PRACTICEFor the full versions of these articles see bmj.com benefit and should not be given for this purpose. The evidence for added calcium in the prevention of hypertensive disorders is conflicting and confusing, and more research is needed in this area. Chronic hypertension Preconception• Tell women taking angiotensin converting enzyme inhibitors and angiotensin II receptor blockers that taking these drugs during pregnancy increases the risk of congenital abnormalities, and that they should discuss other antihypertensive treatments with their healthcare professional if they are planning pregnancy. • Tell women taking chlorothiazide diuretics that taking these drugs during pregnancy increases the risk of congenital abnormalities and neonatal This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists Further information about the guidance, a list of members of the guideline development group, and the supporting evidence statements are in the full version on bmj.com. Why read this summary?Hypertensive disorders of pregnancy cover a spectrum of conditions, including chronic (pre-existing) hypertension, pre-eclampsia, and gestational hypertension (box 1). These conditions are associated with increased perinatal mortality and morbidity. Hypertensive disorders cause one in 50 stillbirths in normal babies and 10% of all preterm births. They contribute to a third of cases of severe maternal morbidity. 1 Pre-eclampsia is one of the most common causes of maternal death in the United Kingdom. 2 This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on how to manage hypertensive disorders during pregnancy. 3 Recommendations NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group's experience and opinion of what constitutes good practice. Evidence levels for the recommendations are in the full version of this article on bmj.com.Reducing the risk of hypertensive disorders in pregnancy • Advise pregnant women of their risk of developing hypertensive disorders during pregnancy (in particular pre-eclampsia; see box 2) and of the need to seek immediate advice from a healthcare professional if they experience symptoms of preeclampsia (severe headache; problems with vision, such as blurring or flashing before the eyes; severe pain just below the ribs; vomiting; sudden swelling of face, hands, or feet). • Advise women with at least one high risk factor for pre-eclampsia or at least two moderate risk factors for pre-eclampsia (box 2) to take 75 mg of aspirin daily from 12 weeks until the birth of the baby. • Although several drugs (nitric oxide donors, progesterone, diuretics, and low molecular weight heparin) and vitamin and nutrient supplement...

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BackgroundIntertrochanteric hip fractures are common and devastating injuries especially for the elderly. Surgical treatment is the optimal strategy for managing intertrochanteric fractures as it allows early rehabilitation and functional recovery. The relative effects of internal fixation strategies for intertrochanteric fracture after operation remain limited to relatively small studies which create uncertainty in attempts to establish evidence-based best practice.MethodsWe conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) and observational studies to assess the clinical effectiveness of two commonly used intramedullary devices: a twin screw integrated cephalomedullary nail (InterTAN) versus a single screw cephalomedullary nail (proximal femoral nail antirotation) in patients with intertrochanteric fractures. The following outcomes were considered: revisions, implant-related failures, non-unions, pain, Harris Hip Score and intraoperative outcomes. Odds ratios or mean differences with 95% confidence intervals in brackets are reported.ResultsSix studies met the inclusion criteria, two randomised controlled trials and four observational studies enrolling 970 patients with mean age of 77 years, and 64% of patients were female. There was a statistically significant difference (p value < 0.05) for revisions OR 0.27 (0.13 to 0.56), implant-related failures OR 0.16 (0.09 to 0.27) and proportion of patients complaining of pain OR 0.50 (0.34 to 0.74). There was no difference in non-unions and Harris Hip Score (p value > 0.05). There was a significant difference in blood loss and fluoroscopy usage in favour of PFNA, whilst no difference in operating times were observed between the two devices.ConclusionsOur meta-analysis suggests that a twin screw integrated cephalomedullary nail InterTAN is clinically more effective when compared to a single screw cephalomedullary nail proximal femoral nail antirotation resulting in fewer complications, fewer revisions and fewer patients complaining of pain. No difference has been established regarding non-unions and Harris Hip Score. Intraoperative outcomes favour PFNA with less blood loss and fluoroscopy usage. Further studies are warranted to explore the cost-effectiveness of these and other implants in managing patients with intertrochanteric fractures.

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Background:National projections of future joint arthroplasties are useful for understanding the changing burden of surgery and related outcomes on the health system. The aim of this study is to update the literature by producing Medicare projections for primary total joint arthroplasty (TJA) procedures until 2040 and 2060.Methods:The present study used data from the Centers for Medicare & Medicaid Services (CMS) Medicare/Medicaid Part B National Summary and combined procedure counts with use of Current Procedural Terminology (CPT) codes to identify whether the procedure was a primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) procedure. In 2019, the annual volume of primary TKA was 480,958 and that of primary THA was 262,369. These values formed a baseline from which we generated point forecasts for 2020-2060 and 95% forecast intervals (FIs).Results:Between 2000 and 2019, the estimated annual volume of THA increased by 177% and that of TKA increased by 156% on average. Regression analysis projected an annual growth rate of 5.2% for THA and 4.44% for TKA. Based on these yearly projected increases, an estimated increase of 28.84% and 24.28% is expected for each 5-year period after 2020 for THA and TKA, respectively. By 2040, the number of THAs is projected to be 719,364 (95% FI, 624,766 to 828,286) and the number of TKA is projected to be 1,222,988 (95% FI, 988,714 to 1,512,772). By 2060, the number of THAs is projected to be 1,982,099 (95% FI, 1,624,215 to 2,418,839) and the number of TKAs is projected to be 2,917,959 (95% FI, 2,160,951 to 3,940,156). In 2019, Medicare data showed that THA constituted approximately 35% of TJA procedures performed.Conclusions:Based on 2019 total volume counts, our model forecasts an increase in THA procedures of 176% by 2040 and 659% by 2060. The estimated increase for TKA is projected to be 139% by 2040 and 469% by 2060. An accurate projection of future primary TJA procedure demands is important in order to understand future health-care utilization and surgeon demand. This finding is only applicable to a Medicare population and demands further analysis to see if this extends to other population groups.Level of Evidence:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.