Surgically-treated Hip Fracture in older People. With Special Emphasis on Mortality Analysis

Hip fractures are associated with significant morbidity and mortality. Cervical and trochanteric fractures have a different morphometry, surgical treatment, and outcome. Polypharmacy, common in older people, is associated with increased mortality. The risk factors for mortality can be identified based on cause-of-death analysis. In this population-based study, 461 older, surgically in 1999-2000 treated hip fracture patients were enrolled. Incidence, morphometry, medication, mortality, and cause-of-death were analysed. Hip fractures were most commonly sustained by women, occurred mostly indoors, and often in institutions. One in four patients had sustained a previous fracture. Routine clinical radiographs revealed no differences in the hip geometry between hip fracture types. Age-adjusted mortality was higher in men than in women during the follow-up. Chronic lung disease and male sex were predictors of mortality after cervical fracture. In men, potent anticholinergics were associated with excess age-adjusted mortality. Men were more likely to die from circulatory disease and dementia after hip fracture than women. Mortality after hip fracture was 3-fold higher than that of the general population, including every cause-of-death class. Fracture prevention in institutions and homes, indoor safety measures, and treatment of chronic lung diseases should be encouraged. Hip morphometry analyses require more accurate measures than that provided by routine radiographs. Careful use of potent anticholinergics may reduce mortality. Compared to the general population, excess mortality after hip fracture was evident up to 9 years after hip fracture. Cause-of-death analysis indicates that all major comorbidities require optimal treatment after hip fracture surgery.

Late effects of cancer at a young age: Registry-based studies of the health of cancer patients and their off-spring

Modern cancer therapy has resulted in increased survival among patients diagnosed with cancer at a young age. These improvements have led to the investigation of late morbidity and mortality associated with cancer and its treatments. The aim of this study was to evaluate late effects of cancer treated at a young age on the health of patients and their offspring. Utilising the nationwide population-based registries in Finland, we evaluated the risk of hypothyroidism and the probability of parenthood in cancer survivors as well as preterm birth, neonatal outcomes, and the risk of cancer among offspring of patients. The survivor cohort, identified from the Finnish Cancer Registry, consisted of 25,784 cancer patients diag-nosed between ages 0 and 34 in 1953–2004. By linkage to the population register, siblings of these patients were identified for comparison. The prevalence of hypothyroidism was higher among former childhood cancer (aged 0–16) patients than in the general population. The probability of parenthood following early onset cancer was overall significantly reduced compared to siblings. Offspring of female cancer survivors were at an increased risk of preterm birth, this risk being highest among patients diagnosed in childhood and early adulthood (aged 20–34 years). The offspring were not, however, at a significantly increased risk of neonatal death or stillbirth, though they were more likely to need monitoring or intensive care in the neonatal period. The risk of sporadic cancer among offspring of male and female cancer survivors was not elevated in comparison to the general population. The study showed that former cancer patients are at risk of certain adverse endocrine and reproductive health outcomes and should be followed for timely intervention. The offspring of cancer survivors do not appear to be at risk for adverse health outcomes.

Fatores preditivos de complicações graves em cirurgia neonatal

OBJETIVO: investigar a incidência e gravidade das complicações pós-operatórias precoces e identificar fatores de risco para o seu desenvolvimento em recém-nascidos submetidos ao tratamento cirúrgico, sob anestesia geral. MÉTODOS: análise retrospectiva dos dados de 437 neonatos com doença crítica submetidos à cirurgia neonatal num centro cirúrgico pediátrico terciário, entre janeiro de 2000 e dezembro de 2010. A gravidade das complicações ocorridas nos primeiros 30 dias de pós-operatório foi classificada utilizando o sistema de Clavien-Dindo para complicações cirúrgicas, sendo considerados graves os graus III a V. Por análise estatística uni e multivariada avaliaram-se variáveis pré e intraoperatórias com potencial preditivo de complicações pós-operatórias graves. RESULTADOS: a incidência de, pelo menos, uma complicação grave foi 23%, com uma mediana de uma complicação por paciente 1:3. Ao todo, ocorreram 121 complicações graves. Destas, 86 necessitaram de intervenção cirúrgica, endoscópica ou radiológica (grau III), 25 puseram em risco a vida, com disfunção uni ou multi-órgão (grau IV) e dez resultaram na morte do paciente (grau V). As principais complicações foram técnicas (25%), gastrointestinais (22%) e respiratórias (21%). Foram identificados quatro fatores de risco independentes para complicações pós-operatórias graves: reoperação, operação por hérnia diafragmática congênita, prematuridade menor que 32 semanas de idade gestacional e cirurgia abdominal. CONCLUSÃO: a incidência de complicações pós-operatórias graves após cirurgias neonatais, sob anestesia geral, permaneceu elevada. As condições consideradas fatores de risco independentes para complicações graves após a cirurgia neonatal podem ajudar a definir o prognóstico pós-operatório em neonatos com doença cirúrgica e orientar as intervenções para melhoria de resultados.

Night admission is an independent risk factor for mortality in trauma patients - a systemic error approach

ABSTRACTObjective:to assess the impact of the shift inlet trauma patients, who underwent surgery, in-hospital mortality.Methods:a retrospective observational cohort study from November 2011 to March 2012, with data collected through electronic medical records. The following variables were statistically analyzed: age, gender, city of origin, marital status, admission to the risk classification (based on the Manchester Protocol), degree of contamination, time / admission round, admission day and hospital outcome.Results:during the study period, 563 patients injured victims underwent surgery, with a mean age of 35.5 years (± 20.7), 422 (75%) were male, with 276 (49.9%) received in the night shift and 205 (36.4%) on weekends. Patients admitted at night and on weekends had higher mortality [19 (6.9%) vs. 6 (2.2%), p=0.014, and 11 (5.4%) vs. 14 (3.9%), p=0.014, respectively]. In the multivariate analysis, independent predictors of mortality were the night admission (OR 3.15), the red risk classification (OR 4.87), and age (OR 1.17).Conclusion:the admission of night shift and weekend patients was associated with more severe and presented higher mortality rate. Admission to the night shift was an independent factor of surgical mortality in trauma patients, along with the red risk classification and age.

Risk factors for mortality in blunt abdominal trauma with surgical approach

ABSTRACTObjective:identify risk factors for mortality in patients who underwent laparotomy after blunt abdominal trauma.Methods:retrospective study, case-control, which were reviewed medical records of blunt trauma victims patients undergoing laparotomy, from March 2013 to January 2015, and compared the result of the deaths group with the group healed.Results:of 86 patients, 63% were healed, 36% died, and one patient was excluded from the study. Both groups had similar epidemiology and trauma mechanism, predominantly young adults males, automobilistic accident. Most cases that evolved to death had hemodynamic instability as laparotomy indication - 61% against 38% in the other group (p=0.02). The presence of solid organ injury was larger in the group of deaths - 80% versus 48% (p=0.001) and 61% of them had other associated abdominal injury compared to 25% in the other group (p=0.01). Of the patients who died 96% had other serious injuries associated (p=0.0003). Patients requiring damage control surgery had a higher mortality rate (p=0.0099). Only one of 18 patients with isolated hollow organ lesion evolved to death (p=0.0001). The mean injury score of TRISS of cured (91.70%) was significantly higher than that of deaths (46.3%) (p=0.002).Conclusion:the risk factors for mortality were hemodynamic instability as an indication for laparotomy, presence of solid organ injury, multiple intra-abdominal injuries, need for damage control surgery, serious injury association and low index of trauma score.

Fifty consecutive pancreatectomies without mortality

Objective: to report the group's experience with a series of patients undergoing pancreatic resection presenting null mortality rates. Methods: we prospectively studied 50 consecutive patients undergoing pancreatic resections for peri-ampullary or pancreatic diseases. Main local complications were defined according to international criteria. In-hospital mortality was defined as death occurring in the first 90 postoperative days. Results: patients' age ranged between 16 and 90 years (average: 53.3). We found anemia (Hb < 12g/dl) and preoperative jaundice in 38% and 40% of cases, respectively. Most patients presented with peri-ampullary tumors (66%). The most common surgical procedure was the Kausch - Whipple operation (70%). Six patients (12%) needed to undergo resection of a segment of the mesenteric-portal axis. The mean operative time was 445.1 minutes. Twenty two patients (44%) showed no clinical complications and presented mean hospital stay of 10.3 days. The most frequent complications were pancreatic fistula (56%), delayed gastric emptying (17.1%) and bleeding (16%). Conclusion : within the last three decades, pancreatic resection is still considered a challenge, especially outside large specialized centers. Nevertheless, even in our country (Brazil), teams seasoned in such procedure can reach low mortality rates.

Gastrosquise: Diagnóstico Pré-natal x Prognóstico Neonatal

Objetivos: determinar a freqüência de diagnóstico pré-natal em recém-nascidos (RN) com gastrosquise operados no Instituto Materno-Infantil de Pernambuco (IMIP) e analisar suas repercussões sobre o prognóstico neonatal. Métodos: realizou-se um corte transversal retrospectivo incluindo 31 casos de gastrosquise submetidos a correção cirúrgica em nosso serviço entre 1995-1999. Calculou-se o risco de prevalência (RP) de morte neonatal e seu intervalo de confiança a 95% para a presença de diagnóstico pré-natal e outras variáveis cirúrgicas e perinatais, realizando-se análise de regressão logística múltipla para determinação do risco ajustado de morte neonatal. Resultados: apenas 10 (32,3%) dos 31 casos de gastrosquise tinham diagnóstico pré-natal e nasceram no IMIP. Nenhum RN com diagnóstico pré-natal foi prematuro, em contraste com 43% daqueles sem diagnóstico pré-natal (p < 0,05). O intervalo entre parto e correção cirúrgica foi maior na ausência (7,7 horas) que na presença de diagnóstico pré-natal (3,8 horas). O tipo de cirurgia, a necessidade de ventilação mecânica assistida e a freqüência de infecção pós-operatória não apresentaram diferença significante entre os dois grupos. A mortalidade neonatal foi mais freqüente no grupo sem diagnóstico pré-natal (67%) do que no grupo com diagnóstico pré-natal (20%). Os outros fatores associados com risco aumentado de morte neonatal foram: idade gestacional <37 semanas, parto em outros hospitais, intervalo parto-cirurgia >4 horas, cirurgia em estágios, necessidade de ventilação mecânica e infecção. Conclusões: o diagnóstico pré-natal foi infreqüente entre RN com gastrosquise e a morte neonatal foi extremamente alta em sua ausência. É necessário aumentar a freqüência de diagnóstico pré-natal e melhorar os cuidados perinatais para reduzir esta elevada mortalidade.

Validação da curva normal de peso fetal estimado pela ultra-sonografia para o diagnóstico do peso neonatal

OBJETIVO: avaliar a concordância entre o peso fetal estimado (PFE) por ultra-sonografia e o neonatal, o desempenho da curva normal de PFE por idade gestacional no diagnóstico de desvios do peso fetal/neonatal e fatores associados. MÉTODOS: participaram do estudo 186 grávidas atendidas de novembro de 1998 a janeiro de 2000, com avaliação ultra-sonográfica até 3 dias antes do parto, determinação do PFE e do índice de líquido amniótico e parto na instituição. O PFE foi calculado e classificado de acordo com a curva de valores normais de PFE em: pequeno para a idade gestacional (PIG), adequado para a idade gestacional (AIG) e grande para a idade gestacional (GIG). A mesma classificação foi feita para o peso neonatal. A variabilidade das medidas e o grau de correlação linear entre o PFE e o peso neonatal foram calculados, bem como a sensibilidade, especificidade e valores preditivos para o uso da curva de valores normais de PFE para o diagnóstico dos desvios do peso neonatal. RESULTADOS: diferença entre o PFE e o peso neonatal variou entre -540 e +594 g, com média de +47,1 g, e as duas medidas apresentaram um coeficiente de correlação linear de 0,94. A curva normal de PFE teve sensibilidade de 100% e especificidade de 90,5% em detectar PIG ao nascimento, e de 94,4 e 92,8%, respectivamente, em detectar GIG, porém os valores preditivos positivos foram baixos para ambos. CONCLUSÕES: a estimativa ultra-sonográfica do peso fetal foi concordante com o peso neonatal, superestimando-o em apenas cerca de 47 g e a curva do PFE teve bom desempenho no rastreamento diagnóstico de recém-nascidos PIG e GIG.