Effect of institution volume on mortality and outcomes in osteoporotic hip fracture care.

Hospitals that treat more patients with osteoporotic hip fractures do not generally have better care outcomes than those that treat fewer hip fracture patients. Institutions that do look after more such patients tend, however, to more consistently perform relevant health assessments. INTRODUCTION: An inveterate link has been found between institution case volume and a wide range of clinical outcomes; for a host of medical and surgical conditions. Hip fracture patients, notwithstanding the significance of this injury, have largely been overlooked with regard to this important evaluation. METHODS: We used the UK National Hip Fracture database to determine the effect of institution hip fracture case volume on hip fracture healthcare outcomes in 2019. Using logistic regression for each healthcare outcome, we compared the best performing 50 units with the poorest performing 50 institutions to determine if the unit volume was associated with performance in each particular outcome. RESULTS: There were 175 institutions with included 67,673 patients involved. The number of hip fractures between units ranged from 86 to 952. Larger units tendered to perform health assessments more consistently and mobilise patients more expeditiously post-operatively. However, patients treated at large institutions did not have any shorter lengths of stay. With regard to most other outcomes there was no association between the unit number of cases and performance; notably mortality, compliance with best practice tariff, time to surgery, the proportion of eligible patients undergoing total hip arthroplasty, length of stay delirium risk and pressure sore risk. CONCLUSIONS: There is no relationship between unit volume and the majority of health care outcomes. It would seem that larger institutions tend to perform better at parameters that are dependent upon personnel numbers. However, where the outcome is contingent, even partially, on physical infrastructure capacity, there was no difference between larger and smaller units.

Heliovaccination: Solar mediated immunity against cancer.

The protective effect of ultraviolet (UV) light against a host of malignancies is well characterised. It was recognised by WHO in their 2006 publication on the global burden of UV-mediated disease. The mechanism by which this oncoprotective effect occurs remains unclear. Vitamin D has been mooted as a potential mediator. However, the evidence does not support this. I suggest that UV irradiation of the skin produces nascent malignant and premalignant cells with associated generic tumor-specific antigens. These are eliminated by immunosurveillance resulting in adaptive immunity. The clonal expansion of these immune cells protects against tumors in other viscera, effectively immunising the host. The evidence for this "heliovaccination" is very strong. Childhood UV exposure protects against cancer in adulthood. Tumor naïve individuals possess anti-tumor antibodies. Antigen-presenting cells mobilise to the skin following specifically UVB skin irradiation. It is time to rethink the link between UV light and cancer.

Patents and intellectual property in orthopaedics and arthroplasty.

The provision of musculoskeletal services comes at a cost. This is, in part, due to the expense of patent-protected orthopaedic implants. However, patents have a finite lifespan. Patents of the most successful implants are now beginning to expire. They will be exposed to competition from generic but equivalent implants. The net effect is potentially a dramatic diminution in cost. One company, Orthimo, has taken advantage of this and begun manufacturing generic implants with identical design specifications to the most bio-durable hip prostheses. This will ultimately have a radical impact upon musculoskeletal healthcare provision with regard to cost and accessibility. The expiration of drug patents, with the subsequent use of generic drugs saves £7.1 billion annually in the United Kingdom and $254 billion in the USA. Estimates suggest the introduction of equivalent implants could result in an annual cost saving to the United Kingdom National Health Service of £120 million. Intellectual property remains an enigmatic area of law. It encompasses anodyne principles that seek to protect innovation but are open to manipulation and exploitation. The last decade has seen the emergence of undesirable practices in the medical industry such as "patent trolling". Here we explore patents and their repercussions for musculoskeletal care.

Male pattern hair loss: Taking one for the team: The selfless gene.

Male pattern hair loss (MPHL) is exceedingly common. It is characterised by onset in early adulthood and progression with age. It has a strong heritable component. The reason for its existence remains unexplained. Given that MPHL is progressive and has its earliest manifestations in young adults it may be a barometer of age. Here we suggest that MPHL may have atavistically allowed women in our species and ancestor species to select younger (but not necessarily the youngest) adult mates. Evidence suggests that conceptions by younger fathers are more likely to lead to live births and less likely to result in miscarriage. Further children fathered by younger men may have improved health and be less likely to suffer from a number of co-morbidities. This is collectively known as the "paternal age affect". Hence the selection of younger males mediated by the MPHL may improve the fitness of the population and of the species at the expense of the individual. Indeed MPHL may have been an evolutionary "nudge" directing women to favour younger partners. It is conceivable that for a species whose success is predicated upon co-operation, collaboration and altruism the gene cannot be exclusively selfish and must have a selfless allele.