Background Concerns of contracting the highly contagious disease COVID-19 have led to a reluctance in seeking medical attention, which may contribute to delayed hospital arrival among traumatic patients. The study objective was to describe differences in time from injury to arrival for patients with traumatic hip fractures admitted during the pandemic to pre-pandemic patients. Materials and methods This retrospective cohort study at six level I trauma centers included patients with traumatic hip fractures. Patients with a non-fall mechanism and those who were transferred in were excluded. Patients admitted 16 March 2019–30 June 2019 were in the “pre-pandemic” group, patients were admitted 16 March 2020–30 June 2020 were in the “pandemic” group. The primary outcome was time from injury to arrival. Secondary outcomes were time from arrival to surgical intervention, hospital length of stay (HLOS), and mortality. Results There were 703 patients, 352 (50.1%) pre-pandemic and 351 (49.9%) during the pandemic. Overall, 66.5% were female and the median age was 82 years old. Patients were similar in age, race, gender, and injury severity score. The median time from injury to hospital arrival was statistically shorter for pre-pandemic patients when compared to pandemic patients, 79.5 (56, 194.5) min vs. 91 (59, 420), p = 0.04. The time from arrival to surgical intervention (p = 0.64) was statistically similar between groups. For both groups, the median HLOS was 5 days, p = 0.45. In-hospital mortality was significantly higher during the pandemic, 1.1% vs 3.4%, p = 0.04. Conclusions While time from injury to hospital arrival was statistically longer during the pandemic, the difference may not be clinically important. Time from arrival to surgical intervention remained similar, despite changes made to prevent COVID-19 transmission.

Objective: Hip fracture surgery in geriatric patients on anticoagulants may increase the risk for blood loss. Anticoagulation reversal may lower these risks; however, data on blood loss and transfusions are limited. The study purpose was to compare outcomes between hip fracture patients 1) not on anticoagulants 2) whose anticoagulants were reversed, and 3) whose anticoagulants were not reversed. Methods: This four-year retrospective cohort study at six Level 1 Trauma Centers enrolled geriatric patients (!65) with isolated hip fractures. The primary outcome was total hospital blood loss (ml). Secondary outcomes: hospital length of stay (HLOS) and volume of packed red blood cells (pRBC) transfusions (ml). Statistical analyses included: Fisher's, chi-squared, Kruskal-Wallis, linear mixed-effect and logistic regression. Bonferroni adjusted alpha ¼ 0.025. Results: Of the 459 patients, 189 (41%) were not on anticoagulants, 186 (41%) were reversed, and 84 (18%) were not reversed. The LS mean (SE) blood loss was 134 ml (12) for not reversed patients and 159 (17) for reversed patients; no significant difference compared to those not on anticoagulants [138 (12)], pdiff ¼ 0.14 and 0.83, respectively. The LS mean (SE) HLOS was significantly longer for the reversed patients, 7.7 (0.4) days, when compared to those not on anticoagulants, 6.8 (0.4), p ¼ 0.02, and when compared to those not reversed, 6.3 (0.6), p ¼ 0.01. There was no significant difference in pRBC transfusions. Conclusion: Not reversing anticoagulants for geriatric hip fractures was not associated with increased volume of blood loss or transfusions when compared to those reversed. Delayed surgery for anticoagulant reversal may be unnecessary and contributing to an increased HLOS.

Background: There are multiple reports on the effect of time to surgery for geriatric hip fractures; it remains unclear if earlier intervention is associated with improved mortality, hospital length of stay (HLOS), or cost. Methods: This was a multi-center retrospective cohort study. Patients (65y.) admitted (1/14-1/16) to six level 1 trauma centers for isolated hip fractures were included. Patients were dichotomized into early (24 h of admission) or delayed surgery (>24 h). The primary outcome was mortality using the CDC National Death Index. Secondary outcomes included HLOS, complications, and hospital cost. Results: There were 1346 patients, 467 (35%) delayed and 879 (65%) early. The early group had more females (70% vs. 61%, p < 0.001) than the delayed group. The delayed group had a median of 2 comorbidities, whereas the early group had 1, p < 0.001. Mortality and complications were not significantly different between groups. After adjustment, the delayed group had no statistically significant increased risk of dying within one year, OR: 1.1 (95% CI:0.8, 1.5), compared to the early group. The average difference in HLOS was 1.1 days longer for the delayed group, when compared to the early group, p-diff<0.001, after adjustment. The average difference in cost for the delayed group was $2450 ($1550, $3400) more expensive per patient, than the early group, p < 0.001. Conclusions: The results of this study provide further evidence that surgery within 24 h of admission is not associated with lower odds of death when compared to surgery after 24 h of admission, even after adjustment. However, a significant decrease in cost and HLOS was observed for early surgery. If causally linked, our data are 95% confident that earlier treatment could have saved a maximum of $1,587,800. Early surgery should not be pursued purely for the motivation of reducing hospital costs. Level of evidence: Level III.

Acute pancreatitis is a well-recognised complication of endoscopic procedures like endoscopic retrograde cholangiopancreatography but not oesophagogastroduodenoscopy (OGD). I report a case of a 33-year-old woman, admitted with severe epigastric pain and vomiting 2 hours after an elective OGD for evaluation of chronic gastrointestinal symptoms. Pancreatitis was diagnosed on the basis of elevated lipase (40 790 U/L; normal 11-82) and findings on imaging studies. Other common causes of acute pancreatitis such as gallstones, alcohol and medications were ruled out. She had an extended hospital course because of severe disease, characterised by systemic inflammatory response syndrome, pleural effusion and ascites but was successfully managed conservatively with bowel rest, hydration and pain management. Acute pancreatitis should be considered a rare complication of OGD and should be considered in differential diagnosis for abdominal pain post OGD. Pathogenesis is likely from direct trauma to pancreas or gas insufflation.

Background: Warfarin reversal is typically sought prior to surgery for geriatric hip fractures; however, patients often proceed to surgery with partial warfarin reversal. The effect of partial reversal (defined as having an international normalized ratio [INR] > 1.5) remains unclear. Methods: This was a retrospective cohort study. Geriatric patients (65 y/o) admitted to six level I trauma centers from 01/2014-01/2018 with isolated hip fractures requiring surgery who were taking warfarin pre-injury were included. Warfarin reversal methods included: vitamin K, factor VIIa, (a)PCC, fresh frozen plasma (FFP), and the "wait and watch" method. An INR of 1.5 defined complete reversal. The primary outcome was the volume of blood loss during surgery; other outcomes included packed red blood cell (pRBC) and FFP transfusions, and time to surgery. Results: There were 135 patients, 44% partially reversed and 56% completely reversed. The median volume of blood loss was 100 mL for both those completely and partially reversed, p ¼ 0.72. There was no difference in the proportion of patients with blood loss by study arm, 95% vs. 95%, p > 0.99. Twenty-five percent of those completely reversed and 39% of those partially reversed had pRBCs transfused, p ¼ 0.08. Of those completely reversed 5% received an FFP transfusion compared to 14% of those partially reversed, p ¼ 0.09. There were no statistically significant differences observed for the volume of pRBC or FFP transfused, or for time to surgery.