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Rapid Responses: Rapid Responses published:
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Anticoagulation to survive the trauma!
- Friedrich Flachsbart (3 October 2003)
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Just a query
- Lisa A Williams (4 October 2003)
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Less Surgery, more prevention.
- Gerard T O' Brien (4 October 2003)
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Re: Less Surgery, more prevention - remember Falls
- Dawn A Skelton, Chris Todd (9 October 2003)
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Evaluating hospital episode statistics.
- Christopher G Moran, Russell Wenn, Christopher White (20 October 2003)
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Friedrich Flachsbart, General medicine 37085 Göttingen
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Dear Sir, The prethrombotic state of fractures should be tested by serial D-Dimer (ELISA). Treatment with anticoagulation, adapted to risk and D-Dimer (ELISA) should be done not only in hospital: The thrombophilic state is now killing later, in praxis. D-Dimer(ELISA) is able to prevent this! Sincerely Yours Friedrich Flachsbart Competing interests: None declared |
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Lisa A Williams, Spr Royal Gwent Hospital Newport
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As a trauma and orthopaedic trainee, I was very interested to read your useful article. From your paper I wasn't sure whether I could work out the total mortality rate for the first year. For me this figure helps to put things into perspective, and is often used in the trauma and orthopaedic world. Competing interests: None declared |
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Gerard T O' Brien, GP 38 Cecil St, Limerick, Ireland.
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Dear Sir, The report by Roberts and Goldcare on post hip fracture mortality 1968 -98 in England (1), highlights the depressingly high mortality rates which have persisted and plateaud; they even suggest that further reductions in these rates may not be possible. The advent of newer hip surgical approaches with minimal invasive techniques (2-4), including non-transsection of muscle, offer the promise of better outcomes and earlier hospital discharges. In this setting the role ambulatory care physicians would be increased with overseeing use of agents like enoxapren to prevent acute thrombo-embolic disorders in these patients. However as suggested in the report, the key issue lies in the diagnosis, prevention and treatment of osteoporosis. Wider use of inexpensive, non-invasive screening devices like ultrasound of the heel(5), are needed, particularly in the elderly and high risk groups such as those on long-term steroids. For these groups and for people with known osteoporosis especially, judicious (if at all) use of benzodiazepines needs to be considered (6). Current work showing lowered mortality from osteoporosis treatment in those with hip fracture (7), underlines the greater importance of primary prevention of hip fracture with these treatments. The finding of higher male mortality from hip fracture, which mirrors earlier work (7), combined with the higher incidence of fracture in females, , emphasises the role for universal screening and treatment of the elderly and risk groups. The adverse outcomes of osteoporotic fractures have been well documented (8), and go far beyond hip fracture itself. The increase in the elderly population and that of high risk groups, makes the challenge even greater. References: (1) Time trends and demography of mortality after fractured neck of femur in an English population, 1968-98: database study. Roberts SE, Goldacre MJ. BMJ 2003;327:771-775. (4 October). (2) Percutaneous compression plating (PCCP) versus dynamic hip screw for pertrochanteric hip fracture- preliminary results. Brandt SE, Lefever S et al. Injury. 2002 Jun;33(5):413-8. (3) The Gotfried PerCutaneous Compression Plate versus the Dynamic Hip screw in the treatment of pertrochanteric hip fractures: minimal invasive treatment reduces operative time and postoperative pain. Janzing HM, Houben BJ et al. Trauma. 2002 Feb;52(2):293-8. (4) Comparative evaluation of surgical approach to operative treatment of patients with hip fracture-[article in Russian]. Samokhin AV. Klin Khir. 2003 Feb;(2):51-5. (5) Quantitative US of the calcaneus: cutoff levels in the distinction of healthy and osteoporotic individuals. Grampp S, Henk C et al. Radiology. 2001 Aug;220(2):400-5. (6) Benzodiazepines and risk of hip fractures in old people: a review of the evidence. Cumming RG, Le Couteur DG. CNS Drugs 2003;17(11):825-37. (7) Mortality and morbidity associated with osteoporosis treatment following hip fracture. Cree MW, Juby AG, Carriere KC. Osteoporosis Int. 2003 Aug 7. (8) Adverse outcomes of osteoporotic fractures in the general population. Melton LJ 3rd. J Bone Miner Res. 2003 Jun;18(6):1139-41. Competing interests: None declared |
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Dawn A Skelton, Co-ordinator Prevention of Falls Network Europe University of Manchester M13 9PL, Chris Todd
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Roberts and Goldacre (1) reveal that mortality after hip fracture in the UK has not declined for 20 years. Thus we need to turn our focus to prevention of hip fracture. Much of the focus has been on diagnosis, prevention and treatment of osteoporosis. , However, we must remember that 9/10 fractures amongst older people happen as a result of a fall (2). Furthermore, at least 95% of hip fractures follow a fall and less than 2% can be attributed to “spontaneous fracture” (3). As Cryer and Patel (4) suggest, the UK must start considering prevention of falls at the same time as the prevention of osteoporosis, rather than considering them as separate entities. Fall prevention has been picked up as part of the NSF for older people, but we need to understand more about the mechanisms involved, and most importantly how to encourage high rates of take up and compliance with known effective interventions (5) In January 2003, the EC funded Prevention of Falls Network Europe(ProFaNE) commenced. This network is co-ordinated in the UK and has 25 participating members across Europe. The main aim of ProFaNE is to co- ordinate research efforts across Europe and disseminate evidence-based practice for falls prevention across Europe. More details can be found on http://www.profane.eu.org Dr Dawn Skelton School of Nursing, Midwifery & Health Visiting, University of Manchester, Oxford Road, Manchester, M13 9PL 1) Roberts SE,Goldacre MJ. Time trends and demography of mortality after fractured neck of femur in an English population, 1968-1998: database study. BMJ 2003;327:771-775 2) Ytterstad B. The Harstad injury prevention study: the characteristics and distribution of fractures amongst elders--an eight year study. Int J Circumpolar Health 1999;58:84-95 3) Nyberg L, Gustafson Y, Berggren D, Brannstrom B, Bucht G. Falls leading to femoral neck fractures in lucid older people. J Am Geriatr Soc 1996;44:156-60 4) Cryer C, Patel S. Falls, fragility and fractures: National Service Framework for Older People; the case for and strategies to implement a joint Health Improvement and Modernisation Plans for Falls and Osteoporosis. Alliance for better bone health. 2001 5) Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cunning RG, Rowe BH. Interventions to prevent falling in the elderly. Cochrane Library of Systematic Reviews CD 000340. Version 3. 2001 Competing interests: None declared |
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Christopher G Moran, Consultant Trauma & Orthopaedic Surgeon Queens' Medical Centre University Hospital Nottingham NG7 2UH, Russell Wenn, Christopher White
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Dear Sir We read this paper with great interest. A fundamental assumption of the work is that the coding for hip fractures has not only been accurate but has also been consistent over a thirty year period. We have recently evaluated the hospital episode statistics for hip fracture patients at our institute and have found error rates of up to 40%. The authors state that they have validated their data and we should be grateful if they could provide more detail on this. If their basic data is not valid and consistent then this weakens the basis of their conclusions. Your faithfully Professor CG Moran MD FRCS(Ed)
Mr R Wenn
Mr C White
Competing interests: None declared |
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