Retrospective interobserver agreement on diagnoses of 4th and 5th carpometacarpal fracture-dislocation and hamate fracture in plain X-ray - Is CT essential after ulnar carpometacarpal pain?

OBJECTIVE: To determine interobserver agreement and reliability of different radiological parameters in the assessment of fracture-dislocation of the 4th and 5th carpometacarpal joints (FD CMC 4-5) and associated hamate fracture on radiographs. MATERIALS AND METHODS: A retrospective, consecutive case series of 53 patients diagnosed with FD CMC 4-5. Emergency room diagnostic radiology images were reviewed by four independent observers. The reviews included assessment of radiological patterns and parameters in relation to CMC fracture-dislocations and associated injuries previously described in the literature, to analyze their diagnostic power (specificity and sensitivity) and reproducibility (interobserver reliability). RESULTS: Among 53 patients, mean age 35.3 years, dislocation of the 5th CMC joint was present in 32/53 (60%) of patients, mostly (11/32 [34%]) associated with 4th CMC dislocation and base of 4th and 5th metacarpal fracture. The most common presentation of hamate fracture, in 4/18 (22%), was associated with combined 4th and 5th CMC dislocation and base of metacarpal fracture. Computed tomography (CT) was performed in 23 patients. Performing CT scan was significantly associated with hamate fracture diagnosis (p < 0.001). Interobserver agreement was slight (0-0.641) for most of the parameters and diagnoses. Sensitivity ranged from 0 to 0.61. Overall, the described parameters had low sensitivity. CONCLUSION: Radiological parameters described for assessment of fracture-dislocation of the 4th and 5th CMC joints and associated hamate fracture have a slight interobserver agreement index in plain X-ray and low sensitivity for diagnostic assessment. These results suggest the need for emergency medicine diagnostic protocols that include CT scan for such injuries. GOV IDENTIFIER: NCT04668794.

Determinants of renal and patient outcomes in a Spanish cohort of patients with ANCA-associated vasculitis and renal involvement.

The classification of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) remains controversial. The main objective of this study was to define the respective values of ANCA serotype-based classification, clinicopathological classification, and histopathological classification in predicting patient and renal outcomes in a Spanish cohort of patients with ANCA with specificity for myeloperoxidase, MPO-ANCA, versus ANCA with specificity for proteinase 3, PR3-ANCA. Two hundred and forty-five patients with ANCA-AAV and biopsy-proven renal involvement diagnosed between 2000 and 2104 were recruited in 12 nephrology services. Clinical and histologic data, renal outcomes, and mortality were analyzed. We applied the Chapel Hill Consensus Conference definition with categories for granulomatosis with the polyangiitis (GPA) and microscopic polyangiitis (MPA), the classification based on ANCA specificity, and the histopathological classification proposed in 2010. Eighty-two percent were MPO-ANCA positive and 18.0% PR3-ANCA positive. Altogether, 82.9% had MPA and 17.1% GPA. The median follow-up was 43.2 months (0.1-169.3). Neither ANCA-based serological nor clinical classification was predictive of renal outcomes or patient survival on bivariate or multivariate Cox regression analysis. Histopathological classification was found to predict development of end-stage renal disease (p = 0.005) in Kaplan-Meier analysis. ANCA specificity was more predictive of relapse than clinicopathological classification in multivariate analysis (HR 2.086; 95% CI 1.046-4.158; p = 0.037). In our Spanish cohort, a majority of patients had an MPO-ANCA-AAV. A classification based on ANCA specificity has a higher predictive value for relapse occurrence and could be used for decision-making with respect to induction treatment and maintenance therapies.

Tendencias y variables predictoras de hospitalización, reingreso y duración de la estancia hospitalaria en los pacientes ambulatorios con insuficiencia cardíaca / Trends and predictors of hospitalization, readmissions and length of stay in ambulatory patients with heart failure

Objetivos. En los pacientes ambulatorios con insuficiencia cardiaca crónica apenas se conocen las variables pronósticas de hospitalización, y es posible que las variables conocidas no sean aplicables a la población de los países mediterráneos. El objetivo del presente estudio es documentar las tendencias longitudinales en las hospitalizaciones e identificar las variables predictoras de ingreso, reingreso y duración de la estancia hospitalaria en la población objeto del estudio. Métodos. Estudio de cohorte retrospectivo, poblacional, efectuado en Cataluña (noreste de España). Se incluyeron a 7.196 pacientes ambulatorios (58,6% mujeres, edad media: 76 años). Se seleccionaron los pacientes elegibles a partir de la historia clínica electrónica de los centros de atención primaria y se les controló durante 3 años. Resultados. A los 3 años del seguimiento, en conjunto, 645 (9,0%) pacientes fueron ingresados por una causa cardiovascular, el 37% presentó un reingreso, y la duración mediana de la estancia hospitalaria fue de 9 (límites intercuartil:5-17) días. La insuficiencia renal crónica (odds ratio [OR]:1,98 [1,62-2,43]), la cardiopatía isquémica (OR:1,72; intervalo de confianza [IC] del 95%:1,45-2,04), la diabetes mellitus (DM) (OR:1,50; IC 95%:1,27-1,78) y la enfermedad pulmonar obstructiva crónica (OR:1,43; IC 95%:1,16-1,77) aumentaron el riesgo de hospitalización. La DM (OR:1,70; IC 95%:1,22-2,38), la cardiopatía isquémica (OR:1,85; IC 95%:1,33-2,58) y la hipertensión arterial (OR:1,66; IC 95%:1,11-2,46) aumentaron el riesgo de reingreso. La insuficiencia renal crónica (OR:2,21; IC 95%:1,70-2,90), la cardiopatía isquémica (OR:2,19; IC 95%:1,73-2,77), la DM (OR:1,70; IC 95%:1,34-2,15), la hipertensión arterial (OR:1,51; IC 95%:1,13-2,01) y la enfermedad pulmonar obstructiva crónica (OR:1,37; IC 95%:1,02-1,83) aumentaron el riesgo de duración prolongada de la estancia hospitalaria. Conclusiones. El presente estudio identificó las variables predictoras de hospitalización, los reingresos y la duración prolongada de la estancia hospitalaria que pueden ayudar a los médicos y gestores hospitalarios a identificar a los pacientes en alto riesgo, que deben ser los destinatarios de la planificación de los servicios y de las acciones preventivas establecidas(AU)

Objectives. Little is known on predictors of hospitalisation in ambulatory patients with chronic heart failure, and known predictors may not apply to Mediterranean countries. Our aim was to document longitudinal trends in hospitalisations and identify patient-related predictors of hospital admission, re-admission and length of stay in the targeted population. Methods. Population-based retrospective cohort study in Catalonia (North-East Spain), including 7196 ambulatory patients (58.6% women; mean age 76 years). Eligible patients were selected from the electronic patient records of primary care practices, and followed for 3 years. Results. At 3 years of follow up overall 645 (9.0%) patients had cardiovascular hospitalisation, 37% were readmitted, and median length of stay was 9 (interquartile range 5–17) days. Chronic kidney disease [odds ratio (OR)=1.98 (1.62–2.43)], IHD [OR=1.72 (1.45–2.04)], DM [OR=1.50 (1.27–1.78)] and chronic obstructive pulmonary disease [OR=1.43 (1.16–1.77)] increased the risk for hospitalisation. DM [OR=1.70 (1.22–2.38)], IHD [OR=1.85 (1.33–2.58)] and HTA [OR=1.66 (1.11–2.46)] increased the risk for readmissions. Chronic kidney disease [OR of 2.21 (1.70–2.90)], IHD [OR of 2.19 (1.73–2.77)], DM [OR=1.70 (1.34–2.15)], HTA [OR=1.51 (1.13–2.01)], chronic obstructive pulmonary disease [OR=1.37 (1.02–1.83)] increased the risk for long length of stay in hospital. Conclusions. Our study identified predictors of hospitalisation, readmissions and long length of stay which can help clinicians and managers to identify high risk patients which should be targeted on service planning and when designing preventive actions(AU)

Trends and predictors of hospitalization, readmissions and length of stay in ambulatory patients with heart failure.

OBJECTIVES: Little is known on predictors of hospitalisation in ambulatory patients with chronic heart failure, and known predictors may not apply to Mediterranean countries. Our aim was to document longitudinal trends in hospitalisations and identify patient-related predictors of hospital admission, re-admission and length of stay in the targeted population. METHODS: Population-based retrospective cohort study in Catalonia (North-East Spain), including 7196 ambulatory patients (58.6% women; mean age 76 years). Eligible patients were selected from the electronic patient records of primary care practices, and followed for 3 years. RESULTS: At 3 years of follow up overall 645 (9.0%) patients had cardiovascular hospitalisation, 37% were readmitted, and median length of stay was 9 (interquartile range 5-17) days. Chronic kidney disease [odds ratio (OR)=1.98 (1.62-2.43)], IHD [OR=1.72 (1.45-2.04)], DM [OR=1.50 (1.27-1.78)] and chronic obstructive pulmonary disease [OR=1.43 (1.16-1.77)] increased the risk for hospitalisation. DM [OR=1.70 (1.22-2.38)], IHD [OR=1.85 (1.33-2.58)] and HTA [OR=1.66 (1.11-2.46)] increased the risk for readmissions. Chronic kidney disease [OR of 2.21 (1.70-2.90)], IHD [OR of 2.19 (1.73-2.77)], DM [OR=1.70 (1.34-2.15)], HTA [OR=1.51 (1.13-2.01)], chronic obstructive pulmonary disease [OR=1.37 (1.02-1.83)] increased the risk for long length of stay in hospital. CONCLUSIONS: Our study identified predictors of hospitalisation, readmissions and long length of stay which can help clinicians and managers to identify high risk patients which should be targeted on service planning and when designing preventive actions.

Factores pronóstico a corto plazo en los ancianos atendidos en urgencias por síndrome coronario agudo con elevación del segmento ST / Short-term prognostic factors in elderly patients treated in emergency departments

Objetivo: Investigar los factores asociados a la mortalidad a corto plazo en los pacientes ancianos que acuden a urgencias por síndrome coronario agudo con elevación del segmento ST (SCAEST).Método: Estudio multicéntrico, longitudinal, observacional, analítico-prospectivo y sin intervención. Se incluyó a pacientes de 70 o más años atendidos en 42 hospitales españoles. Se analizaron 17 variables independientes que pudieran influir en la mortalidad a 30 días. Los datos se obtuvieron a partir de un registro creado para este estudio, de la historia clínica o de la entrevista con el paciente o sus familiares. Se realizó un estudio multivariable mediante regresión logística. Resultados: Se incluyó a 1.137 pacientes, 340 (29,9%) fallecieron a los 30 días de la consulta en urgencias. Cuatro variables se asociaron de forma significativa con la mortalidad: la edad (odds ratio [OR] = 2,71; intervalo de confianza [IC] del 95%, 2,02-3,64), la no realización de angioplastia primaria (AP) (OR = 3; IC del 95%, 1,32-6,81)la clasificación de Killip avanzada (OR = 10,19; IC del 95%, 6,99 -14,85) y la localización anterior del infarto (OR = 1,39; IC del 95%, 1,03-1,86).Conclusiones: Encontramos diversos factores disponibles tras la valoración en urgencias, como la edad, que determinan un mal pronóstico a corto plazo del paciente anciano que consulta por un SCAEST. Ni la clase de Killip, ni la localización anterior del infarto agudo de miocardio ni la edad son susceptibles de modificación, no así la realización de una AP que, a diferencia del tratamiento fibrinolítico, es un factor independiente de no mortalidad a los 30 días (AU)

Objective: To identify factors associated with short-term mortality in patients of advanced age who come to the emergency department with acute coronary syndrome with ST segment elevation.Methods: Prospective longitudinal observational multicenter analytic study without interventions. Patients aged 70 yearsor older who were treated at 42 Spanish hospitals were included. Seventeen independent variables that might influence30-day mortality were analyzed. The information was extracted from the medical records or obtained during interviews with the patient or a family member; it was then recorded in a database developed for this study.Results: A total of 1137 patients were included; 340 (29.9%) died within 30 days of the emergency department visit.Four variables conferred significant risk of mortality. These were age (odds ratio [OR], 2.71; 95% confidence interval [CI],2.02-3.64); lack of primary angioplasty (OR, 3; 95% CI, 1.32-6.81); advanced Killip class (OR, 10.19; 95% CI, 6.99-14.85); and anterior location of the lesion (OR, 1.39; 95% CI, 1.03-1.86).Conclusions: We identified several factors, such as age, that are recorded during emergency department assessment andthat predict poor short-term outcome in the elderly patient treated for acute coronary syndrome with ST segment elevation. Although Killip class, location of the acute myocardial infarction, and age cannot be modified, we did identify a factor (performance of primary angioplasty) that, unlike fibrinolytic treatment, is independently associated with a better outcome in terms of 30-day mortality (AU)

Tratamiento quirúrgico de las pseudoartrosis asépticas de diáfisis humeral: ¿placa a compresión o clavo cerrojado? / Surgical treatment of non-septic humeral diaphyseal non-unions: compression plate or locking nail?

Objetivos. Comparar la placa a compresión con el clavo encerrojado, valorar el empleo del injerto óseo, valorar la utilidad de la cruentación y compresión del foco y determinar la existencia de factores pronóstico en el tratamiento quirúrgico de la pseudoartrosis aséptica de la diáfisis humeral. Material y método. Se ha realizado un estudio clínico multicéntrico incluyendo retrospectivamente 54 pseudoartrosis asépticas de la diáfisis humeral intervenidas entre 1994 y 2003. Se analizaron tres grupos de factores (de filiación, asociados al traumatismo inicial y asociados a la técnica quirúrgica) y se estudió su relación estadística con la consolidación, el tiempo de consolidación y las complicaciones posoperatorias. Resultados. La consolidación de la serie fue del 72,5% con un tiempo medio de consolidación de 21 semanas y un porcentaje de complicaciones del 20,4%. Han aumentado significativamente (p < 0,05) la consolidación: el tratamiento con clavo en las pseudoartrosis atróficas y con placa en las hipertróficas. Han acortado el tiempo de consolidación (p < 0,05) las fracturas inicialmente simples (tipo A) y las tratadas en principio de manera conservadora. Han disminuido las complicaciones posoperatorias (p < 0,05) aquellas fracturas inicialmente simples (tipo A). Conclusiones. No existen diferencias entre los dos implantes estudiados en cuanto a consolidación, tiempo de consolidación y complicaciones, sin embargo, las pseudoartrosis atróficas obtienen mejores resultados con clavo y las hipertróficas con placa. El aporte de injerto no ha demostrado mejorar los resultados. El enclavado debe de realizarse a foco abierto para cruentar y comprimir el foco. No se han encontrado factores pronóstico

Purpose. To compare the use of compression plates with locking nails, to assess the value of bone grafting, to assess the value of curettage and fracture site compression and to determine prognostic factors in the surgical treatment of non-septic humeral diaphyseal non-union. Materials and methods. A retrospective multicenter clinical study was performed of 54 non-septic humeral diaphyseal non-unions surgically treated from 1994 to 2003. Three groups of factors were analyzed (patient characteristics, initial trauma and surgical technique) and their statistic relationship with achievement of union, time to union and postoperative complications. Results. The series had a consolidation rate of 72.5% with a mean time to consolidation of 21 weeks and a complication rate of 20.4%. Factors that significantly increased union (p < 0.05) were: nailing in atrophied non-unions and plates in hypertrophied non-unions. Time to union was shorter (p < 0.05) in initially simple fractures (type A) and those initially treated conservatively. Postoperative complications decreased (p < 0.05) in initially simple fractures (type A). Conclusions. No differences were found between the two implants studied as to union, time to union and complications. However, better results were seen with nailing in atrophied non-unions and plates in hypertrophied non-unions. The use of grafts was not seen to improve results. Open nailing must be carried out so as to perform curettage and compression of the fracture focus. No prognostic factors were identified