POSSUM predicts hospital mortality and long-term survival in patients with hip fractures.

BACKGROUND: Each year, some 18,000 Dutch residents, most of them elderly, suffer a hip fracture. These patients constitute a major, and increasing, healthcare problem with high mortality. In an ageing population, not only the incidence of hip fractures will increase but also comorbidity. Comorbidity is a major cause of high mortality. The physiologic and operative severity score for the enumeration of mortality and morbidity (POSSUM) system predicts mortality and morbidity in surgical patients using physiologic and operative factors. METHODS: For 272 consecutive patients who were treated in our hospital for hip fractures, all complications were registered, and orthopedic POSSUM was performed. Total survival was registered with a mean follow-up of 58 months. Discriminating performance of POSSUM was estimated using receiver-operating curves. After validation, patients were divided into three equal large groups, termed low-risk group, intermediate-risk group, and high-risk group. Kaplan-Meier survival curves were made of each group. RESULTS: Orthopedic POSSUM performed well in predicting mortality with an area under the curve of 0.83 (95% confidence interval 0.76-0.89) and morbidity with an area under the curve of 0.83 (95% confidence interval 0.76-0.90). Three groups that composed of 92 (low risk), 93 (intermediate risk), and 87 (high risk) patients differed significantly in inhospital mortality, all complications, severe complications, and total survival. CONCLUSION: This study has shown that the orthopedic POSSUM is an excellent predictor of inhospital mortality and long-term survival in patients suffering from hip fractures. It is a reasonable predictor of severe postoperative complications. The orthopedic POSSUM is a useful risk stratification and audit tool.

Functional treatment versus plaster for simple elbow dislocations (FuncSiE): a randomized trial.

BACKGROUND: Elbow dislocations can be classified as simple or complex. Simple dislocations are characterized by the absence of fractures, while complex dislocations are associated with fractures. After reduction of a simple dislocation, treatment options include immobilization in a static plaster for different periods of time or so-called functional treatment. Functional treatment is characterized by early active motion within the limits of pain with or without the use of a sling or hinged brace. Theoretically, functional treatment should prevent stiffness without introducing increased joint instability. The primary aim of this randomized controlled trial is to compare early functional treatment versus plaster immobilization following simple dislocations of the elbow. METHODS/DESIGN: The design of the study will be a multicenter randomized controlled trial of 100 patients who have sustained a simple elbow dislocation. After reduction of the dislocation, patients are randomized between a pressure bandage for 5-7 days and early functional treatment or a plaster in 90 degrees flexion, neutral position for pro-supination for a period of three weeks. In the functional group, treatment is started with early active motion within the limits of pain. Function, pain, and radiographic recovery will be evaluated at regular intervals over the subsequent 12 months. The primary outcome measure is the Quick Disabilities of the Arm, Shoulder, and Hand score. The secondary outcome measures are the Mayo Elbow Performance Index, Oxford elbow score, pain level at both sides, range of motion of the elbow joint at both sides, rate of secondary interventions and complication rates in both groups (secondary dislocation, instability, relaxation), health-related quality of life (Short-Form 36 and EuroQol-5D), radiographic appearance of the elbow joint (degenerative changes and heterotopic ossifications), costs, and cost-effectiveness. DISCUSSION: The successful completion of this trial will provide evidence on the effectiveness of a functional treatment for the management of simple elbow dislocations. TRIAL REGISTRATION: The trial is registered at the Netherlands Trial Register (NTR2025).

Cardiac output derived from arterial pressure waveform analysis without calibration vs. thermodilution in septic shock: evolving accuracy of software versions.

BACKGROUND AND OBJECTIVE: We studied the evolution of software in the accuracy of the FloTrac/Vigileo system to measure cardiac output less invasively from arterial pressure waveform analysis without calibration, in comparison with pulmonary artery catheter-derived thermodilution measurements, in patients with septic shock and presumed alterations in vascular tone. METHODS: Nine patients who received a pulmonary artery catheter and were on mechanical ventilation and in sinus rhythm were monitored by the FloTrac/Vigileo. Paired cardiac output measurements by both techniques were analysed for 86 measurements in four patients using the 1.07 software version and 73 measurements in five subsequent patients using the later 1.10 version. RESULTS: For the 1.07 version, bias was -1.6 L min, precision 1.6 L min, limits of agreement -4.8-1.5 L min and error 48%. Measurements correlated at partial r equal to 0.32 (P = 0.003). For the 1.10 version, bias was -1.2 L min, precision 1.1 L min, limits of agreement -3.5-1.0 L min and error 32%. Measurements correlated at partial r equal to 0.90 (P < 0.001 vs. version 1.07). Differences were inversely related to mean cardiac output (P < 0.001, generalized estimating equations), particularly for software version 1.07 vs. 1.10 (P = 0.017, generalized estimating equation). Changes in thermodilution cardiac output over the course of time were also better tracked by the FloTrac/Vigileo when applying the latest software (P < 0.001, generalized estimating equation). CONCLUSIONS: Evolving software versions are thus better able to account for the effect of vascular tone on cardiac output measurements by less invasive waveform analyses without calibration (FloTrac/Vigileo), so that the latter may become useful in the haemodynamic monitoring of septic shock.