Factors affecting mortality in nonagenarian population following surgery for fragility hip fractures: An experience from a tertiary level trauma center in India

Introduction: Fragility hip fractures in nonagenarian patients pose a great challenge in management. To the best of our knowledge, no study has previously evaluated the outcomes and risk factors for mortality after hip fractures in this subgroup of population from the Indian subcontinent. Materials and Methods: A retrospective observational study was performed on nonagenarian patients (aged ?90) who underwent surgery for hip fractures between March 2016 and March 2019. The patients were divided into two groups: “survivor group” (Group A) and “mortality group” (Group B). The demographic data, type of fracture, side of fractured limb, preinjury ambulatory status, American Society of Anesthesiologists (ASA) status, comorbidities, time interval from injury to surgery, operative time, length of hospital stay, and postoperative ambulatory status were recorded from hospital medical records and were studied between the two groups. The follow-up duration of the study was 1 year. Results: Thirty-four patients were included in the study. Both the groups had 17 patients each. Cardiac dysfunction was the most common cause of mortality. The time interval from injury to surgery (odds ratio [OR] = 11.2), gender (OR = 0.23) and postoperative mobility status (OR = 0.07) were found to be significantly different between the two groups. No significant difference in ASA grade, comorbidities, fracture type, preinjury ambulatory status, operative time, and length of hospital stay was seen between the two groups. Conclusions: Risk factors for mortality after hip fracture surgery in the nonagenarian population are male gender, delay in surgery (>3 days) and poor ambulatory status in the postoperative period. Hence, the aim for such patients with hip fractures should be to perform an early surgery and encourage an early ambulation.

Nocturnal symptoms and sleep disturbances in clinically stable asthmatic children.

Presence of nocturnal symptoms is related to asthma severity. Clinically stable asthmatic children, too, report frequent nocturnal symptoms and sleep disturbances. The study determined these parameters in stable, asthmatic children, in their home environment. This case-control, questionnaire-based study in 70 school-going children comprised 40 asthmatics (Group 1) and 30, age/gender matched, healthy children (Group 2). Parents maintained peak expiratory flow (PEF) and sleep diaries for one week. Group 1 had significantly lower mean morning (250.3 vs. 289.1 I/minute) and mean evening PEF values (261.7 vs. 291.3 I/minute). Group 1 (38.95%), reported frequent nocturnal symptoms like cough (36.90%), breathlessness (32.80%), wheeze (27.68%) and chest tightness (14.35%). Sleep disturbances, significant in Group 1 (38, 95% vs. 14.35%), included daytime sleepiness (24.60%), daytime tiredness (20.50%), difficulty in maintaining sleep (15.38%), early morning awakening (14.35%), struggle against sleep during daytime (12.30%), and involuntarily falling asleep (17.43%). On a scale of 1-6, Group 1 scored significant sleep disturbances/patient (3 vs. 0.8); lethargy/tiredness in morning (2.9 vs. 2.2), poorer sleep quality (4.7 vs. 5.4), less parents' satisfaction with child's sleep (4.5 vs. 5.5) and daytime fitness (4.1 vs. 5.3). Group 1, when exposed to environmental tobacco smoke (22, 55%), reported significant nocturnal symptoms (18/22, 81%) and reduced mean morning and evening PEF values (17/22, 77%). It is concluded that clinically stable, asthmatic children reported increased nocturnal symptoms, sleep disturbances and poorer sleep quality. Lack of awareness of asthma-sleep association and its clinical implications could lead to poor asthma control and impaired daytime activity.

Hydrocarbon pneumonitis following diesel siphonage.

In our country, siphoning of diesel/petrol from fuel tanks is a common practice. We describe a 50-year-old farmer, who accidentally aspirated fuel while siphoning from his tractor. A diagnosis of diesel induced aspiration pneumonitis was confirmed by the presence of foam cells on bronchial biopsy. The patient showed gradual recovery with the symptomatic therapy. However two weeks later, he developed sudden chest pain and irregularly irregular pulse that proved fatal. Diesel aspiration leading to bilateral pneumonitis is yet to be reported in our country.

A 35-year old man with a non-resolving pleural effusion.

A thirty-five-year old male, a nonsmoker, was referred to us for evaluation of progressive pulmonary disease. His clinical course during the past 2 years was characterized by paroxysmal attacks of cough with scanty mucoid sputum. This was accompanied by intermittent fever and malaise. There was no history of wheezing, nasal symptoms or loss of weight. Eighteen months prior to referral, based on his symptomatic and roentgenologic profile, he was clinically diagnosed as a case of tuberculous mediastinal lymphadenitis. He was initiated on antituberculous therapy (ATT) comprising rifampicin 450 mg, isoniazid 300 mg, pyrazinamide 1500 mg and ethambutol 800 mg once daily. Prednisolone (10 mg thrice daily) was added after 2 months when the patient did not experience any relief. He was however irregular with the oral steroids and stopped it after 1 month. One year prior to referral, while on ATT for 6 months, he had few episodes of blood-streaked sputum, episodic exertional dyspnoea, and rightsided chest pain that increased on coughing and deep breathing. This was diagnosed as right-sided pleural effusion, and the patient was initiated on second line ATT in the form of kanamycin 1gm intramuscularly, sparfloxacin 400 mg, prothionamide 750 mg, clofazamine 200 mg, clarithromycin 500 mg, thiacetazone 150 mg and isoniazid 300 mg once daily. Kanamycin was stopped after 6 months but the other drugs were continued for a period of 1 year. In spite of regular second line ATT for 1 year, the patient remained symptomatic and as the effusion persisted, he was referred to us for evaluation. Physical examination revealed a middle-aged male in no acute distress. There was no clubbing or cyanosis. Chest examination suggested a right-sided pleural effusion. Examination of other systems, including an ophthalmologic referral, did not detect any abnormality.

Isoniazid associated, painful, bilateral gynaecomastia.

Gynaecomastia is a rarely reported adverse drug reaction due to isoniazid therapy. We describe a 25-year-old, human immunodeficiency virus (HIV)--negative man, who was started on antituberculosis treatment (ATT) with isoniazid (H), rifampicin (R), pyrazinamide (Z) and ethambutol (E) in the combination RHZE for the first two months and RH there on. After four months, while receiving RH, he developed painful bilateral gynaecomastia. ATT had to be stopped because of this adverse drug reaction. Gynaecomastia, however, persisted even after three months of cessation of therapy. A year later, the patient reported complete disappearance of pain and swelling, although right breast continued to appear larger than the left.