Effectiveness of vitamin K in anticoagulation reversal for hip fracture surgery – A prospective observational study

Introduction

Vitamin K antagonists are often used for anticoagulant treatment in hip fracture patients. The optimal handling with such anticoagulants is unclear.We aimed to determine when anticoagulation reversal occurred after vitamin K administration and how often prothrombin complex concentrates (PCCs) were administered. We compared patients’ treatments and outcomes with those of a control group not receiving treatment for anticoagulation.

Patients and Methods

A total of 402 geriatric hip fracture patients were included in this observational study. We collected data on treatment for anticoagulation, time to surgery, and reasons for delay of surgery. In patients taking vitamin K antagonists, we measured the INR (international normalized ratio) on admission and prior to surgery, along with the frequency of PCC administration. Finally, we compared in-hospital mortality and complications between patient groups.

Results

A total of 62 (15%) patients received phenprocoumon prior to their fractures. Surgery was delayed in these patients compared to controls (27 h; 95%CI 23–31 vs. 16 h; 95%CI 19–19; p = 0.001), but surgery delay > 48 h (n = 5; 8%) was not due to a failure of INR reversal. The main reason for these delays was a lack of capacity for surgery. The average INR on admission was 2.1 (± 0.7; range 1.0-3.5) in patients taking phenprocoumon, which decreased to 1.3 (± 0.3; range 1.0-1.6) until surgery. PCCs were administered to 19% of patients. We found no differences in the in-hospital mortality (6.2% vs. 8.1%, p = 0.575) or complication rates (12.9% vs. 9.4%, p = 0.364).

Conclusion

The use of vitamin K seemed to be sufficient for anticoagulation reversal in geriatric hip fracture patients, and it generally led to timely surgery; despite this success, PCCs were sometimes administered for logistical reasons.     

Extracting and summarizing white matter hyperintensities using supervised segmentation methods in Alzheimer's disease risk and aging studies

Precise detection and quantification of white matter hyperintensities (WMH) observed in T2‐weighted Fluid Attenuated Inversion Recovery (FLAIR) Magnetic Resonance Images (MRI) is of substantial interest in aging, and age‐related neurological disorders such as Alzheimer's disease (AD). This is mainly because WMH may reflect co‐morbid neural injury or cerebral vascular disease burden. WMH in the older population may be small, diffuse, and irregular in shape, and sufficiently heterogeneous within and across subjects. Here, we pose hyperintensity detection as a supervised inference problem and adapt two learning models, specifically, Support Vector Machines and Random Forests, for this task. Using texture features engineered by texton filter banks, we provide a suite of effective segmentation methods for this problem. Through extensive evaluations on healthy middle‐aged and older adults who vary in AD risk, we show that our methods are reliable and robust in segmenting hyperintense regions. A measure of hyperintensity accumulation, referred to as normalized effective WMH volume, is shown to be associated with dementia in older adults and parental family history in cognitively normal subjects. We provide an open source library for hyperintensity detection and accumulation (interfaced with existing neuroimaging tools), that can be adapted for segmentation problems in other neuroimaging studies. Hum Brain Mapp 35:4219–4235, 2014. © 2014 Wiley Periodicals, Inc .     

Superior Temporal Sulcus Disconnectivity During Processing of Metaphoric Gestures in Schizophrenia

The left superior temporal sulcus (STS) plays an important role in integrating audiovisual information and is functionally connected to disparate regions of the brain. For the integration of gesture information in an abstract sentence context (metaphoric gestures), intact connectivity between the left STS and the inferior frontal gyrus (IFG) should be important. Patients with schizophrenia have problems with the processing of metaphors (concretism) and show aberrant structural connectivity of long fiber bundles. Thus, we tested the hypothesis that patients with schizophrenia differ in the functional connectivity of the left STS to the IFG for the processing of metaphoric gestures. During functional magnetic resonance imaging data acquisition, 16 patients with schizophrenia (P) and a healthy control group (C) were shown videos of an actor performing gestures in a concrete (iconic, IC) and abstract (metaphoric, MP) sentence context. A psychophysiological interaction analysis based on the seed region from a previous analysis in the left STS was performed. In both groups we found common positive connectivity for IC and MP of the STS seed region to the left middle temporal gyrus (MTG) and left ventral IFG. The interaction of group (C>P) and gesture condition (MP>IC) revealed effects in the connectivity to the bilateral IFG and the left MTG with patients exhibiting lower connectivity for the MP condition. In schizophrenia the left STS is misconnected to the IFG, particularly during the processing of MP gestures. Dysfunctional integration of gestures in an abstract sentence context might be the basis of certain interpersonal communication problems in the patients.Key words: coverbal gestures, integration, fMRI, psychophysiological interaction, concretism     

Vulvar reconstruction using the “lotus petal” fascio-cutaneous flap

Introduction

Vulvar reconstruction using the “lotus petal” fascio-cutaneous flap offers a relatively novel means to restore symmetry and functionality after extirpative gynecologic or oncologic procedures. We sought to assess the success rates and morbidity in a large series of consecutively treated patients.

Methods

We performed a retrospective review of 59 consecutive cases of lotus petal flaps performed at a single institution to more accurately assess success and complication rates.

Results

We identified 80 flaps performed among the 59 patients between September 1, 2008 and March 30, 2013. The median (range) age was 59 years (24–89) and the median (range) BMI was 27 kg/m² (19–34). The indications for vulvar/perineal excision were as follows: 39 (66.1%) vulvar carcinoma or melanoma, 12 (20.3%) vulvar dysplasia, 5 (8.5%) colorectal disease and 3 (5.1%) cases of hidradenitis suppurativa. The mean defect area, determined by post-fixation pathology specimen was 29 cm². Medical or surgical complications occurred in 36% of patients of which superficial wound separation was the most common (15%). There were no cases of complete flap loss, but partial loss occurred in 7 (8.8%) cases. 3 (5.1%) patients required re-operation prior to discharge with one case requiring skin grafting. Delayed surgical revision was required in 4 patients for partial flap loss (2) or stricture/stenosis (2).

Conclusion

The lotus petal flap is safe for use in gynecologic reconstruction, with acceptable short- and long-term complication rates. Previous reports of smaller series likely underestimate the risk of complications through case selection.     

Does CT have an additional diagnostic value over ultrasound in the evaluation of acute inflammatory neck masses in children?

Objectives  

We assessed the additional value of contrast-enhanced CT versus US for evaluation of acute cervical inflammatory masses and choosing treatment strategy.