{"id":1389,"date":"2013-10-11T07:05:19","date_gmt":"2013-10-11T07:05:19","guid":{"rendered":"http:\/\/jacobimed.org\/NS\/?page_id=1389"},"modified":"2013-10-11T07:05:19","modified_gmt":"2013-10-11T07:05:19","slug":"ann-intern-med-morrison-et-al","status":"publish","type":"page","link":"https:\/\/jacobimed.org\/old\/ambulatory\/mlove\/curriculumconsult-specialties\/periop-geriatrics\/ann-intern-med-morrison-et-al\/","title":{"rendered":"Ann Intern Med, Morrison et al"},"content":{"rendered":"

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Articles in PubMed by Author:<\/strong><\/span><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n
\u00a0\"\"\"\"<\/td>\nMorrison, R. S.<\/a><\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"\"\"<\/td>\nSiu, A. L.<\/a> <\/span><\/td>\n<\/tr>\n
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\n<\/span><\/p>\n

REVIEW<\/span><\/span><\/span><\/h4>\n

The Medical Consultant’s Role in Caring for Patients with Hip Fracture
\n<\/span><\/span><\/h2>\n

\"\"<\/a> R. Sean
\nMorrison, MD; Mark R. Chassin, MD, MPP, MPH; and
\nAlbert L. Siu, MD, MSPH <\/span><\/a><\/p>\n

<\/span><\/span><\/p>\n

15 June 1998 | Volume 128 Issue 12_Part_1 | Pages
\n1010-1020<\/strong><\/span>
\n<\/span><\/span><\/p>\n

Background: <\/strong>Hip fractures are an important cause of
\ndeath andfunctional dependence in the United States.
\n<\/span><\/span><\/span><\/p>\n

Purpose: <\/strong>To review the evidence for clinical decisions that
\n<\/sup>medical consultants make for patients with hip fracture andto
\ndevelop recommendations for care.
\n<\/span><\/span><\/span><\/p>\n

Data Sources: <\/strong>Published reports of clinical studies were found
\n<\/sup>by searching MEDLINE and selected bibliographies.
\n<\/span><\/span><\/span><\/p>\n

Study Selection: <\/strong>Studies were included if data were presented
\n<\/sup>on clinical interventions to improve care of conditions typically
\n<\/sup>encountered by medical consultants in the care of patients with
\n<\/sup>hip fracture. Such conditions include timing of surgery, infection
\n<\/sup>prophylaxis, thromboembolic prophylaxis, postoperative nutritional
\n<\/sup>management, urinary tract management, prevention and management
\n<\/sup>of delirium, application and timing of rehabilitation services,
\n<\/sup>and prevention of subsequent falls. Meta-analyses; randomized,
\n<\/sup>controlled trials; or other controlled studies were includedif
\npossible. If no such trials were identified, the best evidencefrom
\nstudies with other designs was included.
\n<\/span><\/span><\/span><\/p>\n

Data Extraction: <\/strong>Interventions were selected on the basis of
\n<\/sup>their efficacy or potential efficacy in improving functional
\n<\/sup>outcome. Trials with positive and negative results were compared
\n<\/sup>for differences in intervention and strength of study methods.
\n<\/span><\/span><\/span><\/p>\n

Data Synthesis: <\/strong>Strong evidence supports medical recommendations
\n<\/sup>for decisions about timing and duration of prophylactic antibiotics,
\n<\/sup>selection of thromboembolic prophylaxis, urinary tract and
\nnutritionalmanagement, and rehabilitative services. Many case series
\nsupportearly surgical repair, although patients who would benefit
\nfromdelay and further medical work-up have not been well
\nidentified.Evidence for decisions about assessment of subsequent
\nrisk forfall and risk for and management of delirium is based
\nlargelyon data from patients without hip fracture but is probably
\napplicable.Future research should target optimal duration of
\nthromboembolicprophylaxis, cost-effectiveness of
\nlow-molecular-weight heparincompared with that of other
\nthromboembolic prophylactic regimens,management of delirium,
\nrehabilitative services, and efficacyof assessment of risk for later
\nfalls.
\n<\/span><\/span><\/span><\/p>\n

Conclusions: <\/strong>The data suggest that evidence-based medical care
\n<\/sup>can improve hip fracture outcomes. The medical consultant hasa
\nkey role in providing this care and managing the preoperative
\n<\/sup>conditions and postoperative complications that may affect optimal
\n<\/sup>functional recovery.
\n<\/span><\/span><\/span><\/p>\n


\n<\/span><\/span><\/p>\n

\n

Hip fractures are an
\nimportant cause of death and functionaldependence. Approximately 250
\n000 hip fractures occur annuallyin the United States, and this
\nnumber is expected to increaseseveral fold in the coming decades [1]<\/a>.
\nThe mortality rate forpersons in the U.S. Medicare population who
\nsustain a hip fractureis 7% at 1 month, 13% at 3 months, and 24% at
\n12 months [2]<\/a>.
\n<\/sup>For patients who survive to 6 months, 60% recover their prefracture
\n<\/sup>walking ability, half recover their prefracture ability to perform
\n<\/sup>activities of daily living, and about 25% recover their prefracture
\n<\/sup>ability to perform instrumental activities of daily living [3]<\/a>.
\n<\/sup>However, after 1 year, only 54% of surviving patients can walk
\n<\/sup>unaided and only 40% can perform independently all physical
\n<\/sup>activities of daily living [3]<\/a>.
\n<\/sup>
\n<\/span><\/span><\/span><\/p>\n

Although surgical repair of the fractured extremity is the cornerstone
\n<\/sup>of therapy, available data suggest that the factors crucialto
\noptimal functional recovery in hip fracture are independentof
\nfracture repair and are instead related to prefracture conditionsand
\npostfracture complications [4]<\/a>.
\nThus, successful care andoutcome of patients with hip fracture
\nrequire an active partnershipbetween the orthopedic surgeon and
\nothers, including the medicalconsultant.
\n<\/span><\/span><\/span><\/p>\n

The medical consultant’s role includes medical evaluation and
\n<\/sup>stabilization of the patient before surgery, prevention and
\n<\/sup>management of postoperative complications (such as delirium),
\n<\/sup>and follow-up after increasingly shorter hospital visits. Despite
\n<\/sup>the involvement of medical consultants in the care of most patients
\n<\/sup>with hip fracture (in one large series of patients with hip
\n<\/sup>fracture, 81% had a presurgical medical consultation [Magaziner
\n<\/sup>J. Personal communication]), many internists have no formal
\n<\/sup>training in this condition and may be unfamiliar with the optimal
\n<\/sup>management of its complications.
\n<\/span><\/span><\/span><\/p>\n

We review the clinical evidence to support decisions that internists
\n<\/sup>are often asked to make for patients with hip fracture, develop
\n<\/sup>evidence-based recommendations, and identify areas requiring
\n<\/sup>further research. Medical decisions include decisions about
\n<\/sup>timing of surgery, infection prophylaxis, thromboembolic prophylaxis,
\n<\/sup>postoperative nutritional management, urinary tract management,
\n<\/sup>prevention and management of delirium, application and timing
\n<\/sup>of rehabilitation services, and prevention of subsequent falls.
\n<\/sup>We excluded preoperative risk assessment and fracture prevention
\n<\/sup>because extensive literature on these subjects already exists.
\n<\/sup>We also excluded topics not usually under the purview of the
\n<\/sup>medical consultant, such as choice of anesthesia and type of
\n<\/sup>surgical repair.
\n<\/span><\/span><\/span><\/p>\n

<\/a><\/span><\/span><\/span><\/p>\n\n\n\n
Methods <\/span><\/p>\n\n\n\n
\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
\"\"Top<\/span>
\n<\/a>\"\"Methods<\/span>
\n\"\"Author & Article
\nInfo<\/span>
\n<\/a>\"\"References<\/span>
\n<\/a><\/span><\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

We did a
\nsystematic review of processes related to the medicalcare of
\npatients with hip fracture, concentrating on processesthat could
\nlead to improved functional outcome (Table
\n1<\/a>). Wesearched the MEDLINE database, using the MeSH terms
\nfemoralfractures, hip fractures, or femoral neck fractures and
\nthekeywords or text words given in Table
\n1<\/a>, for English-languagearticles published from January 1966
\nthrough June 1997. If nostudies were identified, we repeated the
\nsearch with only thekeywords or text words. Articles were reviewed
\nto determinetheir relevance to patients with hip fracture (for
\nexample,elderly persons or patients undergoing lower-extremity
\northopedicprocedures, such as total hip arthroplasty). To identify
\nadditionalstudies, we searched the reference lists of the selected
\narticles.Within each subject area, we included meta-analyses;
\nrandomized,controlled trials; or other controlled studies wherever
\npossible.If no such trials were identified, we included the best
\navailableevidence from studies with other designs. Articles were
\nreviewedindependently by two of the authors, the evidence was
\nsummarized,and recommendations were drafted. If the reviewers
\ndisagreedabout a recommendation, the underlying assumptions leading
\ntothe recommendation were discussed until consensus was
\nreached.Summaries were subsequently reviewed by a panel of content
\nexpertsin orthopedics, internal medicine, geriatrics,
\nrehabilitation,nursing, and nutrition and were revised on the basis
\nof thepanel’s recommendations. Final summaries were prepared,
\nandthe quality of evidence was rated by using ratings adapted
\nfromthe U.S. Preventive Services Task Force [5]<\/a>.
\nMeta-analysis wasbeyond the scope of this paper given the multiple
\ndomains, theheterogeneity of study populations, and the wide
\nvariation inquality and design of the studies.<\/p>\n

<\/a><\/p>\n

<\/span><\/span><\/span><\/p>\n\n\n\n
\n\n\n\n
View
\nthis table:<\/strong>
\n[in
\nthis window]<\/a>
\n[in a new window]<\/a>
\n<\/span><\/td>\n		Table 1. Key Words
\nand Text Phrases Used in MEDLINE Search<\/strong>
\n<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

<\/p>\n

<\/span><\/span><\/span><\/p>\n

<\/a><\/span><\/span><\/span><\/p>\n\n\n\n
Summary of Evidence
\n<\/span><\/p>\n\n\n\n
\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

A
\nsummary of the studies and the strength of the evidence isgiven in
\nTable
\n2<\/a>.<\/p>\n

<\/a><\/p>\n

<\/span><\/span><\/span><\/p>\n\n\n\n
\n\n\n\n
View
\nthis table:<\/strong>
\n[in
\nthis window]<\/a>
\n[in a new window]<\/a>
\n<\/span><\/td>\n		Table 2. Summary of
\nEvidence<\/strong>
\n<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

<\/p>\n

<\/span><\/span><\/span><\/p>\n

Timing of Surgery<\/span><\/strong>
\n<\/span><\/span><\/span><\/p>\n

The timing of surgical repair of hip fracture may affect patient
\n<\/sup>outcomes in two ways. Delay in surgical repair, which causes
\n<\/sup>delay in return to weight bearing, may affect functional recovery.
\n<\/sup>Conversely, failure to stabilize medical problems before surgery
\n<\/sup>may increase risk for perioperative complications. Althoughthe
\northopedist schedules surgery, the rate-limiting step inthis process
\nis often the internist’s preoperative medical evaluation.
\n<\/span><\/span><\/span><\/p>\n

We identified 9 cohort studies [6,7,9,10,54-58]<\/a>;
\n1 randomized,controlled trial of anesthetic techniques that included
\nsurgicaldelay as an independent variable [8]<\/a>;
\nand 1 autopsy series [59]<\/a>
\n<\/sup>that examined the effects of operative timing on post-operative
\n<\/sup>outcome. The results of these 11 studies suggest that early
\n<\/sup>surgical repair (within 24 to 48 hours) is associated with a
\n<\/sup>reduction in 1-year mortality. However, most of the studies
\n<\/sup>either did not control for the presence and severity of comorbid
\n<\/sup>conditions or excluded patients with complicating medical conditions;
\n<\/sup>thus, these data are difficult to interpret. Of the 5 studies
\n<\/sup>that attempted to control for comorbid conditions [6-10]<\/a>,
\n4reported lower mortality rates and 1 [6]<\/a>
\nreported a lower incidenceof confusion and pressure ulcers in
\npatients who underwent surgicalrepair within 48 hours.
\n<\/span><\/span><\/span><\/p>\n

Evidence from cohort studies indicates that for medically stable
\n<\/sup>patients who do not have active comorbid illness (such as unstable
\n<\/sup>angina), surgical repair of hip fracture within the first 24to
\n48 hours of admission is associated with a decrease in 1-year
\n<\/sup>mortality. Patients who would benefit from delay and further
\n<\/sup>medical evaluation have not been well characterized.
\n<\/span><\/span><\/span><\/p>\n

Prophylactic Antibiotics<\/span><\/strong>
\n<\/span><\/span><\/span><\/p>\n

Prophylactic antimicrobial agents are often administered to
\n<\/sup>prevent postoperative wound infections. We reviewed the literature
\n<\/sup>to identify the benefit of antibiotic use for postoperative
\n<\/sup>infections and to identify the optimal timing of administration
\n<\/sup>and duration of use. Three meta-analyses examined prophylactic
\n<\/sup>antibiotic use in patients with hip fracture [11]<\/a>
\n(Table
\n3<\/a>).The first compared antibiotic use with placebo, the second
\ncomparedsingle doses of antibiotics with multiple doses, and the
\nthirdcompared 3 doses of antibiotics with multiple doses. We
\nfoundno randomized trials that examined the timing of
\nantibioticadministration, but we found one large case series
\ninvolvingpatients undergoing elective surgery [12]<\/a>
\n(Table
\n3<\/a>).
\n<\/span><\/span><\/span><\/p>\n

<\/a><\/p>\n

<\/span><\/span><\/span><\/p>\n\n\n\n
\n\n\n\n
View
\nthis table:<\/strong>
\n[in
\nthis window]<\/a>
\n[in a new window]<\/a>
\n<\/span><\/td>\n		Table 3. Dose and
\nTiming of Prophylactic Antibiotics<\/strong>
\n<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

<\/p>\n

<\/span><\/span><\/span><\/p>\n

Meta-analysis of seven studies [60-66]<\/a>
\nthat compared antibioticuse with placebo showed a 44% risk reduction
\nin postoperativeinfection for the antibiotic group. Four studies [64,67-69]<\/a>
\n<\/sup>compared multiple doses (range, 2 to 10 doses) with a single
\n<\/sup>dose of antibiotics given immediately before surgery. Therewas
\na trend toward a reduction in postoperative infection inthe
\nmultiple-dose group. A third meta-analysis summarized twostudies [68,70]<\/a>
\nthat compared 3 doses of antibiotics with multipledoses. No
\nsignificant differences were seen in infection ratesbetween the two
\ngroups. First- and second-generation cephalosporinswere used in most
\nof the studies.
\n<\/span><\/span><\/span><\/p>\n

The only study that addressed optimal timing of antibiotic
\nadministrationwas a cohort study of 2847 elective procedures [12]<\/a>.
\nIn thisstudy, wound infection rates were lowest when antibiotics
\nwereadministered 0 to 2 hours before surgery.
\n<\/span><\/span><\/span><\/p>\n

Considerable evidence from 11 randomized trials [60-70]<\/a>
\nsupportsthe use of prophylactic antibiotics (first- and
\nsecond-generationcephalosporins) in patients with hip fracture.
\nAntibiotics seemto reduce the risk for deep-wound infections by
\napproximately44%, and therapy should probably be continued for 24
\nhours (thatis, about 3 doses should be given). Published data
\nsuggest thatantibiotics should be administered 0 to 2 hours before
\nsurgery.
\n<\/span><\/span><\/span><\/p>\n

Thromboembolic Prophylaxis<\/span><\/strong>
\n<\/span><\/span><\/span><\/p>\n

Venous thromboembolism is a substantial cause of postoperative
\n<\/sup>morbidity and mortality in patients with hip fracture. Despite
\n<\/sup>a clear rationale for prophylaxis and clinical evidence of efficacy,
\n<\/sup>use of prophylaxis is not universal, largely because of questions
\n<\/sup>about which agent is the safest and most effective [71]<\/a>.
\n<\/sup>
\n<\/span><\/span><\/span><\/p>\n

We identified three meta-analyses [13,14,23]<\/a>
\nin which patientswith hip fracture were examined and an additional
\n10 randomized,controlled trials in which prophylactic thromboembolic
\nagentsin hip fracture were examined (Table
\n4<\/a>). One of the meta-analysescompared low-dose heparin with
\nplacebo, one compared low-molecular-weightheparin with placebo or
\nlow-dose heparin, and the third comparedaspirin with no treatment [23]<\/a>.
\nWe found no data on the durationof prophylaxis.
\n<\/span><\/span><\/span><\/p>\n

<\/a><\/p>\n

<\/span><\/span><\/span><\/p>\n\n\n\n
\n\n\n\n
View
\nthis table:<\/strong>
\n[in
\nthis window]<\/a>
\n[in a new window]<\/a>
\n<\/span><\/td>\n		Table 4. Efficacy of
\nThromboembolic Prophylaxis on Prevention of Deep Venous
\nThrombosis*<\/strong>
\n<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

<\/p>\n

<\/span><\/span><\/span><\/p>\n

The studies reviewed strongly support the use of thromboembolic
\n<\/sup>prophylaxis, but which agent is optimal is less clear. Low-dose
\n<\/sup>heparin has been the agent most frequently studied in hip fracture
\n<\/sup>and was associated with a reduction of about 60% in deep venous
\n<\/sup>thromboses in one meta-analysis [13]<\/a>
\n(Table
\n4<\/a>). Low-molecular-weightheparin has also been evaluated by
\nmeta-analysis and was shownto produce a similar reduction in deep
\nvenous thrombosis [14]<\/a>
\n<\/sup>(Table
\n4<\/a>). The latter meta-analysis also pooled data from fourstudies
\nthat compared low-molecular-weight heparin with low-doseheparin and
\nfound no significant differences between the twoagents for
\ndevelopment of deep venous thrombosis. Low-dose heparinseems to
\nproportionately increase the risk for major bleedingepisodes by
\nabout 30% compared with placebo, but the actualpercentage increase
\nis small (overall rates, 3.5% in the heparingroups compared with
\n2.9% in the placebo groups) [13]<\/a>.
\nIn moststudies, heparin therapy was initiated on hospital
\nadmission.
\n<\/span><\/span><\/span><\/p>\n

The use of aspirin as prophylaxis was examined in one meta-analysis
\n<\/sup>of 10 orthopedic trauma trials, 9 of which included only patients
\n<\/sup>with hip fracture and 1 of which included patients with hipand
\npelvic fractures [23]<\/a>
\n(Table
\n4<\/a>). Aspirin was found to significantlyreduce the risk for deep
\nvenous thrombosis and pulmonary embolism.However, when aspirin was
\ncompared with low-molecular-weightheparin for prevention of deep
\nvenous thrombosis in one recenttrial [15]<\/a>,
\nlow-molecular-weight heparin resulted in a relativerisk reduction of
\n37% and no significant difference in bleedingcomplications was
\nseen.
\n<\/span><\/span><\/span><\/p>\n

Several other prophylactic agents have been evaluated (Table
\n4<\/a>).Low-dose warfarin (prothrombin time 1.5 times that of
\ncontrol)was compared with placebo in two studies [16,72]<\/a>
\nand with low-molecular-weightheparin in one study [17]<\/a>.
\nWarfarin seems to confer a reductionin risk for deep venous
\nthrombosis similar to that conferredby heparin, although the one
\nstudy that compared low-molecular-weightheparin and warfarin
\ndirectly suggests that low-molecular-weightheparin may be more
\nefficacious [17]<\/a>.
\nThe use of dextran fordeep venous thrombosis prophylaxis was
\nevaluated in five trials[18-22]<\/a>,
\nand this agent seems to be as efficacious as low-doseheparin [18,20]<\/a>
\nor aspirin [19]<\/a>
\nbut is probably less efficaciousthan low-molecular-weight heparin [19,21,22]<\/a>.
\nPneumatic compressiondevices seem to reduce the incidence of deep
\nvenous thrombosiscompared with no treatment [24]<\/a>.
\n<\/sup>
\n<\/span><\/span><\/span><\/p>\n

Strong evidence supports the use of low-dose heparin or
\nlow-molecular-weightheparin as prophylaxis for deep venous
\nthrombosis starting athospital admission. The latter agent is
\nprobably slightly moreeffective but is more expensive. Aspirin seems
\nto have somebenefit (but to a lesser extent) and may be considered
\nin patientsat high risk for hemorrhagic complications. Several
\nstudiessupport the use of low-dose warfarin; however, the
\nrequiredinternational normalized ratio [INR] monitoring and risk
\nforover- or underanticoagulation are potential drawbacks.
\nNonetheless,some patients may prefer weekly monitoring of the INR to
\ntwice-dailyinjections of heparin or low-molecular-weight heparin.
\nCompressionstockings seem to impart benefit with negligible risk and
\nshouldbe used. Future research should determine the optimal
\ndurationof prophylactic anticoagulation and the cost-effectiveness
\noflow-molecular-weight heparin compared with that of other
\nprophylacticthromboembolic regimens.
\n<\/span><\/span><\/span><\/p>\n

Nutritional Management<\/span><\/strong>
\n<\/span><\/span><\/span><\/p>\n

Malnutrition is associated with increased surgical morbidityand
\nmortality [73]<\/a>.
\nIt has been reported that as many as 20%of patients experiencing hip
\nfracture are severely malnourished[74]<\/a>.
\nInterventions that improve nutritional status may thereforeimprove
\noutcome and decrease complications.
\n<\/span><\/span><\/span><\/p>\n

We identified four randomized, controlled trials of nutritional
\n<\/sup>supplementation in patients undergoing surgery for hip fracture.
\n<\/sup>Three examined oral protein supplementation [25-27]<\/a>,
\nand oneexamined nocturnal nasogastric tube feeding [28]<\/a>.
\n<\/sup>
\n<\/span><\/span><\/span><\/p>\n

Stableforth [27]<\/a>
\ncompared patients with hip fracture randomlyallocated to protein
\nsupplementation with those allocated tousual care; significantly
\nimproved nitrogen and calorie balancewas reported in the group that
\nreceived supplementation. Delmi[26]<\/a>
\nand Tkatch [25]<\/a>
\nand their associates randomly assignedpatients with hip fracture to
\nreceive protein supplementationor usual care [26]<\/a>
\nor placebo [25]<\/a>
\non admission to the orthopedicservice. Patients who received protein
\nsupplementation had significantlymore favorable long-term outcomes
\nat 6 months (none or onlyone minor complication), significantly
\nhigher albumin levels,and significantly shorter overall lengths of
\nstay than patientswho did not receive supplementation.
\n<\/span><\/span><\/span><\/p>\n

Bastow and coworkers [28]<\/a>
\nexamined the effect of nocturnal nasogastrictube feeding in 122
\npatients at increased risk for nutritionalcompromise (arm and
\ntrifold skin circumference <1 SD belowthe mean for home and
\nhospitalized elderly patients [75]<\/a>).
\nPatientswere randomly assigned to receive usual care or nocturnal
\ntubefeedings within 5 days of admission. Mortality in the two
\ngroupsdid not differ significantly, but the study lacked
\nstatisticalpower to detect this difference. Very thin patients had a
\nsignificantreduction in overall length of stay and had significant
\nincreasesin weight (mean gain, 4.2 kg; P < 0.01) compared with
\ncontrols.Patients who received tube feedings achieved independent
\nmobilitysignificantly faster than patients who did not receive
\ntubefeedings. One fifth of patients could not tolerate the
\nnocturnalfeedings.
\n<\/span><\/span><\/span><\/p>\n

Oral protein supplementation seems to be beneficial in reducing
\n<\/sup>minor postoperative complications, preserving body protein stores,
\n<\/sup>and reducing overall length of stay. Patients with evidenceof
\nmoderate to severe malnutrition may benefit from nocturnalenteral
\ntube feeding if they can tolerate it.
\n<\/span><\/span><\/span><\/p>\n

Urinary Tract Management<\/span><\/strong>
\n<\/span><\/span><\/span><\/p>\n

Urinary retention, incontinence, and urinary tract infectionsare
\ncommonly seen after surgery in patients with hip fracture[76]<\/a>.
\nBecause of the frequency of postoperative bladder problems,
\n<\/sup>successful strategies to reduce voiding problems may decrease
\n<\/sup>morbidity.
\n<\/span><\/span><\/span><\/p>\n

We identified two randomized, controlled trials of urinary bladder
\n<\/sup>management in patients undergoing orthopedic surgery [29,30]<\/a>.
\n<\/sup>One study included patients with recent hip fracture, and the
\n<\/sup>other included patients undergoing hip or knee replacement.
\n<\/sup>Michelson and colleagues [30]<\/a>
\nrandomly assigned 100 patientswith knee or hip replacement to have
\ntheir indwelling urinarycatheters removed immediately after surgery
\nor the morning aftersurgery. The group that had the catheter removed
\nthe morningafter surgery had significantly lower rates of urinary
\nretention.Skelly and associates [29]<\/a>
\nrandomly assigned 67 patients withhip fracture to receive an
\nindwelling catheter for 48 hoursafter surgery followed by scheduled
\nintermittent straight catheterizationor scheduled intermittent
\nstraight catheterization immediatelyafter surgery. Spontaneous
\nvoiding occurred significantly earlierin the group that received
\nintermittent catheterization immediatelyafter surgery. The incidence
\nof urinary tract infections didnot significantly differ between the
\ncontrol and interventiongroups in either study.
\n<\/span><\/span><\/span><\/p>\n

Few studies have examined the management of urinary cathetersin
\nhip fracture. The management of catheters may be affectedby previous
\nlevel of continence, mobility, and availabilityof nursing staff.
\nWhenever possible, indwelling catheters shouldprobably be removed
\nwithin 24 hours of surgery, and patientsshould be managed with
\nscheduled intermittent straight catheterization.
\n<\/span><\/span><\/span><\/p>\n

Delirium<\/span><\/strong>
\n<\/span><\/span><\/span><\/p>\n

Delirium occurs in up to 61% of patients with hip fracture [77]<\/a>.
\n<\/sup>Despite its prevalence, delirium is often unrecognized or
\nmisdiagnosed[78]<\/a>.
\nDelirium in hospitalized patients has been shown to increaselength
\nof stay, risk for complications, mortality, and institutionalization
\n<\/sup>[79-83]<\/a>.
\nMost patients who develop delirium have some persistentsymptoms up
\nto 6 months later. In patients with hip fracture,delirium may have
\nan additional effect on functional outcomeby interfering with
\nrehabilitation activities and delaying returnto weight bearing.
\n<\/sup>
\n<\/span><\/span><\/span><\/p>\n

For this review, we focused on three types of investigations.
\n<\/sup>First, we identified studies in which multivariate methods were
\n<\/sup>used to identify risk factors that, if modified, may prevent
\n<\/sup>delirium; 13 studies met these criteria [31-36,77,83-88]<\/a>.
\nSecond,because treatment of the underlying cause is a cornerstone
\nofthe management of delirium, we identified studies that
\nsystematicallydescribed the frequency of different causes of this
\nsyndrome.We found three case series [32,89,90]<\/a>.
\nFinally, we identifiedstudies that focused on the prevention and
\nmanagement of deliriumin patients with hip fracture. We found two
\nnonrandomized studiesthat examined supportive treatment of delirium
\n[37,38]<\/a>.
\n<\/sup>
\n<\/span><\/span><\/span><\/p>\n

With regard to baseline risk factors for delirium, the findings
\n<\/sup>seem fairly consistent across most studies. Advanced age, history
\n<\/sup>of cognitive impairment, greater severity of illness, and history
\n<\/sup>of alcohol use seem to increase the risk for confusion in
\nhospitalizedmedical and surgical patients. In the two studies of
\npatientswith hip fracture, only age, dementia, and prefracture
\nfunctionalstatus predicted development of delirium [37,77]<\/a>.
\nPrecipitatingrisk factors have been more difficult to identify and,
\nwithfew exceptions, a clear understanding of the iatrogenic
\nconditionsthat increase risk for delirium in elderly patients has
\nnotyet emerged. Although many risk factors have been proposed
\n(suchas metabolic disturbances, dehydration, alcohol
\nwithdrawal,urinary retention, changes in environment, psychosocial
\nfactors,and medications [91]<\/a>,
\nonly electrolyte imbalances and some classesof medication (opioids,
\nsedative-hypnotics, and anticholinergics)have been consistently
\nidentified as precipitating factors inprospective trials, and even
\nthese factors are not consistentacross studies. No precipitating
\nfactors were identified inthe two studies of patients with hip
\nfracture, but these studieshad limited power to identify such
\nfactors [37,38]<\/a>.
\n<\/sup>
\n<\/span><\/span><\/span><\/p>\n

As for the cause of delirium, we could not identify any studies
\n<\/sup>that focused exclusively on patients with hip fracture. We identified
\n<\/sup>three case series [32,89,90]<\/a>
\nthat examined this issue in medicaland surgical patients; only one
\nhad specific criteria for assigningcauses. These studies suggest
\nthat the most common causes ofdelirium are fluid and electrolyte
\nimbalances, infection, metabolicdisorders, drug toxicity, and
\nsensory and environmental problems.
\n<\/span><\/span><\/span><\/p>\n

Management of delirium has been based largely on clinical experience
\n<\/sup>because few systematic and controlled studies have been done[91]<\/a>.
\nWe identified two nonrandomized studies involving patientswith hip
\nfracture. Williams and coworkers [37]<\/a>
\ndid a time-sequencetrial of pre- and postoperative nursing
\ninterventions (suchas environmental manipulation, reorientation, and
\nreassurance)in patients with hip fracture. The incidence of delirium
\nwas44% in the treatment group and 52% in the control group.
\nGustafsonand associates [38]<\/a>
\ncompared 103 patients who received treatmentwith 111 historical
\ncontrols admitted 2 to 5 years before theintervention cohort. The
\nintervention in this study consistedof pre- and postoperative
\ngeriatric assessments, oxygen therapyfor hypoxia, early surgery
\n(done as soon as patients were medicallystable), and aggressive
\ntreatment of perioperative decreasesin blood pressure. The incidence
\nof delirium was 61% in thecontrols and 48% in the treatment group.
\nPatients in the treatmentgroup were less likely than controls to be
\nconfused for morethan 7 days (9% compared with 28%) and had a
\nshorter lengthof stay (11.6 days compared with 17.4 days). The
\nindividualcontributions of each component of the intervention to
\nreductionin delirium are not known.
\n<\/span><\/span><\/span><\/p>\n

In summary, although many cohort studies have examined the risk
\n<\/sup>factors for delirium, most analyses have not specifically focused
\n<\/sup>on patients with hip fracture and many studies have lacked adequate
\n<\/sup>statistical power. Nevertheless, the assembled studies indicate
\n<\/sup>numerous recurring, potentially modifiable risk factors for
\n<\/sup>delirium, including electrolyte and metabolic laboratory
\nabnormalities,medications with psychoactive properties, and
\ninfection. Studiesthat have systematically examined causes of
\ndelirium have beensmall. However, their findings indicate several
\ncommon causes,including fluid and electrolyte abnormalities,
\ninfection, drugtoxicity, metabolic disorders, and low cerebral
\nperfusion. Environmentalmanipulation and supportive reorientation
\nseem to reduce theincidence of delirium and benefit acutely
\ndelirious patients.More research on the optimal management of
\ndelirium is needed.
\n<\/span><\/span><\/span><\/p>\n

Rehabilitation<\/span><\/strong>
\n<\/span><\/span><\/span><\/p>\n

Rehabilitative services for patients with hip fracture may include
\n<\/sup>limb and joint mobilization and progressive exercises, physical
\n<\/sup>and occupational therapy to regain mobility and independencein
\nactivities of daily living, physician supervision of therapy,
\n<\/sup>psychological counseling, social work, restorative nursing services,
\n<\/sup>and recreational services. For this review, we focused on selected
\n<\/sup>aspects of rehabilitation that are particularly salient to the
\n<\/sup>internist; we recognize that rehabilitation is a responsibility
\n<\/sup>shared with the surgeon who, depending on the fracture and type
\n<\/sup>of surgery, may have specific recommendations about mobilization
\n<\/sup>and weight bearing. We address the value of early mobilization,
\n<\/sup>intensified interdisciplinary rehabilitation approaches, and
\n<\/sup>intensity and frequency of therapy.
\n<\/span><\/span><\/span><\/p>\n

We identified several reports of programs that used early mobilization
\n<\/sup>or early weight-bearing policies. From these reports, we excluded
\n<\/sup>studies, primarily from the 1960s and 1970s, that reviewed the
\n<\/sup>effects of “early weight-bearing” initiated many days or weeks
\n<\/sup>after the perioperative period; we focused instead on studies
\n<\/sup>that reported on mobilization in the first 24 to 48 hours. We
\n<\/sup>identified one randomized trial [39]<\/a>
\nthat included early mobilizationas part of a larger program of
\naccelerated rehabilitation; wealso identified many trials in which
\nall patients received earlymobilization (in the first 24 to 48
\nhours) [40-45,92-97]<\/a>.
\nInthe case of intensified interdisciplinary rehabilitation
\nprograms,we identified four randomized trials [46,47,98,99]<\/a>.
\nFor theintensity and frequency of physical therapy, we identified
\ntwosmall randomized trials [45,99]<\/a>
\nand two cohort studies thatattempted to control for potential
\nconfounding between patientcharacteristics and receipt of services
\n[3,48]<\/a>.
\n<\/sup>
\n<\/span><\/span><\/span><\/p>\n

The randomized trial that evaluated early mobilization (usually
\n<\/sup>within 24 hours of surgery) did so as part of a program that
\n<\/sup>included early discharge from the hospital and a comprehensive
\n<\/sup>rehabilitation program during and after hospitalization [39]<\/a>.
\n<\/sup>Although that trial found no differences in the physical independence
\n<\/sup>of the 252 patients at 4 months, it showed that so-called accelerated
\n<\/sup>rehabilitation could reduce health care costs. Other studies[40-45,92-97]<\/a>
\nshowed that policies on early mobilization fromthe first day after
\nsurgery can be implemented with acceptablerates of complications [40-42]<\/a>,
\ndischarge destination [40,44]<\/a>,
\n<\/sup>functional outcome [40,43,45]<\/a>,
\nand mortality [42,44]<\/a>.
\n<\/sup>
\n<\/span><\/span><\/span><\/p>\n

Of the four relatively small randomized trials that evaluatedthe
\nbenefits of geriatric interdisciplinary rehabilitation [46,47,98,99]<\/a>,
\n<\/sup>two found no differences in functional outcome [99]<\/a>,
\nmortality,or placement [98]<\/a>.
\nHowever, two studies found positive effectsassociated with these
\nprograms. In a study of 112 patients,Kennie and colleagues [46]<\/a>
\nreported improved functional statusand found that patients were more
\nlikely to be discharged totheir own homes than to a nursing home
\nafter interdisciplinaryrehabilitation. In addition, a randomized
\ntrial of geriatricassessment and rehabilitation in which hip
\nfracture was themost common diagnosis (occurring in 18% of the
\npatients) foundthat geriatric rehabilitation improved the patient’s
\nlikelihoodof returning to the community [47]<\/a>.
\n<\/sup>
\n<\/span><\/span><\/span><\/p>\n

Two randomized trials evaluated intensified physical therapy(that
\nis, therapy sessions twice per day rather than once perday or
\nsupplemental individualized educational sessions) [45,99]<\/a>.
\n<\/sup>Both trials failed to show a benefit in functional outcomes;
\n<\/sup>however, both were small. Therefore, we sought additional evidence
\n<\/sup>of efficacy from cohort studies that attempted to control for
\n<\/sup>potential confounding between patient characteristics and receipt
\n<\/sup>of services. In a cohort study of 162 hospitalized patients,
\n<\/sup>Guccione and associates [48]<\/a>
\nfound that more than one physicaltherapy session per day was
\nassociated with improved functionaloutcome after adjustment for age,
\nprefracture ambulation, andlength of stay. In a study of 536
\npatients, Magaziner and coworkers[3]<\/a>
\nreported that the number of physical therapy sessions (after
\n<\/sup>adjustment for prefracture and other hospital care variables)
\n<\/sup>was associated with improved physical independence at 1 year
\n<\/sup>but did not affect walking ability or ability to perform instrumental
\n<\/sup>activities of daily living.
\n<\/span><\/span><\/span><\/p>\n

In summary, the data suggest that early mobilization is safein
\nselected patients. However, data are lacking on the potential
\n<\/sup>benefits of early mobilization. In the case of interdisciplinary
\n<\/sup>rehabilitation featuring geriatric assessment, randomized trials
\n<\/sup>suggest that these programs can improve functional outcome and
\n<\/sup>increase the likelihood that patients will return to the community.
\n<\/sup>These trials, however, were small and were limited to programs
\n<\/sup>with personnel who have a special interest in orthogeriatrics.
\n<\/sup>For physical therapy services, cohort studies that have adjusted
\n<\/sup>for potential confounders suggest that the frequency of physical
\n<\/sup>therapy probably has an important effect on outcome and that
\n<\/sup>more than one session per day is probably beneficial.
\n<\/span><\/span><\/span><\/p>\n

Assessment of Falls<\/span><\/strong>
\n<\/span><\/span><\/span><\/p>\n

Patients with hip fracture have an increased risk for subsequent
\n<\/sup>fracture [100]<\/a>.
\nInterventions to reduce the likelihood and numberof subsequent falls
\nmay therefore have beneficial effects onoutcome.
\n<\/span><\/span><\/span><\/p>\n

We identified seven randomized trials [50-53,101-103]<\/a>
\nand onepreplanned meta-analysis [49]<\/a>
\nof clinical and social interventionsto reduce falls. None of the
\nstudies specifically targeted patientswith hip fracture. Two of the
\nseven studies [51,52]<\/a>
\nfocusedon patients at risk for falling on the basis of other
\nfactors.Four [50,53,102,103]<\/a>
\nfocused on older persons in the communitywho were otherwise not
\nscreened for risk for falls, and onefocused on frail nursing home
\nresidents [101]<\/a>.
\nA meta-analysis[49]<\/a>
\nincluded eight trials, two of which are cited above [51,101]<\/a>,
\n<\/sup>and examined the effect of exercise and balance on fall prevention.
\n<\/sup>
\n<\/span><\/span><\/span><\/p>\n

The five studies [50,53,101-103]<\/a>
\nthat focused on persons previouslyunscreened for risk for falling
\nrandomly assigned nursing homeresidents [101]<\/a>,
\nsenior centers, or households to such interventionsas low-intensity
\nexercises, counseling on risk-factor reduction,and efforts to
\nidentify and correct environmental hazards. Twoof the studies [50,53]<\/a>
\nshowed that the intervention slightlyreduced the risk for falling
\nbut not the risk for fracturesor falls requiring medical attention.
\nInterventions that targetedolder persons at risk for falling were
\nmore efficacious. Rubensteinand colleagues [52]<\/a>
\nrandomly assigned ambulatory nursing homeresidents to receive usual
\ncare or detailed clinical and environmentalassessments within 1 week
\nof the fall. The intervention didnot significantly reduce the risk
\nfor subsequent falls, butthe intervention group was hospitalized
\nless frequently overthe next 2 years. Tinetti and coworkers [51]<\/a>
\nidentified community-dwellingolder persons with specific risk
\nfactors for falling (such aspostural hypotension or difficulty in
\ntransferring) and randomlyassigned them to receive social visits or
\na multifactorial interventionthat featured medication adjustment,
\nbehavioral instruction,and exercise activities targeted to the
\nperson’s risk factors.This intervention reduced the risk for falling
\n(relative risk,0.69 [95% CI, 0.52 to 0.90]) and the prevalence of
\ntargetedrisk factors. Province and associates [49]<\/a>
\ndid a meta-analysisof eight trials involving diverse patient
\npopulations and severaldifferent interventions, all of which
\nincluded an exercise component.Treatment arms that included the
\nexercise component showed anadjusted incidence rate for falls of
\n0.90 (CI, 0.81 to 0.99),and an adjusted incidence rate for falls of
\n0.83 (CI, 0.70 to0.98) was seen for groups receiving treatment that
\nincludedbalance training compared with controls. No exercise
\ncomponentwas significant for injurious falls, but power was low to
\ndetectthis outcome.
\n<\/span><\/span><\/span><\/p>\n

These studies suggest that interventions to reduce the incidence
\n<\/sup>of falls are more likely to be beneficial if they focus on persons
\n<\/sup>at risk for falls and target specific risk factors or behaviors.
\n<\/sup>Exercise and balance training also seem somewhat effective in
\n<\/sup>decreasing risk for falls. Because persons who have sustained
\n<\/sup>hip fractures are at higher risk for subsequent falls, these
\n<\/sup>findings may be generalizable to this population.
\n<\/span><\/span><\/span><\/p>\n

<\/a><\/span><\/span><\/span><\/p>\n\n\n\n
Conclusions <\/span><\/p>\n\n\n\n
\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

Hip
\nfracture is a common condition that results in death orsubstantial
\nloss of function for more than 150 000 persons annuallyin the United
\nStates. Furthermore, the annual number of hipfractures is expected
\nto double by the year 2040 [104,105]<\/a>.
\n<\/sup>Our literature review suggests that evidence-based medical care
\n<\/sup>can improve clinical outcomes of patients with hip fracture(Table
\n2<\/a>). We identified processes of medical care for whichthe data
\nare unambiguous (such as prophylactic antibiotics andthromboembolic
\nprophylaxis) and others for which the data areless clear and for
\nwhich more research is needed (such as managementof delirium,
\nprevention of falls, duration of thromboembolicprophylaxis, and the
\ncost-effectiveness of low-molecular-weightheparin compared with that
\nof other agents). We believe thatour recommendations will enhance
\nthe ability to predict andmanage the common complications of hip
\nfracture, improve functionand quality of life, and improve the
\nquality of medical careafforded to patients with hip fracture.
\n<\/sup><\/p>\n

Acknowledgment: The authors thank Jay Magaziner, PhD, MSHyg,for
\npermission to cite unpublished data from the Baltimore HipFracture
\nStudy.
\n<\/span><\/span><\/span><\/p>\n

Grant Support: In part by no. U18HS09459-0 from the Agency for
\n<\/sup>Health Care Policy and Research. Dr. Morrison is a Brookdale
\n<\/sup>National Fellow.
\n<\/span><\/span><\/span><\/p>\n

Requests for Reprints: R. Sean Morrison, MD, Department of Geriatrics,
\n<\/sup>Box 1070, The Mount Sinai School of Medicine, One Gustave L.
\n<\/sup>Levy Place, New York, NY 10029; e-mail smorriso@smtplink.mssm.edu.
\n<\/sup>
\n<\/span><\/span><\/span><\/p>\n

Current Author Addresses: Dr. Morrison: Department of Geriatrics,
\n<\/sup>Box 1070, Mount Sinai School of Medicine, One Gustave L. Levy
\n<\/sup>Place, New York, NY 10029.
\n<\/span><\/span><\/span><\/p>\n

Drs. Siu and Chassin: Department of Health Policy, Box 1077,Mount
\nSinai School of Medicine, One Gustave L. Levy Place, NewYork, NY
\n10029.
\n<\/span><\/span><\/span><\/p>\n

<\/a><\/span><\/span><\/p>\n\n\n\n
Author and Article
\nInformation <\/span><\/p>\n\n\n\n
\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
\"\"Top<\/span>
\n<\/a>\"\"Methods<\/span>
\n<\/a>\"\"Author & Article
\nInfo<\/span>
\n\"\"References<\/span>
\n<\/a><\/span><\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

<\/a>This paper is also
\navailable at http:\/\/www.acponline.org.
\nAnn Intern Med.
\n1998;128:1010-1020.
\nFrom Mount Sinai School of Medicine, New York, New York.
\n<\/span>
\n<\/span><\/p>\n

<\/a><\/span><\/span><\/p>\n\n\n\n
References <\/span><\/p>\n\n\n\n
\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
\"\"Top<\/span>
\n<\/a>\"\"Methods<\/span>
\n<\/a>\"\"Author & Article
\nInfo<\/span>
\n<\/a>\"\"References<\/span>
\n<\/span><\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

<\/a>
\n<\/span><\/p>\n

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\nfracture. Am J Med. 1995;98:3S-8S.<\/a>
\n<\/span><\/span><\/span><\/p>\n

2.<\/strong> Lu-Yao GL, Baron JA, Barrett JA, Fischer ES. Treatment and survival
\namong elderly Americans with hip fractures: a population-based study. Am J Pub
\nHealth. 1994;84:1287-91.<\/a>
\n<\/span><\/span><\/span><\/p>\n

3.<\/strong> Magaziner J, Simonsick EM, Kashner TM, Hebel JR, Kenzora JE.
\nPredictors of functional recovery one year following hospital discharge for hip
\nfracture: a prospective study. J. Gerontol. 1990;45:M101-7.<\/a>
\n<\/span><\/span><\/span><\/p>\n

4.<\/strong> Zuckerman JD. Hip fracture. N Engl J Med. 1996;334:1519-25.<\/a>
\n<\/span><\/span><\/span><\/p>\n

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\n<\/span><\/span><\/span><\/p>\n

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\n<\/span><\/span><\/span><\/p>\n

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\n<\/span><\/span><\/span><\/p>\n

8.<\/strong> Davis FM, Woolner DF, Frampton C, Wilkinson A, Grant A, Harrison
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\n<\/span><\/span><\/span><\/p>\n

9.<\/strong> Rogers FB, Shackford SR, Keller MS. Early fixation reduces
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\n<\/span><\/span><\/span><\/p>\n

10.<\/strong> Zuckerman JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH.
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\n<\/span><\/span><\/span><\/p>\n

11.<\/strong> March L, Chamberlain A, Cameron I, Cumming R, Kurrle S, Finnegan
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\n<\/span><\/span><\/span><\/p>\n

12.<\/strong> Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP.
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\n<\/span><\/span><\/span><\/p>\n

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\n<\/span><\/span><\/span><\/p>\n

14.<\/strong> Lassen MR, Borris LC, Christiansen HM, Schott P, Olsen AD,
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\n<\/span><\/span><\/span><\/p>\n

15.<\/strong> Gent M, Hirsh J, Ginsberg JS, Powers PJ, Levine MN, Geerts WH, et
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\nCirculation. 1996;93:80-4.[Abstract\/Free<\/span> Full\u00a0Text]<\/a><\/a>
\n<\/span><\/span><\/span><\/p>\n

16.<\/strong> Morris GK, Mitchell JR. Preventing venous thromboembolism in
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\n<\/span><\/span><\/span><\/p>\n

17.<\/strong> Gerhart TN, Yett HS, Robertson LK, Lee MA, Smith M, Salzman EW.
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 <\/p>\n\n\n\n
\n\n\n\n\n
\"\"\u00a0Article<\/strong><\/span><\/td>\n<\/tr>\n
\n\n\n\n\n\n\n\n\n\n\n
\u00a0\"\"<\/td>\nTable of
\nContents<\/a>
\n<\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nAbstract of this
\narticle<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
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\u00a0\"\"\"\"<\/td>\nMorrison, R. S.<\/a><\/span><\/td>\n<\/tr>\n
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\u00a0\"\"\"\"<\/td>\nSiu, A. L.<\/a> <\/span><\/td>\n<\/tr>\n
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\nCopyright \u00a9 1998 by the
\nAmerican College of Physicians.<\/a><\/span><\/span><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

Search Annals: Advanced search \u00a0Home | Current Issue | Past Issues | Search | Collections | PDA Services | Subscribe | Contact Us | Help | ACP Online\u00a0 Institution: Albert Einstein Coll Med \u00a0 Sign In as Member or Subscriber \u00a0 \u00a0 \u00a0Article \u00a0 Table of Contents \u00a0 Abstract of this article \u00a0 Figures\/Tables List….<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1385,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"class_list":["post-1389","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1389","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/comments?post=1389"}],"version-history":[{"count":1,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1389\/revisions"}],"predecessor-version":[{"id":1390,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1389\/revisions\/1390"}],"up":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1385"}],"wp:attachment":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/media?parent=1389"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}