Outcome of older hip fracture patients on anticoagulation: a comparison of vitamin K-antagonists and Factor Xa inhibitors.

INTRODUCTION: Older hip fracture patients are still challenging in daily clinical practice. Due to the high prevalence of osteoporosis and atrial fibrillation in this age group, the number of fragility fracture patients under oral anticoagulation (OAC) increases. The outcome is still disappointing, short- and long-term mortality and morbidity is high. The impact of pre-existing OAC is not yet clear, especially regarding new OAC drugs like Factor Xa inhibitors (FXa). The purpose of our study was to compare the short-term outcome of older hip fracture patients, without OAC (controls), on Vitamin K antagonists (VKA) and on FXa. MATERIALS AND METHODS: The study is a retrospective case-control study including patients older than 70 years who sustained hip fractures caused by an inadequate trauma and treated at a level 1 trauma center from February 2017 to June 2018. Patient's information was taken from patient's charts. 102 cases were analysed, 61 controls, 41 on OAC (15 on VKA and 26 on FXa). As outcome parameter we defined mortality, perioperative complications, bleeding, need of blood supplements, delay of surgery, length of stay, and a combined outcome parameter (mortality, myocardial infarction, stroke, thromboembolic events, blood preservations, re-vision surgery, major bleeding and decline of hemoglobin). RESULTS: Eight patients died during hospital stay, in-hospital mortality was 7.8%. The highest mortality rate was found in patients on VKA (20%), compared to patients on FXa (3.8%) and controls (6.6%). However, mortality rate did not differ significantly within the groups. The combined endpoint was significantly more frequently seen in patients on OAC compared to controls (p = 0.006). No difference was observed between patients on VKA or FXa. Mean time to surgery and LOS was significantly longer in patients on OAC compared to controls. No significant differences were seen between VKA and FXa. CONCLUSIONS: In our study OAC was significantly associated with worse outcome compared to controls. Marginal differences were observed between patients on FXa or VKA. Further studies involving a higher number of patients are necessary to confirm our results. At that time, some our results have to interpreted carefully and need confirmation.

[Osteoporosis and multimorbidity]. / Osteoporose und Multimorbidität.

Osteoporosis is a systemic bone disease with decreased bone strength and mass resulting in an increased predisposition to fracture risk. Especially older patients have a high risk for fragility fractures. In these patients an isolated view of osteoporosis without consideration of multimorbidity is insufficient. Various diseases are associated with osteoporosis because of shared pathophysiological mechanisms, risk factors or as a consequence of medication. Furthermore, geriatric syndromes, such as falls play an importance role. This article presents an overview about multimorbidity interactions based on selected frequent diseases in older age and shows the management in the clinical practice.

[Acute coronary syndrome in older people]. / Akutes Koronarsyndrom beim älteren Menschen.

The acute coronary syndrome (ACS) is subdivided into ST segment elevation myocardial infarction (STEMI), non-ST segment elevation acute coronary syndrome (NSTE-ACS) and unstable angina pectoris. It poses a particular challenge in terms of diagnostics and treatment, especially in the elderly. Starting with the possibly difficult anamnesis, through the laboratory chemical findings up to special features in the electrocardiogram (ECG), echocardiography and angiography, these patients should be considered in some ways different to the younger population. Because of the mortality and morbidity after ACS, especially in old age, it is important to adhere to evident strategies in diagnostics and treatment and to employ specially trained personnel for people with acute chest pain in order to improve the prognosis and quality of life. A first important step is to provide certified chest pain units which ensure smooth diagnostics and treatment and thus positively influence the clinical decision-making processes.

[Management of osteoporosis after fragility fractures]. / Management der Osteoporose nach Fragilitätsfrakturen.

Osteoporosis is defined as a systemic bone disease with decreased bone strength and an increased susceptibility for fractures. Older people in particular face an increased risk of fractures. These kind of fractures are usually caused by an inadequate trauma and are the so-called fragility fractures. In older adults immediate fracture stabilization and early mobilization have become the standard procedure after a fragility fracture. Treatment of the underlying osteoporosis often plays a minor role in clinical practice. Only a small group of patients are already under osteoporosis medication and even after a fracture occurs only few patients receive osteoporosis drug treatment with the aim to reduce the progression of osteoporosis and to reduce subsequent fractures. In the literature this has been described as the osteoporosis care gap. The following article presents an overview of treatment options and answers many different questions from the clinical routine.

[Antibodies as treatment option in older adults]. / Antikörper als Therapieoption bei geriatrischen Patienten.

Monoclonal antibodies are already used for many different clinical indications. Besides oncology and rheumatology, denosumab is the only antibody that is currently prescribed in older adults with osteoporosis; however, apart from osteoporosis there might be more possible indications for the use of antibodies in chronic diseases and geriatric syndromes. Particularly, with respect to sarcopenia the transition to "doping for older adults" seems to be fluent. The present review provides an overview on the newest developments and prospective options.

[Aortic valve replacement in the elderly]. / Aortenklappenersatz im Alter.

The treatment of severe symptomatic aortic valve stenosis by conventional aortic valve replacement (AVR) or by transcatheter aortic valve implantation (TAVI) has a good perinterventional prognosis even for patients of advanced age. Having a heart team select the best management strategies based on current guidelines for each individual patient is essential for success. Especially in elderly and increasingly multimorbid patients with sometimes severe preconditions, the detection of functional deficits is relevant not only for the mortality but also for perioperative and postoperative complications as well as the functional outcome. Various methods of geriatric assessment are important supplements to standard risk scores. The aim is to implement targeted interventions to minimize the risk factors and to improve the prognosis for elderly patients. The aim of this article is to provide an overview of the current therapy options for aortic valve replacement and to summarize current aspects of treatment options for elderly patients.

[Spinal fractures]. / Wirbelsäulenfrakturen.

Osteoporotic spinal fractures are typical age-related fragility fractures. Their impact on the quality of life is often underestimated; therefore, anti-osteoporotic drug treatment according to the current guidelines is essential. Occult vertebral fractures may be difficult to detect and a differentiation between fresh and old fractures is often only possible with magnetic resonance imaging (MRI) to reveal cancellous bone edema. Treatment recommendations are predominantly based on traumatic fractures in younger adults and are thus not applicable in orthogeriatrics. A new classification currently under validation and presented in this article was developed in order to aid decision-making for operative interventions. Minimally invasive treatment options include vertebroplasty, kyphopasty and internal fixation. The application of cement provides additional stability but can be accompanied by cement-specific complications, such as extravasation and embolism.

[Hemiarthroplasty for femoral neck fracture in the elderly--an operation suitable for teaching?]. / Ist die Versorgung der Schenkelhalsfraktur mittels Duokopfprothese beim alten Menschen ein geeigneter Ausbildungseingriff?

BACKGROUND: Hemiarthroplasty is a common procedure for treating femoral neck fractures in orthogeriatrics. For training purposes the operation may also be performed by supervised residents. Our study aims at evaluating the rates of early surgical complications after hemiarthroplasty in different age groups, comparing operations performed by consultants and residents. METHODS: All patients treated with hemiarthroplasty between December 2006 and July 2011 at our municipal, maximum-care-providing hospital were included in a retrospective cohort. The Excia® stem with a self-centering bipolar head (Aesculap, Tuttlingen) was used in all patients. Educational level of the operator (consultant vs. resident) and operation time were noted as well as early complications including luxation, infection, haematoma, seroma, and early periprosthetic fractures (e.g., intraoperative lesions of the greater trochanter). The complication rates were evaluated and compared by the chi-square test. RESULTS: 241 of 729 hemiarthroplasties were performed by supervised residents. Neither the overall complication rate nor the rates of specific complications differed significantly between the patients operated by consultants and those operated by residents. The result was still true if comparing the different age groups. On average operation time was 8 minutes longer in teaching operations. CONCLUSIONS: Focusing on early surgical complications, the teaching of hemiarthroplasty does not seem to increase the risk to patients of any age. We conclude that the hemiarthroplasty procedure is suitable for teaching younger colleagues in orthogeriatrics. As age is just one of several potential risk factors, additional studies on this topic should be undertaken.

"N-active": a new comanaged, orthogeriatric ward: observations and prospects.

The incidence of hip fractures increases with increasing age. Besides the actual trauma, it is mainly the comorbidities and an increased postoperative complication rate in old patients that lead to increased mortality in this patient population. Around 25% of patients who had previously been living independently continue to need long-term care after a hip fracture. Given this situation, the comanaged orthogeriatric unit "N-active" was opened at the Nuremberg Hospital in December 2010. The following article describes implementation of the ward and preliminary data. These show a positive impact of comanagement in terms of patient outcome, staff satisfaction, and also financial aspects.

Identification of A- and B-site cation vacancy defects in perovskite oxide thin films.

Cation vacancies on both sublattices (V(Ti), V(Sr)) have been identified in homoepitaxial pulsed laser deposited SrTiO3 films using high intensity variable energy positron annihilation lifetime spectroscopy (PALS) measurements. Film nonstoichiometry was varied by varying laser fluence. PALS showed that on increasing the fluence above the Ti/Sr∼1 value, the concentration ratio [V(Sr)]/[V(Ti)] systematically increased. Reducing the fluence into the Ti-poor region below resulted in additional vacancy cluster defect formation. Vacancy concentrations greater than ∼50 ppm were observed in all films.

Increased splanchnic arterial vascular resistance in oldest old patients - possible relevance for postprandial hypotension.

OBJECTIVES: The aim of this study was to evaluate possible age-related changes in mesenteric artery and portal venous blood flow dynamics in relation to systemic haemodynamics in order to delineate putative haemodynamic changes relevant for postprandial hypotension in the elderly. Studies were performed over a wide age-range and for the first time in over 85-year-old patients. DESIGN: Superior mesenteric artery (SMA) parameters (diameter, peak systolic velocity, end diastolic velocity, pulsatility index, volume flow) and portal vein (PV) parameters (diameter, portal vein velocity, volume flow) were measured by duplex ultrasound (General Electrics, Vivid 3) in 98 fasting subjects aged from 21 to 96 years. Systemic vascular parameters such as blood pressure, heart rate and cardiac output (echocardiography) were also determined. Excluded were patients with severe heart failure, liver cirrhosis, sepsis and those with mesenteric artery stenosis. RESULTS: Pulsatility index (PI) was positively correlated with age (r=0.33, p=0.015). In patients over 85 years, PI was significantly increased (p=0.002) as compared to younger controls. Cardiac output was negatively correlated with age (r=-0.247, p=0.005). The other haemodynamic parameters did not show age-dependent alterations. CONCLUSION: The increase of PI in the SMA in patients over 85 years represents an increase of vascular resistance in the splanchnic area, because PI is sensitive to resistance changes of small arterial vessels. The pulsatility index in the splanchnic area seems to rise steeply in oldest old patients, probably as an attempt to compensate diminutions in cardiac output seen in this age group. These findings indicate that the splanchnic vascular bed is already used in the fasting state to guarantee systemic haemodynamics. Vasodilatation of this vascular bed as physiologically seen postprandially may therefore easily induce postprandial hypotension in the oldest old.

Comparison of the Mini Nutritional Assessment, Subjective Global Assessment, and Nutritional Risk Screening (NRS 2002) for nutritional screening and assessment in geriatric hospital patients.

The Mini Nutritional Assessment (MNA), the Subjective Global Assessment (SGA) and the Nutritional Risk Screening (NRS) are screening and assessment tools aimed at detecting malnourished individuals and those at risk for malnutrition. In our study we tested their applicability in geriatric hospital patients and compared the results of the three tools. We examined prospectively all patients of two acute geriatric wards by the MNA, the SGA and the NRS. 121 patients were included in the study. The MNA could be completed in 66.1% of all patients, the SGA in 99.2% and the NRS in 98.3%. There was a significant association of all three tools with the BMI (p<0.01). With regard to serum albumin and to length of hospital stay (p<0.05), only a significant association could be shown for the MNA (p<0.05). Although the categories of the results were not completely identical for the three tools there were more patients at risk or malnourished according to the MNA (70%) than according to the SGA (45%) or the NRS (40.3%). The direct comparison of the NRS with the MNA and the SGA demonstrated significant differences, especially for the latter (p<0.001). In a relevant percentage of those tested, MNA, SGA, and NRS identify different individuals as malnourished or at risk for malnutrition. Because of its association with relevant prognostic parameters, the MNA is still the first choice for geriatric hospital patients. For those patients to whom the MNA cannot be applied, the NRS is recommended.

Acute poisoning in old and very old patients: a longitudinal retrospective study of 5883 patients in a toxicological intensive care unit.

Although morbidity and mortality of acute poisoning are increased in elderly compared to younger patients, little has been published on this topics in the last years (Medline search). To investigate the influence of age on the clinical course of acute poisoning with different toxic agents, a longitudinal retrospective study at the Toxicological Intensive Care Unit (ICU) of the 2nd Department of Internal Medicine (Klinikum Nürnberg, Germany) was performed.A total of 5883 patients treated at our toxicological ICU were enrolled into the study, including all patients of the years 1982, 1992, and 1997. These three years were selected to investigate possible time-dependent changes of intoxication characteristics and quality of therapy at our ICU over a time span of 15 years. For each patient the following data were obtained from a standardized toxicological record: age, gender, toxic agents responsible for acute poisoning, and length of stay at the toxicological ICU. For a subgroup of 3740 patients, the cause of acute poisoning and the clinical outcome was also recorded. As compared with younger patients, mean length of stay at the ICU, indicating a more serious course of acute poisoning, was prolonged in elderly and, i. e., in very old patients (p <0.001). However, this prolongation of time at the ICU was only observed in elderly patients poisoned with drugs or with mixed poisoning including drugs, while mean length of stay was not prolonged in elderly patients poisoned with alcohol, with illegal drugs, chemicals, animal/plant poison, or other toxic agents. Patients with the highest risk of dying in the ICU after acute poisoning were elderly patients attempting suicide with drugs. Mortality in 3740 patients with acute poisoning was 0.24%, while it was 2.17% in the 184 patients being 65 years old or older. Thus, mortality was 9-fold higher in the elderly. Mean length of stay at the ICU decreased significantly from 1982 to 1992 and to 1997 (p <0.001) indicating an improvement of the therapeutical ICU management of acute poisoning and/or less dangerous toxic agents (i. e. less barbiturates). The age-dependent increase of the length of stay at the ICU until very old age (> 80 years) was most pronounced in 1982 and also declined markedly until 1997.Age, suicide attempt, and ingestion of (multiple) drugs seem to be risk factors for a higher mortality and a prolonged stay in the ICU after acute poisoning. Although in general the clinical course after poisoning has more complications and an impaired prognosis in old age, each category of toxic agents (drugs, alcohol, chemicals, etc.) has its own special "risk profile" for elderly patients. However, due to advances in modern ICU medicine the general prognosis of acute poisoning is good in old and even in oldest old patients.