Management of patients with hip fracture receiving anticoagulation: What are we doing in Canada?

BACKGROUND: Direct oral anticoagulants (DOACs) are rapidly replacing warfarin for therapeutic anticoagulation; however, many DOACs are irreversible and may complicate bleeding in emergent situations such as hip fracture. In this setting, there is a lack of clear guidelines for the timing of surgery. The purpose of this study was to evaluate the current practices of Canadian orthopedic surgeons who manage patients with hip fracture receiving anticoagulation. METHODS: In January-March 2018, we administered a purpose-specific cross-sectional survey to all currently practising orthopedic surgeons in Canada who had performed hip fracture surgery in 2017. The survey evaluated approaches to decision-making and timing of surgery in patients with hip fracture receiving anticoagulation. RESULTS: A total of 280 surgeons representing a mix of academic and community practice, seniority and fellowship training responded. Nearly one-quarter of respondents (66 [23.4%]) were members of the Canadian Orthopaedic Trauma Society (COTS). Almost three-quarters (206 [73.6%]) felt that adequate clinical guidelines for patients with hip fracture receiving anticoagulation did not exist, and 177 (61.9%) indicated that anesthesiology or internal medicine had a greater influence on the timing of surgery than the attending surgeon. A total of 117/273 respondents (42.9%) indicated that patients taking warfarin should have immediate surgery (with or without reversal), compared to 63/270 (23.3%) for patients taking a DOAC (p < 0.001). Members of COTS were more likely than nonmembers to advocate for immediate surgery in all patients (p < 0.05). CONCLUSION: There is wide variability in Canada in the management of patients with hip fracture receiving anticoagulation. Improved multidisciplinary communication, prospectively evaluated treatment guidelines and focus on knowledge translation may add clarity to this issue. LEVEL OF EVIDENCE: IV.

Septicemic pasteurellosis causing peracute death and necrotizing myositis in a beef heifer calf (Bos taurus) in Alberta, Canada.

Septicemic pasteurellosis is an acute and fatal bacterial disease of cattle and wild ungulates caused by certain serotypes of Pasteurella multocida. Here we report a single case of septicemic pasteurellosis in a 6-month-old, Red Angus heifer from a cow-calf operation in Alberta, Canada. Postmortem examination revealed necrotizing and hemorrhagic myositis, fibrinous pericarditis and multisystemic bacterial emboli. Pasteurella multocida was isolated from muscle in pure culture, and the capsular antigen group was identified as serogroup B using polymerase chain reaction. To the best of our knowledge, this is the first reported case of septicemic pasteurellosis in beef cattle in Canada. Key clinical message: Veterinary practitioners and diagnosticians should include septicemic pasteurellosis on their list of differential diagnoses when they encounter similar presentations of peracute death and severe necrotizing myositis in cattle in Canada.

Pasteurellose septicémique causant la mort suraiguë et une myosite nécrosante d'une génisse d'embouche ( Bos taurus ) en Alberta, Canada. La pasteurellose septicémique est une maladie bactérienne aiguë et fatale des bovins et des ongulés sauvages causée par certains sérotypes de Pasteurella multocida. Nous rapportons ici un cas unique de pasteurellose septicémique chez une génisse Red Angus âgée de 6 mois provenant d'un élevage vache-veau en Alberta, Canada. L'examen post-mortem a révélé une myosite nécrosante et hémorragique, une péricardite fibrineuse et des embolies bactériennes multi-systémiques. Pasteurella multocida fut isolé du muscle en culture pure, et l'antigène de groupe capsulaire fut identifié comme étant le sérogroupe B à l'aide de la réaction d'amplification en chaîne utilisant la polymérase. À notre connaissance ceci représente le premier cas rapporté de pasteurelle septicémique chez des bovins d'embouche au Canada.Message clinique clé:Les vétérinaires praticiens et les diagnosticiens devraient inclure la pasteurellose septicémique sur leur liste de diagnostic différentiel lorsqu'ils rencontrent des présentations similaires de mortalité suraiguë et de myosite nécrosante sévère chez des bovins au Canada.(Traduit par Dr Serge Messier).

An Innovative Ergometer to Measure Neuromuscular Fatigue Immediately after Cycling.

PURPOSE: When assessing neuromuscular fatigue (NMF) from dynamic exercise using large muscle mass (e.g., cycling), most studies have delayed measurement for 1 to 3 min after task failure. This study aimed to determine the reliability of an innovative cycling ergometer permitting the start of fatigue measurement within 1 s after cycling. METHODS: Twelve subjects participated in two experimental sessions. Knee-extensor NMF was assessed by electrical nerve and transcranial magnetic stimulation with both a traditional chair setup (PRE- and POST-Chair, 2 min postexercise) and the new cycling ergometer (PRE, every 3 min during incremental exercise and POST-Bike, at task failure). RESULTS: The reduction in maximal voluntary contraction force POST-Bike (63% ± 12% PRE; P < 0.001) was not different between sessions and there was excellent reliability at PRE-Bike (intraclass correlation coefficient [ICC], 0.97; coefficients of variation [CV], 3.2%) and POST-Bike. Twitch (Tw) and high-frequency paired-pulse (Db100) forces decreased to 53% ± 14% and 62% ± 9% PRE, respectively (P < 0.001). Both were reliable at PRE-Bike (Tw: ICC, 0.97; CV, 5.2%; Db100: ICC, 0.90; CV, 7.3%) and POST-Bike (Tw: ICC, 0.88; CV, 11.9; Db100: ICC, 0.62; CV, 9.0%). Voluntary activation did not change during the cycling protocol (P > 0.05). Vastus lateralis and rectus femoris M-wave and motor-evoked potential areas showed fair to excellent reliability (ICC, 0.45-0.88). The reduction in maximal voluntary contraction and Db100 was greater on the cycling ergometer than the isometric chair. CONCLUSIONS: The innovative cycling ergometer is a reliable tool to assess NMF during and immediately postexercise. This will allow fatigue etiology during dynamic exercise with large muscle mass to be revisited in various populations and environmental conditions.