Can nutritional and inflammatory indices predict 90-day mortality in fragility hip fracture patients?

INTRODUCTION: Hip fractures in the elderly are related to increased mortality. The identification of patients at risk is essential. Several nutritional and inflammatory parameters were investigated in an effort to find a prognostic indicator for mortality following fragility hip fractures (FHF) surgery. We aim to evaluate their utility and compare between the different factors. METHODS: A retrospective cohort study of patients 65 years and older, who underwent surgery following fragility hip fractures between January 2012 and June 2020, was conducted. Patients who died within 90 days were matched at a 1:1 ratio with surviving controls, based on age, gender, fracture type, and comorbidities. Nutritional and inflammatory indices, including serum albumin, protein energy malnutrition (PEM), albumin-to-globulin ratio (AGR), prognostic nutritional index (PNI), the systemic immune-inflammation index (SII), platelet-to-lymphocyte ratio (PLR), and the neutrophile-to-lymphocyte ratio (NLR), were compared between groups. RESULTS: 304 patients were included, 152 in each group. Patients' demographics were similar. Among all indices evaluated, only the PLR significantly differed between the study groups (236.9 ± 193.5 for the study group vs. 186.6 ± 119.3 for the control group (p = 0.007). In patients who survived the initial hospitalization, the PEM was also found to be correlated with 90 days mortality. DISCUSSION: The PLR was found to be correlated with mortality risk following FHF surgery. As it can be easily calculated from accessible blood tests, we recommend its' routine assessment as a screening tool for personalized management of patients at high risk for mortality.

Descemet membrane endothelial keratoplasty compared with ultrathin Descemet stripping automated endothelial keratoplasty: a meta-analysis.

AIMS: This study aims to compare the clinical outcome of Descemet membrane endothelial keratoplasty (DMEK) and ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) in patients with corneal endothelial dysfunction due to Fuchs' endothelial dystrophy or pseudophakic bullous keratopathy. METHODS: We conducted a meta-analysis using a literature search of Embase, PubMed, Cochrane CENTRAL, ClinicalTrials.gov and WHO ICTRP databases. We included randomised controlled trials (RCTs) and cohort studies that compared DMEK and UT-DSAEK (graft<130 µm), with a follow-up of ≥12 months, published until 20 February 2022. We used the Revised Cochrane risk-of-bias tool for RCTs and the Risk of Bias in Non-Randomised Studies-of Interventions system for cohort studies. RESULTS: Out of 144 records, 8 studies (3 RCTs, 2 fellow-eye studies and 3 cohort studies) were included, encompassing 376 eyes, (N=187 DMEK vs N=189 UT-DSAEK). The 12-month logarithm of the minimum angle of resolution best-corrected visual acuity (BCVA) was better post-DMEK (mean difference -0.06 (95% CI -0.10 to -0.02)), but with higher rebubbling risk: OR 2.76 (95% CI 1.46 to 5.22). Heterogeneity was significant I2=57%. Findings were consistent when excluding retrospective studies, including only studies with low risk of bias or RCTs only. An analysis of studies with mean DSAEK grafts <70 µm showed no significant difference in BCVA between the procedures. Publication bias was found in the BCVA analysis (Egger's test p=0.023). CONCLUSIONS: Post-DMEK BCVA is superior to post-UT-DSAEK when using <130 µm grafts. DSAEK grafts <70 µm may not significantly differ from DMEK. The higher risk of rebubbling with DMEK necessitates an appropriate selection of patients. PROSPERO REGISTRATION NUMBER: CRD42022340805.

Nutritional and Inflammatory Indices and the Risk of Surgical Site Infection After Fragility Hip Fractures: Can Routine Blood Test Point to Patients at Risk?

Background: Surgical site infection (SSI) after fragility hip fracture (FHF) surgery is associated with increased morbidity and mortality. We aim to utilize several established nutritional and inflammatory indices to characterize patients at risk. Patients and Methods: A retrospective cohort study of patients 65 years and older, who underwent surgery following FHFs between January 2012 and June 2020. Those patients who presented with post-operative infection in the year after surgery were compared with patients who did not. The primary outcomes were serum albumin, protein energy malnutrition (PEM), albumin to globulin ratio, prognostic nutritional index (PNI), the systemic immune inflammation index, platelet to lymphocyte ratio, neutrophil to lymphocyte ratio, and body mass index. Results: A total of 1,546 patients, ages 82.4 ± 7.7, were included; 55 of whom presented with SSI. Demographics and comorbidities were similar. Anticoagulation treatment was more prevalent in the infected group (32.7% vs. 13.9%, p < 0.001) as were intra-capsular fractures (60% vs. 42.9%, respectively; p = 0.012). Of all indices estimated, only the PNI and the PEM were found to differ significantly (44.7 ± 9.6 and 26.1% vs. 49.4 ± 17.3 and 13.6% for the study and control groups respectively; p = 0.002 and 0.027). A logistic regression model was calculated to evaluate the contribution of fracture type and anticoagulation treatment as possible confounders. Both indices were found to be significant for infection after regression odds ratio, 2.25 for PEM; (95% confidence interval [CI], 1.089-4.344) and odds ratio, 0.97 for PNI (95% CI, 0.937-0.996). Conclusions: The PNI and the PEM were found to correlate with infection risk after FHF surgery. As both can be easily calculated from an accessible blood test, we recommend their routine use as a screening tool for tailored management of patients at risk for SSI.

Periprocedural antibiotics for urodynamic studies of pediatric neurogenic bladder, empiric or culture-guided? A retrospective cohort study.

INTRODUCTION: Urodynamic studies are fundamental in the care of children with neurogenic bladder. Children with neurogenic bladder who perform clean intermittent catheterization (CIC) are considered a high-risk group for infection after urodynamic studies. Current guidelines are not uniform regarding the duration, type, the need of prophylactic antibiotic treatment or performance of urine culture before urodynamic studies. OBJECTIVE: To assess whether antibiotic prophylactic therapy before urodynamic studies should be empiric or culture-guided in children with neurogenic bladder who perform CIC. STUDY DESIGN: Urine samples were collected from children with neurogenic bladder who require CIC before undergoing a urodynamic study. Urine cultures were collected via sterile urethral catheterization one week before urodynamic studies between 2010 and 2018. Children with signs of urinary tract infection (UTI) or children with bladder augmentation were excluded. Resistance to commonly prescribed periprocedural antibiotic treatments was documented. The probability of antibiotic resistance according to sex, vesicoureteral reflux (VUR) status, consumption of prophylactic antibiotics, and self/caregiver performed CIC was determined by a χ2-test. RESULTS: A total of 278 urine cultures were collected from 185 children with neurogenic bladder. The median age was 8 years (IQR 5-12). The most common etiology for neurogenic bladder was spinal dysraphism (n = 146, 77%). Bacterial growth was detected in 216 (78%) cultures, and the most commonly detected bacterial species was Escherichia. coli (n = 155, 72%). Thirty-six (19%) children had VUR, and 14 of them received continuous prophylactic antibiotics. The probability of resistance to oral antibiotics was amoxicillin (22%), cephalexin (21%), cefuroxime (14%), ciprofloxacin (10%), nitrofurantoin (21%), and sulfamethoxazole/trimethoprim (SMX/TMP) (23%) (See "summary table") No significant differences were found by χ2-test in the probability of resistance to antibiotics according to sex, VUR status, continuous antibiotic prophylaxis or self/caregiver performed CIC. DISCUSSION: The study reveals high resistance level to commonly prescribed oral antibiotic treatments (20-30%). Several studies have challenged the need of routine urine cultures before urodynamic studies due to low risk of post-procedural infection. However, it should be mentioned that not all the patients participating in those studies were with neurogenic bladder or routinely performed CIC. Hence, in this specific group of children, routine urine cultures should not be abandoned. The limitations of the study are: Single-center, retrospective study with no data availability regarding the development of UTI after the urodynamic studies. CONCLUSIONS: Urine cultures of children with neurogenic bladder who require CIC demonstrate significant levels of resistance to commonly prescribed oral antibiotics. These findings support culture-guided periprocedural antibiotic prophylaxis.

Convulsions in children hospitalized for acute gastroenteritis.

The study aim was to examine possible correlates of convulsions in children hospitalized for acute gastroenteritis (AGE). Data collected in a prospective study of AGE hospitalizations in children aged 0-59 months in 3 hospitals in Israel during 2008-2015 were analyzed. Stool samples were tested for rotavirus using immunochromatography and stool culture was performed for the detection of Salmonella, Shigella and Campylobacter We compared clinical and demographic characteristics of children hospitalized for AGE who had convulsions (n = 68, cases) with children hospitalized for AGE without convulsions (n = 3505, controls). Age differed between children with and without convulsions (p = 0.005); the former were mostly toddlers aged 12-23 months (51%) compared to 30% of the control group. A higher percentage of cases tested positive for Shigella (11% vs. 4%, p = 0.002), the opposite was found for rotavirus (2% vs. 30% p < 0.001). A multivariable model showed that body temperature (OR 2.91 [95% CI 1.78-4.76], p < 0.001) and high blood glucose level (> 120 mg/dL) (OR 5.71 [95% CI 1.27-25.58] p = 0.023) were positively related to convulsions in children with AGE, while severe AGE (Vesikari score ≥ 11) was inversely related with convulsions (OR 0.09 [95% CI 0.03-0.24], p < 0.001). Conclusion: Elevated body temperature is associated with convulsions in children with AGE, but not severity of AGE, while hyperglycemia might reflect a neuroendocrine stress reaction to convulsions, AGE or both.