Perspectives towards End-of-Life Care in the Emergency Department of Tertiary Public Hospitals-A Qualitative Analysis.

Background and Objectives: End-of-life care in the emergency department (ED) is gaining importance along with the growth in the ageing population and those with chronic and terminal diseases. To explore key stakeholders' perspectives and experiences regarding end-of-life care in the ED. Materials and Methods: A descriptive qualitative study was conducted from November 2019 to January 2020. Study participants were recruited from the EDs of three tertiary hospitals and community care settings in Singapore through purposive sampling. Data collection included focus group discussions with 36 ED staff, 16 community healthcare professionals, and one-on-one semi-structured interviews with seven family members. Results: Three main themes and several subthemes emerged from the data analysis. (1) Reasons for ED visits were attributed to patients' preferences, families' decisions, limited services and capabilities in the community, and ease of access. (2) Barriers to providing end-of-life management in the ED included: conflicting priorities of staff, cramped environment, low confidence, ineffective communication, and lack of standardised workflows. (3) Discussion about continuity of end-of-life care beyond the ED uncovered issues related to delayed transfer to inpatient wards, challenging coordination of terminal discharge from the ED, and limited resources for end-of-life care in the community. Conclusions: Key stakeholders reported challenges and shared expectations in the provision of end-of-life care in the ED, which could be optimised by multidisciplinary collaborations addressing environmental factors and workflows in the ED. Equipping ED physicians and nurses with the necessary knowledge and skills is important to increase competency and confidence in managing patients attending the ED at the end of their lives.

Effect of critical shoulder angle, glenoid lateralization, and humeral inclination on range of movement in reverse shoulder arthroplasty.

OBJECTIVES: To date, no study has considered the impact of acromial morphology on shoulder range of movement (ROM). The purpose of our study was to evaluate the effects of lateralization of the centre of rotation (COR) and neck-shaft angle (NSA) on shoulder ROM after reverse shoulder arthroplasty (RSA) in patients with different scapular morphologies. METHODS: 3D computer models were constructed from CT scans of 12 patients with a critical shoulder angle (CSA) of 25°, 30°, 35°, and 40°. For each model, shoulder ROM was evaluated at a NSA of 135° and 145°, and lateralization of 0 mm, 5 mm, and 10 mm for seven standardized movements: glenohumeral abduction, adduction, forward flexion, extension, internal rotation with the arm at 90° of abduction, as well as external rotation with the arm at 10° and 90° of abduction. RESULTS: CSA did not seem to influence ROM in any of the models, but greater lateralization achieved greater ROM for all movements in all configurations. Internal and external rotation at 90° of abduction were impossible in most configurations, except in models with a CSA of 25°. CONCLUSION: Postoperative ROM following RSA depends on multiple patient and surgical factors. This study, based on computer simulation, suggests that CSA has no influence on ROM after RSA, while lateralization increases ROM in all configurations. Furthermore, increasing subacromial space is important to grant sufficient rotation at 90° of abduction. In summary, increased lateralization of the COR and increased subacromial space improve ROM in all CSA configurations.Cite this article: A. Lädermann, E. Tay, P. Collin, S. Piotton, C-H Chiu, A. Michelet, C. Charbonnier. Effect of critical shoulder angle, glenoid lateralization, and humeral inclination on range of movement in reverse shoulder arthroplasty. Bone Joint Res 2019;8:378-386. DOI: 10.1302/2046-3758.88.BJR-2018-0293.R1.

An orthopaedic surgeon's guide to ultrasound imaging of the healthy, pathological and postoperative shoulder.

Ultrasound (US) imaging is an efficient, easy to use and inexpensive tool allowing for facilitated diagnosis and management of the painful shoulder. It remains primarily used by radiologists and rheumatologists, despite having shown excellent diagnostic accuracy when used by different medical specialities in their office-based consultation. It also has advantages over other imaging modalities in the evaluation of the postoperative shoulder for rotator cuff integrity and correct anchor and suture placement, as well as rotator cuff analysis following arthroplasty. Integration of US imaging into the orthopaedic surgeon's toolbox can be aided by a basic understanding of US principles, accompanied by a guide outlining basic techniques for evaluation of the healthy, pathological and postoperative shoulder as well as US-guided treatment possibilities.

Hip fractures in the elderly: operative versus nonoperative management.

INTRODUCTION: Hip fractures are common in the elderly. Published studies have not shown significant differences in mortality rates between hip fracture patients who were managed nonoperatively and operatively. This retrospective study looked at 340 patients with hip fractures who were admitted to a local hospital over one year, and compared the long-term mortality between those treated operatively and nonoperatively. METHODS: All patients with hip fractures were identified retrospectively from the hospital's hip registry. Mortality data was collected through nationwide electronic medical records and telephone interviews. RESULTS: Overall mortality rates at one (14.4%) and two years (24.4%) were comparable to those of other studies. Hip fracture patients who were treated nonoperatively had a higher risk of mortality at both one (29.8%) and two years (45.6%) after fracture (p < 0.05). Their risk of mortality was four times higher at one year and three times higher at two years after fracture than the operative group. Patients with a higher American Society of Anesthesiologists (ASA) grade did not show an increased risk in mortality compared to patients with a lower ASA grade at both one year (p = 0.072) and two years (p = 0.360) after fracture. CONCLUSION: Elderly patients with hip fractures should be managed surgically and counselled regarding the increased risk of mortality if treated nonoperatively.

Osteochondral lesions of the talus.

Osteochondral lesions of the talus can present as a late complication of ankle injuries. As the talus is largely covered by articular cartilage, it has a limited ability for repair. Early and accurate diagnosis is important as talar integrity is required for optimal function of the ankle. The common presentation is chronic ankle pain with a history of ankle trauma. Conservative treatment involving a period of casting and non-weight-bearing is recommended for acute, non-displaced osteochondral lesions. Surgical management is recommended for unstable lesions or failed conservative management.