Screening for Falls and Osteoporosis: Prevention Practice for the Hand Therapist

Fractures of the upper extremity are considered a hallmark of underlying osteopenia or osteoporosis and strong predictors of subsequent fractures. Falling is the strongest single risk factor for fractures in older adults. Studies have shown that interventions to prevent falls can significantly reduce this risk factor. Hand therapists working with patients with an upper extremity injury from a fall cannot assume that screening for osteoporosis or the likelihood of falls has been addressed by other health care professionals. The purposes of this article are to 1) summarize osteoporosis and falls risk screening, 2) describe how fall prevention strategies can be integrated into hand therapy practice, and 3) present evidence for federal and professional organizational support of prevention practice.     

Assessing and preventing foot problems in older patients who have diabetes mellitus

The first component of prevention is patient education. The patient and those who provide care for the older diabetic must be fully informed of their problems, but understand the management process and be willing to make the lifestyle changes necessary to prevent complications. Evaluating patients to determine those diabetics who are at risk for foot problems, complication, ulceration, or potential amputation is the second component of prevention. This process must include continuing surveillance and management. Recognizing symptoms and signs of various systems with primary evaluative procedures permits the early identification of complications and secondary prevention of chronic disease. Because Medicare now provides footwear and orthotic coverage for at-risk diabetics as an adjunct to management, early screening, assessment, and detection are essential. The provision of significant patient education can then be added to complement professional education. We have attempted to provide a process for proper referral for care and management that can be employed by all health care providers involved in the evaluation of the patient who has diabetes.     

骨科老年患者跌倒风险评估与干预流程的实施

目的降低骨科老年患者跌倒发生率,保障患者住院安全。方法对照组(110例)采用常规跌倒预防护理措施;观察组(118例)使用骨科老年患者跌倒风险评估表进行跌倒风险评估,依据风险级别采取相应的护理干预措施。结果对照组发生跌倒6例,观察组无跌倒病例,两组比较,差异有统计学意义(P<0.05);观察组患者或家属对护士预防跌倒各项指标的满意率达93.1%～100%。结论依据跌倒风险评估结果实施预防跌倒干预措施,提高了护士参与跌倒预防的积极性及老年患者对跌倒风险因素的认知,从而降低了跌倒发生率。     

Musculoskeletal rehabilitation in osteoporosis: a review.

Measures of musculoskeletal rehabilitation play an integral part in the management of patients with increased fracture risk because of osteoporosis or extraskeletal risk factors. This article delineates current scientific evidence concerning nonpharmacologic approaches that are used in conjunction with pharmacotherapy for prevention and management of osteoporosis. Fractures caused by osteoporotic fragility may be prevented with multidisciplinary intervention programs, including education, environmental modifications, aids, and implementation of individually tailored exercise programs, which are proved to reduce falls and fall-related injuries. In addition, strengthening of the paraspinal muscles may not only maintain BMD but also reduce the risk of vertebral fractures. Given the strong interaction between osteoporosis and falls, selection of patients for prevention of fracture should be based on bone-related factors and on risk factors for falls. Rehabilitation after vertebral fracture includes proprioceptive dynamic posture training, which decreases kyphotic posturing through recruitment of back extensors and thus reduces pain, improves mobility, and leads to a better quality of life. A newly developed orthosis increases back extensor strength and decreases body sway as a risk factor for falls and fall-related fractures. Hip fractures may be prevented by hip protectors, and exercise programs can improve strength and mobility in patients with hip fracture. So far, there is no conclusive evidence that coordinated multidisciplinary inpatient rehabilitation is more effective than conventional hospital care with no rehabilitation professionals involved for older patients with hip fracture. Further studies are needed to evaluate the effect of combined bone- and fall-directed strategies in patients with osteoporosis and an increased propensity to falls.     

Implementation of pressure ulcer prevention best practice recommendations in acute care: an observational study

Pressure ulcers are a common but preventable problem in hospitals. Implementation of best practice guideline recommendations can prevent ulcers from occurring. This 9‐year cohort study reports prevalence data from point prevalence surveys during the observation period, and three practice metrics to assess implementation of best practice guideline recommendations: (i) nurse compliance with use of a validated pressure ulcer risk assessment and intervention checklist; (ii) accuracy of risk assessment scoring in usual‐care nurses and experienced injury prevention nurses; and (iii) use of pressure ulcer prevention strategies. The prevalence of hospital‐acquired pressure ulcers decreased following implementation of an evidence‐based prevention programme from 12·6% (2 years preprogramme implementation) to 2·6% (6 years postprogramme implementation) (P < 0·001). Audits between 2003 and 2011 of 4368 patient medical records identified compliance with pressure ulcer prevention documentation according to best practice guidelines was high (>84%). A sample of 270 patients formed the sample for the study of risk assessment scoring accuracy and use of prevention strategies. It was found usual‐care nurses under‐estimated patients' risk of pressure ulcer development and under‐utilised prevention strategies compared with experienced injury prevention nurses. Despite a significant reduction in prevalence of hospital‐acquired pressure ulcers and high documentation compliance, use of prevention strategies could further be improved to achieve better patient outcomes. Barriers to the use of prevention strategies by nurses in the acute hospital setting require further examination. This study provides important insights into the knowledge translation of pressure ulcer prevention best practice guideline recommendations at The Northern Hospital.     

Knowledge, beliefs and attitudes of kidney transplant recipients regarding their risk of cancer

Aim: Despite an increased risk of cancer post transplant, little is known about the knowledge, beliefs of and attitudes to cancer and its prevention among kidney transplant recipients. This study aims to explore these beliefs and attitudes, to better understand patient motives and potential barriers to early detection of cancer. Methods: Semi‐structured interviews were conducted with 14 kidney and eight kidney–pancreas transplant recipients based at a single transplant centre in Sydney, Australia, between October 2009 and February 2010. Results: Thematic data analysis identified four major themes: (1) skin cancer‐focused: participants were generally only aware about their increased risk of skin cancer and available prevention strategies for that cancer alone; (2) limited awareness: participants knew little about their excess risk for non‐skin cancers and possible preventative and screening strategies; (3) fear of cancer: cancer fears were heightened by prior experiences; some felt vulnerable to cancer and perceived that cancer outcomes were worse than kidney disease; and (4) prioritizing present health issues: participants believed cancer was not imminent and had limited capacity to absorb information about long‐term risks, particularly as current health concerns appeared pressing and important. Conclusion: Awareness of increased cancer risk and cancer screening among kidney transplant recipients is focused narrowly on skin cancer, with limited awareness for other cancers. Recipients prioritized current health issues rather than future risks to health such as cancer. Transplant care providers should provide evidence‐based information on cancer risk and screening, being sensitive to the timing and needs of the patient. Improved knowledge may empower patients to minimize their risk of cancer by participating in screening and cancer prevention programmes.     

Strengths and limitations of standards of care to guide the orthopedic surgeon in VTE prevention

With respect to VTE prevention, several steps can be taken by orthopedic surgeons to ensure the best standard of patient care. All patients should be assessed for VTE risk and appropriate prophylaxis should be provided. Venous thromboembolism prophylaxis guidelines, hospital protocols, and risk assessment models can guide orthopedic surgeons in making individualized decisions. In cases where guidelines offer no direct recommendations, or disagree, standardized care may need to be tempered by clinical judgment and individual patient considerations. Improved health care and better outcomes can be achieved for orthopedic surgery patients by considering VTE prophylaxis from the viewpoint of the clinical guidelines and patient-specific factors.     

Describing variation in the delivery of secondary fracture prevention after hip fracture: an overview of 11 hospitals within one regional area in England

Summary

There is variation in how services to prevent second fractures after hip fracture are organised. We explored this in more detail at 11 hospitals. Results showed that there was unwarranted variation across a number of aspects of care. This information can be used to inform service delivery in the future.

Introduction

Hip fractures are usually the result of low impact falls and underlying osteoporosis. Since the risk of further fractures in osteoporotic patients can be reduced by between 20 and 70 % with bone protection therapy, the NHS is under an obligation to provide effective fracture prevention services for hip fracture patients to reduce risk of further fractures. Evidence suggests there is variation in service organisation. The objective of the study was to explore this variation in more detail by looking at the services provided in one region in England.

Methods

A questionnaire was designed which included questions around staffing, models of care and how the four components of fracture prevention (case finding, osteoporosis assessment, treatment initiation and adherence (monitoring) were undertaken. We also examined falls prevention services. Clinicians involved in the delivery of osteoporosis services at 11 hospitals in one region in England completed the questionnaire.

Results

The service overview showed significant variation in service organisation across all aspects of care examined. All sites provided some form of case finding and assessment. However, interesting differences arose when we examined how these components were structured. Eight sites generally initiated treatment in an inpatient setting, two in outpatients and one in primary care. Monitoring was undertaken by secondary care at seven sites and the remainder conducted by GPs.

Conclusions

The variability in service provision was not explained by local variations in care need. Further work is now needed to establish how the variability in service provision affects key patient, clinical and health economic outcomes.     

Accidental falls and related fractures in 65-74 year olds: A retrospective study of 332 patients

We investigated, by studying medical records, background factors and consequences of accidental falls of patients 65-74 years who attended the Department of Orthopedics' emergency clinic in Lund. We also assessed possible prevention measures. Fractures occurred in three quarters of the registered falls. Women were more prone to sustain fractures than men. Forearm fractures were commonest among women while hip fractures were commonest among men. One third of the patients were admitted to an orthopedic ward because of the fall. The patients who were less healthy had sustained fractures oftener and also needed more hospital care. Information regarding risk factors for falls and fractures were often missing in the patients' medical records. Impaired walking and balance, and medication increased the risk of falls. Such patients constitute a high risk group for future falls and fractures. A newly developed instrument is suggested as a routine in the emergency department to increase the awareness of risk factors for falls in the elderly. Satisfactory documentation is a prerequisite for further treatment and referrals to prevent falls and fractures.     

Preoperative pregnancy testing in a tertiary care children's hospital: a medico-legal conundrum.

STUDY OBJECTIVES: To track physician and nursing practice regarding preoperative pregnancy screening and testing in a setting where testing is the established policy. DESIGN: Prospective study. SETTING: University-affiliated, urban, tertiary care pediatric hospital. PATIENTS: 261 menarcheal patients, aged 10 to 34 years, presenting for ambulatory surgery in a 15-month period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 235 routine pregnancy tests performed, three were positive (1.3%). All patients denied the possibility of pregnancy; all reported last menstrual period less than 3 weeks prior to their scheduled surgery. Two of the three patients whose pregnancy tests were positive were adults. Only two study patients were unsure about the possibility of pregnancy; both patients tested negative. No patient younger than 15 years tested positive (0 of 107). History was an unreliable marker for pregnancy. CONCLUSIONS: Medical history alone may be an unreliable marker for ruling out pregnancy in patients presenting for outpatient surgery in an urban pediatric hospital. The policy for preoperative pregnancy screening adopted by a hospital or health care facility should be predicated on the principle of "best interest of the patient." Considerations must include local law, ethical responsibility, and the balance between cost and risk based on the best and most current scientific information.     

Hip pain in an elite cyclist with Non-Hodgkin’s Follicular Lymphoma: a case report

ObjectiveWe present a case of an elite cyclist that hesitated to follow the medical advice from her practitioners, as she was determined to train and compete resulting in delayed diagnosis and management of a rare hip pathology.Case presentationA 51-year old elite female cyclist had a history of years of hip pain with insidious onset. The chiropractor in this case observed a lack of response to treatment, and advised the patient to get an MRI with suspicion of a labral tear. She eventually agreed to further investigations and was diagnosed with Non-Hodgkin’s follicular lymphoma and a labral tear.SummaryElite athletes are not immune to serious pathology. Chiropractors should be vigilant and ensure to investigate any patients with a lack of response to conservative management. Chiropractors should be aware of the risk of athletic patients that continue to train and compete when advised not to.     

Functional assessments for predicting a risk of multiple falls in independent ambulatory patients with spinal cord injury

Abstract

Background/objectives

Many ambulatory patients with spinal cord injury (SCI) encountered multiple falls and serious consequences after falls, but there was no quantitative practical measure for early identification of individuals at a risk of multiple falls. This study compared the utility of the Berg Balance Scale, Timed “Up & Go” Test, 10-Meter Walk Test, Functional Reach Test (FRT), Step Test, and Five Times Sit-to-Stand Test to predict risk of multiple falls (fall ≥2 times) in these individuals.

Methods

Eighty-three independent ambulatory subjects with SCI were assessed for their functional abilities using the six tests. Then, their fall data were monitored prospectively every 2 weeks for 6 months in total. The first 25 subjects were also involved in the reliability tests.

Results

The FRT showed the best predictive ability for the risk of multiple falls (cut-off score ≥20 cm, sensitivity = 73%, specificity = 55%, area under the receiver characteristic curve = 0.64, and adjusted odd ratio = 3.18, P < 0.05), excellent inter-tester reliability, and good feasibility.

Conclusions

The FRT may be used as a screening tool to predict risk of multiple falls in independent ambulatory individuals with SCI. However, with a moderate level of specificity, a further comprehensive test may be needed to clearly indicate individuals at a risk of falls. In addition, the findings suggest that a higher level of ability increases the risk of multiple falls. Thus, programs for functional integration in an actual environment may be needed to reduce the risk of falls for these individuals.     

Hip fractures and best practice tariffs

Hip fractures or proximal femur fractures describe fractures of the proximal femur from the femoral head to 5 cm below the lower border of the lesser trochanter. Most hip fractures occur in elderly patients whose bones have become weakened by osteopenia or osteoporosis, i.e. a fragility fracture. The prevalence of hip fractures is increasing steadily due to the ageing population. Due to the patient demographic (elderly, likely with multiple comorbidities) numerous guidelines are put in place and continually revised to facilitate best patient outcomes. It is now widely accepted that effective management of hip fractures requires collaborative care between orthopaedic surgeons and orthogeriatricians as part of a Hip Fracture Programme, with a focus on prompt surgery, re-establishing the patient's independence/pre-fracture mobility, and preventing further fractures by assessing falls risk and bone health. The NHS financially incentivizes Healthcare Trusts in the UK to achieve a set of Best Practice Tariffs (BPTs), which were introduced by the British Geriatric Society and the British Orthopaedic Society. The mainstay treatment for hip fractures is surgery, and the choice of surgery depends on the radiological classification of the hip fracture into an intracapsular vs extracapsular fracture and whether the fracture is displaced or non-displaced. This is due to the high risk of avascular necrosis of the femoral head with displaced intracapsular fractures. Other important considerations are the age of the patient, pre-fracture functionality, and comorbidities. This paper will describe hip fractures (particularly fragility hip fractures) including their classification, management and how gold standard care is incentivized by the best practice tariffs.     

The inpatient fracture neck of femur: An important subgroup of patients

Fractured neck of femur (FNOF) is an increasing problem for the National Health Service (NHS) with 61,508 recorded on the National Hip Fracture Database (NHFD) in 2012–2013 and treatment of such patients is estimated to cost the NHS £1.5 billion per year. Inpatients falling in hospital and sustain a FNOF have rarely been studied as a separate group of patients to assess standards of patient care, time to operative management, and patient mortality.Of 694 patients sustaining an acute FNOF at a single trust between January 2012 and June 2013, 40 patients (5.8%) sustained an inpatient FNOF. 19 patients (47.5%) were male and 15 patients (37.5%) had an ASA grade of 4 or 5, compared to 153 patients (23.4%) and 127 patients (19.4%) respectively of “community” FNOF. 39 of 40 patients received operative management.Patients with an “inpatient” FNOF were less likely to be admitted to an orthopaedic ward within 4 h (30%) and receive operative management within 48 h (65%) according to “Blue Book” standards. Results according to best practice tariff (BPT) were also significantly reduced for the “inpatient” FNOF group, with 23 patients (57.5%) receiving operative management within 36 h and only 19 patients (47.5%) achieving BPT compared to 76.5% and 72.5% respectively for “community” FNOF patients. Mortality among inpatients reached 40% at 120 days and 50% at 1 year, significantly higher than community FNOF patients after multivariate analysis.Patients sustaining an “inpatient” FNOF are more likely to have significant medical co-morbidity and require aggressive medical and surgical management, especially due to their increased risk of mortality post-operatively. Such injuries have direct and indirect financial implications to a health care trust, which can be minimised by prompt management of these patients. This study highlights the need for a standardised protocol of management of this important subgroup of patients and for further work on falls prevention strategies within the National Health Service.     

Postoperative falls in the acute hospital setting: characteristics, risk factors, and outcomes in males

Background

Hospital falls are an important cause of morbidity in older surgical patients. The objectives of this study were to describe the characteristics, risk factors, and outcomes for postoperative falls.

Methods

A retrospective study was performed on patients who were admitted to the hospital for more than 23 hours after surgery. Patients who fell within 30 days of their surgery were considered to have experienced a postoperative fall.

Results

Over 5 years and 9,625 inpatient surgical procedures, 154 patients experienced 190 falls. Injuries resulting from postoperative falls included major injury (hip fracture), less than 1%; injury requiring intervention, 2%; injury not requiring intervention, 27%; and no injury, 70%. Variables associated with postoperative falls included older age, functional dependence, lower albumin level, and higher American Society of Anesthesia score.

Conclusions

One or more postoperative falls occurred in 1.6% of surgical inpatients and can lead to significant morbidity. Recognition of fall risk factors will help design postoperative fall prevention programs by identifying patients at highest risk for postoperative falls.     

Accidental falls and related fractures in 65-74 year olds: a retrospective study of 332 patients

We investigated, by studying medical records, background factors and consequences of accidental falls of patients 65-74 years who attended the Department of Orthopedics' emergency clinic in Lund. We also assessed possible prevention measures. Fractures occurred in three quarters of the registered falls. Women were more prone to sustain fractures than men. Forearm fractures were commonest among women while hip fractures were commonest among men. One third of the patients were admitted to an orthopedic ward because of the fall. The patients who were less healthy had sustained fractures oftener and also needed more hospital care. Information regarding risk factors for falls and fractures were often missing in the patients' medical records. Impaired walking and balance, and medication increased the risk of falls. Such patients constitute a high risk group for future falls and fractures. A newly developed instrument is suggested as a routine in the emergency department to increase the awareness of risk factors for falls in the elderly. Satisfactory documentation is a prerequisite for further treatment and referrals to prevent falls and fractures.     

The diagnosis and emergency care of heat related illness and sunburn in athletes: A retrospective case series

Objective:

Heat illnesses contribute to significant morbidity and occasional mortality in athletic populations. Sunburn increases the risk of various skin carcinomas. This report provides an overview of the etiology, symptomatology, risk identification, prevention, and treatment for heat related illnesses and sunburn.

Clinical Features:

Four cases are presented to illustrate the diagnosis and immediate treatment of exercise related heat illness and sunburn.

Intervention and Outcome:

Identification of signs and symptoms combined with prompt treatment, achieved resolution in three athletes presenting with exercise related heat illness and one athlete with sunburn.

Conclusion:

The best treatment approach is prevention. Chiropractors can be an important resource for information regarding prevention and treatment strategies. For mild to moderate heat illness, quick identification of signs and symptoms, followed by rapid cooling and re-hydration comprises treatment. For heat stroke, rapid and aggressive cooling is essential to reduce mortality. Best evidence treatment of sunburn is symptomatic relief with emollients and pain control via medications.     

Accidental falls and related fractures in 65-74 year olds: A retrospective study of 332 patients

We investigated, by studying medical records, background factors and consequences of accidental falls of patients 65-74 years who attended the Department of Orthopedics' emergency clinic in Lund. We also assessed possible prevention measures. Fractures occurred in three quarters of the registered falls. Women were more prone to sustain fractures than men. Forearm fractures were commonest among women while hip fractures were commonest among men. One third of the patients were admitted to an orthopedic ward because of the fall. The patients who were less healthy had sustained fractures oftener and also needed more hospital care. Information regarding risk factors for falls and fractures were often missing in the patients' medical records. Impaired walking and balance, and medication increased the risk of falls. Such patients constitute a high risk group for future falls and fractures. A newly developed instrument is suggested as a routine in the emergency department to increase the awareness of risk factors for falls in the elderly. Satisfactory documentation is a prerequisite for further treatment and referrals to prevent falls and fractures.     

Evaluation,severity and prognostic significance of silent myocardial ischaemia in vascular patients

This paper intends to make an update of recent publications and guidelines for evaluation in coronary symptom-free patients undergoing vascular surgery. It emphasizes the role of preoperative clinical evaluation that should identify the most appropriate testing, and treatment strategies to optimize care of the patient and avoid unnecessary testing in this era of cost containment. Selective preoperative coronary artery disease screening and revascularization achieve excellent perioperative and late results after high-risk vascular surgery. Supplemental preoperative evaluation is discussed (exercise ECG, stress echocardiography and stress tomoscintigraphy). Asymptomatic patients with good functional capacity can undergo intermediate-risk surgery without further non-invasive testing. Conversely, further noninvasive testing is often considered for patients with poor functional capacity or moderate functional capacity but higher-risk surgery especially for patients with 2 or more intermediate risk predictors. Additional testing may be considered on an individual basis for patients without clinical markers but with poor functional capacity prior to vascular surgery, particularly those with several minor clinical risk predictors. Because of a higher prevalence of silent myocardial ischaemia in diabetes mellitus, these patients require specific care. Until further data are available, indications for myocardial revascularization in the perioperative setting are similar to those in the ACC/AHA guidelines for use of myocardial revascularization in general. General practitioners, cardiologists, angiologists, vascular surgeons and anaesthesiologists should collaborate and aim to slow down the progression of atherosclerosis by giving their patients an optimum secondary cardiovascular prevention.