Thirty-day mortality following surgical management of hip fractures during the COVID-19 pandemic: findings from a prospective multi-centre UK study.

PURPOSE: Thirty-day mortality of patients with hip fracture is well researched and predictive; validated scoring tools have been developed (Nottingham Hip Fracture Score, NHFS). COVID-19 has significantly greater mortality in the elderly and comorbid patients which includes hip fracture patients. Non-operative treatment is not appropriate due to significantly higher mortality, and therefore, these patients are often exposed to COVID-19 in the peri-operative period. What is unclear is the effect of concomitant COVID-19 infection in these patients. METHODS: A multicentre prospective study across ten sites in the United Kingdom (responsible for 7% of hip fracture patients per annum in the UK). Demographic and background information were collected by independent chart review. Data on surgical factors included American Society of Anesthesiologists (ASA) score, time to theatre, Nottingham Hip fracture score (NHFS) and classification of fracture were also collected between 1st March 2020 and 30th April 2020 with a matched cohort from the same period in 2019. RESULTS: Actual and expected 30-day mortality was found to be significantly higher than expected for 2020 COVID-19 positive patients (RR 3.00 95% CI 1.57-5.75, p < 0.001), with 30 observed deaths compared against the 10 expected from NHFS risk stratification. CONCLUSION: COVID-19 infection appears to be an independent risk factor for increased mortality in hip fracture patients. Whilst non-operative management of these fractures is not suggested due to the documented increased risks and mortality, this study provides evidence to the emerging literature of the severity of COVID-19 infection in surgical patients and the potential impact of COVID-19 on elective surgical patients in the peri-operative period.

Correction to: Thirty-day mortality following surgical management of hip fractures during the COVID-19 pandemic: findings from a prospective multi-centre UK study.

The published online version contains mistake, as the Fig. 1 legend should read "Kaplan-Meier survival curve for 30-day survival for 2020 cohort COVID-19 positive vs COVID-19 negative" whilst the Fig. 2 legend should read "Kaplan-Meier survival curve for 30-day survival 2020 COVID-19 negative group vs 2019 cohort".

Predictors of mortality in the elderly patient with a fracture of the odontoid process.

AIMS: Fracture of the odontoid process (OP) in the elderly is associated with mortality rates similar to those of hip fracture. The aim of this study was to identify variables that predict mortality in patients with a fracture of the OP, and to assess whether established hip fracture scoring systems such as the Nottingham Hip Fracture Score (NHFS) or Sernbo Score might also be used as predictors of mortality in these patients. PATIENTS AND METHODS: We conducted a retrospective review of patients aged 65 and over with an acute fracture of the OP from two hospitals. Data collected included demographics, medical history, residence, mobility status, admission blood tests, abbreviated mental test score, presence of other injuries, and head injury. All patients were treated in a semi-rigid cervical orthosis. Univariate and multivariate analysis were undertaken to identify predictors of mortality at 30 days and one year. A total of 82 patients were identified. There were 32 men and 50 women with a mean age of 83.7 years (67 to 100). RESULTS: Overall mortality was 14.6% at 30 days and 34.1% at one year. Univariate analysis revealed head injury and the NHFS to be significant predictors of mortality at 30 days and one year. Multivariate analysis showed that head injury is an independent predictor of mortality at 30 days and at one year. The NHFS was an independent predictor of mortality at one year. The presence of other spinal injuries was an independent predictor at 30 days. Following survival analysis, an NHFS score greater than 5 stratified patients into a significantly higher risk group at both 30 days and one year. CONCLUSION: The NHFS may be used to identify high-risk patients with a fracture of the OP. Head injury increases the risk of mortality in patients with a fracture of the OP. This may help to guide multidisciplinary management and to inform patients. This paper provides evidence to suggest that frailty rather than age alone may be important as a predictor of mortality in elderly patients with a fracture of the odontoid process. Cite this article: Bone Joint J 2019;101-B:253-259.

Consenting patients with femoral neck fractures--how well are we involving the patient's relatives?

The consent process is a vital part of the in-patient journey for patients admitted with a fractured neck of femur. However, an aspect that is frequently over-looked is the involvement of a patient's next of kin. We organised a pilot study in our institution to see what steps we could take to make improvements in the way that next of kin involvement was managed, in line with widespread national guidelines.

Temporal variation in major trauma admissions.

INTRODUCTION: Trauma is a significant cause of morbidity and mortality in the UK. Since the inception of the trauma networks, little is known of the temporal pattern of trauma admissions. METHODS: Trauma Audit and Research Network data for 1 April 2011 to 31 March 2013 were collated from two large major trauma centres (MTCs) in the South East of England: Brighton and Sussex University Hospitals NHS Trust (BSUH) and St George's University Hospitals NHS Foundation Trust (SGU). The number of admissions and the injury severity score by time of admission, by weekdays versus weekend and by month/season were analysed. RESULTS: There were 1,223 admissions at BSUH and 1,241 at SGU. There was significant variation by time of admission; there were more admissions in the afternoons (BSUH p<0.001) and evenings (SGU p<0.001). There were proportionally more admissions at the weekends than on weekdays (BSUH p<0.001, SGU p=0.028). There was significant seasonal variation in admissions at BSUH (p<0.001) with more admissions in summer and autumn. No significant seasonal variation was observed at SGU (p=0.543). CONCLUSIONS: The temporal patterns observed were different for each MTC with important implications for resource planning of trauma care. This study identified differing needs for different MTCs and resource planning should be individualised to the network.

A comparative analysis of the patient characteristics and cost of managing intravenous drug users (IVDU) with soft tissue abscesses with non-IVDU.

BACKGROUND: Intravenous drug users (IVDU) often present to hospitals with complex co-morbidities, associated with prolonged in-patient admissions. The aim of this study was to compare a cohort of IVDU patients with soft tissue abscesses with non-IVDUs. We analysed the demographics, comorbidities, location of abscesses, multidisciplinary input and financial costs of managing both groups. METHODS: A retrospective cohort study was conducted between January 2010 and September 2013. Two age and sex matched cohorts were compared: IVDU and non-IVDU. RESULTS: We identified 44 IVDU patients and 54 non-IVDU patients. The IVDU had higher rates of smoking (89% p < 0.001) and unemployment (73% p < 0.05). The most common comorbidities in the IVDU cohort were hepatitis C (17%) and HIV (14%), whereas diabetes mellitus (15%) and hypertension (11%) were the most common in the non-IVDUs (p < 0.01). The most common location for an abscess in non-IVDU patients was the hand, whereas IVDU patients had abscesses in their groin. Groin injecting led to a referral to multiple specialties. The median length of stay for the IVDU patients was 4 days and for non-IVDU patients 1 day (p < 0.01). The average cost of managing IVDU patients in our unit was £1280: for non- IVDU the cost was £530 (p < 0.001). CONCLUSIONS: IVDU patients with soft tissue abscesses have higher rates of smoking, unemployment, infection with hepatitis C and HIV compared to a control group. We have suggested several recommendations to optimise the management of these patients including the implementation of an additional code to compensate for the complexity of their management.

An opportunity in op-notes.

Operative notes in surgical practice are a vital source of information and communication between healthcare professionals as well as being a legal document. Errors and omissions can have serious effects on patient care and lead to confusion. We audited our compliance within trauma and orthopaedics at a busy district general hospital in South East England with the standard set by the Royal College of Surgeons (England) before and after the introduction of an operation note template. We achieved significant improvements in compliance across almost all of the standard's domains and recommend widespread implementation of similar templates nationally.

Perioperative management of traumatic limb amputations due to civilian trauma: current practice and future directions.

Traumatic limb amputations are serious injuries. They require urgent multidisciplinary management and emergency surgical intervention to save life and, where possible, preserve limb function. It is therefore vital that perioperative management follows established evidence-based principles to optimise outcomes. In recent years a vast quantity of research on traumatic amputations in the military setting has been published, but civilian injuries, which often have strikingly different mechanisms, have been neglected. This article reviews existing information on epidemiology, pathophysiology, perioperative management strategies, outcomes and future directions in the field.

Preoperative albumin as a predictor of one-year mortality in patients with fractured neck of femur.

A simple measure to determine one-year mortality following hip fractures has its benefits. Where there is controversy over implant selection, such a scoring system can facilitate the decision-making process. We undertook a retrospective analysis of one-year postoperative mortality of our hip fracture patients and established their admission serum albumin levels to see if there was any correlation between this and one-year mortality. Our results showed one-year mortality was significantly higher (p =0.0049) for those patients with a serum albumin of <35 g/dl. Of the patients with low albumin, we found that there was no statistical significance between one-year mortality and source of admission (p =0.0789). Prefracture serum albumin can be used as a simple predictor of one-year mortality in patients presenting with a fractured neck of femur, thereby aiding operative planning and implant selection with a view to likely survival and possible need for revision.

Increasing compliance with the World Health Organisation's Surgical Safety Checklist.

The World Health Organisation Surgical Safety Checklist (WHO SSC) is a validated tool for reducing in-patient surgical morbidity and mortality. It is not performed universally with full compliance. Two audit cycles were completed at two different trauma and orthopaedic units and compliance was measured. Site 1 was found to have a significantly lower compliance with the team-brief (p<0.001). Following a change in practice the compliance significantly increased (p>0.00001) at Site 1. The team de-brief was found to be consistently poorly complied with. We recommend regular audit of compliance and change in practice for all surgical units, and suggest national monitoring to ensure the benefits of the WHO checklist are applied to all in-patient surgery.

Predicting postoperative urinary retention after lower limb arthroplasty.

A simple scoring system that enables surgeons to make an estimation of the likelihood of postoperative urinary retention (POUR) in patients undergoing lower limb total joint replacement would be a useful one. This would enable selection of high risk patients who merit pre-operative catheterisation in a clean theatre environment rather than risking urinary retention and its associated complications late at night on the ward by junior, inexperienced staff. The International Prostate Symptom Score (IPSS) is such a scoring system and we assessed its reliability in predicting those male patients likely to go into POUR. We selected all male patients undergoing lower limb total joint arthroplasty under spinal anaesthesia and calculated their IPSS. We found a statistically significant increase in the likelihood of POUR as IPSS rises (p = 0.0002). We concluded that the IPSS is a quick and easy method of predicting those at risk of POUR, allowing them to be catheterised prophylactically, preventing possible complications.

Complications and reintervention following elective open abdominal aortic aneurysm repair: a 10-year retrospective analysis.

INTRODUCTION: Recent data have shown higher rates of graft related complication or reintervention in patients undergoing endovascular aneurysm repair compared with open aneurysm surgery (OAS). However, there are fewer data available regarding procedure related reinterventions following OAS. The aim of this study was to investigate the incidence of procedure related complications and reintervention following elective open abdominal aortic aneurysm repair. METHODS: This was a retrospective analysis of prospectively collected data from the dedicated Portsmouth POSSUM database. Data from 361 patients (median age: 72 years, 91.4% male) who underwent elective OAS between 1993 and 2004 were analysed. The incidences of early and late complications and subsequent reintervention were investigated. RESULTS: The median follow-up duration was 10 years 4 months (range: 5 years - 16 years 4 months). There were 52 reinterventions in the follow-up period. Of these, 34.6% were for incisional hernias or small bowel obstruction with the majority of the remaining laparotomies performed for bleeding or distal ischaemic complications. Almost two-thirds (63.5%) of reinterventions occurred in the first 30 days. There were 30 emergency readmissions to the acute surgical wards that did not require reintervention. CONCLUSIONS: OAS carries a significant reintervention rate. In this study, 54% of reinterventions were directly related to laparotomy.

Psychological disorders in survivors of torture: exhaustion, impairment and depression.

Post-traumatic stress disorder (PTSD) has been described as the characteristic sequel to extreme events in life such as war and especially torture. This limitation to a single approach in regard to diagnosis and treatment has been criticised as being a too narrow concept to describe the effects following extreme events in life, especially as most studies so far were limited to PTSD and a small range of symptoms or disorders. The study presents data on psychiatric disorders in a group of exiled survivors of torture presenting to an out-patient department for psychiatry. A DSM-III-R-based psychiatric interview, including the general assessment of functioning scale (GAF), an open list of symptoms and the Vienna diagnostic criteria in regard to depression were used to evaluate a broader range of possible sequels. The most frequent present diagnosis in 44 patients seen over a period of 3 years was PTSD (n = 40), but criteria for a present diagnosis of other disorders were fulfilled in 34 patients, even years after torture, mainly major depression or dysthymia (n = 26). Criteria for functional psychosis were fulfilled in 4 patients. Many patients reported symptoms not assessed by DSM-III-R criteria, including feelings of shame and guilt, and ruminations on existential fears. The impairment as indicated by the GAF (mean 59.1) correlated best with the presence of the endogenomorphic-depressive axial syndrome, but not with duration of imprisonment, age or other factors. Research on sequels to extreme trauma should not be restricted to a simple diagnosis of PTSD, but should continue to look for a broader conceptualisation, including neglected categories like the axial syndrome, as PTSD is common, but might not be the only factor of importance for research and treatment. ICD-10 might offer a more adequate interpretation of sequels.

Capgras syndrome and functional psychosis in 2 survivors of torture.

Functional psychosis has only rarely been described in context with extreme stressors, most studies focusing singularly on posttraumatic stress disorder symptoms. We report for the first time the case histories of 2 patients suffering from Capgras syndrome along with schizoaffective disorder and posttraumatic stress disorder after prior experience of prolonged torture. Interaction of personal life experience and psychiatric disorder are proposed as factors resulting in persistent changes in perception and affect.

Predicting course and outcome in delusional psychoses.

Eighty-four of 90 patients with delusional syndromes of different nosological attribution underwent a 7-year follow-up. From 179 items covering the whole spectrum of psychiatric description of index examination, 20 were found to be statistically significant in predicting different aspects of course and outcome by stepwise discriminant analysis. Course and outcome were defined by 6 criteria (course of illness, course of delusion, development of deficiency, length of inpatient care, adequate activity and social adjustment) encompassing separate (but only partly independent) aspects of a disorder. In contrast to the literature, clinical and psychopathological variables have major prognostic weight for different psychopathological as well as psychosocial aspects of outcome. Ten of the 20 significant items cover psychopathology, 4 pre-index course, 3 precipating events, 2 data from childhood, and 1 premorbid personality. Our results stress the importance of sensitive data collection and a clear separation of different outcome variables.

Prognosis of cardiac phobia.

The 36 inpatients who entered this prospective study were admitted to hospital because of cardiac phobia. Their treatment consisted of a behavior therapy program. Twenty-nine of them could be reexamined after 2 1/2 years: 41% were free of symptoms during more than 75% of the follow-up period; 59% suffered recurrences of their anxiety. One patient had committed suicide. A lower educational level, being single, and interpersonal difficulties and conflicts were the sociodemographic factors associated with a poor prognosis; a long pretreatment period of illness and the presence of depression or agoraphobia on admission were significantly more frequently correlated with an unfavorable outcome. The onset sequence of depression, agoraphobia and anxiety attacks was also of prognostic relevance.

Dysphoric states in the course of manic-depressive illness.

The purpose of the present study is to investigate the relationship between dysphoric states (episodes in which irritable mood is prominent and relatively persistent) and manic-depressive illness. A further purpose is to clarify the probable causal influence of chemotherapy and the social consequences concerning dysphoria. The observations carried out on 14 patients are illustrated by 2 case reports. A strong tie seems to exist between dysphoric state and manic-depressive illness, especially with respect to typical biorhythmic disturbances. Although the origin of such states is generally unknown, there are indications that neuroleptics and lithium may play a major role. Social consequences are on the whole minor, if the disturbances in mood and drive occur acutely and markedly. On the other hand, mild to moderate mood changes (especially when unaccompanied by drive changes) may lead to severe social impairment. The reason for this may be that the latter-mentioned states are misinterpreted by the entourage as personality traits rather than as expressions of an illness.

Approaches to the assessment of schizophrenia in Europe.

All definitions of schizophrenia rely more or less on Kraepelin's hypothesis, Bleuler's theory or Schneider's pragmatic criteria. After a discussion on how these assumptions are referred to in classical and operational diagnostic systems in Europe, the results of a survey of 1983 literature are presented to show what kinds of assessments European workers currently employ. Lastly, guidelines are presented to enable psychopharmacological research to make the best use of the diagnostic systems to suit its purposes: essentially, which system or systems (the polydiagnostic approach for example) one should choose depends upon the symptoms the medication to be tested is supposed to treat, keeping in mind that patient sampling varies according to the system in question.