Intracerebral Hemorrhage Outcomes in the Very Elderly.

BACKGROUND: There is a paucity of outcomes data in patients over 80 years presenting with intracerebral hemorrhage (ICH). The primary aim of our study is to describe outcomes in this patient population. METHOD: Retrospective study of patients admitted with primary ICH from January 2012 to July 2018. Data were obtained from the Rush University Get With The Guidelines database; only patients 80 or above were included. RESULTS: A total of 1713 patients were screened and 220 patients met inclusion criteria. About 68.2% were female and mean age was 85.6 years old. Median ICH score on admission was 2 (IQR 1-3). Location of ICH included: deep (48.2%), lobar (40%), and cerebellum (9.5%). ICH etiologies included hypertensive (51.8%), cerebral amyloid angiopathy (26.8%), coagulopathy (5.9%), and the remaining were undetermined. CT angiograms were performed in 34.5% (n = 76) of patients; of these patients one arteriovenous malformation was identified. Patients underwent the following procedures: external ventricular drains (8.6%), decompression (3.6%), and ventriculoperitoneal shunts (1.8%). Tracheostomy and percutaneous gastrostomy placement were performed in 8.2%. About 4.5% had seizures and 1.5% were treated for status epilepticus. Disposition at hospital discharge included: subacute nursing facility ([SNF] 24.1%), acute rehabilitation (23.2%), hospice (18.2%), death (18.2%), home (11.8%), long-term acute care facility ([LTAC] 3.6%), and unknown (1%). Patients with an ICH score ≥2 on admission had a roughly 6 times higher chance of experiencing an unfavorable outcome (LTAC, SNF, or death), when compared to patients with lower ICH score. CONCLUSIONS: This study shows that a significant proportion (35%) of ICH patients ≥80 years old have a good outcome, with discharge to home or to rehabilitation. Our data suggest that older patients with ICH presenting with supratentorial hemorrhages (volume < 30 cc) without intraventricular extension can have good outcomes despite their age.

The linea aspera as a guide for femoral rotation after tumor resection: is it directly posterior? A technical note.

BACKGROUND: The linea aspera is the rough, longitudinal crest on the posterior surface of the femoral shaft. Most orthopedic surgeons depend on the linea aspera as an intraoperative landmark identifying the true posterior aspect of the femur. We investigated the position of the linea aspera to verify whether the surgeon can rely on this accepted belief. MATERIAL AND METHOD: One hundred and thirty-three femora from 73 patients were evaluated. Four CT cuts were done of the mid femur, and we measured the angle of rotation of the linea aspera at each cut. RESULTS: The linea aspera was externally rotated in most femora evaluated; average angles of rotation were 15.4°, 14°, 11.7°, and 11.5° at 10, 15, 20, and 25 cm from the intercondylar line, respectively. The angle of rotation of the linea aspera was positively correlated with femoral neck anteversion angle and negatively with age. CONCLUSION: The linea aspera is exactly posterior in a minority of individuals, while it is externally rotated to varying degrees in the majority of individuals. The degree of rotation was positively correlated with femoral neck anteversion angle, and negatively with age. To avoid implant malrotation, accurate estimation of the rotation angle should be determined preoperatively. LEVEL OF EVIDENCE: Level IV.

The effects of on-duty napping on intern sleep time and fatigue.

BACKGROUND: Naps during extended work shifts are effective in reducing fatigue in other industries, but the use of a nap as a countermeasure to prevent fatigue in residents is uncertain. OBJECTIVE: To assess the effects of a call-night nap on resident sleep and fatigue. DESIGN: 1-year, within-participant, paired trial with crossover at midmonth. SETTING: Academic teaching hospital. PARTICIPANTS: 38 of 40 internal medicine interns. MEASUREMENTS: Sleep was measured by using wristwatch actigraphy. By using the experience sampling method on a personal digital assistant, random alerts prompted interns to rate fatigue on the 7-point Stanford Sleepiness Scale (7 is most tired). Hospital paging logs and structured interviews provided information on use of coverage. INTERVENTION: For 2 weeks of every month, interns were assigned to the nap schedule, which provided coverage to on-duty interns from midnight to 7:00 a.m. so that they could finish their work and take a nap. The other 2 weeks of the month constituted a standard schedule. RESULTS: Interns received 41 more minutes of sleep while on call with the nap schedule (185 minutes vs. 144 minutes; P < 0.001). When interns with the nap schedule used coverage, they received 68 more minutes of sleep (210 minutes vs. 142 minutes; P < 0.001). Despite these small increases in sleep, interns reported less overall fatigue while on the nap schedule than while on the standard schedule (1.74 vs. 2.26; P = 0.017). Postcall fatigue with the nap schedule was lower by nearly 1 point (2.23 vs 3.16; P = 0.036), which is almost equivalent to the difference between on-call and postcall fatigue with the standard schedule (2.06 vs. 3.16). However, use of coverage by interns on the nap schedule was impaired by their desire to care for their patients and concerns about discontinuity of care. LIMITATIONS: This was a single-institution study that did not have the power to examine outcomes related to intern or patient well-being. CONCLUSIONS: Coverage to allow a nap during an extended duty-hour shift can increase sleep and decrease fatigue for residents.

Radiological assessment of the femoral bowing in Japanese population.

INTRODUCTION: Differences in the magnitude of bowing between races are well-known characteristics of the femur. Asian races have an increased magnitude of femoral bowing but most of the orthopedic implants designed for the femur do not match this exaggerated bowing. We calculated the sagittal and coronal femoral bowing in the Japanese population at different levels of the femur and addressed its surgical significance. MATERIAL AND METHODS: We calculated the sagittal and coronal bowing of 132 Japanese femora using CT scan of the femur. A mathematical calculation of the radius of curvature at proximal, middle, and distal regions of the femur was used to determine the degree of femoral bowing. RESULTS: Mean sagittal bowing of the femur was 581, 188, and 161 mm for the proximal, middle, and distal thirds of the femur and mean lateral bowing was 528, 5092, and 876 mm, respectively. Mean sagittal and coronal bowing for the whole femur was 175 and 2640 mm, respectively. No correlation was found between age, gender, length of femur, and the degree of bowing. CONCLUSION: Our study reveals that femoral bowing in the Japanese population is 175 mm in the sagittal plane and 2640 mm in the coronal plane; these values are greater than the femoral bowing in other ethnic groups studied in the literature. This may result in varying degrees of mismatch between the western-manufactured femoral intramedullary implants and the Japanese femur. We recommend that orthopedic surgeons to accurately perform preoperative evaluation of the femoral bowing to avoid potential malalignment, rotation, and abnormal stresses between the femur and implant.

Therapeutic hypothermia utilization among physicians after resuscitation from cardiac arrest.

OBJECTIVE: We sought to evaluate current physician use of therapeutic hypothermia after cardiac arrest, to ascertain reasons for nonadoption of this treatment, and to determine current cooling techniques employed. DESIGN: Web-based survey. SETTING: International physician cohort in the United States, UK, and Finland. SUBJECTS: Physicians (MD or DO) caring for resuscitated cardiac arrest patients. INTERVENTIONS: An anonymous Web-based survey was distributed to physicians identified through United States-based critical care, cardiology, and emergency medicine directories and critical care networks in the UK and Finland. Recipients were queried regarding use of postresuscitation therapeutic hypothermia. MEASUREMENTS AND MAIN RESULTS: Of the final 13,272 surveys actually distributed to physicians, 2,248 (17%) were completed. Most respondents were attending physicians (82%) at teaching hospitals (76%) who practiced critical care (35%), cardiology (20%), or emergency medicine (22%). Of all replies, 74% of United States respondents and 64% of non-United States respondents had never used therapeutic hypothermia. United States emergency medicine physician adoption of cooling was significantly less than that of United States intensivists (16% vs. 34%, p < .05). The most often cited reasons for nonuse by respondents were "not enough data," "not part of Advanced Cardiac Life Support guidelines," and "too technically difficult to use." Factors associated with increased use included non-United States residence, critical care specialty, and larger hospital size. CONCLUSIONS: Physician utilization of cooling after cardiac arrest remains low. For improved adoption of therapeutic hypothermia, our data suggest that development of better cooling methodology and recent incorporation into resuscitation guidelines may improve use.