老年患者择期开腹手术后感染风险因素分析

目的探讨老年患者择期开腹手术后发生感染并发症的危险因素。方法对2010年5月至2012年2月期间笔者所在医院收治的159例接受择期开腹手术的老年患者的临床资料进行回顾性分析。其中38例（23.90％）术后出现感染并发症（感染组）,121例无感染并发症（无感染组）,比较2组患者术前相关生理学指标、健康状况指标、手术指标以及术后感染并发症及死亡情况的差异。结果本组159例患者术后感染并发症发生率为23.90％（38／159）;术后死亡2例,术后病死率为1.26％。单因素及多因素logistic回归分析结果提示,患者术前的营养风险、糖尿病史和慢性呼吸系统疾病是术后感染并发症的独立危险因素。结论术前改善老年患者肺部疾病、糖尿病及营养状态,可能对降低术后感染并发症发生率有益。     

Expert for Whom? Court-Appointed Versus Party-Appointed Experts

We investigated differences in judges' attitudes between court-appointed and party-appointed forensic psychiatric expert evidence, including who commissioned the report and how this impacted on the judges' perception of the evidence presented. We also investigated the experts' views on being either a party-appointed or court-appointed expert. This survey has no explicit preconceptions. It sought to gather information empirically. The attitudes towards the experts are seen both from the legal professionals' view and from that of the experts themselves. Two groups, one of 107 forensic psychiatric experts (39 psychologists, 65 psychiatrists and three non-specialist medical doctors), and one of 157 legal professionals (44 judges, 74 attorneys and 39 prosecutors) responded to an online survey. We found that 88% of the experts had been appointed by the court and of these, 73% preferred to be court-appointed. Fifty-one per cent had also been party-appointed and the most common principal was the defence attorney (46%). Sixty-two per cent of the judges who had an opinion stated that the party-appointed experts did not assist the court. This indicates that the judges clearly preferred independent court-appointed experts.     

单丝聚丙烯补片修补老年腹壁巨大切口疝治疗体会

目的 分析应用单丝聚丙烯补片修补老年腹壁巨大切口疝的治疗效果.方法 采集2006年1月至2009年12月我院老年巨大切口疝患者36例,使用单丝聚丙烯补片修补,其中肌鞘前修补(Onlay法)12例,肌肉与肌肉间修补(Inlay法)5例,肌肉后腹膜前修补(Sublay法)19例.结果 无切口感染,皮下积液6例,均为Onlay法,9例有不同程度异物感,但不妨碍日常生活.平均随访24个月,无复发.结论 应用单丝聚丙烯补片无张力修补老年腹壁巨大切口疝,可取得满意疗效,采用妥善的术中、术后处理方法,可减少术后并发症的发生.     

Predicting serious complications following bariatric surgery in geriatric patients: development of the GeriBari scoring tool using the MBSAQIP database

BackgroundGeriatric patients have a greater risk of complications after bariatric surgery. The objective of this study was to develop a tool to predict serious complications in geriatric patients after minimally invasive bariatric surgery.ObjectivesTo develop a predictive model, GeriBari, for serious complications in geriatric patients after bariatric surgery.SettingMultiple accredited bariatric surgery centers in the United States and Canada.MethodsThis was a retrospective cohort study of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, which collects 30-day bariatric surgery outcomes from 868 accredited centers. Geriatric patients defined as those ≥65 years old who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) were included. Characteristics associated with serious complications were identified using univariate and multivariable analyses. A predictive model, GeriBari, was derived using a forward selection algorithm from operative years 2015, 2017, and 2019. GeriBari’s robustness was tested against a validation cohort of subjects from operative years 2016 and 2018.ResultsA total of 40,199 geriatric patients underwent LRYGB (27.7%) or LSG (72.3%). Overall, 1866 (4.6%) experienced a complication, which included bleeding (1.6%), reoperation (1.6%), reintervention (1.3%), unplanned intubation (.4%), and pneumonia (.4%). Mortality was higher in the geriatric patients than that in younger patients (.27% versus .08%). GeriBari consists of 12 factors that predicted serious complications and stratified individuals into high- (>6%) and low-risk (<6%) groups. This tool accurately predicted events in the validation cohort with sensitivity of 46.0% and specificity of 100%.ConclusionsGeriBari enables preoperative risk stratification for 30-day serious complications in geriatric patients undergoing bariatric surgery. Stratifying low- and high-risk geriatric patients for adverse events allows for informed clinical decision-making prior to bariatric surgery.     

老年髋部骨折术前下肢深静脉血栓形成高危因素及抗凝治疗分析

目的探讨老年髋部骨折术前下肢深静脉血栓形成(DVT)的独立危险因素并评价抗凝治疗方案,为临床制定合理的抗凝方案提供参考。方法笔者回顾性分析自2014-01—2015-12诊治的536例老年(≥60岁)髋部骨折。对纳入的患者术前发生DVT的可疑危险因素(年龄、性别、是否多处骨折、是否合并恶性肿瘤病史、高脂血症、静脉血栓栓塞症病史、吸烟史、发生骨折至入院时间、糖尿病史等)进行统计分析,得到独立危险因素。对患者抗凝药物的使用情况进行整理分析,参照最新指南评价抗凝治疗方案是否合理。结果共纳入203例,其中术前并发DVT 53例。Logistic回归分析得出高脂血症、抗血小板药物服用史、静脉血栓栓塞症病史、发生骨折至入院时间、骨折前是否长期卧床是独立危险因素(P0.05)。入组患者在住院期间均使用低分子肝素进行DVT的防治,但是剂量疗程有所不同。结论合并高脂血症、既往静脉血栓栓塞症病史、骨折前长期卧床是老年髋部骨折术前并发DVT的独立危险因素,而骨折前有抗血小板药物服用史、发生骨折至入院时间24 h则是有利因素。老年髋部骨折患者抗凝方案基本符合指南推荐,但合理性仍有待改进。     

Live and Deceased Donor Kidney Transplantation in Patients Aged 75 years and Older in the United States

Objective: To examine the outcomes of geriatric ESRD patients selected for kidney transplantation. Design: Data were extracted from the USRDS Standard Analysis Files (SAF). All persons ages 75 and over who received a kidney transplant from 1994 to 2000 were compared with those remaining on dialysis or on a transplant waiting list. Data on mortality or removal from the waiting list were obtained from the United Network for Organ Sharing (UNOS). The main outcome measure was patient and kidney transplant survival. Results: Superior five year survival after kidney transplantation was attained by the geriatric cohort given a live donor transplant (59.9%), compared with recipients of deceased donor kidneys (40.3%), dialysis patients waiting for transplant (29.7%), and those who were not selected for kidney transplantation and remained on dialysis (12.5%). The likelihood of being removed from the waiting list for any reason was higher in this group (over 75) (30.3%) than in the 66–75 age group (26.8%). Their average annual mortality rate on the waiting list was 7.9, compared to 6.6% for those 66–75. Conclusion: Even after the age of 75 years, kidney transplantation provides substantial life prolongation and excellent graft survival. USRDS Disclaimer: The data reported here have been supplied by the United States Renal Data System (USRDS) and the United Network for Organ Sharing (UNOS). The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as official policy or interpretation of the US government.     

Relationship between geriatric nutritional risk index and subpopulation lymphocyte counts in patients undergoing hemodialysis and peritoneal dialysis

We investigated the relationship between geriatric nutritional risk index (GNRI) and subpopulation lymphocyte counts (SLCs) in hemodialysis (HD) and peritoneal dialysis (PD) patients and evaluated whether they can be helpful in the diagnosis of malnutrition in these patients. We examined the GNRI and SLCs of 50 HD patients (mean: 55.8?±?12.7 years; 28 men and 22 women) and 16 Continuous Ambulatory Peritoneal Dialysis (CAPD) patients (mean: 49.8?±?14.5 years; 10 men and six women). The GNRI is calculated based on the serum albumin level, dry weight, and ideal body weight and uses the following equation: GNRI?=?[14.89?×?albumin (g/dL)]?+?[41.7?×?(weight/ideal body weight)]. SLCs were evaluated using flow cytometry. T-tests and χ² tests were performed to compare the two groups. Logistic regression analysis was performed for predicting malnutrition in dialysis patients. The average GNRI value was 100.1?±?8.4 in HD patients and 99.2?±?8.1 in PD patients, and no significant differences in GNRI or SLC were observed between the two groups. SLCs were higher in patients with higher GNRI (GNRI?≥?100) although there was no statistical difference. Logistic regression for predicting malnutrition according to GNRI revealed that age, female sex, and CD19 counts predicted malnutrition in HD and PD patients. These results suggest that GNRI and SLCs (especially CD19 count) may be significant nutritional markers in these patients.     

Morbidity or mortality? Variations in trauma centres in the rescue of older injured patients

IntroductionPrior analysis demonstrates improved survival for older trauma patients (age > 64 years) treated at trauma centres that manage a higher proportion of geriatric patients. We hypothesised that ‘failure to rescue’ (death after a complication during an in-hospital stay) may be responsible for part of this variation. The objective of the study was to determine if trauma centre failure to rescue rates are associated with the proportion of older trauma seen.MethodsWe analysed data from high volume level 1 and 2 trauma centres participating in the National Trauma Data Bank, years 2007–2011. Centres were categorised by the proportion of older trauma patients seen. Logistic regression analyses were used to provide risk-adjusted rates for major complications (MC) and, separately, for mortality following a MC. Models were adjusted for patient demographics, comorbid conditions, mechanism and type of injury, presenting vital signs, injury severity, and multiple facility-level covariates. Risk-adjusted rates were plotted against the proportion of older trauma seen and trends determined.ResultsOf the 396,449 older patients at 293 trauma centres that met inclusion criteria, 30,761 (8%) suffered a MC. No difference was found in the risk-adjusted incidence of MC by proportion of older trauma seen. A MC was associated with 34% of all deaths. Of those that suffered a MC, 7413 (24%) died and 76% were successfully rescued. Centres treating higher proportions of older trauma were more successful at rescuing patients after a MC occurred. Patients seen at centres that treat >50% older trauma were 33% (OR = 0.67, 95% CI 0.47–0.96) less likely to die following a MC than in centres treating a low proportion (10%) of older trauma.ConclusionsCentres more experienced at managing geriatric trauma are more successful at rescuing older patients with serious complications. Processes of care at these centres need to be further examined and used to inform appropriate interventions.