Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods:We randomised 2970 patients from 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were ≥45 years of age were eligible. Patients were randomly assigned to accelerated surgery (goal of surgery within 6 hours of diagnosis; 1487 patients) or standard care (1483 patients). The co-primary outcomes were 1.) mortality, and 2.) a composite of major complications (i.e., mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Outcome adjudicators were masked to treatment allocation, and patients were analysed according to the intention-to-treat principle; ClinicalTrials.gov, NCT02027896. Findings:The median time from hip fracture diagnosis to surgery was 6 hours (interquartile range [IQR] 4-9) in the accelerated-surgery group and 24 hours (IQR 10-42) in the standard-care group, p<0.0001. Death occurred in 140 patients (9%) assigned to accelerated surgery and 154 patients (10%) assigned to standard care; hazard ratio (HR) 0.91, 95% CI 0.72-1.14; absolute risk reduction (ARR) 1%, 95% CI -1-3%; p=0.40. The primary composite outcome occurred in 321 patients (22%) randomised to accelerated surgery and 331 patients (22%) randomised to standard care; HR 0.97, 95% CI 0.83-1.13; ARR 1%, 95% CI -2-3%; p=0.71.Interpretation: Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared to standard care.

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The test results show definite correlation and SBJ test can be used as a field test in performance monitoring, talent identification, military recruit screening and injury prevention.

Summaryobjectives To explore current patterns of diagnosis and treatment, quantify household economic impact and identify household strategies to cover the costs of visceral leishmaniasis (VL) care in rural Bangladesh.method Structured interviews with 113 VL patients from 87 households documenting all provider visits and expenditures for health care for VL, and the ways in which the expenditures were covered.results Patients paid a median of 7 visits to six different providers before beginning VL treatment. All visited the subdistrict government hospital at least once. While health care, including antileishmanial drug therapy, is officially available free of charge at government facilities, 79% of patients reported making informal payments for provider access, diagnostics and drug administration; only 14% of patients received their full drug course from this source. For the 58% of patients who purchased the full treatment course, drug cost constituted 34% of direct expenditure. Median direct expenditure for one VL patient was US$87 and median income lost was $40; median total expenditure was 1.2 times annual per capita income of our study population. Households employed multiple coping strategies to cover expenditures, most commonly sale or rental of assets (62%) and taking out loans (64%).conclusions Visceral leishmaniasis treatment causes a major economic burden in affected families. Control strategies for VL should facilitate timely, affordable diagnosis and treatment of patients to decrease the infection reservoir and to alleviate the economic burden of VL on households.

OBJECTIVEThe clinical outcomes and complications of patients who underwent pedicle subtraction osteotomy (PSO) for various diagnoses were compared. More specifically, the purpose was to identify if outcomes differed between patients with flat-back syndrome after lumbar fusion (FBS-LF) versus patients who underwent surgery for adult spinal deformity (ASD).METHODSA retrospective analysis of 104 patients who underwent a PSO for sagittal plane imbalance was performed. There were 28 patients with FBS-LF and 76 patients with various forms of ASD. Outcome was measured using visual analog scale (VAS)-back, VAS-leg, Oswestry Disability Index (ODI) (range 0–100 for all scales), and EQ-5D scores (range 0–1). Patients also rated their global outcomes as much better, better, unchanged, or worse at follow-up. The minimum follow-up was 1 year (range 1–4 years). Clinical outcomes and complications were compared between the 2 groups of patients.RESULTSThe most common level of PSO was L-3 and L-2; 100 single and 4 double PSOs were performed. The average local correction by PSO itself was 27.2°. The sagittal vertical axis (SVA) improved from a mean preoperative value of 74 ± 23 mm to 49 ± 20 mm at the final follow-up. The VAS-back, ODI, and EQ-5D scores improved significantly for the entire group by 33, 16, and 0.31 points, respectively. In total, 57% of patients reported that they were “much better” or “better” than before surgery. Preoperatively, as well as postoperatively, the FBS-LF patients reported significantly worse VAS scores. According to VAS-back results, the ASD group improved by 34 points compared with 29 points in FBS-LF patients. ODI scores were similar between the 2 groups preoperatively but improved significantly more in the ASD group (18 points) compared with the FBS-LF group (13 points). The EQ-5D scores improved from 0.07 to 0.35 in FBS-LF patients, and from 0.21 to 0.56 on average in ASD patients. Similarly, a “much better” or “better” outcome compared with before surgery was reported by 72% of patients in the ASD group compared with 24% of patients in the FBS-LF group (p < 0.001). The overall reoperation rate was 31%: 46% of patients in the FBS-LF group compared with 25% of patients in the ASD group. There were 19 (18%) dural tears, 14 (13.5%) surgical site infections, 12 (11.5%) instances of pseudarthrosis, 15 (14%) proximal junctional failures, and 2 distal junctional failures. The 12 (11%) neurological complications were dominated by partial weakness of hip flexion and knee extension, and all but 2 of these were temporary.CONCLUSIONSPSO is a safe and effective method for correcting sagittal plane imbalance due to multiple etiologies. The authors found patient satisfaction to be high, and health-related quality of life was greatly improved by the procedure in patients with ASD. In contrast, in FBS-LF patients, a suboptimal outcome was observed and the cautious use of PSO seems warranted in this subset of patients.

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Incidence Pulmonary edema of mountaineers a b s t r a c tBackground: There is uncertainty whether acclimatized low-landers who return to high altitude after a sojourn at low altitude have a higher incidence of pulmonary edema than during the first exposure to high altitude. Methods: This was a prospective cohort study consisting of men ascending to 3400 m by road (N ¼ 1003) or by air (N ¼ 4178). The study compared the incidence of high altitude pulmonary edema during first exposure vs the incidence during re-exposure in each of these cohorts. Results: Pulmonary edema occurred in 13 of the 4178 entries by air (Incidence: 0.31%, 95% CI: 0.18%e0.53%). The incidence during first exposure was 0.18% (0.05%e0.66%) and 0.36% (0.2%e0.64%) during re-exposure (Fisher Exact Test for differences in the incidence (two-tailed) p ¼ 0.534). The relative risk for the re-exposure cohort was 1.95 (95% CI, 0.43%e8.80%). Pulmonary edema occurred in 3 of the 1003 road entrants (Incidence: 0.30%, 95% CI: 0.08%e0.95%). All three cases occurred in the re-exposure cohort. Conclusion: The large overlap of confidence intervals between incidence during first exposure and re-exposure; the nature of the confidence interval of the relative risk; and the result of the Fisher exact test, all suggest that this difference in incidence could have occurred purely by chance. We did not find evidence for a significantly higher incidence of HAPE during re-entry to HA after a sojourn in the plains.ª 2013, Armed Forces Medical Services (AFMS). All rights reserved.

Open reduction and internal fixation results in anatomical restoration of ulna, but this does not translates to better functional outcomes in short term (12 months).