Pre-operative echocardiograms in acute fragility hip fractures: How effective are the guidelines?

ABSTRACT: In 2014, the American College of Cardiology/American Heart Association (ACC/AHA) released guidelines for ordering pre-operative echocardiograms in patients undergoing non-cardiac surgery. The purpose of this study is to determine if pre-operative echocardiograms ordered prior to fragility hip fracture repair are ordered according to these guidelines, change anesthetic management or affect patient outcomes. In addition, we attempted to evaluate the efficacy of the ACC/AHA guidelines.We conducted a 4-year retrospective chart review of acute fragility hip fractures at a single institution. Charts were reviewed to determine which patients met criteria for a pre-operative echocardiogram. Within this group we then compared patients who received a pre-operative echocardiogram to those who did not. Comparisons were made with regard to time to surgery, changes from standard anesthetic management, major adverse cardiac events, length of hospital stay, and 1-year mortality. We also examined which patients received postoperative echocardiograms and the incidence of adverse cardiac events in this group.Of 402 patients, 87 (22%) had ACC/AHA indications for pre-operative echocardiogram, and 42 (48%) of them received one. The indication to order a pre-operative echocardiogram in stable heart failure or valve disease patients if their last echo was greater than 1 year was only followed 23% of the time. In the pre-operative echocardiogram group, anesthetic management was adjusted more frequently (P = .025), and average time to surgery was greater (P < .001). The incidence of a major adverse cardiac event was 10% in the ACC/AHA echocardiogram indicated group and 3% in the non-indicated echocardiogram group. An equal number of echocardiograms were completed postoperatively as were completed under ACC/AHA pre-operative guidelines. Sixty-seven percent of the postoperative echocardiograms did not have ACC/AHA pre-operative indications.Our data demonstrates that pre-operative echocardiograms for "stable heart failure and valvular disease with greater than 1 year from last echocardiogram" is infrequently performed without significant adverse cardiac outcomes. Pre-operative echocardiography was associated with more anesthetic adjustments and longer time to surgery. Postoperative echocardiograms were done for cardiopulmonary complications. Studies need to examine and refine clinical parameters that would improve the selection of patients who would benefit from pre-operative echocardiograms.

The decline of tracheotomy among otolaryngologists: a 14-year review.

OBJECTIVE: To determine the trend of number of tracheotomies performed by otolaryngologists. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral center in central Pennsylvania. SUBJECTS: All patients undergoing tracheotomy between 2000 and 2013. METHODS: Data were gathered from billing records and operative reports to determine the service performing the tracheotomy. In addition, the surgical technique and indication for surgery were recorded. Negative binomial regressions were conducted to examine the number of tracheotomies performed by each specialty as a function of year. RESULTS: In 2000, 44% of tracheotomies were being performed by the otolaryngology service, compared with only 25% in 2013. This is a decline of 22% over time. Since 2000, general surgery steadily increased the number of tracheotomies performed in comparison to the steady decrease performed by otolaryngology. Since 2008, general surgeons have significantly increased the number of percutaneous tracheotomies they perform (76% per year). Over the same period, the number of tracheotomies performed by the cardiothoracic surgery service has steadily increased by 26% per year. Most of the tracheotomies performed by cardiothoracic surgery are percutaneous tracheotomies. CONCLUSION: This study illustrates that otolaryngologists at our institution are performing fewer tracheotomies over time. If this trend continues, the experience of our trainees may become diluted through reduction in surgical volume. While multi-institutional studies are warranted, this review provides a summary of data collected at a tertiary care institution, which may reflect national trends.

Antibody signature of spontaneous clearance of Chlamydia trachomatis ocular infection and partial resistance against re-challenge in a nonhuman primate trachoma model.

BACKGROUND: Chlamydia trachomatis is the etiological agent of trachoma the world's leading cause of infectious blindness. Here, we investigate whether protracted clearance of a primary infection in nonhuman primates is attributable to antigenic variation or related to the maturation of the anti-chlamydial humoral immune response specific to chlamydial antigens. METHODOLOGY/PRINCIPAL FINDINGS: Genomic sequencing of organisms isolated throughout the protracted primary infection revealed that antigenic variation was not related to the inability of monkeys to efficiently resolve their infection. To explore the maturation of the humoral immune response as a possible reason for delayed clearance, sera were analyzed by radioimmunoprecipitation using intrinsically radio-labeled antigens prepared under non-denaturing conditions. Antibody recognition was restricted to the antigenically variable major outer membrane protein (MOMP) and a few antigenically conserved antigens. Recognition of MOMP occurred early post-infection and correlated with reduction in infectious ocular burdens but not with infection eradication. In contrast, antibody recognition of conserved antigens, identified as PmpD, Hsp60, CPAF and Pgp3, appeared late and correlated with infection eradication. Partial immunity to re-challenge was associated with a discernible antibody recall response against all antigens. Antibody recognition of PmpD and CPAF was destroyed by heat treatment while MOMP and Pgp3 were partially affected, indicating that antibody specific to conformational epitopes on these proteins may be important to protective immunity. CONCLUSIONS/SIGNIFICANCE: Our findings suggest that delayed clearance of chlamydial infection in NHP is not the result of antigenic variation but rather a consequence of the gradual maturation of the C. trachomatis antigen-specific humoral immune response. However, we cannot conclude that antibodies specific for these proteins play the primary role in host protective immunity as they could be surrogate markers of T cell immunity. Collectively, our results argue that an efficacious subunit trachoma vaccine might require a combination of these antigens delivered in their native conformation.

Fluorometric high-throughput assay for measuring chlamydial neutralizing antibody.

Chlamydia trachomatis is an obligate intracellular mucosotropic pathogen that causes human infections of global importance. C. trachomatis causes trachoma, the leading cause of preventable blindness worldwide, and is the most common cause of bacterial sexually transmitted disease. Although oculogenital infections are treatable with antibiotics, a vaccine is needed to control C. trachomatis infection. Ideally, a vaccine would provide coverage against most, if not all, naturally occurring antigenically distinct serovariants. The development of a subunit vaccine to prevent oculogenital disease could be advanced by identifying chlamydial antigens that elicit pan-neutralizing antibodies, particularly among infected human populations of known risk factors. There is currently no objective high-throughput in vitro assay to screen human sera for neutralization to aid in identification of these antigens. This report describes an objective, high-throughput in vitro assay that measures C. trachomatis-neutralizing antibodies. Antibody-mediated neutralization of chlamydial infection was performed in a 96-well microtiter format, and neutralization was quantified by immunostaining fixed cells followed by automated fluorometric analysis. This report shows that fluorometric analysis of C. trachomatis infection directly correlates to labor-intensive manual inclusion counts. Furthermore, this report shows that fluorometry can be used to identify C. trachomatis serovar- and serocomplex-specific neutralization. This objective, high-throughput analysis of serum neutralization is amenable to epidemiological studies of human chlamydial infection, human clinical vaccine trials, and preclinical animal model experiments of Chlamydia infection.