Hip Fracture in the Elderly: Early Surgery Improves Survival

Aswan, Egypt (Dr. Noorali Bharwani)
Aswan, Egypt (Dr. Noorali Bharwani)

This month marks 20-years of writing this column. My thanks to the present and previous editors of the Medicine Hat News and of course the readers. Without readers there is no column. Thank you all.

Today, I want to discuss about a very debilitating problem amongst seniors. This is about seniors with hip fractures and what is the best time to operate on them.

In Canada, hospitals admit 30,000 older adults with hip fracture each year.

These patients face an increased risk of death, with up to five per cent of women and 10 per cent of men dying within 30 days. These statistics are published in the Canadian Collaborative Study of Hip Fractures published in the Canadian Medical Association Journal (CMAJ August 07, 2018).

Treatment for hip fracture usually involves a combination of surgery, rehabilitation and medication. Physical therapy and rehabilitation focus on range-of-motion and strengthening exercises. Depending on the type of surgery and whether you have assistance at home, you may need to go from the hospital to an extended care facility.

Timing of operation is very important. Surgery on admission day or the following day was estimated to reduce postoperative death rate among medically stable patients. That is why it is important for hospitals to expedite operating room access for patients whose surgery has already been delayed for nonmedical reasons, says the CMAJ report.

It is generally accepted early operative intervention improves survival by reducing patients’ exposure to immobilization and inflammation.

In 2005, the federal, provincial and territorial governments established a benchmark of 48-hours from admission for 90 per cent of hip fracture surgeries to prevent potentially harmful delays.

However, delays to hip fracture surgery remain common. Patients who are medically stable at presentation may have to wait until a surgeon or an operating room becomes available.

If the hip surgery is done on the day of admission then the cumulative 30-day death rate was 48.9 deaths per 1000 surgeries.

For surgery carried out later, the death rate was significantly higher: 57.0 deaths per 1000 surgeries done on inpatient day three and 69.1 deaths per 1000 surgeries done after inpatient day three.

The study also found patients undergoing the procedure on inpatient day two rather than the day of admission did not change the risk of death.

If all surgeries were done on inpatient day three rather than the day of admission, there would be an additional 5.8 deaths for every 1000 surgeries, and the number of deaths would increase further, to 10.9 deaths for every 1000 surgeries, if all surgeries were done after inpatient day three.

What to expect in the future? Up to 10 percent of adults age 65 or older that have a hip fracture will have another hip fracture within two years. Bisphosphonates and other medications for osteoporosis may help reduce the risk of a second hip fracture.

The study recommends that all medically stable older adults with hip fracture undergo surgery on the day of their admission to hospital or the following day. This approach places the emphasis of managerial efforts on expediting operating room access for patients whose surgery might be delayed for nonmedical reasons.

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What is the best test for breast cancer screening?

A bird on a fall day. (Dr. Noorali Bharwani)
A bird on a fall day. (Dr. Noorali Bharwani)

Is MRI test better than mammography for early detection of breast cancer?

This question applies to women who are at average risk of breast cancer. They have no personal or family history of breast cancer. The controversy over the best way to screen for breast cancer among women at average risk continues.

Regular screening for breast cancer with mammography, breast self-examinations and clinical breast examinations are widely recommended to reduce mortality due to breast cancer.

Unfortunately, the available evidence does not support the use of MRI scans, clinical breast examination or breast self-examination to screen for breast cancer among women at average risk. But we continue to use these investigations.

Recent publications have again questioned the use of MRI alone or in combination with mammography for breast screening. There are more false-positives resulting in more negative biopsies.

Some researchers (JAMA Intern Med. 2018 Apr 1) have concluded that screening with MRI is not for everyone. Women who undergo breast cancer screening with MRI are much more likely to be referred for biopsy – that will ultimately be negative – than if they have screening mammography alone.

The authors of the article warn, “This is even true of women with a personal history of breast cancer. The benefit of possible early detection of breast cancer with MRI has to be carefully weighed against unnecessary additional diagnostic manoeuvres.”

Other authors have concluded that more studies are required to identify women who will benefit from screening MRI to ensure an acceptable benefit-to-harm ratio.

The experts have to determine whether a screening test would benefit or harm the patient. There is risk of harm and cost of false-positive results, overdiagnosis and overtreatment. How many unnecessary biopsies will be done to find one cancer? How many women will have to anxiously wait for days, weeks or months to find out if they have cancer? Not easy questions to answer unless you are sailing in the same boat.

Any positive result from screening has emotional costs such as anxiety and worry for patients and their families, and financial costs to both the patient and the health care system as a result of additional and potentially unnecessary diagnostic tests.

For women with positive results on screening tests, additional diagnostic tests will usually be recommended, such as further mammography, ultrasound and/or tissue sampling with core needle biopsy.

You may ask, “Doctor, what is the best way to screen asymptomatic women with no personal or family history of breast cancer?” The answer lies in the following recommendations from the Canadian Cancer Society:

If you are 40–49: Talk to your doctor about your risk for breast cancer, along with the benefits and potential risks of mammography. The benefits of regular mammography to screen for breast cancer in women younger than 50 are still unclear.

If you are 50–69: Have a screening mammography every 2 years.

If you are 70 or older: Talk to your doctor about how often you should have a mammography.

There is some radiation involved in having mammography. The benefits of mammography and finding breast cancer early outweigh the risk of exposure to the small amount of radiation received during mammography.

Now, here is the good news. The average 5-year survival rate for people with breast cancer is 90 per cent. The average 10-year survival rate is 83 per cent. If the cancer is located only in the breast, the 5-year relative survival rate is 99 per cent. Sixty-two percent of cases are diagnosed at this stage.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

There is some good news for children with peanut allergy.

The White House - Let there be peace! (Dr. Noorali Bharwani)
The White House - Let there be peace! (Dr. Noorali Bharwani)

Allergy to peanuts is the most common children’s food allergy. And the prevalence of peanut allergy is rising. It tends to present early in life, and affected individuals generally do not outgrow it. It is not clear why some people develop allergies while others don’t.

Eight foods are responsible for more than 90 per cent of food allergies: cow’s milk, eggs, soy, wheat, peanuts, tree nuts (walnuts, hazelnuts, almonds, cashews, pecans and pistachios), fish and shellfish. Peanuts and tree nuts are responsible for the majority of serious acute allergic (anaphylactic) reactions.

While EpiPens are used to control general allergic reactions, there is no specific treatment available for peanut allergies – until now. A Harvard University blog of March 1, 2018 (A cure for peanut allergies in sight?) reports that within the past year, three new peanut allergy therapies have gone through clinical trials.

Despite the treatment’s success, there were some safety concerns: 20 per cent of patients discontinued the trial, with 12 per cent withdrawing due to moderate side effects. But there is still hope. The researchers are planning to get FDA approval, which would make it the first protective treatment against peanut allergies, says the Harvard University blog. We have to learn more about the complex mechanisms of peanut allergy and tolerance before success is achieved.

Food allergies affect between four and eight per cent of children and between one and two per cent of adults. The perceived prevalence of food allergies is substantially higher than the actual prevalence. Up to 30 per cent of the general population believe they have a food allergy, and up to 30 per cent of parents believe that their children have a food allergy.

All food allergies have the potential to induce anaphylaxis, but some foods are more likely than others to cause potentially life-threatening reactions. Peanut allergy deserves particular attention. It accounts for the majority of severe food-related allergic reactions, it tends to present early in life, it does not usually resolve, and in highly sensitized people, trace quantities can induce an allergic reaction.

Parents have to understand that all degree of peanut allergy should be taken seriously – even mild allergy can cause serious problems. An allergic response to peanuts usually occurs within minutes after exposure.

Should pregnant women avoid peanuts to prevent peanut allergy in their children?

We need more studies to advise pregnant mothers about avoiding peanuts during pregnancy. We have no evidence to suggest that pregnant women should be encouraged to ingest peanut or suggest an amount of peanut to be ingested to ensure a preventive effect, as there is insufficient evidence to support it at this time, say experts.

To summarize, peanut allergy is the most common cause of food-induced anaphylaxis, a medical emergency that requires treatment with an epinephrine (adrenaline) injector (EpiPen) and a trip to the emergency room.

Call 911 if you or someone else displays severe dizziness, severe trouble breathing or loss of consciousness. There is no time to waste.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Minimally invasive surgery has revolutionized surgical procedures.

Central Park in New York City. (Dr. Noorali Bharwani)
Central Park in New York City. (Dr. Noorali Bharwani)

In minimally invasive surgery, doctors use a variety of techniques to operate with less damage to the body than with open surgery. Minimally invasive surgery is associated with less pain, a shorter hospital stay and fewer complications.

This advantage is achieved by using a technique called laparoscopy where surgery is done through one or more small incisions, using small tubes and tiny cameras and surgical instruments.

Laparoscopic technique was one of the first types of minimally invasive surgery. Another type of minimally invasive surgery is robotic surgery. It provides a magnified, 3-D view of the surgical site and helps the surgeon operate with precision, flexibility and control.

It was in 1902, Georg Kelling from Dresden in Germany performed laparoscopic surgery using dogs. In 1910, Hans Christian Jacobaeus from Sweden used the approach to operate on a human. Over the next couple of decades, the procedure was refined and popularized by a number of people.

Laparoscopic gallbladder surgery (cholecystectomy) was introduced about 25 years ago. In 2011, cholecystectomy was the 8th most common operating room procedure performed in hospitals in North America.

Now laparoscopy has become the approach of choice for cholecystectomy. Other laparoscopic surgical procedures are appendectomy, nephrectomy, hysterectomy and other gynecological procedures. Just like anything else in life, these procedures are not without complications – during or after surgery.

If the laparoscopic surgery is difficult to perform and if the surgeon feels this may cause harm to the patient then the procedure is converted into an open one. Patient has to understand this and give consent to the surgeon to do whatever is safe for the patient.

To make sure that the surgical procedures are carried out safely, the operating room follows a protocol, which takes into account the following:

  • Perform a surgical pause (time out) to confirm the procedure with the team prior to initiating surgery.
  • Verify that the correct materials or equipment was available and functional prior to use.
  • Consider potential harm from misuse of surgical equipment.

Possible intra-operative injuries include damage to the bowel, blood vessels, ureter, reproductive organs, or nerves. The complication rate during surgery increase if the patient is obese and there are adhesions from previous surgeries.

How quickly you can return to normal activities after a cholecystectomy depends on which procedure your surgeon uses and your overall health. People undergoing a laparoscopic cholecystectomy may be able to go back to work in a matter of days. Those undergoing an open cholecystectomy may need a week or more to recover enough to return to work.

In 95 per cent of people undergoing cholecystectomy as treatment for simple biliary colic, removing the gallbladder completely resolves their symptoms. Up to 10 per cent of people who undergo cholecystectomy develop a condition called post-cholecystectomy syndrome. That means patient has symptoms typically similar to the pain and discomfort of biliary colic. Small number of patients may get chronic diarrhea after surgery. This can be controlled with medication like cholesteramine.

Overall, it is a very safe procedure.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!