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Background: The international scale and spread of evidence-based perioperative medicine for older people undergoing surgery (POPS) services has not yet been fully realised. Implementation science provides a structured approach to understanding factors that act as barriers and facilitators to the implementation of POPS services. In this study, we aimed to identify factors that influence the implementation of POPS services in the UK. Methods: A qualitative case study at three UK health services was undertaken. The health services differed across contextual factors (population, workforce, size) and stages of POPS service implementation maturity. Semi-structured interviews with purposively sampled clinicians (perioperative medical, nursing, allied health, and pharmacy) and managers (n = 56) were conducted. Data were inductively coded, then thematically analysed using the Consolidated Framework for Implementation Research (CFIR). Results: Fourteen factors across all five CFIR domains were relevant to the implementation of POPS services. Key shared facilitators included stakeholders understanding the rationale of the POPS service, with support from their networks, POPS champions, and POPS clinical leads. We found substantial variation and flexibility in the way that health services responded to these shared facilitators and this was relevant to the implementation of POPS services. Conclusions: Health services planning to implement a POPS service should use health service-specific strategies to respond flexibly to local factors that are acting as barriers or facilitators to implementation. To support implementation of a POPS service, we recommend health services prioritise understanding local networks, identifying POPS champions, and ensuring that stakeholders understand the rationale for the POPS service. Our study also provides a structure for future research to understand the factors associated with 'unsuccessful' implementation of a POPS service, which can inform ongoing efforts to implement evidence-based perioperative models of care for older people. [ABSTRACT FROM AUTHOR]

Introduction: A proportion of patients sustaining hip fractures present with a concomitant fracture. We aimed to evaluate the relationship between patient characteristics and clinical outcomes, in those with a hip and concomitant fracture compared with those sustaining a hip fracture alone from a clinical service registry.Method: Cross-sectional study using data obtained from a clinical service registry (Nottingham Hip Fracture Database) on patients aged 50 and above who suffered a hip fracture between 1/1/2003 and 31/12/2012. Data was collected on patient demographics, fracture information and healthcare outcomes.Results: 7338 patients of which 75 % were female (mean age 82 (SD 9.4), had a hip fracture with 334 (4.6 %) patients having a concomitant fracture. The majority (58 %) were distal radius or proximal humeral fractures. Only females (p = 0.002), those taking three or fewer medications (p = 0.018) and those on long term steroids (p = 0.048) were more likely to suffer a concomitant fracture. There was no difference in mortality, rates of postoperative complication, intensive care unit or care home admission between both groups. Patients with a concomitant fracture have a 16 % longer average length of stay in hospital (mean difference 1.16; 95 % CI 1.07-1.25, p < 0.001).Conclusions: Patients with concomitant fractures have similar patient characteristics, except gender, polypharmacy and long term steroid use; and outcomes to those presenting with hip fracture alone, except a longer average inpatient stay. [ABSTRACT FROM AUTHOR]

Background: hip fracture represents a huge medical, social and financial burden on patients, their carers and the health and social care systems. For survivors, return to their own home may be a key outcome. The Nottingham Hip Fracture Score (NHFS) is a validated score, based on admission characteristics, for predicting 30-day and 1-year mortality that may be of benefit in predicting return-to-home, directly from the acute orthopaedic ward.Objective: to assess the utility of the NHFS as a predictor of return-to-home in patients following hip fracture.Methods: the NHFS was calculated for all patients admitted from their own home and the correlation between the NHFS and eventual return-to-home was calculated, as well as the probability of discharge by within 7, 14 and 21 days.Results: a total of 6,123 patients were available for analysis. Of which, 3,699 (60%) were discharged from acute hospital to their own home. Increasing NHFS was negatively correlated with eventual return-to-home (r2 = 0.949) and with the proportion of patients discharged back to their own home at 7, 14 and 21 postoperative days, respectively (r2 = 0.84, 0.94, 0.96, respectively).Conclusions: the NHFS is a reliable tool for predicting return-to-home. It may be useful for discharge planning, and for the design of future research trials. [ABSTRACT FROM AUTHOR]

Background: Approximately 70,000 patients/year undergo surgery for repair of a fractured hip in the United Kingdom. This is associated with 30-day mortality of 9% and survivors have a considerable length of acute hospital stay postoperatively (median 26 days). Use of oesophageal Doppler monitoring to guide intra-operative fluid administration in hip fracture repair has previously been associated with a reduction in hospital stay of 4-5 days. Most hip fracture surgery is now performed under spinal anaesthesia. Oesophageal Doppler monitoring may be unreliable in the presence of spinal anaesthesia and most patients would not tolerate the probes. An alternative method of guiding fluid administration (minimally-invasive arterial pulse contour analysis) has been shown to reduce length of stay in high-risk surgical patients but has never been studied in hip fracture surgery.Methods: Single-centre randomised controlled parallel group trial. Randomisation by website using computer generated concealed tables.Setting: University hospital in UK.Participants: 128 patients with acute primary hip fracture listed for operative repair under spinal anaesthesia and aged > 65 years.Intervention: Stroke volume guided intra-operative fluid management. Continuous measurement of SV recorded by a calibrated cardiac output monitor (LiDCOplus). Maintenance fluid and 250 ml colloid boluses given to achieve sustained 10% increases in stroke volume.Control Group: fluid administration at the responsible (blinded) anaesthetist's discretion. The intervention terminates at the end of the surgical procedure and post-operative fluid management is at the responsible anaesthetist's discretion.Primary Outcome: length of acute hospital stay is determined by a blinded team of clinicians. Secondary outcomes include number of complications and total cost of care. Funding NIHR/RfPB: PB-PG-0407-13073.Trial Registration Number: Trial Registration: Current Controlled Trials ISRCTN88284896. [ABSTRACT FROM AUTHOR]

Aim: To examine the associations between visceral adipose tissue (VAT) and brain structural measures at midlife and explore how these associations may be affected by age, sex and cardiometabolic factors., Methods: We used abdominal and brain magnetic resonance imaging data from a population-based cohort of people at midlife in the UK Biobank. Regression modelling was applied to study associations of VAT volume with total brain volume (TBV), grey matter volume (GMV), white matter volume, white matter hyperintensity volume (WMHV) and total hippocampal volume (THV), and whether these associations were altered by age, sex or cardiometabolic factors., Results: Complete data were available for 17 377 participants (mean age 63 years, standard deviation = 12, 53% female). Greater VAT was associated with lower TBV, GMV and THV (P < .001). We found an interaction between VAT and sex on TBV (P < .001), such that the negative association of VAT with TBV was greater in men (β = -2.89, 95% confidence interval [CI] -2.32 to -10.15) than in women (β = -1.32, 95% CI -0.49 to -3.14), with similar findings for GMV. We also found an interaction between VAT and age (but not sex) on WMHV (P < .001). The addition of other cardiometabolic factors or measures of physical activity resulted in little change to the models., Conclusions: VAT volume is associated with poorer brain health in midlife and this relationship is greatest in men and those at younger ages., (© 2024 The Author(s). Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.)

Importance: Bleeding is the most common cause of preventable death after trauma., Objective: To determine the effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) when used in the emergency department along with standard care vs standard care alone on mortality in trauma patients with exsanguinating hemorrhage., Design, Setting, and Participants: Pragmatic, bayesian, randomized clinical trial conducted at 16 major trauma centers in the UK. Patients aged 16 years or older with exsanguinating hemorrhage were enrolled between October 2017 and March 2022 and followed up for 90 days., Intervention: Patients were randomly assigned (1:1 allocation) to a strategy that included REBOA and standard care (n = 46) or standard care alone (n = 44)., Main Outcomes and Measures: The primary outcome was all-cause mortality at 90 days. Ten secondary outcomes included mortality at 6 months, while in the hospital, and within 24 hours, 6 hours, or 3 hours; the need for definitive hemorrhage control procedures; time to commencement of definitive hemorrhage control procedures; complications; length of stay; blood product use; and cause of death., Results: Of the 90 patients (median age, 41 years [IQR, 31-59 years]; 62 [69%] were male; and the median Injury Severity Score was 41 [IQR, 29-50]) randomized, 89 were included in the primary outcome analysis because 1 patient in the standard care alone group declined to provide consent for continued participation and data collection 4 days after enrollment. At 90 days, 25 of 46 patients (54%) had experienced all-cause mortality in the REBOA and standard care group vs 18 of 43 patients (42%) in the standard care alone group (odds ratio [OR], 1.58 [95% credible interval, 0.72-3.52]; posterior probability of an OR >1 [indicating increased odds of death with REBOA], 86.9%). Among the 10 secondary outcomes, the ORs for mortality and the posterior probabilities of an OR greater than 1 for 6-month, in-hospital, and 24-, 6-, or 3-hour mortality were all increased in the REBOA and standard care group, and the ORs were increased with earlier mortality end points. There were more deaths due to bleeding in the REBOA and standard care group (8 of 25 patients [32%]) than in standard care alone group (3 of 18 patients [17%]), and most occurred within 24 hours., Conclusions and Relevance: In trauma patients with exsanguinating hemorrhage, a strategy of REBOA and standard care in the emergency department does not reduce, and may increase, mortality compared with standard care alone., Trial Registration: isrctn.org Identifier: ISRCTN16184981.

Objectives: Age and female sex are risk factors for dementia, and menopause is associated with cognitive dysfunction. Previous work largely considered the effects of sex and menopause as being independent of age. We studied whether age interacts with sex or menopause in explaining imaging biomarkers of dementia during midlife., Methods: In this cross-sectional study of UK Biobank participants with brain magnetic resonance imaging (MRI), we explored the interaction of age with sex or menopausal status in explaining total brain volume (TBV), gray matter volume (GMV), white matter volume (WMV), white matter hyperintensity volume (WMHV), regional cortical volume , and subcortical volume., Results: Data were available for 1827 postmenopausal women, 230 pre/perimenopausal women and 2165 men (median age 63.3 years). There was a significant interaction between age and sex (P = .024) for TBV, where the inverse association age with TBV was steeper in women (β = -5.35 mL/year) than in men (β = -4.77 mL/year). Similar age-sex interactions were also observed for GMV and WMV. In women, there was a significant interaction between age and menopausal status (P = .007) where the inverse association of age with TBV was steeper in postmenopausal (β = -5.89 mL/year) than in pre/perimenopausal women (β = -1.61 mL/year). Similar age-menopause interactions were found in predicting lower GMV and higher WMHV. Differences in the direction of these age-sex and age-menopause interactions were found for regional cortical and subcortical brain volumes., Conclusion: Sex and menopause both interact with age during midlife in explaining MRI biomarkers of dementia. Further work is required to understand the mechanisms driving these interactions to develop strategies for delaying dementia., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)