than the control group, P < 0.05. Each episode of in-hospital vomiting delayed discharge by 20 ± 7 min (mean ± SD). P = 0.007.

Conclusion

The prophylactic administration of perphenazine decreases vomiting by children after tonsillectomy.     

Disease-specific perception of fracture risk and incident fracture rates: GLOW cohort study

Summary

Accurate patient risk perception of adverse health events promotes greater autonomy over, and motivation towards, health-related lifestyles.

Introduction

We compared self-perceived fracture risk and 3-year incident fracture rates in postmenopausal women with a range of morbidities in the Global Longitudinal study of Osteoporosis in Women (GLOW).

Methods

GLOW is an international cohort study involving 723 physician practices across ten countries (Europe, North America, Australasia); 60,393 women aged ≥55 years completed baseline questionnaires detailing medical history and self-perceived fracture risk. Annual follow-up determined self-reported incident fractures.

Results

In total 2,945/43,832 (6.8 %) sustained an incident fracture over 3 years. All morbidities were associated with increased fracture rates, particularly Parkinson's disease (hazard ratio [HR]; 95 % confidence interval [CI], 3.89; 2.78–5.44), multiple sclerosis (2.70; 1.90–3.83), cerebrovascular events (2.02; 1.67–2.46), and rheumatoid arthritis (2.15; 1.53–3.04) (all p?<?0.001). Most individuals perceived their fracture risk as similar to (46 %) or lower than (36 %) women of the same age. While increased self-perceived fracture risk was strongly associated with incident fracture rates, only 29 % experiencing a fracture perceived their risk as increased. Under-appreciation of fracture risk occurred for all morbidities, including neurological disease, where women with low self-perceived fracture risk had a fracture HR 2.39 (CI 1.74–3.29) compared with women without morbidities.

Conclusions

Postmenopausal women with morbidities tend to under-appreciate their risk, including in the context of neurological diseases, where fracture rates were highest in this cohort. This has important implications for health education, particularly among women with Parkinson's disease, multiple sclerosis, or cerebrovascular disease.     

RETRACTED ARTICLE: Antiemetic efficacy of granisetron and metoclopramide in children undergoing ophthalmic or ENT surgery

Purpose

The purpose of this study was to compare the effectiveness of granisetron, metoclopramide and placebo in reducing the frequencies of retching and vomiting in children who had undergone strabismus repair and tonsillectomy with or without adenoidectomy.

Methods

In a randomized, double-blind study, 70 healthy subjects, 4–10 yr of age, were given a single dose of either placebo (saline, n = 24), metoclopramide 0.25 mg · kg^?1 (n = 23) granisetron 40 μg · kg^?1 (n = 23) iv over two to five minutes after the induction of anaesthesia. All subjects received inhalation anaesthesia with sevoflurane and nitrous oxide in oxygen. Rescue antiemetics were administered if two or more episodes of vomiting occurred. Acetaminophen pr or pentazocine iv was given as needed for postoperative pain. All subjects remained in hospital for two days. During the first three and the next 21 hr after anaesthesia, the frequencies of retching and vomiting were recorded by nursing staff.

Results

There was no difference among groups with regard to demographic characteristics, surgical procedures, anaesthetics administered, postoperative managements, or adverse effects. During 0–3 hr after anaesthesia, the frequencies of retching and vomiting were: placebo 62%, metoclopramide 22% and granisetron 13% (P < 0.05). The corresponding frequencies during 3–24 hr after anaesthesia were: placebo 50%, metoclopramide 39% and granisetron 13% (P < 0.05). Four children who had received placebo and three who had received metoclopramide required another rescue antiemetic.

Conclusion

Granisetron 40 μg · kg^?1 is more effective than either metoclopramide or placebo in reducing the frequencies of postoperative retching and vomiting during the first 24 hr after anaesthesia in children who have undergone strabismus surgery and tonsillectomy with or without adenoidectomy.     

RETRACTED ARTICLE: Cardiovascular responses to tracheal extubation or LMA removal in children

Purpose

This study was designed to investigate the cardiovascular effects related to tracheal extubation or laryngeal mask airway (LMA) removal in children.

Methods

Sixty children, ASA physical status I, 4–10 yr of age, undergoing minor elective surgery (inguinal hernia and phimosis) were allocated randomly to have their surgery performed with endotracheal intubation (Group ET, n = 30) or LMA (Group LMA, n = 30) and were studied for cardiovascular responses related to extubation or LMA removal. Changes in heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured before and 1,2,3,5, and 10 min after tracheal extubation or LMA removal when the patients were awake.

Results

The maximal changes in HR, SBP and DBP were less in Group LMA than in Group ET during the observation period (HR; 12 vs 26, SBP; 14vs 28, DBP; 9 vs 13, median,P < 0.05).

Conclusion

Laryngeal mask airway removal elicited less haemodynamic change than tracheal extubation in paediatric patients.