The hanging chin sign as a mortality predictor in geriatric patients at the emergency department: a retrospective cohort study.

BACKGROUND: At the emergency department, there is a need for an instrument which is quick and easy to use to identify geriatric patients with the highest risk of mortality. The so- called 'hanging chin sign', meaning that the mandibula projects over one or more ribs on the chest X-ray, could be such an instrument. This study aims to investigate if the hanging chin sign is a predictor of mortality in geriatric patients admitted through the emergency department. METHODS: We performed an observational retrospective cohort study in a Dutch teaching hospital. Patients of ≥65 years who were admitted to the geriatric ward following an emergency department visit were included. The primary outcome of this study was mortality. Secondary outcomes included the length of admission, discharge destination and the reliability compared to patient-related variables and the APOP screener. RESULTS: Three hundred ninety-six patients were included in the analysis. Mean follow up was 300 days; 207 patients (52%) died during follow up. The hanging chin sign was present in 85 patients (21%). Patients with the hanging chin sign have a significantly higher mortality risk during admission (OR 2.94 (1.61 to 5.39), p < 0.001), within 30 days (OR 2.49 (1.44 to 4.31), p = 0.001), within 90 days (OR 2.16 (1.31 to 3.56), p = 0.002) and within end of follow up (OR 2.87 (1.70 to 4.84),p < 0.001). A chest X-ray without a PA view or lateral view was also associated with mortality. This technical detail of the chest x-ray and the hanging chin sign both showed a stronger association with mortality than patient-related variables or the APOP screener. CONCLUSIONS: The hanging chin sign and other details of the chest x-ray were strong predictors of mortality in geriatric patients presenting at the emergency department and admitted to the geriatric ward. Compared to other known predictors, they seem to do even better in predicting mortality.

Embolization of the Geniculate Arteries Is an Effective Treatment of Recurrent Hemarthrosis Following Total Knee Arthroplasty That Can Be Safely Repeated.

BACKGROUND: Recurrent hemarthrosis is a late complication in up to 1.6% of patients following total knee arthroplasty (TKA). In the absence of intrinsic coagulopathy, one etiology is bleeding of hypertrophic vascular synovium. The aim of this study is to evaluate the clinical outcome of patients referred to our center for angiographic embolization of geniculate arteries for recurrent hemarthrosis following TKA. METHODS: We retrospectively studied a cohort of patients who were referred for geniculate artery embolization following TKA between August 2011 and September 2016. RESULTS: A total of 24 embolization procedures were performed on 14 patients. Seven (50%) of these 14 patients underwent one embolization procedure. Due to symptom recurrence, 4 patients underwent a repeated procedure and 3 patients a third procedure. All embolization procedures were technically successful at the time of the procedure. Two patients reported an inguinal hematoma that healed without further treatment. At follow-up of mean 26.8 months, clinical success was achieved in 12 of the 14 patients (86%). CONCLUSION: Embolization of the geniculate arteries in our study was a safe and effective treatment of recurrent spontaneous hemarthrosis following TKA. Although we have performed a substantial number of reinterventions, results of this study show that this procedure can be safely repeated without adverse events. Our results indicate that embolization could possibly be the treatment of choice when conservative measures fail and can be repeated in the event of recurrent or persistent symptoms.

Intensive rehabilitation in selected hip fracture patients may optimize care efficiency: A retrospective comparison study.

OBJECTIVE: To gather preliminary data on the effectiveness of intensive rehabilitation after hip fracture surgery, as provided in the Transfer Unit (TU) in Leiden, The Netherlands, compared with the effectiveness of rehabilitation in a regular nursing home. Intensive rehabilitation in the TU consists of physical therapy twice daily by dedicated medical staff and aims to shorten hospital stay and duration of rehabilitation, in order to increase the hospital admission capacity and reduce waiting lists for nursing homes. DESIGN: Retrospective cohort study. PATIENTS: A total of 173 hip fracture patients, selected postoperatively for intensive rehabilitation in the TU. Of these, 156 received TU rehabilitation (TU+ group), while 17 were rehabilitated in regular nursing homes for logistic reasons (TU- group). METHODS: Length of hospital stay, rehabilitation duration and survival were compared between TU+ and TU-. RESULTS: Both groups appeared comparable at baseline. TU+ patients had a mean hospital stay of 10.4 vs 12.3 days for TU- patients (p = 0.29), while their rehabilitation duration was 25.2 days shorter: 42.0 vs 67.2 days (p = 0.001). One-year survival was similar (87%). CONCLUSION: Intensive rehabilitation in selected hip fracture patients may reduce rehabilitation duration by almost 4 weeks. Differentiated aftercare appears to increase care efficiency for hip fracture patients in both hospitals and nursing homes and may result in a significant reduction in costs.

Circulating bone morphogenetic protein levels and delayed fracture healing.

OBJECTIVE: Despite adequate treatment 5-30% of bone fracture patients experience delayed union. During normal fracture union, bone morphogenetic proteins (BMPs) induce healing through a sequential cascade of events. Improved fracture healing after BMP-2 or -7 supplementation in patients with impaired fracture union suggests a deficiency of one or more of these factors. We postulated that low levels of circulating BMPs may result in delayed bone healing. The aim of this study was to quantify differences in levels of circulating BMP-2, -4, -6, -7, and -9 in patients that have demonstrated normal or delayed fracture healing. PATIENTS AND METHODS: Blood samples were collected from an unselected cohort of 65 patients that had been treated for a diaphyseal tibia or femur fracture. Patients were divided into a group with fracture healing within nine months after injury and a group with delayed fracture union. BMP plasma concentrations were quantified using ELISAs and compared between these two groups. RESULTS: Circulating plasma levels of BMP-2, -4, -6, and -7 did not differ between 34 patients with normal fracture healing and 31 patients with delayed fracture healing. Also the median BMP-9 plasma levels were not statistically different between the two groups of patients. However, the distribution in the patients with normal union showed a wider range (72-2496 pg/ml) compared with the delayed union group (120-816 pg/ml). CONCLUSION: In general, circulating BMP concentrations are not statistically different between patients who demonstrated normal or delayed fracture healing. High circulating BMP-9 levels seem to be associated with faster fracture healing, but are apparently not decisive.

[Von Meyenburg complexes in the liver: not metastases]. / Von meyenburg-complexen in de lever: geen metastasen.

A 74-year-old woman underwent a laparotomy for a rectal carcinoma. Multiple lesions of the liver were discovered as incidental findings. Histopathology revealed that these were Von Meyenburg complexes (VMCs). VMCs, also called biliary hamartomas, are rare and benign malformations of the bile ducts. The lesions present as diffuse greyish-white to greyish-yellow or black nodules of the liver, which on gross inspection and in radiological examinations strongly resemble liver metastases. VMCs are mostly asymptomatic and therefore often an incidental finding at laparotomy or post-mortem examination. The prevalence of VMC is age dependent and is 5.6% in adult patients at post-mortem examination. VMCs are sometimes associated with cholangiocarcinoma. Diagnostic imaging of VMC is difficult and of little specificity. Intraoperative frozen section analysis to differentiate between malignant and benign lesions has a sensitivity of 97% and a specificity of 99%. The benign nature of VMCs means that they do not require treatment. The patient underwent total mesorectal excision and follow-up after 3, 7 and 9 months did not reveal any indications of recurrent colorectal cancer or metastases.