Admission levels of serum biomarkers have additive and cumulative prognostic value in traumatic brain injury.

Elevated levels of CNS-derived serum proteins are associated with poor outcome in traumatic brain injury (TBI), but the value of adding acute serum biomarker levels to common clinical outcome predictors lacks evaluation. We analyzed admission serum samples for Total-Tau (T-Tau), Neurofilament light chain (Nfl), Glial fibrillary acidic protein (GFAP), and Ubiquitin C-terminal hydrolase L1 (UCHL1) in a cohort of 396 trauma patients including 240 patients with TBI. We assessed the independent association of biomarkers with 1-year mortality and 6-12 months Glasgow Outcome Scale Extended (GOSE) score, as well as the additive and cumulative value of biomarkers on Glasgow Coma Scale (GCS) and Marshall Score for outcome prediction. Nfl and T-Tau levels were independently associated with outcome (OR: Nfl = 1.65, p = 0.01; T-Tau = 1.99, p < 0.01). Nfl or T-Tau improved outcome prediction by GCS (Wald Chi, Nfl = 6.8-8.8, p < 0.01; T-Tau 7.2-11.3, p < 0.01) and the Marshall score (Wald Chi, Nfl = 16.2-17.5, p < 0.01; T-Tau 8.7-12.4, p < 0.01). Adding T-Tau atop Nfl further improved outcome prediction in majority of tested models (Wald Chi range 3.8-9.4, p ≤ 0.05). Our data suggest that acute levels of serum biomarkers are independently associated with outcome after TBI and add outcome predictive value to commonly used clinical scores.

Age-dependent thrombin generation predicts 30-day mortality and symptomatic thromboembolism after multiple trauma.

Trauma-induced coagulopathy (TIC) is a risk factor for death and is associated with deviations in thrombin generation. TIC prevalence and thrombin levels increase with age. We assayed in vivo and ex vivo thrombin generation in injured patients (n = 418) to specifically investigate how age impacts thrombin generation in trauma and to address the prognostic ability of thrombin generation. Biomarkers of thrombin generation were elevated in young (< 40 years) and older (≥ 40 years) trauma patients. In vivo thrombin generation was associated with Injury Severity Score (ISS) and this association was stronger in young than older patients. In vivo thrombin generation decreased faster after trauma in the young than the older patients. Across age groups, in vivo thrombin generation separated patients dying/surviving within 30 days at a level comparable to the ISS score (AUC 0.80 vs. 0.82, p > 0.76). In vivo and ex vivo thrombin generation also predicted development of thromboembolic events within the first 30 days after the trauma (AUC 0.70-0.84). In conclusion, younger trauma patients mount a stronger and more dynamic in vivo thrombin response than older patients. Across age groups, in vivo thrombin generation has a strong ability to predict death and/or thromboembolic events 30 days after injury.

The Effectiveness and Safety of Direct Oral Anticoagulants Following Lower Limb Fracture Surgery: A Systematic Review and Meta-analysis.

OBJECTIVES: Venous thromboembolism (VTE) is a well-established complication after many orthopaedic injuries, such as hip and lower limb fractures. The use of direct oral anticoagulants (DOACs, previously termed novel oral anticoagulants) is well-established as thromboprophylaxis after major elective orthopaedic surgery, but not in the nonelective setting. The aim of this study was to investigate the effectiveness and safety of DOACs after nonelective lower limb fracture surgery. DATA SOURCES: A systematic literature search of the MEDLINE, EMBASE, CINAHL, and CENTRAL databases was conducted. No limitation was placed on publication date, with only manuscripts printed in English were eligible. STUDY SELECTION: Included studies were either randomized controlled trials or prospective and retrospective comparative studies. Included studies compared DOACs to conventional methods of thromboprophylaxis in the postoperative period after surgical management of lower limb fractures. DATA EXTRACTION: Outcomes included VTE, bleeding, wound complications, mortality, and adverse events. Eight studies met inclusion criteria, of which 7 compared direct factor Xa inhibitors (XaIs) with conventional VTE prophylaxis and one study compared a direct thrombin inhibitor with conventional VTE prophylaxis. DATA SYNTHESIS: Revman 5.3 (Nordic Cochrane Centre, Denmark) was used to complete the meta-analysis and generate forest plots. CONCLUSIONS: XaIs were shown to have lower rates of deep vein thrombosis (Odds ratio 0.59; 95% confidence interval, 0.46-0.76; P < 0.0001) and less pharmacologically attributable adverse events (Odds ratio 0.62; 95% confidence interval, 0.46-0.82; P = 0.0007). There was difference between DOACs and conventional VTE prophylaxis regarding mortality, PE, symptomatic deep vein thrombosis, or bleeding events. The results generally support the use of DOACs for VTE prophylaxis after nonelective lower limb fracture surgery, such after hip fracture. The results more strongly support the use of XaIs; however, more evidence is needed to fully assess DOACs' role in clinical practice. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Do anticoagulants affect outcomes of hip fracture surgery? A cross-sectional analysis.

INTRODUCTION: The management of patients with a hip fracture is affected by the use of oral anticoagulants. A cross-sectional analysis was undertaken to investigate health outcome differences in those anticoagulated compared to those not anticoagulated. METHODS: Patients aged 50 years and over presenting to a large university hospital with hip fractures were identified from the service registry. Patient characteristics and health outcomes between those not anticoagulated were compared with those anticoagulated (warfarin and direct oral anticoagulants, DOAC). RESULTS: 200/2307 (9%) patients were anticoagulated. 84% were on warfarin, and the rest a DOAC. Compared to those anticoagulated, there was a higher prevalence of dementia (25% vs. 18%, p = 0.02) and a lower prevalence of cardiovascular disease (54% vs. 78%, p < 0.01), atrial fibrillation (10% vs. 82%, p < 0.01), and polypharmacy (55% vs. 76%, p < 0.01). Renal function was lower in the anticoagulated group. Time to operation for those not anticoagulated and anticoagulated was a median (IQR) of 25 (15) and 27 (18) hours. There was no difference in blood transfusion and hospital mortality. Postoperative complications were similar except a higher rate of renal failure (14% vs. 19%, p = 0.04) and heart failure (1% vs. 5%, p < 0.01), and a longer length of stay [median (IQR): 14 (10) vs. 16 (12) days] in the anticoagulated group. This was no longer significant after adjustment of confounders. CONCLUSION: There was no statistically significant difference in health outcomes between those anticoagulated and those not after adjusting for patient characteristics. It was feasible to avoid significant delay in hip fracture surgery in those anticoagulated.

Bosworth fracture dislocation of the ankle: - Two case reports with perioperative illustration.

The Bosworth fracture dislocation of the ankle is rare and present difficulties in treatment if not immediately recognized. Here we present two cases with pre- and postoperative x-rays and perioperative image of the dislocation. The fracture dislocations were further complicated by talocrural dislocations and were treated with open reduction and internal fixation.

Volar plating of distal radius fractures does not restore the anatomy.

INTRODUCTION: The objective of this study was to evaluate whether volar locking plating can restore the anatomical volar tilt of 12° and the anatomical length of the radius relative to the ulna. We retrospectively reviewed the radio-graphic outcome of distal radius fractures treated with two different first-generation locking plate systems; VariAx (Stryker) and Acu-Loc (Acumed). METHODS: Three independent observers evaluated radial volar tilt and ulnar variance (> 2 mm) on radiographs taken preoperatively, immediately after the operation and five weeks later. In addition, the radial inclination, distal radio-ulnar joint incongruity and articular step-off were assessed in order to describe the personality of the fracture. RESULTS: A total of 576 fracture cases were included in the study. Preoperatively, the mean volar tilt was 18 ± 6° and -15 ± 11° for volarly and dorsally displaced fractures, respect-ively. After operation, the mean volar tilt was 4.5 ± 6° without any significant changes after five weeks, p = 0.79 and no significant differences with respect to fracture type or type of plate. Thus, the anatomical angulation of 12° was not achieved at any point in time after surgery (p < 0.001). Shortening of the radius (> 2 mm ulnar variance) was still seen in 9% of the cases immediately after surgery and in 22% after five weeks. CONCLUSIONS: Volar locking plating did not restore the anatomy after distal radius fractures. The clinical implication of these findings is unclear because the functional outcome of the patients was not available. Level of evidence, level IV. FUNDING: none. TRIAL REGISTRATION: not relevant.

Distal radius fractures are difficult to classify.

BACKGROUND: Traditionally, distal radius fractures (DRFs) have been described using eponyms, e.g. Colles, Smith, Barton, Chauffeur. During the last half of the 20th century several classification systems for DRF have emerged. We evaluated the inter- and intra-observer agreement of the AO/OTA, Frykman and Older classification systems. METHODS: Four observers, an intern, an orthopaedic registrar, an orthopaedic consultant and a radiology consultant, independently evaluated DRF radiograms and classified the fractures according to the AO/OTA, Frykman and Older classification systems. After an interval of 6 months, radiograms of 30 randomly chosen patients were re-evaluated by the same observers. RESULTS: Radiograms of 573 DRF patients were evaluated in the study. The inter-observer reliability of the AO/OTA fracture types (A, B and C) was 'weak' (kappa = 0.45). The agreement dropped to 'minimal' (kappa = 0.24) regarding the AO/OTA groups (A2, A3, B1, B2, B3, C1, C2 and C3). The reliability of the Frykman classification system was 'weak' (kappa = 0.41), and we observed the lowest inter-observer reliability for the Older classification system (kappa = 0.10). The kappa values for the intra-observer reproducibility of the AO/OTA fracture types (A, B and C) ranged from 0.58 to 0.87. For the AO/OTA groups (A2, A3, B1, B2, B3, C1, C2 and C3) the reproducibility was lower ranging from 'minimal' to 'weak'. The intra-observer reproducibility of the Frykman system was 'weak' to 'moderate' and even worse for the Older classification system. CONCLUSION: Based on these findings the AO/OTA classification system seems to be most reliable for routine use, however, with lower kappa values concerning the agreement for the groups. The Frykman and Older classification systems cannot be recommended because of less convincing results.

Complications of volar locking plating of distal radius fractures in 576 patients with 3.2 years follow-up.

BACKGROUND: Volar plating of unstable distal radius fractures (DRF) has become the favoured treatment. The complication rates vary from 3 to 36%. The purpose of the study was to estimate the complication rate of volar plating of DRF and its association with AO/OTA fracture type, surgeon experience and type of volar plate. METHODS: Retrospectively, all patients treated with volar plating of a DRF between February 2009 and June 2013 at Aarhus University Hospital, Denmark were included. AO/OTA fracture type, surgeon experience (1st year, 2nd-5th year resident or consultant), type of plate (VariAx®, Acu-Loc®) and complications were extracted from the electronic medical records. Complications were categorized as carpal tunnel syndrome, other sensibility issues, tendon complications including irritation and rupture, deep infections, complex regional pain syndrome and unidentified DRUJ or scapholunar problems. Reoperations including hardware removal were also charted. RESULTS: 576 patients with a median age of 63 years (min: 15; max: 87) were included. 78% were female and the mean observation time was 3.2 years (min: 2.0; max: 5.4). 78% (n=451) of the patients were treated with VariAx® and 22% (n=125) with Acu-Loc®. The overall complication rate was 14.6% (95% CI 11.8-17.7) including carpal tunnel syndrome or change in sensibility in 5.2% and tendon complications in 4.7%. Five flexor tendon ruptures and 12 extensor tendon ruptures were observed. The reoperation rate was 10.4% including 41 cases of hardware removal. A statistically significant association between AO/OTA fracture type C and complications was found. No statistically significant association between complication rate and surgeon experience and type of plate was observed. CONCLUSION: The majority of DRF patients treated with a volar plate suffer no complications. However, the overall complication rate of 14.6% is substantial. Intra-articular fractures, e.g. AO/OTA-type 23C1-3, had significantly higher complication rates. Neither surgeon experience, nor type of volar plate was able to predict complications.

Effect of Teriparatide or Risedronate in Elderly Patients With a Recent Pertrochanteric Hip Fracture: Final Results of a 78-Week Randomized Clinical Trial.

We present final results of a study comparing teriparatide 20 µg every day (QD) with risedronate 35 mg once per week (QW) started within 2 weeks after surgery for a pertrochanteric hip fracture. Patients with BMD T-score ≤ -2.0 and 25OHD ≥9.2 ng/mL were randomized to receive 26-week double-dummy treatment plus calcium and vitamin D, followed by 52-week open-label treatment with the same assigned active drug. Primary endpoint was change from baseline in lumbar spine (LS) BMD at 78 weeks. Secondary and exploratory endpoints were change in BMD at the proximal femur, function, hip pain (Charnley score and 100 mm Visual Analog Scale [VAS]), quality of life (Short Form-36), radiology outcomes, and safety. Data were analyzed with mixed models for repeated measures (MMRM) and logistic regression. Totally, 224 patients were randomized; 171 (teriparatide: 86) contributed to the efficacy analyses (mean ± SD age: 77 ± 7.7 years, 77% females). Mean baseline LS, femoral neck (FN), and total hip (TH) T-scores were -2.16, -2.63, and -2.51, respectively. At 78 weeks, BMD increased significantly more with teriparatide compared to risedronate at the LS (+11.08% versus +6.45%; p < 0.001) and FN (+1.96% versus -1.19%; p = 0.003), with no significant between-group difference in TH BMD. Timed up-and-go (TUG) test was significantly faster with teriparatide at 6, 12, 18, and 26 weeks (differences: -3.2 to -5.9 s; p = 0.045 for overall difference). Hip pain during TUG test by 100 mm VAS was significantly lower with teriparatide at 18 weeks (adjusted difference: -11.3 mm, p = 0.033; -10.0 and -9.3 mm at 12 and 26 weeks, respectively; p = 0.079 for overall difference). Other secondary and exploratory outcomes were not different. Teriparatide group showed two new hip fractures versus seven with risedronate (p = 0.171) and more frequent hypercalcemia and hyperuricemia. In conclusion, 78-week treatment with teriparatide showed significantly greater increases in LS and FN BMD, less pain, and a faster TUG test versus risedronate. © 2016 American Society for Bone and Mineral Research.

Blood transfusion strategy and risk of postoperative delirium in nursing homes residents with hip fracture. A post hoc analysis based on the TRIFE randomized controlled trial.

OBJECTIVES: To investigate whether a liberal blood transfusion strategy [Hb levels ≥11.3 g/dL (7 mmol/L)] reduces the risk of postoperative delirium (POD) on day 10, among nursing home residents with hip fracture, compared to a restrictive transfusion strategy [Hb levels ≥9.7 g/dL (6 mmol/L)]. Furthermore, to investigate whether POD influences mortality within 90 days after hip surgery. METHODS: This is a post hoc analysis based on The TRIFE - a randomized controlled trial. Frail anemic patients from the Orthopedic Surgical Ward at Aarhus University Hospital were enrolled consecutively between January 18, 2010 and June 6, 2013. These patients (aged ≥65 years) had been admitted from nursing homes for unilateral hip fracture surgery. After surgery, 179 patients were included in this study. On the first day of hospitalization, all enrolled patients were examined for cognitive impairment (assessed by MMSE) and delirium (assessed by CAM). Delirium was also assessed on the tenth postoperative day. RESULTS: The prevalence of delirium was 10 % in patients allocated to a liberal blood transfusion strategy (LB) and 21 % in the group with a restrictive blood transfusion strategy (RB). LB prevents development of delirium on day 10, compared to RB, odds ratio 0.41 (95 % CI 0.17-0.96), p = 0.04. Development of POD on day 10 increased the risk of 90-day death, hazard ratio 3.14 (95 % CI 1.72-5.78), p < 0.001. CONCLUSION: In nursing home residents undergoing surgery for hip fracture, maintaining hemoglobin level above 11.3 g/dL reduces the rate of POD on day 10 compared to a RB. Development of POD is associated with increased mortality.

Effects of Teriparatide Compared with Risedronate on Recovery After Pertrochanteric Hip Fracture: Results of a Randomized, Active-Controlled, Double-Blind Clinical Trial at 26 Weeks.

BACKGROUND: Osteoporosis drugs might affect fracture-healing. We therefore studied the effects of teriparatide in comparison with risedronate on recovery after pertrochanteric hip fractures. METHODS: The study was a randomized, multicenter, active-controlled, 78-week trial comparing teriparatide (20 µg/day) with risedronate (35 mg/week) initiated within 2 weeks after fixation of a low-trauma pertrochanteric hip fracture (AO/OTA 31-A1 or 31-A2). The main inclusion criteria were a bone mineral density T-score of ≤-2.0 and 25-OH-vitamin D of ≥9.2 ng/mL. During the first 26 weeks, patients received study medication with oral or injectable placebo plus calcium and vitamin D in a double-blinded fashion. Secondary (Timed Up-and-Go [TUG] test, hip pain, Short Form [SF]-36 health status, and safety) and exploratory (radiographic outcomes and ability to walk) 26-week end points are reported. RESULTS: Of the 224 patients who were randomized, 171 (86 teriparatide, 85 risedronate) were included in the analysis. The mean age was 77 ± 8 years, 77% were female, and 26% had a prior history of low-trauma fracture. The teriparatide group completed the TUG test in a shorter time at 6, 12, 18, and 26 weeks (differences of -5.7, -4.4, -3.1, and -3.1 seconds, respectively; p = 0.021 for the overall difference). They also reported less pain on a visual analog scale immediately after the TUG test at 12 and 18 weeks (adjusted absolute differences of 10.6 and 11.9 mm, respectively; p < 0.05). There were no significant between-group differences in the SF-36 score, Charnley hip pain score, ability to walk, or use of walking aids during follow-up. Radiographic healing at 6, 12, and 26 weeks, mechanical failure of the implant (teriparatide, 7; risedronate, 8), loss of reduction (teriparatide, 2; risedronate, 4), and nonunion (0 cases) were not significantly different. Mild hypercalcemia and hyperuricemia were more frequent with teriparatide. CONCLUSIONS: Teriparatide was associated with less pain and a shorter time to complete the TUG test between 6 and 26 weeks compared with risedronate. Other fracture-recovery outcomes were similar. The results should be interpreted with caution as these were secondary end points. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Blood transfusion and overall quality of life after hip fracture in frail elderly patients--the transfusion requirements in frail elderly randomized controlled trial.

BACKGROUND: We examined possible associations between different red blood cell (RBC) transfusion strategies, overall quality of life (OQoL), and recovery of activities of daily living (ADL) in operated frail elderly hip fracture patients, and the possibility that OQoL was related to ADL recovery. METHODS: A prospective, assessor-blinded, randomized controlled trial was carried out among 157 elderly residents (≥65 years) from nursing homes and sheltered housing facilities with Mini-Mental State Examination scores ≥5 points. Patients were assigned to either a restrictive RBC transfusion strategy [hemoglobin (Hb) < 9.7 g/dL, 6 mmol/L] or a liberal strategy (Hb < 11.3 g/dL, 7 mmol/L) during the first 30 days after surgery. An interview-based questionnaire, the depression list (DL) assessing OQoL, and the modified Barthel Index (MBI) assessing ADL performance, were conducted on day 30 and 1 year after hip fracture surgery. Sum-scores of DL, MBI, and their changes from day 30 until 1 year (expressing recovery) were compared between RBC transfusion groups. Possible associations between changes of DL and MBI sum-scores were tested for across total patient population. RESULTS: There was no association between OQoL and RBC transfusion strategies on day 30 or at 1 year. The DL sum-score changes were similar for both groups, (ie, 1.06 points) [95% confidence interval (CI) -0.62, 2.76)] P = .21. The MBI sum-scores increased at 1 year following the liberal transfusion strategy (ie, by 6.86 points) (95% CI 0.41, 13.3) P = .03. Recoveries of OQoL and ADL were associated: ß = -0.06 (95% CI -0.11, -0.01) P = .02. CONCLUSIONS: According to our Hb threshold criteria, OQoL and RBC transfusion strategies for frail elderly hip fracture patients are not associated. However, for survivors with less severe dementia, ADL recovery after 1 year is greater following a liberal transfusion strategy than a restrictive strategy. OQoL progress and ADL recovery were associated.

Blood transfusion and risk of infection in frail elderly after hip fracture surgery: the TRIFE randomized controlled trial.

OBJECTIVES: It is still under debate that red blood cell (RBC) transfusions might increase the risk of healthcare-associated infections after hip fracture surgery. Previously, we found that a liberal RBC transfusion strategy improved survival in nursing home residents. Our aim, therefore, was to investigate whether a more liberal RBC transfusion strategy was associated with a higher infection risk in frail elderly hip fracture patients. DESIGN: Prospective, assessor-blinded, randomized and controlled trial. SETTINGS: Orthopedic ward, Geriatric ward, and Hospital-at-home. PATIENTS: 284 consecutively hospital-admitted elderly with hip fracture from nursing homes or sheltered housing facilities were included. INTERVENTION: A restrictive RBC transfusion strategy (hemoglobin <9.7 g/dL; 6 mmol/L) compared with a liberal strategy (hemoglobin <11.3 g/dL; 7 mmol/L) administered within 30 days after surgery. MAIN OUTCOME MEASUREMENTS: Leukocytes and C-reactive protein (CRP) in repeated blood samples within 30 days, and number of all infections (pneumonia, urinary tract infection, and other infections) within 10 days. RESULTS: 88 % of the patients received a RBC transfusion. A median of 1 RBC unit (interquartile range (IQR): 1-2) was transfused for the restrictive strategy group versus 3 RBC units (IQR: 2-5) for the liberal group. Leukocytes and CRP measurements were similar for both groups. Rates of infection were 72 % for the restrictive group compared to 66 % for the liberal group (risk ratio 1.08; 95 % confidence interval 0.93-1.27, p value 0.29). CONCLUSIONS: A more liberal RBC transfusion strategy was not associated with higher risk of infection among residents from nursing homes or sheltered housing undergoing hip fracture surgery.

Postoperative blood transfusion strategy in frail, anemic elderly patients with hip fracture: the TRIFE randomized controlled trial.

BACKGROUND AND PURPOSE: Hip fracture (HF) in frail elderly patients is associated with poor physical recovery and death. There is often postoperative blood loss and the hemoglobin (Hb) threshold for red blood cell (RBC) transfusions in these patients is unknown. We investigated whether RBC transfusion strategies were associated with the degree of physical recovery or with reduced mortality after HF surgery. PATIENTS AND METHODS: We enrolled 284 consecutive post-surgical HF patients (aged ≥ 65 years) with Hb levels < 11.3 g/dL (7 mmol/L) who had been admitted from nursing homes or sheltered housing. Allocation was stratified by residence. The patients were randomly assigned to either restrictive (Hb < 9.7 g/dL; < 6 mmol/L) or liberal (Hb < 11.3 g/dL; < 7 mmol/L) RBC transfusions given within the first 30 days postoperatively. Follow-up was at 90 days. RESULTS: No statistically significant differences were found in repeated measures of daily living activities or in 90-day mortality rate between the restrictive group (where 27% died) and the liberal group (where 21% died). Per-protocol 30-day mortality was higher with the restrictive strategy (hazard ratio (HR) = 2.4, 95% CI: 1.1-5.2; p = 0.03). The 90-day mortality rate was higher for nursing home residents in the restrictive transfusion group (36%) than for those in the liberal group (20%) (HR = 2.0, 95% CI: 1.1-3.6; p = 0.01). INTERPRETATION: According to our Hb thresholds, recovery from physical disabilities in frail elderly hip fracture patients was similar after a restrictive RBC transfusion strategy and after a liberal strategy. Implementation of a liberal RBC transfusion strategy in nursing home residents has the potential to increase survival.

Prothrombin fragment 1+2 in urine as a marker on coagulation activity in patients with suspected pulmonary embolism.

INTRODUCTION: We have recently reported that increased levels of urine prothrombin fragment 1+2 reflected radiologically verified deep vein thrombosis. In this study we evaluated whether urine prothrombin fragment 1+2 was associated with pulmonary embolism in non-selected patients. MATERIALS AND METHODS: Patients with clinical suspected pulmonary embolism were interviewed on comorbidities and medications. Urine was collected from each patient before radiological examination and snap frozen until analysed on urine prothrombin fragment 1+2 with an ELISA kit. Imaging of the pulmonary arteries were conducted with contrast enhanced computer tomography. RESULTS: Pulmonary embolism was diagnosed in 44/197 patients. Non-significantly higher urine prothrombin fragment 1+2 levels were found in non-selected patients with pulmonary embolism vs. those without (p=0.324). Significantly higher urine prothrombin fragment 1+2 levels were found in the pulmonary embolism positive patients without comorbidities (n=13) compared to the control group (n=28) (p=0.009). The calculated sensitivity, specificity and negative predictive value using the lowest detectable urine prothrombin fragment 1+2 level was 82%, 34% and 87%, respectively. CONCLUSIONS: There was no significant urine prothrombin fragment 1+2 level difference in patients with and without pulmonary embolism. In non-comorbide pulmonary embolism positive patients the urine prothrombin fragment 1+2 levels were significantly higher compared to the control group. The negative predictive value found in this study indicates that uF1+2 has the potential to identify patients with a low risk of PE.

Thrombin split products (prothrombin fragment 1 + 2) in urine in patients with suspected deep vein thrombosis admitted for radiological verification.

INTRODUCTION: The appearance of prothrombin fragment 1 + 2 (F1 + 2) in urine has been associated with postoperative hypercoagulability and thromboembolism. We wanted to assess if F1 + 2 was released in urine (uF1 + 2) in patients with procoagulant disorders, and if higher levels were found in patients with radiological verified deep vein thrombosis (DVT). MATERIALS AND METHODS: Consecutive patients were interviewed on comorbidities and medications. An unselected total cohort (n = 534) and a control cohort (n = 177) were analysed. A urine sample (10 ml) was collected and snap frozen before levels of uF1 + 2 were measured with an ELISA kit. Visualisation of DVT was done with compression ultrasound, supplied with venography when feasible. All patients were followed up for 3-6 months. RESULTS: DVT was diagnosed in 108/534 patients. Statistical significant higher uF1 + 2 levels were found in patients with DVT (p < 0.001), in DVT positive patients with ongoing malignancy (p = 0.034) and in pregnant women compared to the control cohort (p < 0.001). Non-significant increased urine concentrations were found in DVT positive vs. DVT negative patients with infections and traumas. CONCLUSIONS: Levels of uF1 + 2 was associated with DVT both in the total cohort and in the control cohort as well as in most patients with coexisting conditions.

[Collaboration between geriatricians and orthopaedic surgeons on elderly patients]. / Samarbejde mellem geriatri og ortopædkirurgi hos ældre patienter.

Close collaboration between geriatricians and orthopaedic surgeons on elderly patients with hip fractures reduces mortality, the number of complications, and the length of hospital stay and increases the functional abilities of the patients. In some Danish hospitals the two groups of doctors work closely together, in others there are few or no geriatricians.