Six-week Mortality Research Articles

Is self-rated health an independent prognostic factor of six-week mortality in older patients hospitalized for an acute condition?

To determine whether self-rated health is a prognostic factor of six-week mortality, independently of other known objective prognostic factors. The SAFMA study was a prospective cohort, which recruited patients from the University Hospital of Martinique Acute Care for Elders unit (French West Indies) from January to June 2012. Patients aged 75 or older and hospitalized for an acute condition were eligible. The outcome was time to death within the six-week follow-up. The main explanatory variable was self-rated health. Sociodemographic and clinical characteristics were considered as covariates. Cox's proportional hazards model was used. The mean age of the 223 patients included was 85.1±5.5years. Six-week mortality rate was 14.8%; none were lost to follow-up. In total, 123 claimed "very good to good" health, and 100 "medium to very poor" health. Self-rated health was the only independent prognostic factor associated with 6-week mortality (hazard ratio 2.61; 95% confidence interval 1.18-5.77; p=.02), when adjusting for known prognostic factors such as age, dimensions of the comprehensive geriatric assessment and comorbidity burden. The association between self-rated health and short-term mortality could have implications for clinical practice, particularly in helping in the estimation of prognosis in acute care setting.

Randomized Comparison of Intermediate-Dose Cytarabine Plus Mitoxantrone (IMA) Versus Standard-Dose Cytarabine Plus Daunorubicin (DA) for Induction Therapy in AML Patients >60 Years. Results from the SAL 60+ Trial

Background:Most patients (pts) diagnosed with Acute Myeloid Leukemia (AML) are older than 60 years. Although intensive induction chemotherapy in medically fit pts is still the standard practice and a prerequisite for long-term survival, elderly pts have a higher risk of treatment related morbidity and lower remission rates than younger AML pts. An optimized induction treatment would combine high complete remission (CR) rates with tolerable toxicity. The combination of intermediate-dose cytarabine plus mitoxantrone (IMA) has been reported to result in high CR rates (73.5%) with acceptable toxicity in 86 elderly AML pts (Niederwieser et al., Blood 2002, abstr. 1337). We present the mature final results of a randomized-controlled trial comparing efficacy and tolerability of IMA with the standard 7+3 induction regimen consisting of daunorubicin plus cytarabine (DA).Patients and Methods:In the 60+ trial of the Study Alliance Leukemia (SAL), AML pts >60 years and medically fit for chemotherapy were randomized to receive either intermediate-dose cytarabine (1000 mg/m2 BID days 1,3,5,7) plus mitoxantrone (10 mg/m2 days 1-3) (IMA) or standard induction therapy with cytarabine (100 mg/m2 continuously days 1-7) plus daunorubicin (45 mg/m2 days 3-5) (DA). All pts in CR after DA received intermediate-dose cytarabine plus amsacrine (MAMAC) as consolidation treatment, whereas pts in CR after IMA were consolidated with standard-dose cytarabine plus mitoxantrone (2+5). Primary study endpoint was the CR rate with an expected difference of 15% in favor of IMA. Secondary endpoints were the incidence of serious adverse events (SAEs), time to relapse (TTR), relapse-free survival (RFS), and overall survival (OS).Results:Between February 2005 and October 2009, 852 pts were screened for study inclusion and 485 pts started study treatment, of which 241 pts were randomized for treatment arm A (DA) and 244 for treatment arm B (IMA). The median age was 69 years. Pt characteristics were equally distributed between the two arms. According to a strict definition, all patients with early death, study drop-out, or failed remission assessment were categorized as being not in CR. The CR rate amongst all 485 pts treated in the study was 47%. The CR rate after DA was 39% (95%-CI; 33-45) versus 55% (95%-CI; 49-61) after IMA (OR 1.89, p=0.001). If all first CRs were taken into account including those achieved after trial discontinuation, the CR rates after DA versus IMA induction were 55% versus 64% (p=0.043). Separate analyses addressing age, cytogenetics, de novo AML, NPM1 and FLT3-ITD confirmed higher CR rates after IMA induction throughout these subgroups. Six-week mortality was 14% in both arms. The median duration of ≥ grade 3 neutropenia was 23 days after DA I and 25 days after IMA (p=0.031). The median duration of thrombocytopenia ≥ grade 3 was 16 versus 20 days after DA I and IMA I, respectively (p<0.001). The incidences of non-hematologic toxicities were not significantly different except for a higher incidence of liver toxicity (odds ratio IMA/DA = 0.52; p=0.001) and gastrointestinal symptoms (OR IMA/DA = 0.62; p=0.041) after DA.In the course of treatment, 11 pts in each arm (5%) received allogeneic stem cell transplantation.After a median follow-up of 66 months, RFS curves are superimposable in the first year with a similar median RFS of 11 months and 10 months after DA and IMA, respectively. However, a separation of RFS curves developed with longer follow up, resulting in 1-year RFS rates of 45% versus 46%, but 3-year RFS rates of 29% versus 14% in the DA versus IMA arms, respectively (p=0.042). The median OS for all randomized pts was 10 months in both arms; 1-year and 3-year OS rates were 45% and 19% after DA versus 44% and 19% after IMA (p=0.513).Conclusion:The results indicate that elderly AML pts benefit from a dose escalation of cytarabine in induction therapy by significantly higher CR rates and similar toxicity compared to a standard 7+3 approach. In our trial, this did not translate into a survival advantage, most likely due to differences in consolidation treatment of the respective treatment arms. In combination with an effective consolidation strategy such as high-dose cytarabine or allogeneic transplantation, our current results favor the use of intermediate dose cytarabine in induction for pts with a curative AML treatment approach. [Display omitted] DisclosuresEinsele:Celgene: Consultancy, Honoraria, Research Funding, Speakers Bureau; Janssen: Consultancy, Honoraria, Research Funding, Speakers Bureau; Novartis: Consultancy, Honoraria, Speakers Bureau; Amgen/Onyx: Consultancy, Honoraria, Speakers Bureau. Thiede:Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; AgenDix GmBH: Equity Ownership. Platzbecker:Amgen, Inc.: Honoraria; GlaxoSmithKline: Honoraria, Research Funding; Celgene: Honoraria; Novartis: Honoraria. Ehninger:Cellex GmbH: Equity Ownership.

P433 IS TIPS INDICATED IN CIRRHOTIC PATIENTS WITH CHILD–PUGH B SCORE AND ACTIVE VARICEAL BLEEDING?

Background: The indication of early transjugular intrahepatic portosystemic sunt (TIPS) in case of variceal bleeding is currently debated. In particular, Child-Pugh C patients and Child-Pugh B patients with active bleeding are considered by the Baveno V consensus as high risk of treatment failure in case of variceal bleeding. However, there are no strong data confirming that active bleeding at endoscopy is predictive of bad survival pronostic in ChildPugh B patients. Aims: We aimed to determine which subgroup of patients could beneficiate from an early TIPS. Methods: We reviewed all consecutive cirrhotic patients admitted to our University Hospital for variceal bleeding between January 2007 and December 2011. The primary endpoint was the mortality at six weeks. Results: One hundred and forty-three patients were included: 114 men, mean age 58.4 years (31-89). Alcohol was the main cirrhosis etiology (73.9%). Patients were classified in Child-Pugh A (18.2%), Child-Pugh B (39.2%) and Child-Pugh C (42.6%). The varices were esophageal in 97.9% of the cases, gastric in 11.2% (GOV 10.5%, IGV 0.7%), ectopic in 6.3%. Twenty-six patients (18.2%) had an hepatocellular carcinoma, 22 patients (15.4%) a portal thrombosis. Active bleeding during initial endoscopy was observed in 30 patients (24.1%). During the acute phase, a pharmacological treatment associating vasoactive drugs (octreotide 94.2%) and antibiotic prophylaxis (third-generation cephalosporins, quinolones) were used respectively in 92.5% and 75% of the cases. In 118 patients (88.5%), an endoscopic therapy was performed (band ligation in 94%). A balloon tamponade was used in 7 patients because of failure of pharmacological and endoscopic treatment. Six patients underwent a TIPS placement including three in an early stage (within 72 hours). A bleeding recurrence was observed in 27% (8.3% between day 3 and day 5, 5.5% between day 6 and 42, and 13.2% between day 6 and six month). The six-week mortality rate was 18.9% (27 patients): Child A=0 (0%), Child B=1 (1.8%) and Child C=26 (42.6%). Child-Pugh C and early bleeding recurrence (day 3 to 5) were associated with an increased mortality at six weeks (respectively p<0.001 and p=0.05). Active bleeding during initial endoscopy was also a risk factor of six-week mortality (p=0.001). Therefore, in the subgroup of Child-Pugh B patients, active bleeding was not a risk factor of six-week mortality (p=1). Conclusions: The six-week mortality was 18.9%, which is in accordance with Baveno V consensus (10-20%). This mortality rate could probably be decreased by amore frequent use of early TIPS, which should be considered in patients at high-risk of mortality (Child-Pugh C). In our study, like in the study of Thabut et al, active bleeding at endoscopy was not associated with a poor survival in Child B patients.

Endoscopic treatment of esophageal varices in patients with liver cirrhosis.

Variceal bleeding is a life-threatening complication of portal hypertension with a six-week mortality rate of approximately 20%. Patients with medium- or large-sized varices can be treated for primary prophylaxis of variceal bleeding using two strategies: non-selective beta-blockers (NSBBs) or endoscopic variceal ligation (EVL). Both treatments are equally effective. Patients with acute variceal bleeding are critically ill patients. The available data suggest that vasoactive drugs, combined with endoscopic therapy and antibiotics, are the best treatment strategy with EVL being the endoscopic procedure of choice. In cases of uncontrolled bleeding, transjugular intrahepatic portosystemic shunt (TIPS) with polytetrafluoroethylene (PTFE)-covered stents are recommended. Approximately 60% of the patients experience rebleeding, with a mortality rate of 30%. Secondary prophylaxis should start on day six following the initial bleeding episode. The combination of NSBBs and EVL is the recommended management, whereas TIPS with PTFE-covered stents are the preferred option in patients who fail endoscopic and pharmacologic treatment. Apart from injection sclerotherapy and EVL, other endoscopic procedures, including tissue adhesives, endoloops, endoscopic clipping and argon plasma coagulation, have been used in the management of esophageal varices. However, their efficacy and safety, compared to standard endoscopic treatment, remain to be further elucidated. There are safety issues accompanying endoscopic techniques with aspiration pneumonia occurring at a rate of approximately 2.5%. In conclusion, future research is needed to improve treatment strategies, including novel endoscopic techniques with better efficacy, lower cost, and fewer adverse events.

Treatment of proximal vertebral artery disease

Vertebral arterial disease (VAD) is a less commonly recognized and treated source of cerebrovascular ischemia compared with carotid artery disease. Patients are often referred for treatment after they have developed symptoms in the form of transient ischemic attacks or had a posterior hemispheric stroke. Traditional treatment of VAD has been surgical. More recently, endovascular treatment of VAD has been utilized. We performed a retrospective review of our institutional experience in treating VAD from 2001 to 2010. For treatment of proximal VAD, perioperative morbidity is lower for the endovascular group than for the surgical group, but six-week mortality was higher for the endovascular group. Complete resolution of symptoms occurred more frequently with surgery than with endovascular therapy. Therefore surgical reconstruction appears to be preferable to angioplasty and stenting for treatment of proximal vertebral artery occlusive disease.

The Year in Cardiology 2012: coronary intervention

I am delighted to provide readers of the European Heart Journal with an overview of scientific data relating to Coronary Intervention in 2012. This article aims to summarize the important publications and presentations; it includes a summary of the main interventional meetings (ACC, EuroPCR, ESC, TCT, and AHA) together with a selection of important publications from the major general and specialist journals. Throughout Europe there has been a move towards percutaneous coronary intervention (PCI) being performed in units without on-site cardiac surgery. In the UK, over 60% of units do not have on-site surgery and these units generally perform a lower volume of PCI than those with on-site surgery (median of 435 compared with 1454 procedures, respectively). The need for emergency surgery is now a very uncommon complication. The Atlantic CPORT Investigators randomized, in a non-inferiority design, nearly 19 000 patients undergoing PCI to a hospital with or without on-site surgery in a ratio of 1–3. Six-week mortality was virtually identical (1.0 vs. 0.9%) and 9-month major adverse cardiac events (MACE) were also similar (11.2 vs. 12.1%); however, target vessel revascularization (TVR) was higher without on-site surgery (6.5 vs. 5.4%, P = 0.01). This difference was seen regardless of the definition of TVR and regardless of stent type and may reflect a more conservative approach or a lower initial success rate without on-site surgery. In the USA, a very small proportion of total PCI was performed without on-site surgery and it remains to be seen whether this study will alter that proportion.1 Public reporting of patient outcomes following PCI is an important tool to monitor the quality of care; however, it may lead some operators to become ‘risk-averse’. Joynt et al . reported a retrospective observational study of patients admitted with an acute coronary syndrome to US hospitals in …

Esophageal Varices: Pathophysiology, Approach, and Clinical Dilemmas

Esophageal Varices: Pathophysiology, Approach, and Clinical Dilemmas

Adherence to guidelines in bleeding oesophageal varices and effects on outcome: comparison between a specialized unit and a community hospital

Randomized controlled trials have shown beneficial effects of vasoactive drugs, endoscopic treatment and prophylactic antibiotics on the outcome of bleeding oesophageal varices (BOV). However, translating guidelines based on randomized controlled trials into clinical practice is difficult. Our aims were to compare adherence to evidence-based guidelines in BOV between a specialized unit and a community hospital, and to investigate whether differences in adherence affected the outcome. Two cohorts hospitalized during 2000-2007 with a first episode of BOV were retrospectively enrolled, one in a community hospital comprising 66 patients and one in a specialized unit comprising 111 patients. Data on treatment, rebleeding and mortality were collected from medical records according to the Baveno III/IV Criteria. Treatments in the specialized unit versus the community hospital were: vasoactive drugs 79 vs. 66% (P = 0.06), prophylactic antibiotics 55 vs. 27% (P < 0.01), endoscopic treatment 86 vs. 74% (P= 0.04) and Sengstaken-Blakemore tube was used in 5 vs. 21% (P < 0.01). Secondary prophylaxis with pharmacological, endoscopic or transjugular intrahepatic portosystemic shunt therapy was initiated in 91 vs. 74% (P < 0.01) (specialized vs. community). Six-week mortality was 17 vs. 24% (P = 0.25) with 5-day mortality of 6 vs. 3% (P = 0.34) and mortality day 6-42, 12 vs. 22% (P = 0.07) (specialized vs. community). Failure to control bleeding and failure to prevent rebleeding were not statistically different. Our study shows that patients with BOV are more likely to receive therapy according to guidelines when hospitalized in a specialized unit compared with a community hospital. This however did not affect mortality.

Prognostic Features of Galactomannan Antigenemia in Galactomannan-Positive Invasive Aspergillosis

Prognostic features of serum galactomannan (GM) remain poorly defined in patients with GM-positive invasive aspergillosis (GPA). We identified 93 patients with proven or probable invasive aspergillosis (IA) and GM values of >or=0.50 from January 2005 to March 2009. We used Cox modeling of time to 6- and 12-week mortality for the GM level at the time of diagnosis (GM(0)), GM decay in the week following diagnosis in 72 patients with >or=2 GM values, other predictors of mortality, and antifungal use during the week following diagnosis. Six-week mortality was 55% in the whole cohort and 43% in patients with >or=2 GM determinations. The hazard ratio (HR) of GM(0) per unit increase and 1-week GM decay per unit decline per week were 1.25 (95% confidence interval [CI], 1.01 to 1.54; P = 0.04) and 0.78 (95% CI, 0.63 to 0.96; P = 0.02), respectively, adjusting for other predictors of IA mortality; these values remained stable after adjusting for antifungal use and were predictive of all-cause mortality at 12 weeks with similar adjusted HR values. We conclude that the combination of GM(0) and 1-week GM decay is predictive of all-cause mortality in patients with GPA, independent of other traditional risk factors for mortality and antifungal exposure, supporting GM decay as a potential surrogate endpoint for future antifungal therapeutic trials.

Predicting early mortality among elderly patients hospitalised in medical wards via emergency department: the SAFES cohort study.

The aim of the study was, by early identification of deleterious prognostic factors that are open to remediation, to be in a position to assign elderly patients to different mortality risk groups to improve management. Prospective multicentre cohort. Nine French teaching hospitals. One thousand three hundred and six (1 306) patients aged 75 and over, hospitalised after having passed through Emergency Department (ED). Patients were assessed using Comprehensive Geriatric Assessment (CGA) tools. A Cox survival analysis was performed to identify prognostic variables for six-week mortality. Receiver Operating Characteristics analysis was used to study the discriminant power of the model. A mortality risk score is proposed to define three risk groups for six-week mortality. Crude mortality rate after a six week follow-up was 10.6% (n=135). Prognostic factors identified were: malnutrition risk (HR=2.1; 95% CI: 1.1-3.8; p=.02), delirium (HR=1.7; 95% CI: 1.2-2.5; p=.006), and dependency: moderate dependency (HR=4.9; 95% CI: 1.5-16.5; p=.01) or severe dependency (HR=10.3; 95% CI: 3.2-33.1; p < .001). The discriminant power of the model was good: the c-statistic representing the area under the curve was 0.71 (95% IC: 0.67 - 0.75; p < .001). The six-week mortality rate increased significantly (p < .001) across the three risk groups: 1.1% (n=269; 95% CI=0.5-1.7) in the lowest risk group, 11.1% (n=854; 95% CI=9.4-12.9) in the intermediate risk group, and 22.4% (n=125; 95% CI=20.1-24.7) in the highest risk group. A simple score has been calculated (using only three variables from the CGA) and a practical schedule proposed to characterise patients according to the degree of mortality risk. Each of these three variables (malnutrition risk, delirium, and dependency) identified as independent prognostic factors can lead to a targeted therapeutic option to prevent early mortality.

Long‐term prognosis of cirrhotics with an upper gastrointestinal bleeding episode: Does infection play a role?

We evaluated the effect of infection on the short- and long-term outcome of cirrhotic patients with upper gastrointestinal bleeding (UGIB), in a series of patients not submitted to antibiotic prophylaxis. The cirrhotic patients hospitalized for UGIB were prospectively followed up until the last visit, death, or transplantation. A standard screening protocol was used for bacterial infection at admission. In total, 205 patients were included in the study. Antibiotics were administered in 79 (38.5%) patients and an infection was documented in 64 (31.4%) patients. In total, 130 (63.4%) patients died after a mean (SD) follow up of 23.8 (30.9) months. Six-week mortality was higher in the infected patients (P < 0.0001). The mortality of patients who were alive 6 weeks after admission was not different between the infected and non-infected patients. Antibiotic use or bacterial infection, the Child-Pugh score, hepatocellular carcinoma, and creatinine were the independent predictors of 6-week mortality. Age and the Child-Pugh score were the only predictors of mortality of the patients who had survived for more than 6 weeks after acute bleeding. In total, 51 (24.9%) patients rebled, 37 (18.1%) within 5 days of admission. Rebleeding was more frequent (41.8% vs 14.3%, P < 0.0001) in infected patients, mostly due to differences in early rebleeding (31.6% vs 9.5%, P = 0.0001). Bacterial infection is associated with failure to control UGIB and early mortality in cirrhotic patients, but does not seem to affect the outcome of patients who overcome the bleeding episode.

Clinical Features and Treatment Outcomes of Upper Gastrointestinal Bleeding in Patients with Cirrhosis

With recent progress in treatment modalities, mortality from upper gastrointestinal (UGI) bleeding has decreased appreciably. The aim of this study was to establish how UGI bleeds are managed in Korean patients with cirrhosis and to evaluate treatment outcomes. A total of 479 episodes of acute UGI bleeding in 464 patients with cirrhosis were included during a six-month period at nine tertiary medical centers. Treatment outcomes were assessed by failure to control bleeding, rebleeding and mortality. The source of bleeding was esophagogastric varices in 77.7% of patients, nonvariceal lesions in 15.9%, and undefined in 6.5%. For control of bleeding, endoscopic and pharmacologic treatments were used in 74.7% and 81.9% of patients, respectively. Variceal ligation was a major technique for endoscopic treatment (90%), and terlipressin and somatostatin were the main pharmacologic agents used (96.4%). Initial hemostasis was achieved in 86.8% of cases, but rebleeding occurred in 3.8% and 16.8% of cases within five days and six weeks of hemorrhage, respectively. Five-day and six-week mortality were 11.3% and 25.9%, respectively. Survival of patients with variceal bleeding seems to be remarkably improved than previous reports, which may suggest the advances in hemostatic methods for control of variceal hemorrhage.

Abstract 848: Growth-differentiation Factor-15 Promotes Anti-inflammatory Effects And Enhances Survival After Experimental Myocardial Infarction

Growth-differentiation factor (GDF)-15 is a stress-responsive TGF-ß related cytokine. GDF-15 plasma levels are increased and provide independent prognostic information in patients with acute coronary syndrome. After coronary ligation in mice, GDF-15 protein expression is rapidly induced and remains elevated within the infarcted myocardium for at least 7 days. We therefore postulated that GDF-15 is involved in wound healing post MI. The left descending coronary artery was ligated in male GDF-15 knock-out (KO, n=36), heterozygous (+/-, n=72) and wild-type mice (WT, n=26). Six-week mortality was significantly enhanced in KO (81%) and +/- (67%), as compared to WT mice (35%, P=0.004 by log-rank test). Four days after MI, no differences in infarct size (H.E. staining), cardiac dimensions, wall thickness, and systolic function (echocardiography) were observed (n=8 –12 per group). However, cardiac rupture was more frequent in KO (31%) as compared to WT mice (4%, P&lt;0.01). Immunohistochemistry on day 4 demonstrated significantly elevated numbers of granulocytes (KO, 514±61/mm 2 vs. WT, 181±22/mm 2 ; P=0.003) and macrophages (KO, 176±19/mm 2 vs. WT, 89±11/mm 2 ; P=0.002) within the infarct border zone of KO mice (n=8–12 per group). This was paralleled by an increase in MMP-9 activity (in-gel zymography) within the infarct border zone (KO, 246±33% vs. WT, 100±14%; n=8–10; P=0.004); no differences in TIMP1 expression were noted between both genotypes. In vitro, pre-stimulation with GDF-15 dose-dependently inhibited the migration of human granulocytes towards the chemoattractant fMLP (10 −8 mol/L) in transwell migration chambers (3 μm pore size), control 100%; GDF-15 0.5ng/mL 78±5%, 5ng/mL 47±10%, 50ng/mL 34±10% (P&lt;0.001). Our data identify GDF-15 as an endogenous anti-inflammatory cytokine that inhibits leukocyte infiltration, and promotes wound healing and survival after myocardial infarction.

Thrombin is effective in arresting bleeding from gastric variceal hemorrhage.

Gastric variceal hemorrhage is associated with a high morbidity and mortality. We report the efficacy and safety of bovine thrombin in the treatment of bleeding gastric varices. At endoscopy 52 patients with hematemesis were diagnosed with bleeding gastric varices. Patients were treated by intravariceal injection with bovine thrombin and underwent further endoscopy at 72 hr and then at two-week intervals. Initial hemostasis was achieved in 49/52 patients (94%). Bleeding-related mortality at 72 hr after the index bleed was 3/52 (6%). The mean amount of thrombin used to achieve initial hemostasis was 1070 IU (range 400-2000 IU) and no adverse drug effects were observed. The median number of treatment sessions required to achieve gastric variceal ablation was 2 (range 1-3). At six weeks, 9 of 49 surviving patients (18%) rebled and one further patient died. The six-week mortality in patients treated with thrombin was 4/52 (8%). In conclusion, safe and effective hemostasis of bleeding gastric varices can be achieved by intravariceal injection with thrombin.

Treatments and outcomes of nursing-home-acquired pneumonia.

Bronchopulmonary infections have been considered the leading cause of hospital admissions and death in the nearly 2 million nursing home residents in the United States. Very little is known about the treatments and outcomes of this entity. The purpose of our study was to document the incidence, treatments, and outcomes of nursing-home-acquired pneumonia in hospitalized and nonhospitalized patients. We conducted a retrospective chart review during a 24-month period of patients from two community nursing homes in upstate New York with a total average population of 330 residents. The main outcome measure was 6-week mortality. Pneumonia was diagnosed in 129 patients, whose overall 6-week mortality rate was 24.8 percent. Ninety-one patients were cared for in the nursing home, and 38 patients were hospitalized. Six-week mortality rate for the nonhospitalized group was 18.7 percent. The hospitalized group's 6-week mortality rate was significantly higher at 39.5 percent. There were no significant differences between the hospitalized and nonhospitalized groups before their diagnosis that predicted outcome. For many patients nursing-home-acquired pneumonia can be successfully treated in a nursing home with oral antibiotics at a considerable cost savings when compared with hospitalization.

Lumbar Spinal Fusion

Regional variations in lumbar spinal fusion rates suggest a poor consensus on surgical indications. Therefore, complications, costs, and reoperation rates were compared for elderly patients undergoing surgery with or without spinal fusion. Subjects were Medicare recipients who underwent surgery in 1985, with 4 years of subsequent follow-up. There were 27,111 eligible patients, of whom 5.6% had fusions. Mean age was 72 years. Patients undergoing fusion had a complication rate 1.9 times greater than those who had surgery without fusion. The blood transfusion rate was 5.8 times greater, nursing home placement rate 2.2 times greater, and hospital charges 1.5 times higher (all P < 0.0005). Six-week mortality was 2.0 times greater for patients undergoing fusions (P = 0.025). Reoperation rates at 4 years were no lower for patients who had fusion surgery and results were similar in most diagnostic subgroups. Indications for fusion among older patients require better definition, preferably based on outcomes from prospective controlled studies.

Hip Arthroplasty Surgery in Manitoba

A review of all (1279) total hip arthroplasties in the Province of Manitoba, Canada, from 1973 to 1978 demonstrates an increase in the number of operations except in the very elderly. Six-week operative mortality was decreased from 2.4% to .6%, and time spent in the hospital has decreased from 54 to 40 days. Utilization of medical services by patients before and after surgery, as recorded by the Manitoba Health Services Commission, enables identification of all serious postoperative complications. Two years after surgery, 95.2% of patients were alive, and 16% had a contralateral hip arthroplasty. Fourteen patients (2.7%) required revision surgery within two years; 20 patients (4%) were readmitted to the hospital with other surgical complications, including trochanteric bursitis, osteomyelitis, pulmonary embolism, and so forth. Visits to physicians for arthritis-related problems and to chiropractors decreased in the two years after surgery compared with the two years before.

Hospital Mortality and Long-term Survival in Relation to Preoperative Function in Elderly Patients with Bronchogenic Carcinoma

During an eight-year period, 82 patients 70 years of age or older were operated on for bronchogenic carcinoma. Hospital mortality was 15.9%, and five-year survival was 32%. Results of preoperative dynamic spirometry and bicycle ergometry were predictive for postoperative six-week mortality but not for long-term survival.

Are cardiac arrhythmias important in stroke?

Ambulatory electrocardiography was performed on 21 consecutive acute stroke patients on the day of admission and 14 and 42 days later. There was no statistically significant difference in cardiac arrhythmias between stroke patients and a group of age- and sex-matched controls. There was considerable variation in the frequency of cardiac arrhythmias on each day but none of the arrhythmias was associated with a sudden deterioration in the condition of the patients and no arrhythmias produced symptoms in either the stroke or the control groups. Fourteen per cent of stroke patients had an associated acute myocardial infarction and 57% had a history of previous heart disease. While a history of previous heart disease or the occurrence of major ventricular arrhythmias were associated with an increased six-week mortality rate, routine continuous monitoring of cardiac rhythm would not appear to be of value in acute stroke.

Closed retrograde intramedullary nailing of peritrochanteric fractures of the femur with a new nail.

Two hundred and forty patients with intertrochanteric and subtrochanteric fractures were treated by closed intramedullary nailing with a new nail inserted retrograde via the medial condyle. After insertion, the alignment of the nail is nearly parallel to the line of load-bearing. Early weight-bearing was achieved for most patients with intertrochanteric and stable subtrochanteric fractures. A review of the 176 fractures that had at least an eight-month follow-up revealed loss of reduction in 2.3 per cent. There were no cases of implant failure, delayed union, non-union, or infection. The six-week mortality rate was 3.7 per cent and the eight-month rate, 10.4 per cent.