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Introduction:Increasing numbers of patients with hip fractures also have advanced comorbidities. A majority are treated surgically. However, a significantly increasing percentage of medically unfit patients with unacceptably high risk of perioperative death are treated nonoperatively. Important questions about patients’ prefracture quality of life (QOL) and future perspectives should be asked before considering different treatment options to assess what kind of treatment is advisable in frail elderly high-risk patients with a hip fracture.Objective:The aim of this review was to provide an overview of differences in mortality, health-related QOL [(HR)QOL], functional outcome, and costs between nonoperative management (NOM) and operative management (OM) of hip fractures in patients above 65 years.Methods:A systematic literature search was performed in EMBASE, OvidSP, PubMed, Cochrane Central, and Web of Science for observational studies and trials. Observational studies and randomized controlled trials comparing NOM with OM in hip fracture patients were selected. The methodological quality of the selected studies was assessed according to the Methodological Index for Nonrandomized Studies (MINORS) or Furlan checklist.Results:Seven observational studies were included with a total of 1189 patients, of whom 242 (20.3%) were treated conservatively. The methodological quality of the studies was moderate (mean: 14.7, standard deviation [SD]: 1.5). The 30-day and 1-year mortalities were higher in the nonoperative group (odds ratio [OR]: 3.95, 95% confidence interval [CI]: 1.43-10.96; OR: 3.84, 95% CI: 1.57-9.41). None of the included studies compared QOL, functional outcome, or health-care costs between the 2 groups.Conclusion:This systematic review and meta-analysis demonstrated that only a few studies with small number of patients comparing NOM with OM were published. A significantly higher 30-day and 1-year mortality was revealed in nonoperatively treated hip fracture patients. No data were found examining (HR)QOL and costs. Further work is needed to enable shared decision-making and to initiate NOM in frail elderly patients with advanced comorbidity and limited life expectancy.

IMPORTANCEThe development and expansion of intracranial hematoma are associated with adverse outcomes. Use of tranexamic acid might limit intracranial hematoma formation, but its association with outcomes of severe traumatic brain injury (TBI) is unclear.OBJECTIVE To assess whether prehospital administration of tranexamic acid is associated with mortality and functional outcomes in a group of patients with severe TBI. DESIGN, SETTING, AND PARTICIPANTSThis multicenter cohort study is an analysis of prospectively collected observational data from the Brain Injury: Prehospital Registry of Outcome, Treatments and Epidemiology of Cerebral Trauma (BRAIN-PROTECT) study in the Netherlands. Patients treated for suspected severe TBI by the Dutch Helicopter Emergency Medical Services between February 2012 and December 2017 were included. Patients were followed up for 1 year after inclusion. Data were analyzed from January 10, 2020, to September 10, 2020.EXPOSURES Administration of tranexamic acid during prehospital treatment. MAIN OUTCOMES AND MEASURESThe primary outcome was 30-day mortality. Secondary outcomes included mortality at 1 year, functional neurological recovery at discharge (measured by Glasgow Outcome Scale), and length of hospital stay. Data were also collected on demographic factors, preinjury medical condition, injury characteristics, operational characteristics, and prehospital vital parameters.RESULTS A total of 1827 patients were analyzed, of whom 1283 (70%) were male individuals and the median (interquartile range) age was 45 (23-65) years. In the unadjusted analysis, higher 30-day mortality was observed in patients who received prehospital tranexamic acid (odds ratio [OR], 1.34; 95% CI, 1.16-1.55; P < .001), compared with patients who did not receive prehospital tranexamic acid. After adjustment for confounders, no association between prehospital administration of tranexamic acid and mortality was found across the entire cohort of patients. However, a substantial increase in the odds of 30-day mortality persisted in patients with severe isolated TBI who received prehospital tranexamic acid (OR, 4.49; 95% CI, 1.57-12.87; P = .005) and after multiple imputations (OR, 2.05; 95% CI, 1.22-3.45; P = .007).CONCLUSIONS AND RELEVANCE This study found that prehospital tranexamic acid administration was associated with increased mortality in patients with isolated severe TBI, suggesting the judicious use of the drug when no evidence for extracranial hemorrhage is present.

The experience of impaired QOL appears to depend on living alone, inability to return to work and pre-accidental comorbidity rather than on the injured body area or the severity of the injury. Duration of hospital or ICU stay is important to subsequent QOL, even if ISS or body region is not.

NCT02508675.

HEMS treatment is associated with a non-significantly higher risk of in-hospital mortality for patients with TBI and a non-significantly lower risk for patients without TBI. This increased risk of mortality in TBI patients is attributable to the increased prehospital time. These results indicate that HEMS does not have a positive impact on survival.

BackgroundChronic pain is the main drawback of the Lichtenstein procedure for inguinal hernia repair, with a reported incidence of 15–40%. The transinguinal pre-peritoneal (TIPP) technique seems to be associated with less chronic pain, comparable to the total extra peritoneal (TEP) technique. The aim of this study was to evaluate 3 years of TIPP and Lichtenstein experience since the start of our Hernia Center Brabant in January 2006.MethodsPatient records of unilateral primary inguinal anterior hernia corrections (TIPP and Lichtenstein) performed since the opening of Hernia Center Brabant (2006–2008) were evaluated in a retrospective study. ASA class 4 and 5, <18 years, recurrences and bilateral hernias were excluded. In the TIPP technique, a Polysoft™ Hernia Patch was placed into the preperitoneal space using an anterior protocol led approach. The Lichtenstein technique was performed as described by Amid [Amid et al (1996) Eur J Surg 162:447–453] and modified with a soft mesh. One of the hernia surgeons decided peroperatively which technique to perform. Baseline characteristics and postoperative complications were assessed retrospectively. The attempted follow up period was 6 months. Chronic pain was assessed in both groups as mild (VAS 1–3), moderate (VAS 4–6) or severe (VAS 7–10). Chronic pain was defined in both groups as any pain sensation lasting longer than 3 months postoperatively, or when local injection of analgesia was necessary. Patients who did not come back because of chronic pain after regular follow up were regarded as free of pain.ResultsA total of 496 patients were included in this study; 225 TIPP and 271 Lichtenstein anterior inguinal hernia operations were analyzed. Data from one TIPP-patient were lost. Both groups were comparable with regard to baseline characteristics regarding age (p = 0.059), gender (p = 0.478) and ASA-classification (p = 0.104). TIPP: mean age 52.7 years, ASA-classification I: 54%, II: 36% and III: 5.3%. A total of 7.6% complications were assessed; recurrence (n = 1), bleeding (and re-operation) (n = 4); 10 patients (4.4%) experienced chronic pain. Persisting sensation loss occurred in 0.9%. Lichtenstein: mean age 57.3 years, ASA-classification I: 51%, II: 38% and III: 11%. A total of 8.5% complications were assessed; recurrence (n = 3), bleeding (and re-operation) (n = 3); 11 Lichtenstein patients (4.1%) experienced chronic pain. Persisting sensation loss occurred in 2.2%. Limitations of this retrospective study were incomplete follow up (31.3% had only one post operative visit 14 days after surgery) and these patients were further regarded as free of pain. Therefore, possible under-reporting of chronic pain could be present. The study was not double blind.ConclusionThis retrospective study design revealed no significantly better results for the TIPP procedure as compared to the Lichtenstein technique. The incidence of chronic pain reported in this retrospective study has been low in both groups since the opening of the Hernia Center Brabant. These results form the basis...

ObjectivesThe aims of this study were to examine the pattern of changes over time in health status (HS) and quality of life (QoL) in the first year after hip fracture and to quantify the association between frailty at the onset of hip fracture and the change in HS and QoL 1 year later. The major hypothesis was that frailty, a clinical state of increased vulnerability, is a good predictor of QoL in patients recovering from hip fracture.DesignProspective, observational, follow-up cohort study.SettingSecondary care. Ten participating centres in Brabant, the Netherlands.Participants1091 patients entered the study and 696 patients completed the study. Patients with a hip fracture aged 65 years and older or proxy respondents for patients with cognitive impairment were included in this study.Main outcome measuresThe primary outcomes were HS (EuroQol-5 Dimensions questionnaire) and capability well-being (ICEpop CAPability measure for Older people). Prefracture frailty was defined with the Groningen Frailty Indicator (GFI), with GFI ≥4 indicating frailty. Participants were followed up at 1 month, 3 months, 6 months and 1 year after hospital admission.ResultsIn total, 371 patients (53.3%) were considered frail. Frailty was negatively associated with HS (β −0.333; 95% CI −0.366 to −0.299), self-rated health (β −21.9; 95% CI −24.2 to −19.6) and capability well-being (β −0.296; 95% CI −0.322 to −0.270) in elderly patients 1 year after hip fracture. After adjusting for confounders, including death, prefracture HS, age, prefracture residential status, prefracture mobility, American Society of Anesthesiologists grading and dementia, associations were weakened but remained significant.ConclusionsWe revealed that frailty is negatively associated with QoL 1 year after hip fracture, even after adjusting for confounders. This finding suggests that early identification of prefracture frailty in patients with a hip fracture is important for prognostic counselling, care planning and the tailoring of treatment.Trial registration numberNCT02508675