Dedicated anticoagulation management protocols in fragility femoral fracture care - a source of significant variance and limited effectiveness in improving time to surgery: The hip and femoral fracture anticoagulation surgical timing evaluation (HASTE) study.

INTRODUCTION: Approximately 20 % of femoral fragility fracture patients take anticoagulants, typically warfarin or Direct Oral AntiCoagulant (DOAC). These can impact timing of surgery affecting patient survival. Due to several possible approaches and numerous factors to consider in the preoperative workup of anticoagulated patients, potential for variations in clinical practice exist. Some hospitals employ dedicated anticoagulation management protocols to address this issue, and to improve time to surgery. This study aimed to determine the proportion of hospitals with such protocols, compare protocol guidance between hospitals, and evaluate the effectiveness of protocols in facilitating prompt surgery. METHODS: Data was prospectively collected through a collaborative, multicentre approach involving hospitals across the UK. Femoral fragility fracture patients aged ≥60 years and admitted to hospital between 1st May to 31st July 2023 were included. Information from dedicated anticoagulation management protocols were collated on several domains relating to perioperative care including administration of reversal agents and instructions on timing of surgery as well as others. Logistic regression was used to evaluate effects of dedicated protocols on time to surgery. RESULTS: Dedicated protocols for management of patients taking warfarin and DOACs were present at 41 (52.6 %) and 43 (55.1 %) hospitals respectively. For patients taking warfarin, 39/41 (95.1 %) protocols specified the dose of vitamin k and the most common was 5 milligrams intravenously (n=21). INR threshold values for proceeding to surgery varied between protocols; 1.5 (n=28), 1.8 (n=6), and 2 (n=6). For patients taking DOACs, 35/43 (81.4 %) and 8/43 (18.6 %) protocols advised timing of surgery based on renal function and absolute time from last dose respectively. Analysis of 10,197 patients from 78 hospitals showed fewer patients taking DOACs received surgery within 36 h of admission at hospitals with a dedicated protocol compared to those without (adjusted OR 0.73, 95% CI 0.54-0.99, p=0.040), while there were no differences among patients taking warfarin (adjusted OR 1.64, 95% CI 0.75-3.57, p=0.219). CONCLUSIONS: Around half of hospitals employed a dedicated anticoagulation management protocol for femoral fragility fracture patients, and substantial variation was observed in guidance between protocols. Dedicated protocols currently being used at hospitals were ineffective at improving the defined targets for time to surgery.

The impact of anticoagulant medications on fragility femur fracture care: The hip and femoral fracture anticoagulation surgical timing evaluation (HASTE) study.

INTRODUCTION: Due to their hypocoagulable state on presentation, anticoagulated patients with femoral fragility fractures typically experience delays to surgery. There are no large, multicentre studies previously carried out within the United Kingdom (UK) evaluating the impact of anticoagulant use in this patient population. This study aimed to evaluate the current epidemiology and compare the perioperative management of anticoagulated and non-anticoagulated femoral fragility fracture patients. METHODS: Data was prospectively collected through a collaborative, multicentre approach involving hospitals across the United Kingdom. Femoral fragility fracture patients aged ≥60 years and admitted to hospital between 1st May to 31st July 2023 were included. Main outcomes under investigation included time to surgery, receipt of blood transfusion between admission and 48 h following surgery, length of stay, and 30-day mortality. These were assessed using multivariable linear and logistic regression, and Cox proportional hazards models. Only data from hospitals ≥90 % case ascertainment with reference to figures from the National Hip Fracture Database (NHFD) were analysed. RESULTS: Data on 10,197 patients from 78 hospitals were analysed. 18.5 % of patients were taking anticoagulants. Compared to non-anticoagulated patients, time to surgery was longer by 7.59 h (95 %CI 4.83-10.36; p < 0.001). 42.41 % of anticoagulated patients received surgery within 36 h (OR 0.54, 95 %CI 0.48-0.60, p < 0.001). Differences in time to surgery were similar between countries however there was some variation across units. There were no differences in blood transfusion and length of stay between groups (OR 1.03, 95 %CI 0.88-1.22, p = 0.646 and 0.22 days, 95 %CI -0.45-0.89; p = 0.887 respectively). Mortality within 30 days of admission was higher in anticoagulated patients (HR 1.27, 95 %CI 1.03-1.57, p = 0.026). CONCLUSIONS: Anticoagulated femoral fragility fracture patients comprise a substantial number of patients, and experience relatively longer delays to surgery with less than half receiving surgery within 36 h of admission. This may have resulted in their comparatively higher mortality rate. Inclusion of anticoagulation status in the minimum data set for the NHFD to enable routine auditing of performance, and development of a national guideline on the management of this growing and emerging patient group is likely to help standardise practice in this area and improve outcomes.

Características de Oligoryzomys longicaudatus asociadas a la presencia del virus Andes (Hantavirus) / Oligoryzomys longicaudatus characteristics' associated with the presence of Andes virus (Hantavirus)

Oligoryzomys longicaudatus is the main reservoir of Andes virus (AND), which causes hantavirus pulmonary syndrome in Patagonia. The factors associated with the presence of antibodies against AND in this species are unknown. This study used a logistic regression model to analyze which characteristics of O. longicaudatus, captured in northern Argentinean Patagonia, led to an increased probability of an animal having antibodies against AND and to relate these characteristics to possible mechanisms of transmission of the virus within the population. Sex, age, body mass, and wounds were important predictors regarding the presence of antibodies against AND within O. longicaudatus populations. The probability of a wounded male O. longicaudatus adult having AND antibodies increased in parallel with the body mass. The probability of having antibodies was more than 80% in individuals with body masses above 44 gram. However, the possible transmission mechanism of AND within O. longicaudatus population is still uncertain and further studies involving a larger number of individuals and prolonged monitoring including the process of seroconversion are needed.

Oligoryzomys longicaudatus es el principal reservorio del virus Andes Sur (AND) causante del síndrome pulmonar por hantavirus en la Patagonia. Aún se desconoce qué características individuales están asociadas a una mayor presencia de anticuerpos contra AND en esta especie. En este estudio, mediante un modelo de regresión logística evaluamos qué características de O. longicaudatus, capturados en la Patagonia norte de Argentina, incrementan la probabilidad de un individuo de presentar anticuerpos contra AND para relacionarlos con posibles mecanismos de transmisión del virus dentro de la población. El sexo, la edad, la masa corporal y las heridas resultaron factores importantes para la circulación y persistencia del virus dentro de la población de O. longicaudatus. La probabilidad de que un O. longicaudatus, macho, adulto con heridas presente anticuerpos contra AND aumentó con el incremento de la masa corporal, siendo esta probabilidad mayor al 80% en individuos con masas corporales mayores a 44 g. Sin embargo, el posible mecanismo de transmisión de AND dentro de la población de O. longicaudatus queda aún incierto, por lo que son necesarios estudios futuros que involucren un mayor número de individuos y un tiempo prolongado de seguimiento en su proceso de seroconversión.