Standardised Warfarin Reversal Expedites Time to Theatre for Fractured Neck of Femur Surgery and Improves Mortality Rates: A Matched Cohort Study.

BACKGROUND: This study aims to evaluate outcomes for warfarinised hip fracture patients and compare them with a matched nonwarfarinised group, before and after the introduction of national hip fracture guidelines in the United Kingdom. METHODS: A retrospective cohort study of 1743 hip fracture patients was undertaken. All patients admitted taking warfarin were identified. These patients were then matched to nonwarfarinised patients using nearest neighbour propensity score matching, accounting for age, sex, hip fracture type, and Nottingham Hip Fracture Score. A pre-guideline group (no standardised warfarin reversal regimen) and a post-guideline group (standardised regimen) were identified. Outcomes assessed included time to INR less than 1.7, time to theatre, length of stay, and 30-day and 1-year mortality. RESULTS: Forty-six warfarinised hip fracture patients were admitted in the pre-guideline group (mean age 80.5, F:M 3:1) and 48 in the post-guideline group (mean age 81.2 years, F:M 3:1). Post-guideline patients were reversed to a safe operative INR level within 18 hours of admission, decreasing the time to first dose vitamin K (p<0.001). 70% of warfarinised patients were operated upon within 36 hours, compared to 19.6% with no regimen (p<0.05). After anticoagulation reversal protocol, thirty-day mortality decreased from 15.2% to 8.3% and 1-year mortality from 43.5% to 33% for warfarinised patients, which is comparable to nonwarfarinised matched patients. There was no significant change in the length of stay pre- and post-guideline for both groups of patients. CONCLUSIONS: Proactive anticoagulant management and expedient surgery reduces morbidity and mortality when managing this surgically challenging subset of hip fracture patients.

10-year results of the Birmingham Hip Resurfacing: a non-designer case series.

INTRODUCTION: Recent controversies surrounding metal-on-metal (MoM) hip resurfacing has led to a substantial decline in its use. Despite this, there is good evidence to support the use of specific implants in select patients. PATIENTS AND METHODS: A retrospective analysis of Birmingham Hip Resurfacing (BHR) patients with a minimum of 10 years follow-up was performed. Functional scoring was performed with the Oxford Hip Score (OHS) and failure was defined as revision for any cause. 111 patients underwent 121 BHR procedures. All patients had a minimum follow-up of 10 years. 70 patients (63%) were male. Mean patient age at surgery was 52.5 years (male 53.9 years, female 48.8 years). RESULTS: Overall survival at 10 years was 91% (97% male, 80% female). There was a statistically significant improvement in OHS postoperatively which remains at 10-year follow-up (p = <0.05). There was no significant difference in scores between the male and female groups. Revisions were most often in patients with smaller component sizes but this was not found to be statistically significant. CONCLUSIONS: Our results reflect that of the wider literature in that good outcomes can be obtained with this implant in a select group of patients and results are comparable to that of conventional hip arthroplasty in patients of a similar age.

Dynamic remodelling of synapses can occur in the absence of the parent cell body.

BACKGROUND: Retraction of nerve terminals is a characteristic feature of development, injury and insult and may herald many neurodegenerative diseases. Although morphological events have been well characterized, we know relatively little about the nature of the underlying cellular machinery. Evidence suggests a strong local component in determining which neuronal branches and synapses are lost, but a greater understanding of this basic neurological process is required. Here we test the hypothesis that nerve terminals are semi-autonomous and able to rapidly respond to local stimuli in the absence of communication with their parent cell body. RESULTS: We used an isolated preparation consisting of distal peripheral nerve stumps, associated nerve terminals and post-synaptic muscle fibres, maintained in-vitro for up to 3 hrs. In this system synapses are intact but the presynaptic nerve terminal is disconnected from its cell soma. In control preparations synapses were stable for extended periods and did not undergo Wallerian degeneration. In contrast, addition of purines triggers rapid changes at synapses. Using fluorescence and electron microscopy we observe ultrastructural and gross morphological events consistent with nerve terminal retraction. We find no evidence of Wallerian or Wallerian-like degeneration in these preparations. Pharmacological experiments implicate pre-synaptic P2X7 receptor subunits as key mediators of these events. CONCLUSION: The data presented suggest; first that isolated nerve terminals are able to regulate connectivity independent of signals from the cell body, second that synapses exist in a dynamic state, poised to shift from stability to loss by activating intrinsic mechanisms and molecules, and third that local purines acting at purinergic receptors can trigger these events. A role for ATP receptors in this is not surprising since they are frequently activated during cellular injury, when adenosine tri-phosphate is released from damaged cells. Local control demands that the elements necessary to drive retraction are constitutively present. We hypothesize that pre-existing scaffolds of molecular motors and cytoskeletal proteins could provide the dynamism required to drive such structural changes in nerve terminals in the absence of the cell body.