Retrospective high volume comparative study suggests that patients on aspirin could have immediate surgery for hip fractures without significant blood loss.

PURPOSE: This study aimed to investigate the effects of aspirin on peri-operative hidden blood loss during hip fracture surgery by adjusting for possible factors affecting blood loss using a propensity score matching method. METHODS: We retrospectively collected data from a cohort of isolated hip fracture patients (aged ≥ 65 years)who underwent surgery from January 2010 to December 2019. The study's primary outcome was blood loss from admission to the day after surgery in the aspirin and control groups. We estimated the hidden blood loss, calculated based on patient's blood volume, haemoglobin measurements, and blood transfusions. The secondary outcome focused on the requirement for blood transfusion. We adjusted for possible factors affecting blood loss using a propensity score matching method and statistically examined the effects of aspirin on hip fracture surgery. RESULTS: We enrolled 806 patients of whom 271 (34%) were taking anticoagulant and antiplatelet drugs, while 114 (14%) were taking only aspirin (aspirin group). A total of 535 patients were not taking antiplatelets and anticoagulants (control group). In propensity score matching, 103 patients were matched. Aspirin was not associated with a significantly higher risk of hidden blood loss (aspirin group; median 598 mL [410-783 mL] vs control group; median 556 ml [321-741 mL], p = 0.14) and higher risk of blood transfusion requirement (aspirin group; 49 patients [48%] vs control group; 39 patients [38%], p = 0.21). CONCLUSION: Aspirin did not affect peri-operative blood loss in hip fracture surgery. We concluded that patients taking aspirin can safely undergo hip fracture surgery without delay.

Bleeding sites in elderly trauma patients who required massive transfusion: a comparison with younger patients.

INTRODUCTION: Among elderly patients with severe trauma, the sites of massive hemorrhage and their clinical characteristics are not well understood. Therefore, we investigated the sites of massive hemorrhage in patients with severe trauma, and compared the results for younger and elderly patients. METHODS: A cohort of severe trauma patients (Injury Severity Score ≥16) admitted from March 2007 to December 2014 was reviewed retrospectively. The inclusion criterion was massive bleeding, which was defined as bleeding that required the transfusion of ≥10 red cell concentrate units within 24 hours of admission, or as cases of early death that occurred despite continuous blood transfusion and before the patient could receive ≥10 red cell concentrate units within the first 24 hours after their admission. RESULTS: Eighty-four patients met our inclusion criterion. The younger group (<65 years old) included 40 patients (48%), whereas the older group (≥65 years old) included 44 patients (52%). The percentage of nondiagnosable cases at the primary survey (massive bleeding due to multisite damage caused by a bone fracture or contusion, retroperitoneal hematoma without a pelvic ring fracture and with stable pelvic ring fracture) was 14% in the younger group and 40% in the older group (odds ratio, 3.92; 95% confidence interval, 1.37-11.27, P = .017). CONCLUSIONS: Even if no abnormalities are observed at the primary survey of elderly patients with severe trauma, physicians should consider the possibility of massive bleeding.

Conservative treatment of fragility fracture of the pelvis: A retrospective study.

BACKGROUND: Although an increasing number of studies have reported the usefulness of early minimally invasive surgery (MIS) or fragility fracture of the pelvis (FFP), MIS is difficult to perform in every hospital, partly because of equipment problems. Moreover, different opinions exist on FFP treatment methods and the indication for surgery is usually determined by the fracture type. Since our hospital follows a conservative approach as the basic treatment, this study examined the outcomes of such an FFP approach. HYPOTHESIS: FFP outcomes are influenced by the fracture type and walking ability before the injury. PATIENTS AND METHODS: We investigated the bone fusion rate, bone fusion duration, unloading duration, walking ability trends, and outcomes in 76 patients with FFP treated conservatively at our hospital. RESULTS: The union rate, mean period until union, and follow-up period were 93.4%, 3.3 months, and 14.3 months, respectively. Walking ability significantly decreased from 5.1 points before the injury to 4.4 points during the last follow-up (p<0.01). The average unloading period was 12.8 days, and FFPs showed a high bone fusion rate, even with conservative treatment. DISCUSSION: Most patients eventually returned to their pre-injury status despite slightly decreased walking ability. Given the invasive nature of surgery, the indications for surgery should be carefully assessed after considering the risk-benefit ratio. LEVEL OF EVIDENCE: III; retrospective study.

Relationship between site-specific bone mineral density in the proximal femur and instability of proximal femoral fractures: A retrospective study.

BACKGROUND: Proximal femoral fractures can occur in patients with osteoporosis. However, the relationship between bone mineral density (BMD) of the proximal femur and fracture type and instability remains unclear. This study aimed to determine whether there is a relationship between the site-specific BMD of the proximal femur and the instability of proximal femoral fracture. HYPOTHESIS: The instability of proximal femoral fractures is related to the site-specific BMD of the proximal femur. PATIENTS AND METHODS: Using dual-energy X-ray absorptiometry (DEXA), the BMD on the non-fractured side was retrospectively examined in 252 women who underwent surgery for proximal femoral fracture at our hospital. The BMD was measured at three sites: the femoral neck (neck), trochanter (trochanter), and intertrochanteric region (inter). The BMD at several sites was compared between the femoral neck and trochanteric fractures. Femoral neck fractures were classified into the displaced and non-displaced types, and trochanteric fractures were classified into stable and unstable types. A comparative analysis was conducted for each proximal femur site and fracture type. RESULTS: Both total and site-specific BMDs were lower in trochanteric fractures than in femoral neck fractures. No difference was observed between BMD and displaced or non-displaced femoral neck fractures. However, the BMD of the intertrochanteric region was lower in unstable trochanteric fractures (0.57±0.12g/cm2) than in stable trochanteric fractures (0.61±0.11g/cm2) [p<0.05]. DISCUSSION: Several factors, including the patient's age and the bone component of each region, may influence the lower BMD in trochanteric fractures. In trochanteric fractures, the site-specific BMD of the proximal femur may predict the type of fracture and the degree of instability, especially in those with low BMD at the intertrochanteric site. The study findings suggest that a decrease in the BMD of the intertrochanteric region of femoral trochanteric fractures, which is thought to be involved in instability, is associated with fracture type instability. LEVEL OF EVIDENCE: III, retrospective study.

Delayed surgery after hip fracture affects the incidence of venous thromboembolism.

BACKGROUND: Venous thromboembolism (VTE) is one of the most common complications of hip fracture surgeries, and it is unclear whether delayed surgery affects the incidence of VTE. This study aimed to examine the association between delayed surgery and VTE incidence by statistically adjusting for factors that may influence VTE incidence. METHODS: We included 862 patients ≥ 65 years with hip fractures who underwent surgery between October 2010 and December 2020. We examined the effect of surgical delay 48 h after injury on postoperative VTE. Patients with and without VTE were assigned to groups V and NV, respectively. Those with and without proximal deep venous thrombosis (DVT) were assigned to PD and NPD groups, respectively. Univariate analysis was performed to identify factors that might influence DVT development. Risk factors for developing VTE and proximal DVT were analyzed using logistic regression analysis to determine whether delayed surgery was a risk factor. RESULTS: VTE was observed in 436 patients (40%) and proximal DVT in 48 patients (5.6%). Univariate analysis showed significant differences in the time from trauma to surgery between the V and NV groups and between the PD and NPD groups. In multivariate analysis, surgery 48 h later was also a risk factor for developing VTE and proximal DVT. CONCLUSION: A delay in surgery beyond 48 h after a hip fracture injury is a risk factor for developing VTE and proximal DVT.

Radiographic prediction of the results of long-term treatment with the Pavlik harness for developmental dislocation of the hip.

In 1957, Pavlik introduced the Pavlik harness as a useful treatment for developmental dislocation of the hip (DDH), and subsequent studies have documented favorable outcomes among patients treated with this device. However, there are only a few articles reporting how early radiographic measurements can be used to determine the prognosis after treatment with the Pavlik harness. In this study, 217 hips from 192 patients whose DDH treatment with the Pavlik harness was initiated before they were 6 months old and whose follow-up lasted at least 14 years (rate, 63.8%) were analyzed using measurements from radiographs taken immediately before and after harness treatment, and at 1, 2, and 3 years of age. Severin's classification at the final follow-up was I or II in 71.9% and III or IV in 28.1% of the hips, respectively. Avascular necrosis of the femoral head (AVN) was seen in 10% of the hips. Stepwise multiple regression analysis was performed to retrospectively determine whether any radiographic factors were related to the final classification as Severin I/II or III/IV. Receiver operating characteristic (ROC) curves were drawn for these factors, and a Wiberg OE angle (Point O was the middle point of the proximal metaphyseal border of the femur) of 2 degrees on the 3-year radiographs was found to be the most useful screening value for judging the acetabular development of DDH cases after treatment with a Pavlik harness, with a sensitivity of 71% a specificity of 93%, and a likelihood ratio of 10.1.

Early predictors for massive transfusion in older adult severe trauma patients.

BACKGROUND: Many scoring systems for the early prediction of the need for massive transfusion (MT) have been reported; in most of these, vital signs are regarded as important. However, the validity of these scoring systems in older patients remains unclear because older trauma patients often present with normal vital signs. In this study, we investigated the effectiveness of previously described scoring systems, as well as risk factors that can provide early prediction of the need for MT in older severe trauma patients. METHODS: We prospectively collected data from a cohort of severe trauma patients (ISS ≥16 and age ≥16years) admitted from January 2007 to March 2015. Trauma Associated Severe Hemorrhage (TASH), Assessment of Blood Consumption (ABC), and Prince of Wales Hospital (PWH) scores were compared between a younger and an older group. Furthermore, the predictors associated with MT in older severe trauma patients were assessed using multivariable logistic regression analyses. RESULTS: The area under the curve (AUC) was significantly smaller for older group than for younger group for all three scoring systems (p<0.05). The most important risk factors to predict the need for MT were related to anatomical factors including FAST results (odds ratio (OR): 5.58, 95% confidence interval (CI): 2.10-14.99), unstable pelvic fracture (OR: 21.56, 95% CI: 6.05-90.78), and long bone open fracture of the lower limbs (OR: 12.21, 95% CI: 4.04-39.09), along with pre-injury anticoagulant agent use (OR: 5.22, 95% CI: 1.30-19.61), antiplatelet agent use (OR: 3.81, 95% CI: 1.57-9.04), lactate levels (OR: 1.20, 95% CI: 1.04-1.39) and shock index (OR: 2.67, 95% CI: 1.05-6.84). Traditional vital signs were not early risk factors. CONCLUSION: We suggest that MT in older trauma patients should be considered on the basis of anatomical factors, pre-injury anticoagulant or antiplatelet agent use, lactate level and SI even if traditional vital signs are normal.

Effect of pre-injury anticoagulant and antiplatelet agents on blood loss in elderly patients with severe trauma.

Aim: It has been widely reported that pre-injury use of anticoagulant and antiplatelet agents can affect traumatic brain injury and the associated risk of mortality, however, the effect of these agents on non-head injury site-related blood loss remains unclear. Therefore, we investigated the effects of pre-injury anticoagulant and antiplatelet agents on the transfusion amount and the need for massive transfusion in elderly patients with severe trauma. Methods: We retrospectively reviewed a cohort of elderly patients with severe trauma (age, ≥65 years; Injury Severity Score, ≥16) between September 2006 and March 2014. The selected patients were subsequently divided into patients who were: only taking warfarin, aspirin, or clopidogrel; taking various combinations of these agents; and a control group who were not taking any of these agents. Results: During the study period, 67 patients (20%) were taking anticoagulant and antiplatelet agents and 272 patients were included in the control group. Among these patients, 10 were receiving only warfarin, 28 were receiving only aspirin, 14 were receiving only clopidogrel, and 13 were receiving various combinations of these medications. The amount of red cell concentrate and need for massive transfusions were only significantly increased in the warfarin group (P < 0.05). Furthermore, the warfarin group had a significantly higher risk of needing a massive transfusion with multivariate logistic regression analysis (odds ratio, 5.03; 95% confidence interval, 1.25-20.20; P < 0.05). Conclusion: Patients who were receiving only warfarin before their injury had an increased risk of bleeding due to non-head injuries.

Evaluation of thermoporometry for characterization of mesoporous materials.

The accuracy of thermoporometry (TPM) in terms of the characterization of SBA-15 is examined based on a model that classifies the water in the mesopores into two different types: freezable pore water, which can form cylindrical ice crystals, and nonfreezable pore water, which cannot undergo a phase transition during a differential scanning calorimetry (DSC) measurement. Applying the empirical relationship between the sizes of the ice crystals formed in the mesopores and the solidification temperature of the freezable pore water to a thermogram (a recording of the heat flux during the solidification of the freezable pore water) yielded a size distribution of the ice crystals. The size of the ice crystals increased slightly with repetitive freezing, indicating that the mesopores were enlarged by formation of the ice crystals. Adding the thickness, t(nf), of the nonfreezable pore water layer to the ice crystal-size distribution calculated from the thermogram allowed for the determination of the porous properties of SBA-15. The porous properties attained from TPM experiments were compared with the results attained through the combination of Ar gas adsorption experiments and nonlocal density functional theory (NLDFT) analysis. The porous properties determined by TPM were confirmed to be quite sensitive to the t(nf) value.

Admission fibrinogen levels in severe trauma patients: A comparison of elderly and younger patients.

INTRODUCTION: Acute coagulopathy of trauma has been much discussed recently. However, the changes in coagulation markers after trauma in the elderly are unknown. Furthermore, the baseline fibrinogen level is high in elderly patients, and the question remains as to whether fibrinogen levels also decrease early and the degree of decrease in elderly trauma patients. The purpose of this study was to compare coagulation markers including the fibrinogen level on admission in younger and elderly severe trauma patients. METHODS: A cohort of severe trauma patients (Injury Severity Score (ISS) ≥16), admitted from January 2011 to June 2014, with coagulation markers including the fibrinogen level on admission available, was reviewed retrospectively. The patients were divided into a younger (16-64 years old) and an older (≥65 years old) group based upon their age at presentation. Activated partial thromboplastin time (aPTT), international normalized ratio (INR), fibrinogen, and D-dimer were compared between the younger and older groups. RESULTS: There were 251 patients who met the inclusion criteria for this analysis. The younger group included 117 patients and the older group included 134 patients. The median aPTT (26.3 vs 27.5s, P=0.001) and median D-dimer levels (18.8 vs 40.2 µg/dL, P=0.006) were significantly higher in the older group. However, the fibrinogen level (205 vs 248 mg/dL, P<0.001) was significantly higher in the older group. The regression lines of fibrinogen and age in non-massive transfusion and massive transfusion cases are given by Y=1.03 X+185 (r=0.24, r(2)=0.06, P<0.001) and Y=0.86 X+134 (r=0.25, r(2)=0.06, P=0.09) respectively, and the fibrinogen levels tended to increase with older age in severe trauma patients. CONCLUSIONS: The fibrinogen level did not show a low value as it can in younger patients in elderly patients. Therefore, the fibrinogen level is difficult to use as an early indicator of acute blood loss with haemorrhage in elderly severe trauma patients, as it can be used in younger patients. Thus, it is necessary to keep in mind that the fibrinogen level increases by approximately 1mg/dL when the age increases by 1 year and to carefully observe the fibrinogen level even if the admission level is not low.

Evaluation of pore size distribution in boundary region of micropore and mesopore using gas adsorption method.

This paper discusses an accurate method of pore size distribution evaluation in boundary regions of micropores and mesopores using the gas adsorption process on the basis of the capillary condensation theory, which is liable to be underestimated with the existing BJH and DH methods. A typical nitrogen adsorption isotherm for highly ordered mesoporous silica, which has cylindrical pores with diameter smaller than 4 nm, is considered to be type IV and it is well known for the steep increase of the amount adsorbed through capillary condensation in the region of the relative pressure P/P0 smaller than 0.4. In calculating the distribution of the pore size from the change of the amount adsorbed due to capillary condensation, it is important to accurately predict both the multilayer thickness t of the adsorbed nitrogen molecules and the critical radius rc where capillary condensation occurs. It is necessary to consider the curvature of the adsorption layer-gas phase interface when predicting the multilayer thickness t of nitrogen adsorbed within the pore of highly ordered mesoporous silica. Revision of the Kelvin equation is also required when rc is to be predicted. While the predicted value of t based on the Broekhoff and de Boer theory is matched well with the value of t which is actually measured using highly ordered mesoporous silica, and the predicted value of rc based on the GTKB-Kelvin-cylindrical equation that has been revised considering the effect of the interfacial curvature on the interfacial tension of the adsorption layer-gas phase interface is matched with the value of rc which is actually measured using highly ordered mesoporous silica. A combination method of the Broekhoff and de Boer equation and the GTKB-Kelvin-cylindrical equation is proposed as a means of accurately evaluating, from the nitrogen adsorption isotherm, the pore size distribution in the highly ordered mesoporous silica in boundary region of micropore and mesopore. The proposed new method of pore size evaluation features high accuracy and offers the convenience of obtaining the pore size distribution without repeated calculations by employing the same algorithm as DH method. The pore size predicted by the Halsey equation and the Kelvin equation of the conventional DH method is about 20% smaller than the pore size predicted by the newly proposed evaluation method.

Nonlinear effects of electrolyte diodes and transistors in a polymer gel medium.

The polarization curve of an acid-base interface in a hydrogel medium has a diode characteristic. Two of each such electrolyte diodes can be combined to give an electrolyte transistor. When a salt is added to the alkaline or to the acidic part of a reverse biased electrolyte diode, the current response is highly nonlinear. If the salt is added to the acidic side, even bistability can be observed. This bistability can generate complex oscillations in a base-acid-base electrolyte transistor. These nonlinear effects are studied experimentally and theoretically. While the nonlinear salt effect can be explained with the Nernst-Planck equations, to understand the bistable behavior further investigations are necessary. (c) 1999 American Institute of Physics.

[A case of multiple organ dysfunction following postoperative epididymitis].

We report a case of multiple organ dysfunction following epididymitis. A 53-year-old male patient was admitted to our emergency room with bilateral clavicular fractures, multiple costal fractures and left hemopneumothorax due to a traffic accident. Open reduction of the right clavicular fracture was performed under general anesthesia on the sixth hospital day. A bladder balloon catheter was inserted after induction of anesthesia. The clinical course in the perioperative period was satisfactory and the bladder balloon catheter was removed on the seventh hospital day. However, spontaneous left scrotal pain with tenderness, intense heat with swelling developing on the tenth hospital day, and hypotension, dyspnea and oliguria were noted on the eleventh hospital day. Blood chemistry data showed severe inflammatory findings. Chest X-ray showed acute respiratory distress syndrome. Blood coagulation data showed pre-disseminated intravascular coagulation. The patient's condition continued to deteriorate and we suspected septic shock due to left epididymitis. Emergent left orchiectomy was performed under local anesthesia on the twelfth hospital day. Postoperatively he recovered rapidly. We consider that multiple organ dysfunction following postoperative epididymitis was caused by cytokines released due to systemic inflammatory response syndrome (SIRS) after the trauma, operation, and placement of the bladder catheter. In conclusion, it is important to note that patients with SIRS should undergo further examinations of septic shock immediately and resection of the causative tissue should be performed as soon as possible.

Characterization of carbon cryogel microspheres as adsorbents for VOC.

Adsorption characteristics of carbon cryogel microspheres (CC microspheres) with controlled porous structure composed of mesopores (2 nm

Enhancement effect of carbon adsorbent on ozonation of aqueous phenol.

Removal of aqueous phenol was examined by the simultaneous use of ozone and porous carbon adsorbents possessing different porous structures and surface properties. The removal efficiency of aqueous phenol was higher with the simultaneous use of ozone and carbon adsorbents than the use of ozone alone, due to the adsorptive-concentration effect of the adsorbents. The enhancement effect of macroporous carbon cryogel beads (CCB) on the ozonation of aqueous phenol was confirmed to be greater than in microporous activated carbon beads. Introduction of acidic functional groups to CCB by liquid-phase oxidation significantly diminished the adsorptive-concentration effect of CCB, since the interaction of aqueous phenol with the surface of CCB decreased.

Femoral neck fractures in older patients: indication for osteosynthesis.

In almost all the patients over 65 years of age with intracapsular femoral neck fractures who we treated over a 2-year period, we used osteosynthesis with Ace 6.5-mm cannulated cancellous screws. We then followed them for at least 24 months. Each of the seven nondisplaced fractures healed. Of the 20 displaced fractures, 14 were rated as healed, 5 as failures, and 1 as a late segmental collapse. Among the 14 displaced fractures with an operative delay of 1 day, 12 healed, whereas only 2 of the 6 fractures with an operative delay of 2 days or more did so. Of the 12 typical fractures (with a medial spike in the head fragment), 10 healed, as did 4 of the 8 crescent or mixed-type fractures. The treatment of choice for nondisplaced fractures is osteosynthesis. Displaced fractures that occur on the day of operation or the day before should be treated with osteosynthesis if they are the typical type. The rest of the displaced fractures should be considered candidates for primary prosthetic replacement.