Is decreasing mortality in total hip and knee arthroplasty patients dependent on patients’ comorbidity?

Background and purpose — Mortality after primary total hip and knee arthroplasty (THA and TKA) has declined, and the proportion of THA and TKA patients with comorbid conditions has increased. We therefore wanted to examine changes in comorbidity burden over time and the impact of comorbid on mortality following primary total hip and knee arthroplasty in patients with osteoarthritis.

Patients and methods — We used the Danish arthroplasty registers to identify THA and TKA patients from 1996 through 2013. From administrative databases, we collected data on pre-surgery hospital history for all patients, which were used to calculate the Charlson comorbidity index (CCI). Patients were divided into 4 groups: CCI-none, CCI-low, CCI-moderate, and CCI-high. We calculated the relative risk (RR) of mortality within 90 days after surgery with a 95% confidence interval (CI), with stratification according to CCI group and year of surgery.

Results — 99,962 THAs and 63,718 TKAs were included. The proportion of THAs with comorbidity increased by 3–4% in CCI-low, CCI-moderate, and CCI-high patients, from 1996–1999 to 2010–2013. The overall 90-day mortality risk declined for both procedures. Compared to CCI-none, THA patients with low, moderate, and high comorbidity burdens had an RR of 90-day mortality of 1.9 (95% CI: 1.6–2.4), 1.9 (CI: 1.5–2.5), and 3.3 (CI: 2.6–4.2), respectively. Similar increases in proportions and RRs were observed in TKAs.

Interpretation — Despite the fact that the proportion of THA and TKA patients with comorbidities has increased over the past 18 years, the overall mortality has declined. The mortality risk depended on the comorbidity burden and did not decline during the study period for THA and TKA patients with a moderate or high comorbidity burden at the time of surgery.     

Can we avoid surgery in elderly patients with renal masses by using the Charlson comorbidity index?

OBJECTIVE

To determine the safety of surveillance for localized contrast‐enhancing renal masses in elderly patients whose comorbidities precluded invasive management; to provide an insight into the natural history of small enhancing renal masses; and to aid the clinician in identifying those patients who are most suitable for a non‐interventional approach.

PATIENTS AND METHODS

We conducted a retrospective chart review of 26 consecutive patients (16 men and 10 women), who were followed for ≥1 year, with localized solid enhancing renal masses between 1998 and 2006. These patients were unfit or unwilling to undergo radical or partial nephrectomy. None had their tumours surgically removed. Study variables included age, presentation, tumour size, growth rate, Charlson comorbidity index (CMI) and available pathological data.

RESULTS

The mean (range) patient age was 78.14 (63–89) year, with a mean follow‐up of 28.1 (12–72) months. The mean tumour size was 4.25 (2.5–8.7) cm at diagnosis. The tumour growth rate was 0.44 cm/year; among smaller masses (T1a) it was 0.15 cm/year, vs 0.64 cm/year in the larger masses (T1b and T2). The mean CMI was 2.96. There were 11 deaths overall; 10 patients died from unrelated illnesses. One death was directly attributable to metastatic renal cancer; this patient had an initial tumour diameter of 5.4 cm and a CMI of 6. All patients who died had a CMI of ≥3.

CONCLUSIONS

Elderly patients with small renal tumours (T1a) and comorbidity scores of ≥3 were more likely to die as a result of their comorbidities rather than the renal tumour. Surveillance of small renal masses appears to be a safe alternative in elderly patients who are poor surgical candidates, where the overall growth rate appears to be slow.     

Is gain in health-related quality of life after a total hip arthroplasty depended on the comorbidity burden?

Background and purpose — Using patient-reported health-related quality of life (HRQoL), approximately 10% of patients report some degree of dissatisfaction after a total hip arthroplasty (THA). The preoperative comorbidity burden may play a role in predicting which patients may have limited benefit from a THA. Therefore, we examined whether gain in HRQoL measured with the EuroQol-5D (EQ-5D) at 3 and 12 months of follow-up depended on the comorbidity burden in THA patients

Patients and methods — 1,582 THA patients treated at the Regional Hospital West Jutland from 2008 to 2013 were included. The comorbidity burden was collected from an administrative database and assessed with the Charlson Comorbidity Index (CCI). The CCI was divided into 3 levels: no comorbidity burden, low, and high comorbidity burden. HRQoL was measured using the EQ-5D preoperatively and at 3 and 12 months’ follow-up. Association between low and high comorbidity burden compared with no comorbidity burden and gain in HRQoL was analyzed with multiple linear regression.

Results — All patients, regardless of comorbidity burden, gained significantly in HRQoL. A positive association between comorbidity burden and gain in HRQoL was found at 3-month follow-up for THA patients with a high comorbidity burden (coeff: 0.09 (95% CI 0.02 – 0.16)) compared with patients with no comorbidity burden.

Interpretation — A comorbidity burden prior to THA does not preclude a gain in HRQoL up to 1 year after THA.     

Radical cystectomy in patients over 70?years of age: impact of comorbidity on perioperative morbidity and mortality

Purpose

To analyze the impact of comorbidity on the perioperative complication rate after radical cystectomy in patients over 70?year of age.

Methods

Between April 1993 and August 2010, 830 radical cystectomies were performed at our institution. Of the 830 patients, 365 patients (44.0%) were ??70-year-old (median age 74?year). This group of elderly patients was compared with a younger group of 465 patients (56.0% of the whole cohort) aged under 70?year (median 63?year).

Results

The group of elderly patients had a significantly higher prevalence of concomitant diseases e.g., hypertension (57.3% vs. 38.5%), coronary heart disease (27.1% vs. 14.8%) and diabetes (25.5% vs. 14.6%). Perioperative complications were significantly more frequent in the elderly group: 31.0% versus 21.5% overall complication rate, P?=?0.002. Mortality rate was almost similar in both groups: 0.6% (elderly) versus 0.5% (younger). Within the elderly group, the overall complication rate was significantly higher in patients with an ASA score ??3 (37.0%) than in patients with an ASA score ??2 (25.0%) (P?<?0.02). Multivariate logistic regression analysis was used to identify that chronic obstructive lung disease, ASA score and age were independent predictive factors for perioperative complications.

Conclusions

Elderly patients have a higher prevalence of concomitant systemic diseases. Some concomitant diseases can affect surgical outcome after radical cystectomy, particularly the frequency and character of perioperative complications. It is therefore of paramount importance to conduct a comorbidity assessment and preoperative conditioning of each patient, with a special focus on the patient??s individual risk factors and age.     

The influence of comorbidity on the postoperative survival in elderly (≥ 75 years old) with lung cancer

Objectives

We conducted a multi-institutional prospective observational study of elderly patients (≥?75 years-old) with resected non-small cell lung cancer. In this report, we have followed the cohorts for 2 years after surgery and examined both the influence of preoperative comorbidity [Adult Comorbidity Evaluation-27 (ACE-27) index] on the postoperative survival and the change in the Karnofsky Performance Status (KPS).

Methods

From March 2014 to April 2015, 264 patients were prospectively registered from 22 hospitals affiliated with the National Hospital Organization. The mean age at the time of surgery was 79.3 years (range 75–90 years), and 41% of the patients were ≥?80 years of age. A total of 26% underwent sublobar resection. The study endpoints were the postoperative overall survival (OS), its prognostic factors, and the changes in the postoperative KPS.

Results

The 2-year OS was 85.3% (95% confidence interval 80.4–89.1%). Male gender, age?≥?80, a smoking history, grade 2 of ACE-27, and an advanced disease stage were significantly poor prognostic factors for the OS in the univariate risk analysis. The multivariate analysis showed that male gender, age?≥?80, an advanced disease stage and sublobar resection were significantly poor prognostic factors for the OS. In comparison with the preoperative KPS, no marked decline was observed in the postoperative chorological change of KPS.

Conclusions

In the surgical treatment of elderly patients, the comorbidity as assessed by the ACE-27 index might affect the postoperative survival, and therefore should be taken into accounts in the preoperative evaluation of the surgical indications.

     

Both comorbidity burden and low testosterone can explain symptoms and signs of testosterone deficiency in men consulting for sexual dysfunction

Low testosterone(T)is frequent in men with chronic illnesses.The clinical features of T deficiency(TD)overlap with those of chronic diseases.The aim of this study is to evaluate the relative contribution of chronic disease score(CDS)and low T to the presenee of TD symptoms.A consecutive series of 3862 men(aged 52.1±13.1 years)consulting for sexual dysfunction were studied.Several clinical and biochemical parameters were collected,in eluding the structured interview,ANDROTEST,for the assessme nt of TD symptoms.Penile color Doppler ultrasound(PCDU)was also performed.Based on the medications taken,the CDS was calculated.For a subset of 1687 men,information on mortality was collected(follow-up of 4.3±2.6 years).Higher CDS was associated with lower free and total T(TT)as well as with higher ANDROTEST score.When introducing CDS and TT in multivariable models adjusted for age,severe erectile dysfunctio n and impaired morning erectio ns were associated with both CDS(odds ratio and 95%confide nee interaval,OR[95%Cl]=1.25[1.13;1.37]and 1.38[1.29;1.48],respectively)and low TT(OR[95%Cl]=1.11[1.00;1.23]and 1.13[1.06;1.21],respectively).Similar results were obtained for PCDU parameters.Hypoactive sexual desire was associated with low TT(OR[95%Cl]=1.21[1.13;1.30]),whereas it was inversely related with CDS(OR[95%Cl]=0.91[0.84;0.97]).When considering mortality for major cardiovascular events,TT<8 nmol I1,but not CDS,was a significant predictor(hazard ratio[95%Cl]=5.57[1.51;20.63]).Chronic illnesses are associated with an overt TD.Both chronic diseases and low T can be invoIved in determining symptoms present in subjects complaining for sexual dysfunction.This should be considered in the diagnostic workup for TD.     

Impact of Charlson’s comorbidity index on overall survival following tumor nephrectomy for renal cell carcinoma

Objective  

To study the impact of Charlson’s comorbidity index on overall survival following radical and partial nephrectomy performed for renal cell carcinoma (RCC).     

Traumatic lacunar infarction in basal ganglion in children

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What about sentinel node practice in early-staged cutaneous melanoma in France in 2003?

AIM: The aim of this study was to establish the status of sentinel lymph node (SLN) biopsy procedure in cutaneous melanoma in France in 2002. MATERIAL AND METHODS: This study was based upon the statistics of the main French melanoma centers. A short questionnary was sent to Head Physician by email. The authors asked for the global attitude as far as SLN was concerned, number of cutaneous melanoma diagnosed during year 2002 and of SLN procedures performed, critters of inclusion and postoperative management in each case. Abstension could be argued in a free item. Answers were sent back by email. RESULTS: The authors collected 22 answers coming from overall territory; 64% performed SLN procedure (14 centers), 36% applied "wait and watch" policy. Staffs performing SLN diagnosed a mean of 101 (8-400) melanoma and biopsied a mean of 21 (0-53) sentinel nodes. The others diagnosed a mean of 151 (15-250) melanoma. Patients were enrolled for Breslow thickness upper to 1.5 mm in 71%, to 1 mm in 29%. Ulceration was a critter of inclusion in 93% (21 staffs), 100% enrolled patients whose tumor presented signs of regression. SLN was performed for primary sites located overall body in 71%, only in limbs and trunk in 29%. Positive node lead to regional lymph node clearance, then observation or interferon protocol. Negative node lead to "wait and watch policy" in 14%, different interferon protocols according to Breslow thickness in 86%. CONCLUSION: SLN procedure is not homogenous in France. France is divided as far as SLN is concerned. If 64% are performing SLN, more than 50% of the new melanoma are not included in the trial.     

A population-based study on trend in incidence of distal radial fractures in adults in Taiwan in 2000�C2007

Summary  

This population-based study was conducted using claims data obtained from the National Health Insurance to investigate the trend in incidence of distal radial fractures in adults in Taiwan from 2000 to 2007. Our results revealed an increasing trend, particularly among women >50 years of age.     

Dantrolenbevorratung in Anästhesie und Intensivmedizin in Deutschland

Background

A malignant hyperthermia (MH) crisis is a potentially fatal complication in anesthesia and intensive care units (ICU). Rapid administration and adequate dosage of dantrolene is the only known effective pharmacological and causal treatment of an MH crisis. International anesthesiology societies recommend an initial dose of 2.0–2.5?mg/kg body weight (BW). The necessary total dosage should be titrated up to 10?mg/kg BW depending on the effectiveness.

Objective

The goal of this study was an analysis of the stocking situation of dantrolene in Germany. A national survey was conducted amongst members of the German Society of Anaesthesia and Intensive Care (DGAI).

Material and methods

A questionnaire consisting of 19 items was posted online to all DGAI members from 2 September to 30 September 2015. The questionnaire dealt with characterization of the participants, the administration of triggering substances in the operating room and in the ICU of the respective hospitals. The main part covered the amount of stocked dantrolene, the place of storage and emergency availability of stocked dantrolene from elsewhere.

Results

The questionnaire was posted online to 12,415 DGAI members with a response rate of 13.5% (n = 1673). The highest response rate was from 259 directors and heads of anesthesiology units representing 28.3%. In total 93,7% of participants use volatile anesthetics and 82,3% use succinylcholine. In the event of an MH-crisis 40.4% of participants have 36 or more vials of dantrolene available within 5?min, 27.4% have only 24 vials and 18.7% only have 12 vials. Of the anesthesiologists in outpatient surgery 70.6% have a dantrolene stock of less than 36 vials. In those cases with insufficient dantrolene stock, 35.5% of hospitals have no agreement with neighboring hospitals. In the ICU setting, 51.8% of responding participants indicated the use of volatile anesthetics, but only 25.7% stock dantrolene in the ICU. For succinylcholine, 77.3% stated using the drug in the ICU, and 26.0% have a dantrolene stock in the ICU.

Conclusion

Almost all anesthesiologists participating in the online survey use volatile anesthethics and/or succinylcholine. Whereas almost all participants have access to dantrolene, more than half of the units have a stock of dantolene, which is less than that recommended by the DGAI. In the case of low dantrolene stock, only 61% of anesthesia departments have access to additional dantrolene within a time frame of 15min?. The results of this online survey demonstrate that the stock of dantrolene may be insufficient in some German hospitals and anesthesiology practices.