Orthogeriatric Care Following Hip Fracture: Improving Post-Operative Outcomes in an Aged Population

INTRODUCTION

Hip fractures globally are associated with high levels of morbidity, mortality, and significant financial burden. This audit aimed to assess the impact of orthogeriatric liaison care on post-operative outcomes following surgical management of neck or femur fractures.

METHODS

Here, 258 patients who underwent hip fracture surgery over 1-year were included. Data were collected as an audit following the transition to an orthogeriatric liaison care model, involving regular orthogeriatric review (thrice weekly ward rounds, daily board rounds), superseding orthogeriatric review as requested. The audit is meant to assess the development of post-operative non-surgical site infection (NSSI) and mortality and duration of inpatient stay. Outcomes were compared to previous data from our hospital site in 2015/2016.

RESULTS

Patients with severe cognitive impairment and systemic disease (Abbreviated Mental Test Score (AMTS) < 7 and American Society of Anesthesiologists (ASA) grade ≥ 3) showed significantly elevated NSSI risk, consistent across the study periods. Both periods demonstrated an increased risk of NSSI associated with admission from nursing homes. Despite the 2021/2022 cohort being notably older, NSSI risk decreased from 40.6% to 37.2% after implementing the orthogeriatric care model. NSSI risk was notably reduced for severe cognitive impairment (51.6% vs. 71%), and the p-value was 0.025. Average hospital stay decreased post-intervention (2.4 days shorter), with a notable reduction for NSSI patients (3.4 days shorter). Overall mortality rates were similar, although mortality due to infection was significantly reduced in 2021/2022 (44.4% vs. 93.3%), and the p-value was 0.003.

CONCLUSION

The orthogeriatric liaison care model significantly decreased NSSI only in individuals with severe cognitive impairment and infection-associated mortality. This highlights the integral role of orthogeriatricians in the care of elderly hip fracture patients.

Recurrent abdominal laparotomy wound infection and dehiscence in a patient with zinc and selenium deficiency associated with Roux-en-Y gastric bypass: Case report and literature review

We report a case of a 72-year-old woman who developed recurrent abdominal laparotomy wound dehiscence and infection following a hepatico-jejunostomy. Her surgical history included a Roux-en-Y gastric bypass (RYGB) that was carried out 11 years ago. Upon further assessment in the current admission, she was found to be deficient in both selenium and zinc. Daily multivitamin and mineral tablets and a nutritional supplement drink were prescribed to address her deficiencies. After 2 months of supplementation, the laparotomy wound had made significant healing progress and no further surgical input was required. This case illustrates the importance of assessing micronutrient levels in patients with a history of bariatric surgery who present with poor wound healing and infection. Bariatric patients should also be educated about the risks of nutritional deficiencies and encouraged to adhere to prescribed dietary and lifestyle changes. Importantly, family medicine and primary care physicians need to consider an adequate level of supplementation of micronutrients in all patients with RYGB surgery.

HIV and an Ageing Population-What Are the Medical, Psychosocial, and Palliative Care Challenges in Healthcare Provisions

The continuing increase in patient numbers and improvement in healthcare provisions of HIV services in the UK, alongside the effectiveness of combined antiretroviral therapy (cART), has resulted in increasing numbers of the ageing population among people living with HIV (PLWH). It is expected that geriatricians will need to deal with many older people living with HIV (OPLWH) as life expectancy increases. Therefore, geriatric syndromes in OPLWH will be similar to the normal population, such as falls, cognitive decline, frailty, dementia, hypertension, diabetes and polypharmacy. The increase in the long-term use of cART, diabetes, dyslipidaemia and hypertension may lead to high prevalence of cardiovascular disease (CVD). The treatment of such conditions may lead to polypharmacy and may increase the risk of cART drug-drug interactions. In addition, the risk of developing infection and cancer is high. OPLWH may develop an early onset of low bone mineral density (BMD), osteoporosis and fractures. In this review, we have also provided potential psychosocial aspects of an ageing population with HIV, addressing issues such as depression, stigma, isolation and the need for comprehensive medical and psychosocial care through an interdisciplinary team in a hospital or community setting. OPLWH have a relatively high burden of physical, psychological, and spiritual needs and social difficulties, which require palliative care. The holistic type of palliative care that will improve physical, emotional and psychological wellbeing is discussed in this review.

Hyperacute synchronous cardiocerebral infarction in a patient with new-onset atrial fibrillation: a case of myocardial infarction with nonobstructive coronary arteries

Hyperacute synchronous cardiocerebral infarction (CCI) is an extremely rare condition with an incidence of 0.009%. In the acute stage of ischemic stroke, there is a high prevalence of ECG abnormalities. Prolonged QTc, atrial fibrillation (AF) and ECG changes indicative of ischemic heart disease, such as Q waves, ST depression, and T wave inversion, were the most prevalent changes. There are three types of simultaneous CCI: cardiac conditions that cause cerebral infarction, cerebral infarction caused by cardiac conditions, and (c) dysregulation of the brain-heart axis or cerebral infarction causing myocardial infarction. Herein, we present a case of hyperacute synchronous CCI in an elderly patient with new-onset AF and myocardial infarction with nonobstructive coronary arteries (MINOCA).

Bone Health in People Living with HIV/AIDS: An Update of Where We Are and Potential Future Strategies

The developments in Human Immunodeficiency Virus (HIV) treatment and in the care of people living with HIV (PLWHIV) and Acquired Immunodeficiency Syndrome (AIDS) over the last three decades has led to a significant increase in life expectancy, on par with HIV-negative individuals. Aside from the fact that bone fractures tend to occur 10 years earlier than in HIV-negative individuals, HIV is, per se, an independent risk factor for bone fractures. A few available antiretroviral therapies (ARVs) are also linked with osteoporosis, particularly those involving tenofovir disoproxil fumarate (TDF). HIV and hepatitis C (HCV) coinfection is associated with a greater risk of osteoporosis and fracture than HIV monoinfection. Both the Fracture Risk Assessment Tool (FRAX) and measurement of bone mineral density (BMD) via a DEXA scan are routinely used in the assessment of fracture risk in individuals living with HIV, as bone loss is thought to start between the ages of 40 and 50 years old. The main treatment for established osteoporosis involves bisphosphonates. Supplementation with calcium and vitamin D is part of clinical practice of most HIV centers globally. Further research is needed to assess (i) the cut-off age for assessment of osteoporosis, (ii) the utility of anti-osteoporotic agents in PLWHIV and (iii) how concomitant viral infections and COVID-19 in PLWHIV can increase risk of osteoporosis.

Fracture Neck of the Femur: A Case of Two Pathologies

We report a case of a 65-year-old woman who sustained a left neck of femur (NOF) fracture following low-energy trauma. Computed tomography (CT) scan for the neck, chest, abdomen and pelvis was normal apart from enlargement of the right lobe of the thyroid. Interestingly, thyroid function was normal. While waiting for the result of thyroid cytology and bone histology, the patient recovered well from the operation and started to engage well with physiotherapy. The result of the investigation showed presence of diffuse large B-cell lymphoma in the left NOF and right lobe of the thyroid. As the presence of lymphoma only in these two organs is extremely rare, it is not yet clear what is underlying mechanism for such association. Therefore, such observations may raise many future research questions as detailed in the discussion of this case report. This case also illustrates the importance of a multidisciplinary approach in identifying, evaluating, and treating unique and complex presentations of NOF fracture, with a focus on the patient's history, clinical examination and applying diagnostic tools.

Clinical Case 28—Hyperacute synchronous cardiocerebral infarction in a patient with new-onset atrial fibrillation: a rare case of MINOCA

Introduction

Hyperacute synchronous cardiocerebral infarction (CCI) is an extremely rare condition with an incidence of 0.009%. Herein, we present a case of hyperacute synchronous CCI in an elderly patient with new-onset atrial fibrillation (AF).

Case report

An 80-year-old male patient was referred to our emergency department due to acute onset left hemiparesis and dysarthria. Computed tomography (CT) of the brain showed a hyperdense M3-M4 branch of the right middle cerebral artery. The electrocardiogram (ECG) revealed new-onset AF without specific signs of acute myocardial ischemia. Subsequent ECG revealed AF with Q waves and ST elevation in leads V1-V6, II, III, and aVF, while the patient remained hemodynamically stable, without symptoms indicative of myocardial ischemia. Intravenous tissue plasminogen activator (alteplase) was administered. During the thrombolytic therapy, the patient expressed sudden severe upper back pain, while the ECG showed ‘tombstone’ ST elevation in leads V1-V6, II, III, and aVF. The thrombolytic therapy was immediately terminated and a CT angiography of the aorta was performed, which did not show any evidence of aortic dissection. Coronary angiography revealed no angiographically significant coronary artery stenosis. ECG evolution, echocardiography, and coronary angiography findings were consistent with myocardial infarction with non-obstructive coronary arteries (MINOCA).

Discussion

There are several conditions that lead to simultaneous acute CCI. The precise pathophysiological mechanism that leads to this synchronous CCI is difficult to be identified. In our case, the presence of new-onset AF can partly explain this situation as a source of both cerebral and coronary embolism.