Retrospective Analysis of Risk Factors in Geriatric Hip Fracture Patients Predictive of Surgical Intensive Care Unit Admission.

INTRODUCTION: Although numerous risk factors and prediction models affecting morbidity and mortality in geriatric hip fracture patients have been previously identified, there are scant published data on predictors for perioperative Surgical Intensive Care Unit (SICU) admission in this patient population. Determining if a patient will need an SICU admission would not only allow for the appropriate allocation of resources and personnel but also permit targeted clinical management of these patients with the goal of improving morbidity and mortality outcomes. The purpose of this study was to identify specific risk factors predictive of SICU admission in a population of geriatric hip fracture patients. Unlike previous studies which have investigated predominantly demographic, comorbidity, and laboratory data, the present study also considered a frailty index and length of time from injury to presentation in the Emergency Department (ED). METHODS: A total of 501 geriatric hip fracture patients admitted to a Level 1 trauma center were included in this retrospective, single-center, quantitative study from January 1, 2019, to December 31, 2022. Using a logistical regression analysis, more than 25 different variables were included in the regression model to identify values predictive of SICU admission. Predictive models of planned versus unplanned SICU admissions were also estimated. The discriminative ability of variables in the final models to predict SICU admission was assessed with receiver operating characteristic curves' area under the curve estimates. RESULTS:  Frailty, serum lactate > 2, and presentation to the ED > 12 hours after injury were significant predictors of SICU admission overall (P = 0.03, 0.038, and 0.05 respectively). Additionally, the predictive model for planned SICU admission had no common significant predictors with unplanned SICU admission. Planned SICU admission significant predictors included an Injury Severity Score (ISS) of 15 and greater, a higher total serum protein, serum sodium <135, systolic blood pressure (BP) under 100, increased heart rate on admission to ED, thrombocytopenia (<120), and higher Anesthesia Society Association physical status classification (ASA) score (P = 0.007, 0.04, 0.05, 0.002, 0.041, 0.05, and 0.005 respectively). Each SICU prediction model (overall, planned, and unplanned) demonstrated sufficient discriminative ability with the area under the curve (AUC) values of 0.869, 0.601, and 0.866 respectively. Finally, mean hospital Length of Stay (LOS) and mortality were increased in SICU admissions when compared to non-SICU admissions. CONCLUSION: Of the three risk factors predictive of SICU admission identified in this study, two have not been extensively studied previously in this patient population. Frailty has been associated with increased mortality and postoperative complications in hip fracture patients, but this is the first study to date to use a novel frailty index specifically designed and validated for use in hip fracture patients. The other risk factor, time from injury to presentation to the ED serves as an indicator for time a hip fracture patient spent without receiving medical attention. This risk factor has not been investigated heavily in the past as a predictor of SICU admissions in this patient population.

Predicting Instability Risk Following Hemiarthroplasty for Femoral Neck Hip Fractures in Geriatric Patients.

BACKGROUND: Although a rare complication, dislocation following hemiarthroplasty (HA) for a femoral neck hip fracture is associated with increased mortality, readmission, and possible revision surgery. To date many of the specific risk factors have been difficult to demonstrate. Patient factors, surgical factors, as well as morphological factors need to be assessed. Therefore, the purpose of this study was to elucidate the risk factors for dislocation of HA following femoral neck hip fractures in the geriatric population. METHODS: This was a retrospective review of 270 patients who had hip fractures. Medical records between the years 2016 and 2022 informed binomial regression predictive models. The discriminative ability of variables in the final model and acetabular anteversion to predict dislocation was assessed with area under the curve (AUC) estimates. RESULTS: Center edge angle (odds ratio 1.23), abduction angle (odds ratio 1.17), and depth width ratio (2.96e-11) were significant predictors of dislocation (P = .003, .028, and <.001, respectively). Center edge angle and depth width ratio (<44.1 ° and .298), respectively, were cut scores for risk. Dementia had a high discriminative of ability, as did men (AUC = 0.617, 0.558, respectively). Acetabular anteversion was not predictive of dislocation (P = .259) and theorized anteversion safe zones had poor discriminative ability with AUCs of 0.510 and 0.503, respectively. CONCLUSIONS: Morphological factors related to hip dysplasia and a shallow acetabulum, which can be assessed with a radiograph alone, were found to be predictors of instability following HA in the elderly. Hemiarthroplasty implant design and manufacturer, and also acetabular version did not contribute to instability risk.

Resource Deployment in Response to Trauma Patients.

Background Variance in the deployment of the trauma team to the emergency department (ED) can result in patient treatment delays and excess burden on ED personnel. Characteristics of trauma patients, including mechanism of injury, injury type, and age, have been associated with differences in trauma resource deployment. Therefore, this retrospective, single-site study aimed to examine the deployment patterns of trauma resources, the characteristics of the trauma patients associated with levels of trauma resource deployment, and the deployment impact on ED workforce utilization and non-trauma ED patients. Methodology This was an investigator-initiated, single-institution, retrospective cohort study of all patients designated as a trauma response and admitted to a community hospital's ED from July 01, 2019, through July 01, 2022. Results Resource deployment for trauma patients varied by mechanism of injury (p < 0.001), injury type (p < 0.001), and patient age groups (p < 0.001). Specifically, there was a lower average trauma activation for geriatric trauma patients with a fall as a mechanism of injury compared to all younger patient groups with any mechanism of injury (F(5) = 234.49, p < 0.001). In the subsample, there was an average of 3.35 ED registered nurses (RNs) allocated to each trauma patient. Additionally, the ED RNs were temporarily reallocated from an average of 4.09 non-trauma patients to respond to trauma patients, despite over a third of the trauma patients in the subsample being the trauma patients being discharged home from the ED. Conclusions Trauma activation responses need to be standardized with a specific plan for geriatric fall patients to ensure efficient use of trauma and ED personnel resources.

Lateral femoral cutaneous nerve palsy following shoulder surgery in the beach chair position: a report of 4 cases.

Neuropathy of the lateral femoral cutaneous nerve can present as pain, decreased sensation, and/or burning or tingling on the anterolateral thigh. We present 4 cases of lateral femoral cutaneous nerve palsy following shoulder surgery in the beach chair position, all of which occurred in obese patients. This complication, to our knowledge, has never been reported in conjunction with the beach chair position. We believe that the neurapraxia was due to external compression by the patients' abdominal pannus. Full resolution of symptoms can be expected within 6 months following conservative management. A preoperative discussion regarding this complication should occur with obese patients undergoing shoulder surgery in the beach chair position.

A sustainable training strategy for improving health care following a catastrophic radiological or nuclear incident.

The detonation of a nuclear device in a US city would be catastrophic. Enormous loss of life and injuries would characterize an incident with profound human, political, social, and economic implications. Nevertheless, most responders have not received sufficient training about ionizing radiation, principles of radiation safety, or managing, diagnosing, and treating radiation-related injuries and illnesses. Members throughout the health care delivery system, including medical first responders, hospital first receivers, and health care institution support personnel such as janitors, hospital administrators, and security personnel, lack radiation-related training. This lack of knowledge can lead to failure of these groups to respond appropriately after a nuclear detonation or other major radiation incident and limit the effectiveness of the medical response and recovery effort. Efficacy of the response can be improved by getting each group the information it needs to do its job. This paper proposes a sustainable training strategy for spreading curricula throughout the necessary communities. It classifies the members of the health care delivery system into four tiers and identifies tasks for each tier and the radiation-relevant knowledge needed to perform these tasks. By providing education through additional modules to existing training structures, connecting radioactive contamination control to daily professional practices, and augmenting these systems with just-in-time training, the strategy creates a sustainable mechanism for giving members of the health care community improved ability to respond during a radiological or nuclear crisis, reducing fatalities, mitigating injuries, and improving the resiliency of the community.

Contrasting roles of protein kinase C in induction versus suppression of group I mGluR-mediated epileptogenesis in vitro.

Activation of group I metabotropic glutamate receptors (mGluRs) elicits persistent ictaform discharges in guinea pig hippocampal slices, providing an in vitro model of epileptogenesis. The induction of these persistent ictaform bursts is prevented by l-cysteine sulfinic acid (CSA), an agonist at phospholipase D (PLD)-coupled mGluRs. Studies described herein examined the role of protein kinase C (PKC) in both the group I mGluR-mediated induction and CSA-mediated suppression of this form of epileptogenesis. Intracellular recordings were performed from CA3 stratum pyramidale and synchronized burst length was monitored. In the presence of 50 microM picrotoxin, a gamma-aminobutyric acid type A antagonist, 250- to 500-ms synchronized bursts were elicited. (S)-3,5-Dihydroxyphenylglycine (DHPG, 50 microM), an agonist at group I mGluRs, increased the burst length to 1-3 s in duration, a change that persisted after agonist washout. This persistent change in burst length was elicited in the presence of 10 microM chelerythrine, a PKC inhibitor, indicating that DHPG-induced epileptogenesis is PKC independent. However, although PLD activation with CSA (100 microM) was highly effective at suppressing group I mGluR-mediated induction of burst prolongation, CSA application in the presence of chelerythrine was no longer effective and resulted in the expression of persistent ictaform bursts. These data suggest that CSA-mediated suppression of group I mGluR-induced epileptogenesis is PKC dependent. We propose that CSA mediates its effect by PLD-driven activation of PKC, which may desensitize the phospholipase C-linked group I mGluRs and thereby prevent group I mGluR-induced epileptogenesis.

Abordaje: un aspecto de la clinica / Boarding: a clinical aspect

Se analizan cuatro casos clinicos, uno visto en la enfermidad aguda y los otros tres seguidos por periodos de 08, 23 y 28 meses. El abordaje diagnostico fue diferente en cada caso, siendo de destacar en el interrogatorio dos aspectos: primero la investigacion de las enfermedades anteriores hasta la actual, identificando lasd caracteristicas individualizantes del enfermo; y en segundo lugar interrogando a la madre del nino que queremos curar, con respecto a los 09 meses de gestacion, como si fuese la "voz viva de la conciencia intrauterina". En el examen clinico destacamos en tercer lugar la observacion de los movimientos del cuerpo y en cuarto lugar la observacion de los movimientos de los brazos y su relacion con el enfermo. La validez de estas actitudes semiologicas como recursos que coadyuvaron para aproximarnos a la dinamica del sufrimiento del enfermo, etsa confirmada por la evolucion satisfactoria con el tratamiento

Abordaje: un aspecto de la clinica / Boarding: a clinical aspect

Se analizan cuatro casos clinicos, uno visto en la enfermidad aguda y los otros tres seguidos por periodos de 08, 23 y 28 meses. El abordaje diagnostico fue diferente en cada caso, siendo de destacar en el interrogatorio dos aspectos: primero la investigacion de las enfermedades anteriores hasta la actual, identificando lasd caracteristicas individualizantes del enfermo; y en segundo lugar interrogando a la madre del nino que queremos curar, con respecto a los 09 meses de gestacion, como si fuese la "voz viva de la conciencia intrauterina". En el examen clinico destacamos en tercer lugar la observacion de los movimientos del cuerpo y en cuarto lugar la observacion de los movimientos de los brazos y su relacion con el enfermo. La validez de estas actitudes semiologicas como recursos que coadyuvaron para aproximarnos a la dinamica del sufrimiento del enfermo, etsa confirmada por la evolucion satisfactoria con el tratamiento