Therapeutic anticoagulation complications in the elderly: a case report

Background: The demographic transition leads to a continuously growing number of elderly patients who receive therapeutic anticoagulation by reason of several comorbidities. Though therapeutic anticoagulation may reduce the number of embolic complications in these patients, major complications such as bleeding complications need to be kept in mind when considering such therapy. However, evidence regarding the choice of anticoagulation agents in chronic kidney disease patients of higher age is limited. In this report, a guideline-based anticoagulation treatment which led to a fulminant atraumatic bleeding complication is discussed. Case presentation: We present the case of an 85-year-old female stage V chronic kidney disease patient who suffered from a diffuse arterial, subcutaneous bleeding in her lower left leg due a therapeutic anticoagulation using low molecular weight heparin (LMWH). Anticoagulation was started in accordance with general recommendations for patients with atrial fibrillation, and the dosage was adapted for the patient's renal function. Nevertheless, the above-mentioned complication occurred, and the bleeding led to a hemorrhagic shock and an acute kidney injury on top of a chronic kidney disease. The hematoma required surgical evacuation and local coagulation in the operating room. In the further course, the patient underwent additional four surgical interventions due to a superinfected skin necrosis, including skin grafting. Furthermore, the patient needed continuous renal replacement therapy, as well as intensive care unit treatment, for a total of 47 days followed by 36 days of geriatric rehabilitation. Afterwards, she was discharged from the hospital to her previous nursing home. Discussion and conclusions: Although therapeutic anticoagulation may sufficiently protect patients at cardiovascular risk, major complications such as bleeding complications may occur at any time. Therefore, physicians need to regularly re-evaluate any prior indication for therapeutic anticoagulation. With this case report, we hope to draw attention to the cohort of geriatric patients and the need for more and well differentiated study settings to preferably prevent any potentially avoidable complications

Comparing Perioperative Outcome Measures of the Dynamic Hip Screw and the Femoral Neck System

Background and Objective: Various fixation devices and surgical techniques are available for the management of proximal femur fractures. Recently, the femoral neck system (FNS) was introduced, and was promoted on the basis of less invasiveness, shorter operating time, and less fluoroscopy time compared to previous systems. The aim of this study was to compare two systems for the internal fixation of femoral neck fractures (FNF), namely the dynamic hip screw (DHS) with an anti-rotation screw (ARS) and an FNS. The outcome measures included operating room time (ORT), dose–area product (DAP), length of stay (LOS), perioperative changes in haemoglobin concentrations, and transfusion rate. Materials and Methods: A retrospective single-centre study was conducted. Patients treated for FNF between 1 January 2020 and 30 September 2021 were included, provided that they had undergone closed reduction and internal fixation. We measured the centrum-collum-diaphyseal (CCD) and the Pauwels angle preoperatively and one week postoperatively. Results: In total, 31 patients (16 females), with a mean age of 62.81 ± 15.05 years, were included. Fracture complexity assessed by the Pauwels and Garden classification did not differ between groups preoperatively. Nonetheless, the ORT (54 ± 26.1 min vs. 91.68 ± 23.96 min, p < 0.01) and DAP (721 ± 270.6 cGycm² vs. 1604 ± 1178 cGycm², p = 0.03) were significantly lower in the FNS group. The pre- and postoperative CCD and Pauwels angles did not differ statistically between groups. Perioperative haemoglobin concentration changes (–1.77 ± 1.19 g/dl vs. –1.74 ± 1.37 g/dl) and LOS (8 ± 5.27 days vs. 7.35 ± 3.43 days) were not statistically different. Conclusions: In this cohort, the ORT and DAP were almost halved in the patient group treated with FNS. This may confer a reduction in secondary risks related to surgery

Collagen wrapping and local platelet-rich fibrin do not improve the survival rates of ACL repair with dynamic intraligamentary stabilization: a retrospective case series after ≥5 years postoperatively.

PURPOSE Anterior cruciate ligament (ACL) repair has been recommended as a treatment principle for ACL tears. Several authors have advocated a potential role for primary repair techniques in the ACL decision tree. However, long-term results have been controversial. This study aims to determine the survival of the primarily repaired ACL after dynamic intraligamentary stabilization (DIS) with and without augmentation. METHODS Between 2014 and 2019, 102 patients with isolated proximal ACL ruptures underwent DIS repair within 21 days from injury and were available for follow-up either clinically or telephonically after ≥5 years postoperatively. In 45 cases, DIS repair was augmented with collagen fleece wrapping, platelet-rich fibrin (PRF) or both. Failure was defined as traumatic re-rupture or conversion to ACL reconstruction. The patients being available for physical examination underwent a.-p. stability measurement with a KT-1000 device. Functional outcome was measured with the IKDC, Tegner and Lysholm scores. Kaplan-Meier survival analysis, Log-Rank Test and Binominal logistic regression were performed. RESULTS After a minimum 5-year follow-up, 71/102 (69.6%) DIS repairs were not re-reptured and clinically and/or subjectively stable. Augmentation did not improve survival rates (p = 0.812). The identified factors influencing failure were a younger age and a pre-injury Tegner activity level of ≥7. 95.7% of those patients with an intact ACL repair had normal or near normal knee function based on the IKDC scoring system. CONCLUSIONS The 5-year overall survival rate of DIS was 69.6%. Collagen fleece wrapping and local PRF application did not improve survival. Patients not suffering failure of repair demonstrated high satisfaction. Nevertheless, the results are inferior to those of established ACL reconstruction procedures. LEVEL OF EVIDENCE Case series, Level IV

Outcome Analysis of the Use of Cerament® in Patients with Chronic Osteomyelitis and Corticomedullary Defects

Background: Chronic osteomyelitis (OM) is a progressive but mostly low-grade infection of the bones. The management of this disease is highly challenging for physicians. Despite systematic treatment approaches, recurrence rates are high. Further, functional and patient-reported outcome data are lacking, especially after osseous defects are filled with bioresorbable antibiotic carriers. Objective: To assess functional and patient-reported outcome measures (PROM) following the administration of Cerament (R) G or V due to corticomedullary defects in chronic OM. Methods: We conducted a retrospective study from 2015 to 2020, including all patients who received Cerament (R) for the aforementioned reason. Patients were diagnosed and treated in accordance with globally valid recommendations, and corticomedullary defects were filled with Cerament (R) G or V, depending on the expected germ spectrum. Patients were systematically followed up, and outcome measures were collected during outpatient clinic visits. Results: Twenty patients with Cierny and Mader type III OM were included in this study and followed up for 20.2 +/- 17.2 months (95%CI 12.1-28.3). Ten of these patients needed at least one revision (2.0 +/- 1.3 revisions per patient (95%CI 1.1-2.9) during the study period due to OM persistence or local wound complications. There were no statistically significant differences in functional scores or PROMs between groups. Conclusion: The use of Cerament (R) G and V in chronic OM patients with corticomedullary defects appears to have good functional outcomes and satisfactory PROMs. However, the observed rate of local wound complications and the OM persistence rate may be higher when compared to previously published data

The ischiofemoral space of the hip is influenced by the frontal knee alignment

Purpose: The ischiofemoral distance (IFD), defined as the distance between the ischial tuberosity and the lesser trochanter of the femur, is gaining recognition as an extra-articular cause of hip pain. It is unknown whether the IFD is influenced by the frontal knee alignment. The aim of this study was to determine the influence of realignment surgery around the knee on the IFD. It was hypothesized that valgisation osteotomy around the knee is associated with reduction of the IFD. Methods: A consecutive series of 154 patients undergoing frontal realignment procedures around the knee in 2017 were included in this study. Long-leg standing radiographs were obtained before surgery and postoperatively. The IFD was measured between the ischium and the lesser trochanter at three different levels (proximal, middle and distal margins of the lesser trochanter parallel to the horizontal orientation of the pelvis) on standardized long-leg radiographs with the patient in upright standing position. The knee alignment was determined by measuring the hip knee ankle angle, mechanical lateral distal femur angle and the medial mechanical proximal tibia angle. Linear regression was performed to determine the influence of the change of frontal knee alignment on the IFD. Results: Linear regression showed a direct influence of the overall change in frontal knee alignment on the IFD of the hip, regardless of the site of the osteotomy (beta-0.4, confidence-interval - 0.5 to - 0.3, p < 0.001). Valgisation osteotomy around the knee induced a significant reduction of the ipsilateral IFD (p < 0.001), while varisation osteotomy induced a significant increase (p < 0.001). The amount of ISD change was 0.4 mm per corresponding degree of change in frontal knee alignment. Conclusion: These findings are relevant to both the hip and knee surgeons when planning an osteotomy or arthroplasty procedure. Correction of a malalignment of the knee may resolve an ischiofemoral conflict in the hip. The concept deserves inclusion in the diagnostic workup of both the hip and knee joints

Gender authorship trends in spine research publications - Research across different countries from 1976 to 2020.

•Gender trends in authorship showed an increase in female authors from 1976 to 2020.•In 2020, Europe had the highest and Asia the lowest proportion of female authors.•The Netherlands had the highest proportion of women and Japan the lowest

Risk factors and a predictive model for under-five mortality in Nigeria: evidence from Nigeria demographic and health survey

<p>Abstract</p> <p>Background</p> <p>Under-5 mortality is a major public health challenge in developing countries. It is essential to identify determinants of under-five mortality (U5M) childhood mortality because these will assist in formulating appropriate health programmes and policies in order to meet the United Nations MDG goal. The objective of this study was to develop a predictive model and identify maternal, child, family and other risk factors associated U5M in Nigeria.</p> <p>Methods</p> <p>Population-based cross-sectional study which explored 2008 demographic and health survey of Nigeria (NDHS) with multivariable logistic regression. Likelihood Ratio Test, Hosmer-Lemeshow Goodness-of-Fit and Variance Inflation Factor were used to check the fit of the model and the predictive power of the model was assessed with Receiver Operating Curve (ROC curve).</p> <p>Results</p> <p>This study yielded an excellent predictive model which revealed that the likelihood of U5M among the children of mothers that had their first marriage at age 20-24 years and ≥ 25 years declined by 20% and 30% respectively compared to children of those that married before the age of 15 years. Also, the following factors reduced odds of U5M: health seeking behaviour, breastfeeding children for > 18 months, use of contraception, small family size, having one wife, low birth order, normal birth weight, child spacing, living in urban areas, and good sanitation.</p> <p>Conclusions</p> <p>This study has revealed that maternal, child, family and other factors were important risk factors of U5M in Nigeria. This study has identified important risk factors that will assist in formulating policies that will improve child survival.</p

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10&nbsp;years; 78.2% included were male with a median age of 37&nbsp;years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020