Mary Louise Skovron

Autoimmune-Associated Congenital Heart Block: Demographics, Mortality, Morbidity and Recurrence Rates Obtained From a National Neonatal Lupus Registry

OBJECTIVES The present study describes the demographics, mortality, morbidity and recurrence rates of autoimmune-associated congenital heart block (CHB) using information from the Research Registry for Neonatal Lupus. BACKGROUND Isolated CHB detected at or before birth is strongly associated with maternal autoantibodies to 48-kD SSB/La, 52-kD SSA/Ro and 60-kD SSA/Ro ribonucleoproteins and is a permanent manifestation of the neonatal lupus syndromes (NLS). Available data are limited by the rarity of the disease. RESULTS The cohort includes 105 mothers whose sera contain anti-SSA/Ro or anti-SSB/La antibodies, or both, and their 113 infants diagnosed with CHB between 1970 and 1997 (56 boys, 57 girls). Of 87 pregnancies in which sufficient medical records were available, bradyarrhythmia confirmed to be CHB was initially detected before 30 weeks of gestation in 71 (82%) (median time 23 weeks). There were no cases in which major congenital cardiac anatomic defects were considered causal for the development of CHB; in 14 there were minor abnormalities. Twenty-two (19%) of the 113 children died, 16 (73%) within 3 months after birth. Cumulative probability of 3-year survival was 79%. Sixty-seven (63%) of 107 live-born children required pacemakers: 35 within 9 days of life, 15 within 1 year, and 17 after 1 year. Forty-nine of the mothers had subsequent pregnancies: 8 (16%) had another infant with CHB and 3 (6%) had a child with an isolated rash consistent with NLS. CONCLUSIONS Data from this large series substantiate that autoantibody-associated CHB is not coincident with major structural abnormalities, is most often identified in the late second trimester, carries a substantial mortality in the neonatal period and frequently requires pacing. The recurrence rate of CHB is at least two- to three-fold higher than the rate for a mother with anti-SSA/Ro-SSB/La antibodies who never had an affected child, supporting close echocardiographic monitoring in all subsequent pregnancies, with heightened surveillance between 18 and 24 weeks of gestation.

Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip

We prospectively studied 367 patients who had a fracture of the hip, to determine the effect of an operative delay on postoperative complications and on the one-year mortality rate. All of the patients were at least sixty-five years old, cognitively intact, living at home, and able to walk before the fracture. An operative delay was defined as an interval of three calendar days or more between the time of admission to the hospital and the operation. The operation was performed within two calendar days after admission in 267 (73 per cent) of the patients. When the factors of the patients age and sex and the number of pre-existing medical conditions were controlled, it was found that an operative delay beyond this period approximately doubled the risk of the patient dying before the end of the first postoperative year. When the patients age and sex and the severity of pre-existing medical conditions were controlled, there was also an increase in mortality associated with an operative delay, although this was not significant. With the numbers studied, an operative delay beyond two calendar days did not have a significant effect on the prevalence of complications during hospitalization. We concluded that an operative delay of more than two calendar days after admission is an important predictor of mortality within one year for elderly patients who have a fracture of the hip and who are cognitively intact, able to walk, and living at home before the fracture. Optimally, such patients should have the operation within two calendar days after admission to the hospital.

Delayed childbearing and the outcome of pregnancy.

Whether women who delay childbearing are at increased risk for adverse outcomes of pregnancy is of concern because of the growing proportion of first births to older women. We assessed the effect of advancing maternal age on the outcome of pregnancy in first births in a hospital-based cohort study of 3917 private patients who were 20 years of age or older with a singleton gestation. There was a slight elevation in the risk of having a low-birth-weight infant among women who were 35 years of age or older (adjusted odds ratio, 1.3; 95 percent confidence interval, 0.9 to 1.9) as compared with the risk among women 20 to 29 years of age. However, there was no evidence that women between 30 and 34 or those 35 and older had an increased risk of having a preterm delivery or of having an infant who was small for gestational age, had a low Apgar score, or died in the perinatal period. In contrast, even after controlling for sociodemographic and medical risk factors, we found that women who were 35 or older were significantly more likely to have specific antepartum and intrapartum complications and those who were 30 or older were significantly more likely to have both cesarean sections and infants who were admitted to the newborn intensive care unit. This study suggests that although older primiparous women have higher rates of complications of pregnancy and delivery, their risk of a poor neonatal outcome is not appreciably increased.

Hip fractures in the elderly: predictors of one year mortality.

OBJECTIVE To determine the one year mortality following hip fracture in an ambulatory, community dwelling, cognitively intact elderly population and to examine the role of specific type, number, and severity of associated medical comorbidities. DESIGN Prospective, consecutive. METHODS Six hundred twelve elderly who sustained a non-pathologic hip fracture were followed. RESULTS Twenty-four patients (4%) died during hospitalization; seventy-eight (12.7%) died within one year of fracture. The factors that were predictive of mortality, based on multivariate analysis, were patient age > 85 years, preinjury dependency in basic activities of daily living, a history of malignancy other than skin cancer, American Society of Anesthesiologists rating of operative risk 3 or 4, and the development of one or more in-hospital postoperative complications; all factors other than the development of an in-hospital complication were independent of treatment. CONCLUSION These results indicate that efforts at reducing one year mortality after hip fracture should be directed at the prevention of postoperative complications.

Predictors of functional recovery after hip fracture in the elderly.

Three hundred thirty-eight community dwelling, ambulatory, elderly patients who sustained a hip fracture were observed prospectively to determine which patient and fracture characteristics at hospital admission predicted functional recovery at 3, 6, and 12 months. Multiple logistic regression was performed to estimate the simultaneous contributions of the predictor variables to failure of functional recovery. Before sustaining a fracture, 16% of patients were dependent on basic activities of daily living and 46% were dependent on instrumental activities of daily living. By 1 year after fracture, 73% of the patients had recovered to their basic activities of daily living status before fracture whereas only 48% had recovered to their instrumental activities of daily living status before fracture. Patients who were age 85 years or older, who lived alone before sustaining a fracture, and who had one or more comorbidities were at increased risk of delay or failure in recovering basic activities of daily living. Only instrumental activities of daily living independence before fracture predicted failure to recover instrumental activities of daily living function by 3 and 6 months after fracture. At 1 year, patient age 85 years or older was the only predictor of failure to recover instrumental activities of daily living function that existed before fracture. Based on characteristics at admission, a group of patients at high risk for failure to recover basic activities of daily living function within 1 year of sustaining a hip fracture can be identified.

Ambulatory ability after hip fracture. A prospective study in geriatric patients.

Three hundred thirty-six community-dwelling, previously ambulatory, geriatric patients with hip fracture were observed prospectively to determine ambulatory ability at a minimum follow up of 1 year. One hundred thirty-seven (41%) patients maintained their pre-fracture ambulatory ability at a minimum followup of 1 year; 134 (40%) patients remained ambulatory but became more dependent on assistive devices; 39 (12%) previous community ambulators became household ambulators, and 26 (8%) patients became nonfunctional ambulators. Analysis was performed to determine which pre- and postinjury factors were predictive of failure to recover ambulatory capacity 1 year after fracture. Potential predictor variables analyzed included age, gender, number of comorbid conditions, pre-fracture ambulatory ability, prefracture living situation, fracture type, American Society of Anesthesiologists rating of operative risk, type of surgery, and number of postoperative complications. Multiple logistic regression analysis identified significant contributions of age, prefracture ambulatory ability, American Society of Anesthesiologists rating of operative risk, and fracture type to ambulatory recovery.

Sociocultural factors and back pain. A population-based study in Belgian adults.

A population-based survey of approximately 4000 adults in Belgium, a bi-cultural country with a uniform health care system, explored the relationships of socio-cultural and employment factors to the reported experience of low back pain (LBP). Predictors of 1) history of LBP, 2) first LBP, and 3) daily LBP were examined by multiple logistic regression analysis. Thirty-three percent of the population had current LBP, including 5% experiencing their first episode; 26% had past but not current LBP, and 41% had never had LBP. Increasing age (OR > 2.0, P = .000) and female gender (OR 2.16, P = .000) were associated with history of LBP; only gender (OR 1.40, P = .02) was associated with first episode; neither was associated with daily LBP. Language was associated with history (OR 1.80, P = .000) and first occurrence (OR 1.77, P = .000) but not daily LBP. Among those employed, work dissatisfaction was associated with history of LBP (OR > 2.4, P = .02) and daily LBP (OR 3.85, P = .02), but not with first episode. The results suggest that sociocultural factors influence the expression of LBP, but not the risk of chronicity once LBP is reported, and that work satisfaction may not be causally related to LBP, but may intervene along with type of occupation in the possibility of continuing employment once LBP is present. Prospective studies are needed to confirm these results and elucidate causal relationships.

Non-specific low-back pain among schoolchildren: a field survey with analysis of some associated factors

A study population composed of 1,755 children 8-16 years of age were surveyed using a 15-item, self-administered questionnaire. The response rate was 97.7%. The purpose of the survey was to evaluate the possible association between low-back pain and certain social factors and predicaments. Descriptive statistics and logistic regression analysis showed that parental history of treated low-back pain (adjusted odds ratio 2.10; p < 0.001), competitive sports activity (adjusted odds ratio 1.73; p = 0.003), and time spent watching television (adjusted odds ratio 1.23; p = 0.05) significantly increased the risk for low-back pain among children, controlling for the childs age and gender.

Cardiopulmonary resuscitation in a hospitalized population: Prospective study of factors associated with outcome

A prospective study of advanced cardiopulmonary resuscitation (CPR) was carried out on 226 patients in order to examine factors predicting successful resuscitation and 6 month survival. The mean age of all patients was 70 years and median age was 74. Cardiopulmonary resuscitation was successful in 40.5% (137) of all arrests and in 48.7% (110) of the first arrests. Thirty of 207 patients with one or more cardiac arrests were discharged alive (14%). Twenty-one of our patients were alive at 6 months (10.3%). Patients in ventricular fibrillation and/or ventricular tachycardia at the time of arrest were more likely to have successful outcomes. When the patient required Isuprel or bicarbonate, cardiopulmonary resuscitation was significantly less successful. We found no correlation of immediate outcome with the following variables: location of arrest; time of day; pre-existence of shock; coma; stroke; malignancy. Uremia and/or chronic obstructive pulmonary disease was not significantly associated with failed resuscitation. Most notable in our results of specific treatments was the evidence for the need to improve the initial pH, particularly when it was less than 7.2. Failure to do so by the time the second blood gas was drawn was associated with failure of cardiopulmonary resuscitation. Our results also suggest that the adequate treatment of metabolic acidosis, and improved ventilatory management with improved PO2 and optimization of PCO2, play a role in the better outcome of cardiopulmonary resuscitation.

Does blood transfusion increase the risk of infection after hip fracture

OBJECTIVE To determine whether allogeneic red blood cell transfusion is a predictor for developing an in-hospital postoperative urinary tract, respiratory, or wound infection. STUDY DESIGN Prospective, consecutive. METHODS Six hundred eighty-seven community-dwelling, ambulatory, geriatric hip fracture patients were prospectively followed; all patients had operative fracture treatment and received perioperative antibiotics. RESULTS Sixty-eight patients had a culture-positive infection before operative treatment. One hundred thirty-four of the remaining 619 patients (21.6%) developed a postoperative infection, primarily a urinary tract infection. The infection rate was 26.8% in transfused patients compared with 14.9% in nontransfused patients (p = 0.001). When stratifying by the type of infection, only the risk of urinary tract infection was statistically significant (p = 0.001). After controlling for the effect of patient age, sex, number of preinjury medical comorbidities, American Society of Anesthesiologists (ASA) rating of operative risk, fracture type, surgical delay, type of surgery, type of anesthesia, operative time, and blood loss, the relationship between allogeneic red blood cell transfusion and postoperative urinal tract infection remained statistically significant. CONCLUSIONS Geriatric hip fracture patients who receive allogeneic red blood cell transfusions are at higher risk for developing a postoperative urinary tract infection than are those patients who are not transfused.