Comorbid Profile Rather than Age Determines Hip Fracture Mortality in a Nonagenarian Population

Background

In light of poor outcomes with nonoperative management of hip fractures, orthopedic surgeons are faced with difficult decisions about which patients are too ill or too old for surgical treatment.

Questions/Purposes

This study sought to investigate if patients over 90 years had different preoperative laboratory, clinical, and injury characteristics than younger patients with the same injury. We compared our cohort with previously published data. We wished to identify if there were pre-injury risk factors associated with 30-day mortality, which could be modified to enhance postoperative outcomes.

Methods

This is a retrospective review of 198 operatively managed hip fractures in patients 75 years or older. We collected data on demographics, select preoperative laboratory values, injury type, comorbidities, and 30-day mortality.

Results

Eleven (5.6%) of the cohort died within 30 days of surgery, 6.3% in the younger group, and 3.7% in the older group; the difference was not statistically significant. For baseline characteristics, there was no difference between the age groups for pre-injury comorbidities, hemoglobin, serum albumin, BUN, prevalence of UTI, or fracture type. A total of 67 (35.8%) patients had evidence of UTI on admission.

Conclusions

These findings reveal that in our dichotomized cohort, pre-injury characteristics were similar and age alone was not an independent predictor of mortality. These data may inform decision-making for orthopedic surgeons and the medical providers who consult to optimize these patients for surgery. We identified high rates of UTI in both age groups, a potentially remediable factor to optimize outcomes in hip fracture surgery in elderly patients.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-015-9435-y) contains supplementary material, which is available to authorized users.     

Relationship between changes in pulmonary kinetics and autonomic regulation of blood flow

Various regulatory mechanisms of pulmonary oxygen uptake () kinetics have been postulated. The purpose of this study was to investigate the relationship between vagal withdrawal, measured using RMSSDRR, the root mean square of successive differences in cardiac interval (RR) kinetics, a mediator of oxygen delivery, and kinetics. Forty‐nine healthy adults (23 ± 3 years; 72 ± 13 kg; 1.80 ± 0.08 m) performed multiple repeat transitions to moderate‐ and heavy‐intensity exercise. Electrocardiography, impedance cardiography, and pulmonary gas exchange parameters were measured throughout; time domain measures of heart rate variability were subsequently derived. The parameters describing the dynamic response of , cardiac output () and RMSSDRR were determined using a mono‐exponential model. During heavy‐intensity exercise, the phase II τ of was significantly correlated with the τ of RR (r = 0.36, P < 0.05), Q (r = 0.67, P < 0.05), and RMSSDRR (r = 0.38, P < 0.05). The τ describing the rise in Q explained 47% of the variation in τ, with 30% of the rate of this rise in Q explained by the τ of RR and RMSSDRR. No relationship was evident between kinetics and those of Q, RR, or RMSSDRR during moderate exercise. Vagal withdrawal kinetics support the concept of a centrally mediated oxygen delivery limitation partly regulating kinetics during heavy‐, but not moderate‐, intensity exercise.     

Assessing the effect of a true-positive recall case in screening mammography: does perceptual priming alter radiologists' performance?

Objective:

To measure the effect of the insertion of less-difficult malignant cases on subsequent breast cancer detection by breast imaging radiologists.

Methods:

The research comprises two studies. Study 1: 8 radiologists read 2 sets of images each consisting of 40 mammographic cases. Set A contained four abnormal cases, and Set B contained six abnormal cases, including two priming cases (less difficult malignancies) placed at intervals of three and five subsequent cases before a subtle cancer. Study 2: 16 radiologists read a third condition of the same cases, known as Set C, containing six abnormal cases and two priming cases immediately preceding the subtle cancer cases. The readers were asked to localize malignancies and give confidence ratings on decisions.

Results:

Although not significant, a decrease in performance was observed in Set B compared with in Set A. There was a significant increase in the receiver operating characteristic (ROC) area under the curve (z = −2.532; p = 0.0114) and location sensitivity (z = −2.128; p = 0.0333) between the first and second halves of Set A and a marginal improvement in jackknife free-response ROC figure of merit (z = −1.89; p = 0.0587) between the first and second halves of Set B. In Study 2, Set C yielded no significant differences between the two halves of the study.

Conclusion:

Overall findings show no evidence that priming with lower difficulty malignant cases affects the detection of higher difficulty cancers; however, performance may decrease with priming.

Advances in knowledge:

This research suggests that inserting additional malignant cases in screening mammography sets as an audit tool may potentially lead to a decrease in performance of experienced breast radiologists.The effectiveness of screening mammography in detecting breast cancer relies heavily on accurate observer performance;¹ however, miss rates of 10–30% have been reported.^2,3 The challenge for radiologists is to gain comprehensive experience in the appearance of abnormality and keep their recall rate within acceptable limits given the low incidence of the disease.^4–6 It has been proposed that the insertion of “test malignant cases” into a “real life” clinical screening mammography set may increase cancer detection rates by artificially increasing the prevalence.⁷ However, by specifically increasing the prevalence of abnormality, there may be inadvertent effects on the detection of subsequent “real” cases.Previous work on the impact on increasing abnormality prevalence on radiologic performance has provided diverse conclusions, with one study suggesting that varying prevalence was unlikely to alter the accuracy of the radiologists,⁸ another suggesting increased diagnostic efficacy with increasing prevalence⁹ and a further arguing no significant effect.¹⁰ A study focusing on prevalence expectation, whilst showing no significant impact on reporting accuracy, did show that visual search, in terms of interpretation time and the number of visual fixations per image, was significantly changed when higher prevalence was expected.¹¹A recent study of expert breast radiologists showed that they tend to miss a much higher percentage of malignant lesions in a setting closer to the actual low-prevalence level found in the clinic than under high prevalence test conditions.⁷ However, in that study, although the false-negative rate significantly increased in the clinic setting, the false-positive rate decreased in the low-prevalence condition, although by a non-significant amount. Moreover, owing to the difficulties of performing such a study in the clinical setting, the same radiologists did not interpret the same inserted cases in both the low and high prevalence parts of the study, and as reader variability usually comprises the largest component of variance in a reader study, care should be taken when interpreting these results.Research in cognitive psychology has shown that human visual perception of the elements in our environment is greatly dependent on what was previously seen.¹² For example, detection of a target is facilitated by having seen the target (or a lookalike) before, and this effect is called “perceptual priming”. Perceptual priming as a mechanism for improving cancer detection in low-prevalence contexts such as screening mammography is an under explored area of research. In this context, priming can be understood as a mechanism that “highlights” the presence of a given target by increasing the saliency of the stimulus.¹³ It is generally accepted in the cognitive psychology literature that priming can be used to direct visual attention towards an explicit target, and that observers become proficient at finding targets when salient prompts are employed.^14,15 This has real relevance in clinical imaging, not just as an attempt to improve diagnostic efficacy but also to establish the impact of audit cases randomly inserted into a reading set to test radiologic performance. The hypothesis of the study is that the addition of malignant cases of lower difficulty (herein called “primers”) would increase the likelihood that the readers would detect subsequent malignant cases of higher difficulty presented at intervals between one and five cases after the primers.     

Error consistency and the evaluation of treatment outcomes

The consistency/variability of error substitution patterns may hold important implications for subgrouping children with speech disorders, as well as for relationships between learning and generalization patterns. There is a need to quantify and examine the range of consistency/variability within the speech disordered population as it relates to system-wide change. This investigation compared two groups of preschool children (N = 10 each) differing in the consistency/variability of errors on a variety of pre-treatment and treatment outcome measures. The Error Consistency Index (ECI), a measure of error variability across the entire phonological system, was used to identify groups at the extreme ends of the ECI distribution from a larger participant pool. Each participant was treated on three target singletons from among obstruents /s, z, f, integral, tintegral, k, g/ and liquids /l, r/ and change on these targets, as well as their generalization to untrained positions was assessed. Although there were significant differences between the variable and consistent groups on all pre-treatment measures, there were no significant group differences in target and generalization learning or in per cent consonants correct (PCC) change. These findings provide evidence to suggest that relationships observed between error variability for individual phonemes and learning of those targets may differ from those observed when consistency/variability is quantified for the entire system and change across a number of phonemes, and the system as a whole, is examined.     

Nanoparticles for drug delivery in Parkinson’s disease

Journal of Neurology - Although effective symptomatic treatments for Parkinson’s disease (PD) have been available for some time, efficient and well-controlled drug delivery to the brain has...     

Becoming psychotherapists: Experiences of novice trainees in a beginning graduate class

The authors investigated the experiences related to becoming psychotherapists for 5 counseling psychology doctoral trainees in their first prepracticum course. Qualitative analyses of weekly journals indicated that trainees discussed challenges related to becoming psychotherapists (e.g., being self-critical, having troubling reactions to clients, learning to use helping skills), gains made during the semester related to becoming psychotherapists (e.g., using helping skills more effectively, becoming less self-critical, being able to connect with clients), as well as experiences in supervision and activities that helped them cope with their anxieties. Results are discussed in 5 broad areas: feelings about self in role of psychotherapist, awareness of reactions to clients, learning and using helping skills, reactions to supervision, and experiences that fostered growth. Implications for training and research are provided. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

Brains are Important Too: Reply to Hall,Carter, and Barnett

The authors and I agree on many features of addiction, such as its developmental (versus pathological) nature. But because I rely on much of the same data as the Brain Disease Model of Addiction (BDMA), they seem to conflate my work with that of my opponents. Indeed they are generally skeptical of the use of neuroscientific data to help understand addiction, calling it "immature." Thus my work is also suspect. Hall and colleagues believe that it is impossible to look at neural and social processes at the same time, yet that is exactly what I do. I suggest that interdisciplinary approaches to addiction are crucial.     

Heteronymous Ia‐afferent connections in the upper limb following stroke

Synergistic arm movement patterns are common following stroke and may arise through enhanced spinally mediated reflex connections between muscles. Our goal was to investigate the excitability of heteronymous Ia‐afferent pathways in people with chronic stroke. Responses to tendon taps of the flexor carpi radialis (FCR) muscle were recorded in FCR, biceps brachii (BB), and middle deltoid (MD) of 13 people with stroke and 13 controls. Heteronymous reflexes were elicited in BB and MD in some, but not all, stroke and control subjects. The prevalence and size of the heteronymous responses were not significantly different between groups. Homonymous reflex responses in FCR were significantly larger in the stroke group. We found that the excitability of heteronymous Ia‐mediated pathways from FCR to BB and MD muscles is not enhanced following stroke, despite exaggerated homonymous reflexes, and they are therefore not likely to contribute to coactivation of forearm and more proximal upper limb muscles. Muscle Nerve, 2010