Preoperative International Normalized Ratio Thresholds in Hip Fracture: An Analysis of the National Surgical Quality Improvement Program

Background: Hip fractures are one of the most common orthopaedic injuries among the elderly, and as life expectancy continues to rise, the incidence of hip fractures has increased. The international normalized ratio (INR) is routinely obtained preoperatively to assess a patient’s readiness for surgery to evaluate bleeding risk. We aimed to 1) assess the relationship between preoperative INR in hip fracture patients and postoperative complication rates and 2) establish an INR threshold under which patients would be safe to proceed to surgery without INR correction. Methods: We retrospectively reviewed cases of hip fracture surgical stabilization in the American College of Surgeons National Surgical Quality Improvement Program from January 1, 2012 to December 31, 2018. Cases were stratified into four groups based on preoperative INR levels: 1) \u3c 1.4, 2) ≥1.4 and Results: Thirty-five thousand nine hundred-ten cases were identified, with 33,484 (93.2%) performed on patients with preoperative INR \u3c 1.4, 867 (2.4%) on INR ≥1.4 and Conclusions: In this study we found a threshold of INR\u3c 1.6 to be safe for patients prior to undergoing hip fracture surgery. Below this value patients avoid an increased risk of both transfusions and 30-day mortality seen at higher INR values. These findings may allow for adjustments to preoperative protocols and improve outcomes of hip fracture surgery in this population

Effects of systematic asymmetric discounting on physician-patient interactions: a theoretical framework to explain poor compliance with lifestyle counseling

BACKGROUND: This study advances the use of a utility model to model physician-patient interactions from the perspectives of physicians and patients. PRESENTATION OF THE HYPOTHESIS: In cases involving acute care, patient counseling involves a relatively straightforward transfer of information from the physician to a patient. The patient has less information than the physician on the impact the condition and its treatment have on utility. In decisions involving lifestyle changes, the patient may have more information than the physician on his/her utility of consumption; moreover, differences in discounting future health may contribute significantly to differences between patients' preferences and physicians' recommendations. TESTING THE HYPOTHESIS: The expectation of differences in internal discount rate between patients and their physicians is discussed. IMPLICATIONS OF THE HYPOTHESIS: This utility model provides a conceptual basis for the finding that educational approaches alone may not effect changes in patient behavior and suggests other economic variables that could be targeted in the attempt to produce healthier behavior

Timely Reversal of Profound Acute Vision Loss in a Case of Dural Carotid-Cavernous Fistula

Dural carotid cavernous fistulae are abnormal connections between the carotid system and the cavernous sinus via small shunt vessels. Anterior drainage of blood shunted through the cavernous sinus into the orbital venous system accounts for the typical features of presentation. Vision loss has been reported by a variety of proposed mechanisms including elevated IOP, hypoxic venous stasis, retinal vessel occlusion, ischemic optic neuropathy, mechanical compression, and others. Many cases can be observed and spontaneous resolution is common, often preceded by partial thrombosis with transient worsening of symptoms. It is not clear whom it is safe to observe through this process. Treatment often restores vision unless the vision loss has occurred via glaucoma or an ischemic insult

Determining a preoperative international normalised ratio threshold safe for hip fracture surgery.

INTRODUCTION: The purpose of this study was first, to assess the relationship between preoperative INR (international normalised ratio) and postoperative complication rates in patients with a hip fracture, and second, to establish a threshold for INR below which the risk of complications is comparable to those in patients with a normal INR. METHODS: We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program and found 35,910 cases who had undergone surgery for a hip fracture between 2012 and 2018. Cases were stratified into 4 groups based on their preoperative INR levels: \u3c1.4; ⩾1.4 and \u3c1.6; ⩾1.6 and \u3c1.8 and ⩾1.8. These cohorts were assessed for differences in preoperative factors, intraoperative factors, and postoperative course. Multivariate logistic regression was used to assess the risk of transfusion, 30-day mortality, cardiac complications, and wound complications adjusting for all preoperative and intraoperative factors. RESULTS: Of the 35,910 cases, 33,484 (93.2%) had a preoperative INR \u3c 1.4; 867 (2.4%) an INR ⩾1.4 and \u3c1.6; 865 (2.4%) an INR ⩾ 1.6 and \u3c1.8 and 692 (1.9%) an INR ⩾ 1.8. A preoperative INR ⩾ 1.8 was independently associated with an increased risk of bleeding requiring transfusion. A preoperative INR ⩾ 1.6 was associated with an increased risk of mortality. CONCLUSIONS: We found that an INR of \u3c1.6 is a safe value for patients who are to undergo surgery for a hip fracture. Below this value, patients avoid an increased risk of both transfusion and 30-day mortality seen with higher INR values. These findings may allow adjustment of preoperative protocols and improve the outcome of hip fracture surgery in this group of patients