老年髋部骨折患者术后感染的预防与控制

目的 探索老年髋部骨折患者术后感染的预防和控制措施,以预防与控制其术后感染,提高治愈率.方法 对医院2008年1月-2010年12月手术治疗的223例＞65岁髋部骨折患者进行回顾性调查分析.结果 223例髋部骨折患者中,167例合并有≥1种其他科疾病,以心血管疾病、糖尿病和呼吸系统疾病为主;入院后平均手术时间(4.29±2.45)d;手术方式为内固定或髋关节置换;术后感染共6例占2.7％,其中手术部位感染2例占0.9％,呼吸道感染1例占0.45％,尿路感染3例占1.35％.结论 对老年髋部骨折患者术后感染的预防和控制,除预防性应用抗菌药物外,应尽早请相关科室会诊,共同评估患者病情及制定围手术期治疗方案,重视围手术期镇痛和早期功能锻炼、离床活动.     

Determinants of vitamin D status in adult Crohn's disease patients, with particular emphasis on supplemental vitamin D use

OBJECTIVE: To investigate determinants (pathophysiologic and physiologic, behavioural and lifestyle) of vitamin D status in Irish Crohn's disease (CD) patients. DESIGN: A cross-sectional observational study. SETTING: Cork City, Ireland (52 degrees N). SUBJECTS: Crohn's Disease patients (n=58; mean age 38.1 years) were recruited from Cork University Hospital. RESULTS: Fifty and nineteen percent of Irish CD patients were vitamin D deficient (defined by serum 25 hydroxyvitamin (OH) D levels <50 nmol/l) during winter and summer, respectively. Multiple regression analysis showed that summer-time serum 25 (OH) D levels were positively associated with use of vitamin D supplements (P=0.033) and negatively associated with smoking (P=0.006) and being male (P=0.063). During winter-time, use of vitamin D supplements (P=0.041) and sun habits (P=0.066) were positively associated, whereas small intestinal involvement (P=0.005) and body mass index (BMI) (P=0.083) were negatively associated with serum 25 (OH) D levels. There was no significant association between other non-pathophysiologic (age, dietary calcium or vitamin D) or pathophysiologic factors (steroid use, resection), and serum 25 (OH) D levels, at either season. Approximately 41 and 60% of the total variation in summer- and winter-time serum 25 (OH) D, respectively, was explained by this model. CONCLUSION: A high proportion of Irish CD patents had some level of vitamin D deficiency (<50 nmol/l) during late-wintertime. Use of regular low-dose supplemental vitamin D, particularly by patients with small intestinal involvement, cessation of smoking and adequate, but responsible, exposure to summer sunlight as well as maintaining BMI in the normal range could help maintain adequate vitamin D levels during wintertime.     

Vitamin D status and concentrations of serum vitamin D metabolites and osteocalcin in elderly patients with femoral neck fracture: a follow-up study

Vitamin D status and the serum osteocalcin concentration in patients with femoral neck fractures were studied as follows. Thirty-seven elderly patients (P) with fracture of the femoral neck were studied, whereas 24 age-matched persons (C) seen at the out-patient department for non-orthopaedic reasons served as controls. The dietary intake of vitamin D, estimated using a vitamin D score based on food items known to be the main sources of vitamin D, was significantly lower in the patients than in the controls. There was no difference in the serum 25-hydroxy-vitamin D (25-OH-D) (P: 22.3 +/- 7.5 nmol/l; C: 27.5 +/- 13.5) or the serum 1,25-dihydroxy-vitamin D3 concentration (P: 86 +/- 43 pmol/l; 31) C: 85 +/- 31) between the groups. The 25-OH-D concentration was, however, low as compared to reference values, suggesting vitamin D deficiency in both groups. There was no difference in the serum osteocalcin concentration between the groups (P: 3.1 +/- 1.7 micrograms/l; C: 3.4 +/- 1.5). One year later the serum osteocalcin concentrations (5.9 +/- 2.2 micrograms/l, n = 11) was significantly higher (P less than 0.005) in the patients than at the time of the fracture (3.2 +/- 2.2 micrograms/l), indicating an active bone turnover in the patients still present 1 year after the fracture.     

Sunlight and vitamin D status in normal Saudi subjects

Serum levels of the circulating form of vitamin D3, 25-hydroxycholecalciferol [25-(OH)D3], were determined in 59 university students, 26 males and 33 females, aged 18 to 26 yr and in 24 elderly subjects, 13 males and 11 females, with a mean age of 62 +/- 13 yr. The level of 25-(OH)D3 was significantly lower in the elderly persons (p less than 0.001) than in young students of both sexes, and was significantly higher in females than in males. Serum levels of 1, 25- and 24, 25-dihydroxycholecalciferol were measured in adult males and found to be within the normal range. A group of elderly patients were exposed to natural uv light, and the circulating levels of 25-(OH)D3, serum phosphorus, and alkaline phosphatase were determined both before and 1 day after the last exposure. The exposure to natural uv light resulted in a 2 1/2-fold increase in the level of 25-(OH)D3 and a significant decrease in the activity of alkaline phosphatase, but no significant change in serum phosphorus concentrations was observed. It is concluded that the low vitamin D3 status in Saudis is mainly due to avoidance of sunlight exposure and other factors discussed below.     

老年髋关节骨折术后的护理研究

目的:探讨老年髋关节骨折术后的康复护理要点.方法:64例老年髋关节骨折患者折行髋关节或股骨头置换术为研究对象,随机将患者分成对照组(32例)与观察组(32例),对照组予普通护理,观察组术后在普通护理基础上进行康复综合护理,评估两组老年髋关节骨折患者术后的恢复情况.结果:与对照组比较,观察组髋关节局部疼痛、髋关节功能恢复等情况均优于对照组,两组比较差异有统计学意义(P<0.05).结论:应用康复综合护理可以促进老年髋关节骨折术后患者早日康复,值得临床推广应用.     

老年人血浆维生素K和D水平的季节变化

目的了解老年人群血浆维生素K和维生素D水平的季节变化。方法对85名健康老年人用放射免疫分析法测定春秋两季血浆维生素D(25(OH)D)和甲状旁腺素(PTH)含量,用高压液相色谱法测定血浆维生素K含量。结果血浆维生素K水平女性在春秋两季均明显高于男性,而男性和女性各自无季节性差异。无论男女秋季血浆维生素(25(OH)D)水平明显高于春季,同一季节内男女间差异无统计学意义。维生素D缺乏率女性春季为63.4%,秋季为7.3%。男性春季为65.9%,秋季无缺乏者。春季维生素D缺乏率显著高于秋季(P<0.05)。男女秋季血浆PTH浓度明显低于春季。老年女性春季血浆25(OH)D浓度和血浆PTH浓度之间呈负相关(r=-0.426,P<0.001)。结论该人群血浆25(OH)D和PTH有明显的季节变化,春季血浆25(OH)D水平低。而血浆维生素K没有季节变化。     

人工髋关节置换术治疗老年髋关节骨折的疗效分析

目的:研究分析人工髋关节置换术治疗老年髋关节骨折的临床疗效.方法:选取我院骨科2014年1月-2016年1月期间收治的98例老年髋关节骨折患者作为研究对象,以随机选取的方式将其分成研究组49例并对其实施人工髋关节置换术进行治疗,参照组49例采取PFNA术进行治疗,并对两组患者术后临床疗效和手术效果其中包括(手术时间、术中出血量、术后引流量、骨折愈合时间)进行对比分析.结果:研究组老年患者采用人工髋关节置换术治疗后,临床疗效总有效率为91.80％,参照组的临床疗效总有效率为77.60％,两组对比,研究组临床疗效明显高于参照组,同时研究组的手术效果也明显优于参照组,两组差异明显有统计学意义(P<0.05).结论:治疗老年髋关节骨折采用人工髋关节置换术,其临床疗效良好,可降低手术时间,减少术中出血量、术后引流量,有效的控制了术后并发症的发生率,提高骨折愈合速度,使老年患者尽早恢复活动能力.结果显示,人工髋关节置换术是目前临床治疗老年髋关节骨折最佳方法,值得在临床推广和应用.     

Nutritional status and energy expenditure in elderly patients with recent hip fracture during a 2-month follow-up

A 2-month follow-up of nutritional status was performed in forty elderly patients with recent hip fracture. Patients were nutritionally assessed on admission to our rehabilitation unit (day 0), then monthly (day 30, day 60) by measurement of resting energy expenditure (REE), anthropometric, impedance and biological variables. Patients were defined as undernourished (n 13) or normally nourished (n 27) on the basis of mid-arm circumference (MAC) and triceps skinfold thickness (TST) measurements. Seven patients recovered a walking autonomy and were discharged from the hospital before day 30 (group I) whereas thirteen patients were discharged after day 30 (group II); twenty patients remained in the study at day 60 (group III). MAC and TST decreased in normally nourished patients from group III throughout the study whereas they did not change in group II or in undernourished patients from group III. REE values in relation to fat-free mass were increased compared with normal values and were similar in the three groups on day 0; they did not change during the study. Daily energy intake in relation to body weight was higher in group I and increased in group II and in undernourished patients from group III throughout the study. In contrast, it was below the recommended value at day 0 and it did not significantly improve in normally nourished patients from group III. Serum albumin, transthyretin and transferrin levels on day 0 were below reference intervals in the three groups. Albumin levels increased in group III throughout the study. Inflammatory proteins decreased in groups II and III, with C-reactive protein levels returning to normal values in group II by day 30 and in group III at day 60, while orosomucoid levels did not become completely normal over this period. Our findings indicate no improvement in nutritional status in undernourished patients after surgery for recent hip fracture, despite an adequate energy intake. An insufficient spontaneous energy intake for normally nourished patients was associated with a delayed favourable outcome resulting in a prolonged duration of hospitalization. A hypermetabolic state persisted during the 3 months after surgery.     

Factors that influence functional prognosis in elderly patients with hip fracture

The purpose of this study was to evaluate in aged patients with hip fracture, the degree of recovery at discharge and after discharge relative to the pre-fracture walking level, to clarify the factors involved in unsuccessful recovery. The patients were 189 patients aged 60 years and older who underwent surgery between 1988 and 1994. Patients who died within 1 year or lacked data on walking were excluded. Multiple logistic regression analysis was applied to data on the walking level before fracture, that at discharge, and the best walking level after discharge, to clarify factors involved in unsuccessful recovery. The rate of recovery to the pre-fracture level was 55.1% at discharge. Unsuccessful recovery at discharge was influenced by prior dementia, a history of cerebrovascular diseases, and an age of 85 or more years. Analysis showed an “after-discharge” recovery rate of 63.2%. Prior dementia and the residence outside one’s own home influenced unsuccessful recovery rate. These findings suggested that it is important to provide patients with such factors a more effective postoperative rehabilitation program not merely the standard rehabilitation program. In addition, a walking rehabilitation program should be offered to those who were re-hospitalized or admitted to other health care facilities.     

Oral vitamin D3 decreases fracture risk in the elderly

Vitamin D3 (or its physiologic equivalent, ergocalciferol), administered at a dose of 100,000 IU every 4 months for 5 years, is effective for primary prevention of fractures in the active elderly aged 65 to 85 years. This treatment regimen has no effect on cardiovascular, cancer, or all-cause mortality. Despite a seemingly large dose averaging 800 IU per day, this regimen is a safe, cheap (<$2 per year), and effective therapy for primary prevention of fractures.     

High prevalence of hypovitaminosis D and K in patients with hip fracture

Although hip fracture is considered to be associated with hypovitaminosis D and K, few reports have previously studied both of them. We have studied the vitamin D- and K-status as well as the general nutritional status in ninety-nine patients with hip fracture. Mean serum concentration of 25hydroxy-vitamin D (25OH-D) in female fractured patients was only approximately 9 ng/mL, suggesting severe vitamin D deficiency. There was no significant difference between the two groups in serum concentration of intact parathyroid hormone in both genders and serum 25OH-D levels in the male subjects. Plasma concentrations of phylloquinone (vitamin K1; PK) and menaquinone-7 (MK-7) were significantly lower in the fractured group than in the control group in both genders. Logistic regression analysis indicated that circulating concentrations of albumin, PK and 25OH-D were the significant and independent determinants of fracture risk, with their higher concentrations associated with decreased fracture risk. Finally, principal component analysis (PCA) was performed to summarize the clinical parameters into smaller numbers of independent components. Three components were obtained, each representing the overall nutritional status, the vitamin D status, and the vitamin K status. In conclusion, our study has shown that patients with hip fracture have vitamin D and K deficiency independent of general malnutrition.     

Attributions of control by hip fracture patients

Some hospitalized hip fracture patients assume responsibility for their accidents whereas others do not. Patients also differ in the control they project over their recovery and over future accidents. Patient's expressions of control may provide diagnostic clues and an avenue for social work intervention.     

康复早期介入对髋部骨折老年患者肺部感染的影响分析

目的探讨康复早期介入对老年髋部骨折肺部感染的影响。方法选择2012年6月-2016年6月就诊的髋部骨折患者864例,随机分为研究组和对照组,各432例,两组均给予基础治疗,对照组给予常规骨科康复训练,研究组采用康复早期介入,观察患者术后2周并发症发生情况,对肺部感染患者的痰、尿、血等进行细菌培养和鉴定,对术后2周、1个月、3个月、6个月患者的髋关节功能及活动能力进行评定,对两组患者的骨愈合程度进行判定。结果研究组肺部感染12例,感染率2.78%,显著低于对照组37例感染率8.56%(P<0.05),研究组患者治疗后2周、1个月、3个月、6个月髋关节功能评分分别为(54.23±6.54)分、(67.33±5.41)分、(81.04±5.65)分、(92.21±5.48)分,均高于对照组(40.84±5.44)分、(45.83±4.95)分、(60.40±6.40)分、(73.83±6.95)分,差异有统计学意义(P<0.05);共检测出104株病原菌,其中革兰阴性菌59株占56.73%,革兰阳性菌39株占37.50%,真菌6株占5.77%;治疗前,两组患者生活活动能力比较差异无统计学意义,干预后两组患者生活活动能力评分均显著较治疗前升高,差异有统计学意义(P<0.05),研究组患者治疗有效率为97.69%显著高于对照77.31%(P<0.05)。结论康复早期介入能够显著降低老年髋部骨折患者肺部感染发生率,提高髋关节功能和生活活动能力,提高治疗有效率。     

Nutritional status among patients with hip fracture in relation to pressure ulcers

BACKGROUND & AIMS: Patients with a hip fracture often have a poor nutritional status that is associated with increased risk of complications, morbidity and mortality. The aim of this study was to investigate the effects of an improved care intervention in relation to nutritional status and pressure ulcers. An intervention of best practices for patients with hip fracture was introduced, using the available resources effectively and efficiently with a not too complicated or expensive intervention. METHODS: A quasi-experimental study of 478 patients consecutively included between April 1, 2003 and March 31, 2004. A new evidence-based clinical pathway was introduced on October 1, 2003. The results from the first 210 patients in the control group and the last 210 patients in the intervention group are presented in this article. RESULTS: The total number of patients with a hospital-acquired pressure ulcer was in the intervention group, 19 patients, and in the control group, 39 patients (p = 0.007). No patient younger than 65 years developed a pressure ulcer. There were no statistical significant differences between the groups with respect to blood biochemical variables at inclusion. Patients in the control group had higher arm muscle circumference (AMC) (p = 0.05), calf circumference (CC) (p = 0.038) and body mass index (BMI) (p = 0.043) values. Abnormal anthropometrical tests of BMI, triceps skin fold (TSF) <10th percentile and AMC <10th percentile were found in 12 patients in the control group and in 4 patients in the intervention group. None of the 4 patients in the intervention group developed pressure ulcers. However, 2 of the 12 patients in the control group were affected. CONCLUSIONS: It is possible to reduce the development of hospital-acquired pressure ulcers among elderly patients with a hip fracture even though they have poor prefracture nutritional status. Results in this study indicate the value of the new clinical pathway, as number of patients who have developed pressure ulcers during their stay in hospital has been reduced by 50%.