Identifying a standard set of outcome parameters for the evaluation of orthogeriatric co-management for hip fractures

BACKGROUND AND PURPOSE

Osteoporotic fractures are an increasing problem in the world due to the ageing of the population. Different models of orthogeriatric co-management are currently in use worldwide. These models differ for instance by the health-care professional who has the responsibility for care in the acute and early rehabilitation phases. There is no international consensus regarding the best model of care and which outcome parameters should be used to evaluate these models. The goal of this project was to identify which outcome parameters and assessment tools should be used to measure and compare outcome changes that can be made by the implementation of orthogeriatric co-management models and to develop recommendations about how and when these outcome parameters should be measured. It was not the purpose of this study to describe items that might have an impact on the outcome but cannot be influenced such as age, co-morbidities and cognitive impairment at admission.

METHODS

Based on a review of the literature on existing orthogeriatric co-management evaluation studies, 14 outcome parameters were evaluated and discussed in a 2-day meeting with panellists. These panellists were selected based on research and/or clinical expertise in hip fracture management and a common interest in measuring outcome in hip fracture care.

RESULTS

We defined 12 objective and subjective outcome parameters and how they should be measured: mortality, length of stay, time to surgery, complications, re-admission rate, mobility, quality of life, pain, activities of daily living, medication use, place of residence and costs. We could not recommend an appropriate tool to measure patients' satisfaction and falls. We defined the time points at which these outcome parameters should be collected to be at admission and discharge, 30 days, 90 days and 1 year after admission.

CONCLUSION

Twelve objective and patient-reported outcome parameters were selected to form a standard set for the measurement of influenceable outcome of patients treated in different models of orthogeriatric co-managed care.

Surgeons save bones: an algorithm for orthopedic surgeons managing secondary fracture prevention

Postmenopausal osteoporosis has a big impact on health care budget worldwide, which are expected to double by 2050. In spite of severe medical and socioeconomic consequences from fragility fractures, there are insufficient efforts in optimizing osteoporotic treatment and prevention. Undertreatment of osteoporosis is a well known phenomenon, particularly in elderly patients. Treatment rates remain low across virtually all patient, provider, and hospital-level characteristics, even after fragility fractures. In-hospital initiation is one of the options to increase treatment rates and improve osteoporosis management. However, multiple factors contribute to the failure of initiating appropriate treatment of osteoporosis in patients with fragility fractures. These include a lack of knowledge in osteoporosis and an absence of a comprehensive treatment guideline among family physicians and orthopedic surgeons. Furthermore, orthopedic surgeons are hardly willing to accept their responsibility for osteoporosis treatment due to the fact that they are usually not familiar with the initiation of specific drug treatments. The presented algorithm offers trauma surgeons and orthopedic surgeons a safe and simple guided pathway of treating osteoporosis in postmenopausal women appropriately after fragility fractures based on the current literature. From our point of view, this algorithm is useful for almost all cases and the user can expect treatment recommendations in more than 90 % of all cases. Nevertheless, some patients may require specialized review by an endocrinologist. The proposed algorithm may help to increase the rate of appropriate osteoporosis treatment hence reducing the rates of fragility fractures.

High-precision x-ray polarimetry

The polarization purity of 6.457- and 12.914-keV x rays has been improved to the level of 2.4×10(-10) and 5.7×10(-10). The polarizers are channel-cut silicon crystals using six 90° reflections. Their performance and possible applications are demonstrated in the measurement of the optical activity of a sucrose solution.

Public health advocacy for the Berlin Declaration on tuberculosis in the former Soviet Union: The view of Médecins Sans Frontières

To assist international efforts to address major gaps in the availability and accessibility of quality diagnosis and treatment for multi-drug resistant tuberculosis, Médecins Sans Frontières has adapted an approach combining three sets of interlinked strategies: direct provision of medical care, operational research, and public health advocacy. The activities undertaken are reviewed each in turn, with stress on the ways that they impact upon and consolidate each other. In spite of new opportunities, including technologies which significantly improve diagnosis and new, more patient-centred approaches, a much broader international mobilization is needed in order to confront MDR-TB. It is also questionable as to whether existing technologies are successful enough to provide a solid basis for expanded national programs.

An overview of the report of the national commission on sleep disorders research

The National Comission on Sleep Disorder Research evaluated the status of insomnia and other sleep disorders in the US. The Commission found that insomnia is prevalent affecting 20-30 million Americans, has significant morbidity especially related to attention and memory processes and cost the US an estimated $ 15 billion a year. It also estimated that all of these figures should rise significantly by the year 2000. Other sleep disorders (eg, narcolepsy and sleep apnea) although less prevalent have significant costs to patients and society associated with them. The Commission recommended that the US develop a research and education program to develop new insights into the basic mechanisms of sleep disorder. The education program needs to be directed to the general public; medical practitioners, as well as patients.

Twelve months of nightly zolpidem does not lead to rebound insomnia or withdrawal symptoms: a prospective placebo-controlled study

Rebound insomnia, worsened sleep when discontinuing use of a hypnotic, is reported in some short-term studies. No study has prospectively assessed, using patient reports or nocturnal polysomnography (NPSG), the likelihood of rebound insomnia with chronic hypnotic use. The objectives of this study was to assess in primary insomniacs the likelihood of experiencing rebound insomnia and a withdrawal syndrome on repeated placebo substitutions over 12 months of nightly zolpidem use. A group of 33 primary insomniacs, without psychiatric disorders or drug and alcohol abuse, 32-65 years old, 15 men and 18 women, were randomized to take zolpidem 10 mg (n = 17) or placebo (n = 16) nightly for 12 months. In probes during months 1, 4, and 12, placebo was substituted for 7 consecutive nights in both the zolpidem and placebo groups. NPSGs were collected and Tyrer Bezodiazepine Withdrawal Symptom Questionnaires were completed on the first two discontinuation nights. Rebound insomnia was not observed on the first two and the seventh discontinuation nights and its likelihood did not increase over the 12 months of nightly zolpidem use. Some individuals did show rebound insomnia, approximately 30-40% of participants, but the percentage of 'rebounders' did not differ between the placebo and zolpidem groups and did not increase across 12 months. No clinically significant withdrawal symptoms on the Tyrer were observed on the discontinuation nights over the 12 months of nightly use. Chronic nightly hypnotic use at therapeutic doses by primary insomniacs does not lead to rebound insomnia or withdrawal symptoms.

Functional outcome and mortality in geriatric distal femoral fractures

BACKGROUND

Fragility fractures are a major health care problem worldwide. Due to the ageing population an increase of distal femoral fractures is to be expected. We studied the long-term functional outcome and their influencing factors in geriatric patients with LISS-plated distal femoral fractures.

PATIENTS AND METHODS

A cohort study with functional long-term follow up examination was carried out in a level one trauma centre on distal femoral fracture patients 65 years and older. Of 53 consecutive patients who were treated in our hospital, 43 patients with a mean age of 80 years met our inclusion criteria. 48.8% died within the study period of 5.3 years. On the remaining patients the residential status, the Barthel index and the Parker score were assessed.

RESULTS

The mean Barthel index was 47.7 and the mean Parker score was 3.5. 23% were found to be totally housebound and 26% were not able to perform any social activity. Only 18% were able to walk unaided. Patients with any medical complication had significantly higher mortality rates. Patients with extraarticular fractures had better mobility scores. Nursing home residents showed higher mortality rates but compared to patients coming from their own home the difference regarding Barthel and Parker scores remained non-significant.

CONCLUSION

This study documents the poor functional long-term outcome of geriatric patients with distal femoral fractures. In comparison to other fragility fracture patients it seems that this population is at higher risk to die in-hospital during their perioperative course. Medical complications have to be avoided as they were found to be associated with worse functional outcome and higher mortality rates. An osteoporosis therapy may be associated with reduced mortality rates also in these patients.

A 30 T pulsed magnet with conical bore for synchrotron powder diffraction

We report on the design, construction, and operation of a horizontal field, 30 T magnet system with a conical bore optimized for synchrotron x-ray powder diffraction. The magnet offers ±31° optical access downstream of the sample, which allows to measure a sufficiently large number of Debye rings for an accurate crystal structure analysis. Combined with a 290 kJ generator, magnetic field pulses of 60 ms length were generated in the magnet, with a rise time of 4.1 ms and a repetition rate of 6 pulses/h at 30 T. The coil is mounted inside a liquid nitrogen bath. A liquid helium flow cryostat reaches into the coil and allows sample temperature between 5 and 250 K. The setup was used on the European Synchrotron Radiation Facility beamlines ID20 and ID06.

The Tyrolean Geriatric Fracture Center: an orthogeriatric co-management model

BACKGROUND

The aging population is growing rapidly and this change results in an increase in the number of fragility fracture patients. Several reports describe their poor outcome. Integrated models of care have been published in order to improve quality of patient care. We established an orthogeriatric model of care at the Department of Trauma Surgery in Innsbruck in cooperation with the Department of Geriatric Medicine (Hochzirl) and the Department for Anesthesiology. This report describes our concept as well as initial experience.

PATIENTS AND METHODS

We included all geriatric patients according to the definition of the German Geriatric Society. In all patients, basic demographic data, Charlson Comorbidity Index, and type of fracture were recorded. Main principles of the newly implemented system are the integration of a geriatrician in our team of trauma surgeons and anesthesiologists, prioritization of patients, development of our own clinical treatment guidelines, regular interdisciplinary and interprofessional meetings, a special outpatient clinic for these patients, and the better cooperation with the nearby Department of Geriatric Medicine.

RESULTS

A total of 529 patients met our inclusion criteria during 2010; 77.4% were female and the mean age was 84.1 years. The overall medical complication rate was 20.4%. Of the patients, 36.1% had hip fractures and 70.5% could be operated mainly using spinal anesthesia within 24 h and their mean length of stay was significantly shorter than operations performed 5 years previously. At 3 months, 86.7% of the patients had returned home and, thus, had reached their prefracture residency.

CONCLUSION

A coordinated, multidisciplinary model for the treatment of fragility fractures has the potential to improve the quality of patient care. Several international studies report superior outcome and our own findings are promising as well. We could show that our major goals, e.g., reduction of complications, shortening the length of stay, and restoration of the prefracture residency, can be improved by implementing such a model.

[Rare cause of acute neck pain]

The acute calcific tendinitis of the longus colli muscle is a rare inflammatory process of the prevertebral muscles. The clinical picture includes acute neck pain, limited range of motion of the cervical spine with stiffness and odynophagia. The laboratory findings demonstrate inflammatory signs. The incidence of the disease peaks between the third and sixth decade. The knowledge of the characteristic radiologic findings and the self-limiting course prevents the patient from needless medical and surgical interventions.

Photon regeneration experiment for axion search using x-rays

In this Letter we describe our novel photon regeneration experiment for the axionlike particle search using an x-ray beam with a photon energy of 50.2 and 90.7 keV, two superconducting magnets of 3 T, and a Ge detector with a high quantum efficiency. A counting rate of regenerated photons compatible with zero has been measured. The corresponding limits on the pseudoscalar axionlike particle-two-photon coupling constant is obtained as a function of the particle mass. Our setup widens the energy window of purely terrestrial experiments devoted to the axionlike particle search by coupling to two photons. It also opens a new domain of experimental investigation of photon propagation in magnetic fields.

Neuroaxial versus general anaesthesia in geriatric patients for hip fracture surgery: does it matter?

The influence of the mode of anaesthesia on outcome of geriatric patients with hip fractures is a controversial issue in the medical literature. In the light of an ageing society, a conclusive answer to this question is of growing importance. The purpose of this review was to assess the effect of neuroaxial and general anaesthesia on mortality and morbidity in geriatric patients sustaining a hip fracture. Following a current literature search within the Pubmed and Cochrane database (1967-2010), 34 randomised controlled trials, 14 observational studies and eight reviews/meta-analysis publications were included. Potentially outcome-influencing factors such as mortality, deep vein thrombosis, pulmonary embolism, postoperative confusion and other anaesthesia-related outcomes were evaluated. After analysing the current literature with 56 references, covering 18,715 patients with hip fracture, it can be concluded that spinal anaesthesia is associated with significantly reduced early mortality, fewer incidents of deep vein thrombosis, less acute postoperative confusion, a tendency to fewer myocardial infarctions, fewer cases of pneumonia, fatal pulmonary embolism and postoperative hypoxia. General anaesthesia has the advantages of having a lower incidence of hypotension and a tendency towards fewer cerebrovascular accidents compared to neuroaxial anaesthesia. Otherwise, general anaesthesia and respiratory diseases were significant predictors of morbidity in hip fracture patients. These data suggest that regional anaesthesia is the preferred technique, but the limited evidence available does not permit a definitive conclusion to be drawn for mortality or other outcomes. For hip fracture surgery, the choice of anaesthesia (general or neuroaxial) is made by the anaesthesiologist and is based on the patient's preference, comorbidities, potential general postoperative complications and the clinical experience of the anaesthesiologist. The overall therapeutic approach in hip fracture care should be determined jointly by the orthopaedic surgeon, the geriatrician and the anaesthesiologist (multidisciplinary approach).

Excessive sleepiness: under-recognized and essential marker for sleep/wake disorder management

BACKGROUND

Research during the past few decades has provided substantial evidence indicating that excessive sleepiness (ES) and associated sleep/wake disorders can result in significant morbidity and mortality. However, symptomatology (e.g., ES) and the relationships among common morbidities (e.g., cardiovascular disease, metabolic disorders, mood impairment) and sleep/wake disorders remain under-recognized in clinical practice, particularly in primary care. Yet assessment of sleep/wakefulness and associated symptoms can often be easily conducted in the primary care setting, providing valuable information to facilitate the diagnosis and management of sleep/wake disorders.

OBJECTIVE

To provide a conceptual and educational framework that helps primary care physicians comprehensively assess, differentially diagnosis, and appropriately manage patients presenting with ES or ES-related sleep/wake disorders.

METHODS

Comprised of six sleep specialists and six primary care physicians, the Sleep/Wake Disorders Working Group (SWG) used a modified, two-round Delphi approach to create and harmonize consensus recommendations for the assessment, diagnosis, treatment, and ongoing management of patients with common sleep/wake disorders related to ES.

RESULTS

After a review of the relevant literature, the SWG arrived at consensus on a number of clinical recommendations for the assessment and management ES and some of the most commonly associated sleep/wake disorders. Ten consensus statements – five each for assessment/diagnosis and treatment/ongoing care – were created for ES, insomnia, obstructive sleep apnea, circadian rhythm disorders, restless legs syndrome, and narcolepsy.

CONCLUSION

ES and ES-related sleep/wake disorders are commonly encountered in the primary care setting. By providing an educational framework for primary care physicians, the SWG hopes to improve patient outcomes by emphasizing recognition, prompt diagnosis, and appropriate ongoing management of ES and associated sleep/wake disorders.

Outcome in geriatric fracture patients and how it can be improved

Geriatric fractures are an increasing medical problem worldwide. This article wants to give an overview on the literature concerning the outcome to be expected in geriatric fracture patients and what can be done to improve it. In literature, excess mortality rates vary from 12% to 35% in the first year after a hip fracture, and also, other geriatric fractures seem to reduce the patient's remaining lifetime. Geriatric fractures and, in particular, hip fractures constitute a major source of disability and diminished quality of life in the elderly. Age, gender, comorbid conditions, prefracture functional abilities, and fracture type have an impact on the outcome regarding ambulation, activities of daily living, and quality of life. Comprehensive orthogeriatric comanagement might improve the outcome of geriatric fracture patients. For the future, well designed, large prospective randomized controlled trials with clear outcome variables are needed to finally prove the effectiveness of existing concepts.

Ortho-geriatric service--a literature review comparing different models

In the fast-growing geriatric population, we are confronted with both osteoporosis, which makes fixation of fractures more and more challenging, and several comorbidities, which are most likely to cause postoperative complications. Several models of shared care for these patients are described, and the goal of our systematic literature research was to point out the differences of the individual models. A systematic electronic database search was performed, identifying articles that evaluate in a multidisciplinary approach the elderly hip fracture patients, including at least a geriatrician and an orthopedic surgeon focused on in-hospital treatment. The different investigations were categorized into four groups defined by the type of intervention. The main outcome parameters were pooled across the studies and weighted by sample size. Out of 656 potentially relevant citations, 21 could be extracted and categorized into four groups. Regarding the main outcome parameters, the group with integrated care could show the lowest in-hospital mortality rate (1.14%), the lowest length of stay (7.39 days), and the lowest mean time to surgery (1.43 days). No clear statement could be found for the medical complication rates and the activities of daily living due to their inhomogeneity when comparing the models. The review of these investigations cannot tell us the best model, but there is a trend toward more recent models using an integrated approach. Integrated care summarizes all the positive features reported in the various investigations like integration of a Geriatrician in the trauma unit, having a multidisciplinary team, prioritizing the geriatric fracture patients, and developing guidelines for the patients' treatment. Each hospital implementing a special model for geriatric hip fracture patients should collect detailed data about the patients, process of care, and outcomes to be able to participate in audit processes and avoid peerlessness.