Strategies to improve end-of-life decision-making and palliative care following hip fracture in frail older adults: a scoping review.

BACKGROUND: Although surgery is the gold standard following a hip fracture, the potential for rehabilitation and survival rates are low in frail older patients. Some patients may derive more benefit from palliative care. The objectives of this review were to identify the available strategies to improve end-of-life decision-making and palliative care for frail patients with hip fractures and to synthetise their level of support. METHODS: We conducted a scoping review of the scientific and grey literature, searching seven databases and websites of associations. We included all study designs, expert opinion articles and clinical practice guidelines (CPGs). Data were synthetised according to the Approach to Patient with Limited Life Expectancy and Hip Fracture framework. The number of research items and their level of evidence were tabulated for each of the recommended strategies. RESULTS: Of the 10 591 items identified, 34 were eligible. The majority of included articles were original research studies (n = 15). Half of the articles and CPGs focused on intervention categories (55%) such as goals of care discussion and comfort care, followed by factors to consider in the end-of-life decision-making process (25%) and prognosis assessments (20%), mainly through the estimation of life expectancy. The level of evidence for these strategies remains low, given the limited number of prospective studies supporting them. CONCLUSIONS: This scoping review highlighted that end-of-life care in frail older patients with a hip fracture remains understudied. The strategies identified could be prioritised for future research to improve the well-being of the target population while promoting sustainable resource management.

Enhancing Emergency Department Pain Management for Older Adults with the Hip Fracture Fast-Track (HFFT) Protocol in a Middle-Income Country.

Purpose: This study aimed to evaluate the impact of the Hip Fracture Fast-Track (HFFT) protocol, designed specifically for older patients at our hospital, which commenced on January 1, 2022, on the management of emergency department (ED) pain in older adults with hip fractures. Patients and Methods: Retrospective pre- and post-study data from electronic health records (EHR) at our hospital, using the International Classification of Diseases (ICD)-10 codes S72.0, S72.1, S72.8, and S72.9, were utilized. The study included patients aged 65 years or older who presented to the ED with low-energy, non-pathologic isolated hip fractures or proximal femur fractures. The pre-HFFT period included patients from January 1, 2020, to December 31, 2021, and the post-HFFT period included patients from January 1, 2022, to October 31, 2023. Data were compared for the proportion of patients undergoing pain evaluation in the ED, before discharge, time to first analgesia, number of patients receiving pain relief in the ED, and the use of fascia iliaca compartment blocks (FICBs) and pericapsular nerve group blocks (PENGBs). Results: The final analysis involved 258 patients, with 116 in the pre-protocol group and 142 in the post-protocol group. The rate of analgesic use increased significantly in the post-HFFT group (78 [67.24%] vs 111 [78.17%], P = 0.049). The rate of pain score screening at triage increased from 51.72% before the HFFT protocol to 86.62% post-HFFT protocol (p < 0.001). Compared with the pre-HFFT protocol, the post-HFFT protocol exhibited a higher rate of FICB (0% vs 14.08%, p < 0.001) and PENGB (0% vs 5.63%, p = 0.009) administration. Conclusion: The HFFT protocol's implementation was associated with improved ED pain evaluation and analgesic administration in older adults with hip fractures. These findings indicate that tailored protocols, such as the HFFT, hold promise for enhancing emergency care for this vulnerable population.

Association between preoperative persistent hyperglycemia and postoperative delirium in geriatric hip fracture patients.

BACKGROUND: The management of preoperative blood glucose levels in reducing the incidence of postoperative delirium (POD) remains controversial. This study aims to investigate the impact of preoperative persistent hyperglycemia on POD in geriatric patients with hip fractures. METHODS: This retrospective cohort study analyzed medical records of patients who underwent hip fracture surgery at a tertiary medical institution between January 2013 and November 2023. Patients were categorized based on preoperative hyperglycemia (hyperglycemia defined as ≥ 6.1mmol/L), clinical classification of hyperglycemia, and percentile thresholds. Multivariate logistic regression and propensity score matching analysis (PSM) were employed to assess the association between different levels of preoperative glucose and POD. Subgroup analysis was conducted to explore potential interactions. RESULTS: A total of 1440 patients were included in this study, with an incidence rate of POD at 19.1% (275/1440). Utilizing multiple logistic analysis, we found that patients with hyperglycemia had a 1.65-fold increased risk of experiencing POD compared to those with normal preoperative glucose levels (95% CI: 1.17-2.32). Moreover, a significant upward trend was discerned in both the strength of association and the predicted probability of POD with higher preoperative glucose levels. PSM did not alter this trend, even after meticulous adjustments for potential confounding factors. Additionally, when treating preoperative glucose levels as a continuous variable, we observed a 6% increase in the risk of POD (95% CI: 1-12%) with each 1mmol/L elevation in preoperative glucose levels. CONCLUSIONS: There exists a clear linear dose-response relationship between preoperative blood glucose levels and the risk of POD. Higher preoperative hyperglycemia was associated with a greater risk of POD. CLINICAL TRIAL NUMBER: NCT06473324.

Proximal femoral nail antirotation versus InterTan nail for the treatment of intertrochanteric fractures: A systematic review and meta-analysis.

PURPOSE: This meta-analysis compared the efficacy and safety of Proximal Femoral Nail Antirotation (PFNA) and InterTan Nail in the treatment of intertrochanteric fractures. Given the high incidence of femoral intertrochanteric fractures in the elderly population and its impact on quality of life, choosing the most effective and safest surgical option is crucial. PFNA and InterTan are currently two commonly used techniques, but there is a lack of systematic evaluation comparing their safety and effectiveness. This study aims to fill this knowledge gap through Meta-analysis, providing clinicians with evidence-based treatment recommendations. MATERIALS AND METHODS: A computer search was used to search for published literature on PFNA and InterTan in the treatment of intertrochanteric fractures in PubMed (Medline), Web of Science, Embase, Cochrane Library (CENTRAL), Cinahl, CBM, and CNKI.A total of 853 related literatures were retrieved, and 15 literatures were finally included. Newcastle-Ottawa-Scale and Cochrane systematic review methodologies were used to assess the quality of the literature. Meta-analysis was performed using Review Manager 5.4 software, following data extraction. RESULTS: The comparison found that during the surgical treatment of intertrochanteric fractures, the operation time, fluoroscopy time, and blood loss in the PFNA group were significantly shorter than those in the InterTan group, and the difference was statistically significant. In terms of postoperative complication rates, the InterTan group had a significant advantage over the PFNA group. Shaft fracture, varus collapse, cut out, screw migration, and pain of hip and thigh were the most likely to occur in the PFNA group, and the differences were all statistically significant. In terms of postoperative efficacy, the results of the PFNA group and the InterTan group were comparable, and there was no significant differences. CONCLUSIONS: When selecting surgical techniques for the treatment of femoral intertrochanteric fractures, it is necessary to conduct individualized assessments based on the patient's overall health status, surgical tolerance, and post-operative recovery needs. For patients who cannot tolerate long-term surgery or are in poor physical condition, PFNA may be more appropriate. While for patients who can tolerate long-term surgery or have more complex conditions, InterTan may be more suitable.

Trends in hip fracture rates in spain from 2001 to 2018.

The present study includes the longest period of analysis with the highest number of hip fracture episodes (756,308) described in the literature for Spain. We found that the age-adjusted rates progressively decreased from 2005 to 2018. We believe that this is significant because it may mean that measures such as prevention and treatment of osteoporosis, or programs promoting healthy lifestyles, have had a positive impact on hip fracture rates. PURPOSE: To describe the evolution of cases and rates of hip fracture (HF) in patients 65 years or older in Spain from 2001 to 2018 and examine trends in adjusted rates. METHODS: Retrospective, observational study including patients ≥65 years with acute HF. Data from 2001 to 2018 were obtained from the Spanish National Record of the Minimum Basic Data Set of the Ministry of Health. We analysed cases of HF, crude incidence and age-adjusted rates by sex, length of hospital stay (LOS) and in-hospital mortality, and used joinpoint regression analysis to explore temporal trends. RESULTS: We identified 756,308 HF cases. Mean age increased 2.5 years, LOS decreased 4.5 days and in-hospital mortality was 5.5-6.5%. Cases of HF increased by 49%. Crude rate per 100,000 was 533.3 (95% confidence interval [CI], 532.1-534.5), increasing 14.0% (95%CI, 13.7-14.2). Age-adjusted HF incidence rate increased by 6.9% from 2001 (535.7; 95%CI, 529.9-541.5) to 2005 (572.4; 95%CI, 566.7-578.2), then decreased by 13.3% until 2017 (496.1, 95%CI, 491.7-500.6). Joinpoint regression analysis indicated a progressive increase in age-adjusted incidence rates of 1.9% per year from 2001 to 2005 and a progressive decrease of -1.1% per year from 2005 to 2018. A similar pattern was identified in both sexes. CONCLUSIONS: Crude incidence rates of HF in Spain in persons ≥65 years from 2001 to 2018 have gradually increased. Age-adjusted rates show a significant increase from 2001 to 2005 and a progressive decrease from 2005 to 2018.

Patient and proxy perspectives in decision-making for geriatric hip fracture management in the Netherlands: a qualitative study.

OBJECTIVE: The objective of this study was to explore the perspectives with the decision-making process between surgery and palliative, non-operative management of geriatric hip fracture patients and their proxies. DESIGN: A qualitative interview study was performed. Patients and proxies were asked to participate in semi-structured interviews. Data were analysed using reflexive thematic analysis according to Braun and Clarke's six-step guide. SETTING AND PARTICIPANTS: Hip fracture patients in the Netherlands were eligible for inclusion. For hip fracture patients with a pre-existing diagnosis of dementia and for patients who opted for palliative, non-operative management, proxies were included. RESULTS: A total of 16 interviews were conducted, consisting of 4 patient interviews and 12 proxy interviews. Five themes were identified during thematic analysis: (1) underlying patient values, (2) the provision of information, (3) reasons to consider either palliative, non-operative management or surgery, (4) involvement in decision and (5) realisation of expectations. Information provided by the physician varied in terms of desired level of detail but involved discussing the advantages and disadvantages of surgery and palliative, non-operative management. Patients and proxies underscored the importance of achieving optimal quality of life, and the disparity between expected and actual treatment outcomes was unpleasant and negatively influenced the overall experience. CONCLUSIONS: In-depth analysis provided a unique insight into the patient and proxy perspectives in shared decision-making for geriatric hip fracture management in the acute setting. Overall, there were differences between reported experiences and preferences of participants. This heterogeneity stresses the importance of keeping a person-centred approach during shared decision-making. Other key considerations during shared decision-making include physicians informing patients from professional experience and communicating sensitively about both treatment options and prognosis. Physicians should aim to provide realistic, sensitive and timely information to both patients and proxies during the choice between curation and palliation for their hip fracture.

Relationship between muscle and subcutaneous adipose tissue size and density and proximal femur bone in elderly women with hip fracture.

BACKGROUND: Both osteoporosis and sarcopenia are associated with aging, increasing the likelihood of falls in older adults and consequently raising the risk of hip fractures (HF). AIMS: To explore the relationship between the size and density of muscle and subcutaneous adipose tissue (SAT) and the bone mineral density (BMD) of the proximal femur in elderly women with HF. METHODS: Quantitative computed tomography (QCT) was conducted on the hips of 661 female participants who experienced low-energy acute HFs to measure both areal BMD (aBMD) and volume BMD (vBMD). Measurements were taken for the cross-sectional area (CSA) and density of the muscle around the hip and adjacent SAT. Multivariable linear regression models were applied to assess the relationship between these parameters. RESULTS: Most increases in the density of the gluteus medius and minimus muscle (G.Med/MinM) were correlated with higher BMD in the femoral neck fracture (FNF) group with osteoporosis. In the FNF group, gluteus maximus muscle (G.MaxM) density was negatively associated with the BMD parameters of the proximal femur in individuals with osteoporosis, while they were positively associated with nonosteoporosis. In the intertrochanteric fracture (ITF) group without osteoporosis, both FN aBMD and FN vBMD showed significant correlations with G.Med/MinM density. DISCUSSION: In women with HFs, bone and muscle are closely related. CONCLUSIONS: In older women with HFs, density but not CSA of the G.Med/MinM were associated with BMD parameters of the proximal femur. Osteoporosis may influence the relationship between G.MaxM density and proximal femur BMD in elderly women with FNF.

Conversion Birmingham Hip Resurfacing in Managing Post-traumatic Arthritis With Retained Femoral Hardware: A Case Report.

CASE: A 70-year-old man with a year-long history of arthritic pain in his left hip presented to our clinic. He had a left intertrochanteric hip fracture 6 years ago, fixed with an open reduction internal fixation with a cephalomedullary nail. He underwent a conversion Birmingham Hip Resurfacing (BHR) with removal of the proximal helicoidal blade and retention of the intramedullary nail. At 7-year follow-up, the patient reported satisfactory clinical outcomes and excellent radiographic fixation. CONCLUSION: This case highlights using conversion BHR in patients with post-traumatic arthritis with retained femoral hardware as an alternative to conventional total hip arthroplasty.

Development and validation of an artificial intelligence model for the classification of hip fractures using the AO-OTA framework.

BACKGROUND AND PURPOSE: Artificial intelligence (AI) has the potential to aid in the accurate diagnosis of hip fractures and reduce the workload of clinicians. We primarily aimed to develop and validate a convolutional neural network (CNN) for the automated classification of hip fractures based on the 2018 AO-OTA classification system. The secondary aim was to incorporate the model's assessment of additional radiographic findings that often accompany such injuries. METHODS: 6,361 plain radiographs of the hip taken between 2002 and 2016 at Danderyd University Hospital were used to train the CNN. A separate set of 343 radiographs representing 324 unique patients was used to test the performance of the network. Performance was evaluated using area under the curve (AUC), sensitivity, specificity, and Youden's index. RESULTS: The CNN demonstrated high performance in identifying and classifying hip fracture, with AUCs ranging from 0.76 to 0.99 for different fracture categories. The AUC for hip fractures ranged from 0.86 to 0.99, for distal femur fractures from 0.76 to 0.99, and for pelvic fractures from 0.91 to 0.94. For 29 of 39 fracture categories, the AUC was ≥ 0.95. CONCLUSION: We found that AI has the potential for accurate and automated classification of hip fractures based on the AO-OTA classification system. Further training and modification of the CNN may enable its use in clinical settings.

Risk of internal fixation treatment in intertrochanteric fracture based on different lateral femoral wall thickness: finite element analysis.

OBJECTIVE: The thickness of the lateral femoral wall, which is an important indicator for evaluating the stability and integrity of intertrochanteric fractures, has been widely studied in recent years. However, as a typical representative of internal fixation treatment, there are few reports on the biomechanical comparison between PFNA and DHS + CS. This study focused primarily on the biomechanical effects of different lateral femoral wall thicknesses on two types of internal fixation through finite element analysis. METHODS: We randomly recruited a healthy adult and collected his femoral CT data to establish a model of femoral intertrochanteric fracture with different lateral femoral wall thicknesses. Following PFNA and DHS + CS fixation, femoral models were simulated, and variations in stress and displacement of the internal fixation and femoral head were recorded under the same physiological load. RESULTS: First, finite element mechanical analysis revealed that the stress and displacement of the internal fixation and femoral head were lower in the femoral model after PFNA fixation than in the DHS + CS model. Second, as the outer wall thickness decreased, the stress and deformation endured by both types of internal fixation gradually increased. CONCLUSIONS: Finite element analysis determined that PFNA exhibits significantly better biomechanical stability than DHS + CS when subjected to varying lateral femoral wall thicknesses. Moreover, lateral femoral wall thickness substantially affects the stability of the two internal fixation biomechanical environments. When the thickness of the lateral femoral wall is too small, we do not recommend using extramedullary fixation because there is a significant risk of internal fixation fracture.

Phantomless calibration of CT scans for hip fracture risk prediction in silico: Comparison with phantom-based calibration.

Finite element models built from quantitative computed tomography images rely on element-wise mapping of material properties starting from Hounsfield Units (HU), which can be converted into mineral densities upon calibration. While calibration is preferably carried out by scanning a phantom with known-density components, conducting phantom-based calibration may not always be possible. In such cases, a phantomless procedure, where the scanned subject's tissues are used as a phantom, is an interesting alternative. The aim of this study was to compare a phantom-based and a phantomless calibration method on 41 postmenopausal women. The proposed phantomless calibration utilized air, adipose, and muscle tissues, with reference equivalent mineral density values of -797, -95, and 38 mg/cm3, extracted from a previously performed phantom-based calibration. A 9-slice volume of interest (VOI) centred between the femoral head and knee rotation centres was chosen. Reference HU values for air, adipose, and muscle tissues were extracted by identifying HU distribution peaks within the VOI, and patient-specific calibration was performed using linear regression. Comparison of FE models calibrated with the two methods showed average relative differences of 1.99% for Young's modulus1.30% for tensile and 1.34% for compressive principal strains. Excellent correlations (R2 > 0.99) were identified for superficial maximum tensile and minimum compressive strains. Maximum normalised root mean square relative error (RMSRE) values settled at 4.02% for Young's modulus, 2.99% for tensile, and 3.22% for compressive principal strains, respectively. The good agreement found between the two methods supports the adoption of the proposed methodology when phantomless calibration is needed.

Gait dynamic stability evaluation in patients undergoing hip joint fractures - tools to measure rehabilitation effectiveness.

A hip joint fracture includes a break in the thigh (femur) or coxa bone near the pelvis. During fracture healing, stability and weight bearing by the affected limb are key indicators to measure patients' improvement. Conventionally, the rehabilitation effectiveness is monitored through clinical examinations, patients' feedback, and few studies also reported instrumented gait evaluations. A gap remains there to numerically quantify the recovery in patients' stability and weight bearing in response to rehabilitation therapies. This study introduces Nyquist and Bode (N&B) methods to analyse the instrumented gait signals further and evaluate gait stability in hip fracture patients during weight loading and unloading transitions. The centre of pressure (CoP) data was recorded using force plates for conditions: coxa hip fracture (HC), femur hip fracture (HF), and normal hip joint (NH). The time rate of CoP signals illustrated two major impulses during the loading and unloading phases which were modelled in time and frequency domains. The frequency models were further analysed by applying N&B methods and stability margins were computed for both impaired and healthy conditions. Results illustrated a significant decrease (Kruskal-Wallis's test, p < 0.001) in the intralimb walking stability of both fracture conditions. Further, Spearman's correlation between CoP velocities of fractured and intact limbs illustrated significant interlimb dependencies to maintain walking stability (p < 0.001) during weight loading and unloading transitions. Overall, the HF impairment illustrated the least intralimb walking stability and relatively greater interlimb dependencies. Clinically, these methods and findings are important to measure the recovery in patients undergoing rehabilitation after a hip joint or other lower limb impairments.

Perioperative Administration of Tranexamic Acid and Low Molecular Weight Heparin for Enhanced Blood Management in Intertrochanteric Fractures: A Randomized Controlled Study.

BACKGROUND This prospective study from a single center aimed to compare the perioperative blood loss (PBL) in 79 patients with intertrochanteric fractures (IF) treated with intramedullary nailing (IMN) using 3 regimens of combined tranexamic acid (TXA) and low molecular weight heparin (LMWH), proposing a novel therapy of 4-dose TXA. MATERIAL AND METHODS We recruited 79 patients and randomly divided them into 3 groups. The 4-dose TXA group (22 patients) received 1.0 g intravenous TXA 30 min before surgery and 1.0 g at intervals of 3, 6, and 9 h before surgery. The 1-dose TXA group (25 patients) received 1.0 g intravenous TXA 30 min before surgery, while the control group (32 patients) did not receive TXA. LMWH was applied 12 h after surgery in each group. The primary metrics evaluated included hidden blood loss (HBL), total blood loss (TBL), and the number and incidence rate of deep vein thrombosis (DVT). RESULTS Analysis of the HBL revealed that the 4-dose TXA group had the lowest average (583.13±318.08 ml), followed by the 1-dose TXA group (902.94±509.99 ml), and the control group showed the highest (1154.39±452.06 ml) (P<0.05). A similar result was observed for TBL (4-dose group: 640.86±337.22 ml, 1-dose group: 971.74±511.14 ml, control group: 1226.27±458.22 ml, P<0.05). Regarding DVT, the 4-dose TXA group had 5 cases (incidence rate 22.73%), the 1-dose TXA group had 6 cases (incidence rate 24.00%), and the control group had 8 cases (incidence rate 25.00%), with no significant difference among groups (P>0.05). CONCLUSIONS Treatment using 4-dose TXA and LMWH can effectively reduce PBL without increasing the DVT risk in IF patients with IMN.

Hip Fracture Risk Assessment Tools for Adults Aged 80 Years and Older.

Importance: While adults aged 80 years and older account for 70% of hip fractures in the US, performance of fracture risk assessment tools in this population is uncertain. Objective: To compare performance of the Fracture Risk Assessment Tool (FRAX), Garvan Fracture Risk Calculator, and femoral neck bone mineral density (FNBMD) alone in 5-year hip fracture prediction. Design, Setting and Participants: Prognostic analysis of 3 prospective cohort studies including participants attending an index examination (1997 to 2016) at age 80 years or older. Data were analyzed from March 2023 to April 2024. Main Outcomes and Measures: Participants contacted every 4 or 6 months after index examination to ascertain incident hip fractures and vital status. Predicted 5-year hip fracture probabilities calculated using FRAX and Garvan models incorporating FNBMD and FNBMD alone. Model discrimination assessed by area under receiver operating characteristic curve (AUC). Model calibration assessed by comparing observed vs predicted hip fracture probabilities within predicted risk quintiles. Results: A total of 8890 participants were included, with a mean (SD) age at index examination of 82.6 (2.7) years; 4906 participants (55.2%) were women, 866 (9.7%) were Black, 7836 (88.1%) were White, and 188 (2.1%) were other races and ethnicities. During 5-year follow-up, 321 women (6.5%) and 123 men (3.1%) experienced a hip fracture; 818 women (16.7%) and 921 men (23.1%) died before hip fracture. Among women, AUC was 0.69 (95% CI, 0.67-0.72) for FRAX, 0.69 (95% CI, 0.66-0.72) for Garvan, and 0.72 (95% CI, 0.69-0.75) for FNBMD alone (FNBMD superior to FRAX, P = .01; and Garvan, P = .01). Among men, AUC was 0.71 (95% CI, 0.66-0.75) for FRAX, 0.76 (95% CI, 0.72-0.81) for Garvan, and 0.77 (95% CI, 0.72-0.81) for FNBMD alone (P < .001 Garvan and FNBMD alone superior to FRAX). Among both sexes, Garvan greatly overestimated hip fracture risk among individuals in upper quintiles of predicted risk, while FRAX modestly underestimated risk among those in intermediate quintiles of predicted risk. Conclusions and Relevance: In this prognostic study of adults aged 80 years and older, FRAX and Garvan tools incorporating FNBMD compared with FNBMD alone did not improve 5-year hip fracture discrimination. FRAX modestly underpredicted observed hip fracture probability in intermediate-risk individuals. Garvan markedly overpredicted observed hip fracture probability in high-risk individuals. Until better prediction tools are available, clinicians should prioritize consideration of hip BMD, life expectancy, and patient preferences in decision-making regarding drug treatment initiation for hip fracture prevention in late-life adults.

A Multidisciplinary Approach to Hip Fractures: Evaluating Outcomes on Mortality and Secondary Hip Fractures.

Fracture liaison services (FLS) have been introduced in Japan and several other countries to reduce medical complications and secondary fractures. We aimed to evaluate the effects of the implementation of an FLS approach on patient outcomes during hospitalization at our hospital and over a 2-year follow-up post-injury. This retrospective cohort study included patients ≥ 60 years admitted to our hospital for hip fragility fractures between October 1, 2016, and July 31, 2020. Patient groups were defined as those treated before (control group, n=238) and after (FLS group, n=196) establishment of the FLS protocol at our institution. The two groups were compared in terms of time to surgery, length of hospital stay, and the incidence of complications after admission, including secondary hip fracture and mortality rates. The follow-up period was 24 months. FLS focuses on early surgery within 48 h of injury and assessing osteoporosis treatment before injury to guide post-discharge anti-osteoporosis medication. FLS reduced the length of hospital stay (p<0.001) and the prevalence of complications after admission (p<0.001), particularly cardiovascular disease, and it increased adherence to anti-osteoporosis medication. These FLS effects resulted in lower secondary hip fracture and mortality rates at 12 and 24 months post-injury. FLS for fragility hip fractures can improve patient outcomes during hospitalization and over a 2-year follow-up period.

Development and validation of machine learning models to predict perioperative transfusion risk for hip fractures in the elderly.

BACKGROUND: Patients with hip fractures frequently need to receive perioperative transfusions of concentrated red blood cells due to preoperative anemia or surgical blood loss. However, the use of perioperative blood products increases the risk of adverse events, and the shortage of blood products is prompting us to minimize blood transfusion. Our study aimed to construct a machine learning algorithm predictive model to identify patients at high risk for perioperative transfusion early in hospital admission and to manage their patient blood to reduce transfusion requirements. METHODS: This study collected patients hospitalized for hip fractures at a university hospital from May 2016 to November 2022. All patients included in the analysis were randomly divided into a training set and validation set according to 70:30. Eight machine learning algorithms, CART, GBM, KNN, LR, NNet, RF, SVM, and XGBoost, were used to construct the prediction models. The models were evaluated for discrimination, calibration, and clinical utility, and the best prediction model was selected. RESULTS: A total of 805 patients were included in the study, of whom 306 received transfusions during the perioperative period. We screened eight features used to construct the prediction model: age, fracture time, fracture type, hemoglobin, albumin, creatinine, calcium ion, and activated partial thromboplastin time. After evaluating and comparing the performance of each of the eight models, the model constructed by the XGBoost algorithm had the best performance, with MCC values of 0.828 and 0.939 in the training and validation sets, respectively. In addition, it had good calibration and clinical utility in both the training and validation sets. CONCLUSION: The model constructed by the XGBoost algorithm has the best performance, using this model to identify patients at high risk for transfusion early in their admission and promptly incorporating them into a patient blood management plan can help reduce the risk of transfusion.

Relationship between preoperative hemoglobin levels and length of stay in elderly patients with hip fractures: A retrospective cohort study.

Globally, hip fractures in elderly individuals are a prevalent and serious issue. Patients typically have a longer length of stay (LOS), which increases the risk of complications and increases hospitalization costs. Hemoglobin (Hb) is a routine blood test that is associated with disease prognosis. This study aimed to investigate the relationship between preoperative Hb and LOS in elderly hip fracture patients and to determine a reliable transfusion threshold. The clinical data of hip fracture patients (aged ≥ 60 years) admitted to the Department of Orthopaedics, Shenzhen Second People's Hospital, between January 2012 and December 2021 were retrospectively analyzed. Multiple linear regression analysis was used to assess the linear relationship between preoperative Hb and LOS. Smooth curve fitting was performed to investigate potential nonlinear relationships. In the case of discovering nonlinear relationships, a weighted two-piecewise linear regression model was built, and the inflection points were determined using a recursive algorithm. Subgroup analyses were conducted based on age and gender. A total of 1444 patients with an average age of (77.54 ±â€…8.73) years were enrolled. After adjusting for covariates, a nonlinear relationship was found between preoperative Hb and LOS. The two-piecewise linear regression model revealed an inflection point of 10 g/dL. On the left of the inflection point (Hb < 10 g/dL), the LOS was reduced by 0.735 days for every 1 g/dL increase in Hb (ß = -0.735, 95% confidence interval: -1.346 to -0.124, P = .019). On the right side of the inflection point (Hb > 10 g/dL), the relationship was not statistically significant (ß = 0.001, 95% confidence interval: -0.293 to 0.296, P = .992). In elderly hip fracture patients, there is a nonlinear association between preoperative Hb and LOS. However, when Hb levels were <10 g/dL, there was a negative correlation with the LOS. No correlation was observed when Hb levels were >10 g/dL. These findings underscore the importance of timely intervention to manage Hb levels in elderly patients with hip fractures, potentially reducing hospitalization durations and associated complications.

Osteoporosis and Fracture Risk Associated with Novel Antidepressants: A Systematic Review and Meta-Analysis.

BACKGROUND: The use of antidepressants, especially selective serotonin reuptake inhibitors (SSRIs), has been linked to adverse effects on bone health, but findings are conflicting. This study aimed to quantify the associations between newer antidepressants and bone mineral density (BMD) and fracture risk through a comprehensive meta-analysis. METHODS: Observational studies on the association between the use of novel antidepressants and BMD and hip fracture were systematically searched in PubMed, Embase, CINAHL, Cochrane Library, and Scopus. Random effects meta-analyses were conducted to pool results across the eligible studies. The heterogeneity, publication bias, and influence were assessed extensively. RESULTS: 14 eligible studies with 1,417,134 participants were identified. Antidepressant use was associated with significantly lower BMD compared to non-use at all skeletal sites examined, with pooled standardized mean differences (SMD) ranging from -0.02 (total hip) to -0.04 (femoral neck). Importantly, antidepressant use was associated with a 2.5-fold increased risk of hip fracture (pooled odds ratio (OR) 2.50, 95% CI 2.26-2.76). While heterogeneity was detected, the overall findings were robust in sensitivity analyses. CONCLUSIONS: This meta-analysis provided strong evidence that novel antidepressants, especially widely used SSRIs, have detrimental impacts on bone health. The observed associations with decreased BMD and doubled hip fracture risk have important clinical implications.

Association of frailty with adverse outcomes in surgically treated geriatric patients with hip fracture: A meta-analysis and trial sequential analysis.

OBJECTIVE: Some studies have associated frailty and prognostic outcomes in geriatric hip fracture patients, but whether frailty can predict postoperative outcomes remains controversial. This review aims to assess the relationship between frailty and adverse postoperative outcomes in geriatric patients with hip fracture. METHODS: Based on electronic databases, including PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, Chinese National Knowledge Infrastructure, and WanFang Data, we systematically searched for studies that investigated the association between frailty and adverse outcomes among patients aged 60 or over after hip fracture surgery. Stata 17.0 and Trial Sequential Analysis viewer software were used to obtain pooled estimates and verify whether the sample size was sufficient and the evidence robust. RESULTS: Twenty-one studies involving 49,196 patients were included for quantitative analysis. Compared with nonfrail patients, frail patients had a higher risk of inpatient mortality (risk ratio [RR] = 1.93, 95% confidence interval [CI]: 1.66-2.23), 30-day mortality (RR = 2.13, 95% CI: 1.23-3.70), and 1-year mortality (RR = 2.44, 95% CI: 1.47-4.04). Frailty can significantly predict postoperative complications (RR = 1.76, 95% CI: 1.38-2.23), including delirium, pneumonia, cardiac complications, urinary tract infection, and surgical site infection; the association between frailty and deep venous thrombosis/pulmonary embolism and acute kidney injury needs further analysis. Trial sequential analysis showed that the findings regarding mortality were reliable and robust. CONCLUSION: This meta-analysis provides detailed information indicating that frailty is a substantial predictor of mortality and selected postoperative complications.