Fractures of the femoral neck in Australian Aboriginals and Torres Strait Islanders.

The objective was to study patients of Aboriginal and Torres Strait Islander origin who were admitted to Cairns Base Hospital with the diagnosis of femoral neck fracture. An analysis of all 232 admissions with this diagnosis between November 1997 and July 2000 was carried out. Information was gathered from data accumulated on the Clinical Pathways database; other local data was also considered. Patients registered as being of Aboriginal and Torres Strait Islander origin have a lower incidence of these fractures than might be expected on an overall population basis, but similar rates on age-standardised data. The female age profile is substantially older than the female non-indigenous osteoporotic fracture group. Indigenous females develop osteoporotic type fractures of the femoral neck at a later age than do non-indigenous females. This may reflect a genetic difference in bone mineral density or a healthy lifestyle in earlier days. Further research is suggested.

Caring about carepaths.

This short paper describes an experiment in the use of clinical pathways for orthopaedic patients at Cairns Base Hospital. We rapidly found they improved the management of cost and quality, and that there were many beneficial side-effects. Our approach was subsequently adopted in other departments. Unfortunately, external support for further developments has not been forthcoming and we argue that this may be an unwise move.

Variance analysis in clinical pathways for total hip and knee joint arthroplasty.

Clinical pathways are being increasingly used for daily patient care. The pathways consist of a sequence of critical treatment events matched to the patient's recovery. Variance analysis identifies deviations from the pathway and can be used for quality improvement and clinical audit. The aim of this study is to analyse the variances from clinical pathways in two common elective orthopaedic operations. A prospective variance analysis was performed from the clinical pathways of all patients undergoing total hip and total knee arthroplasty over a 12 month period. Variances were categorised according to their source and then further divided into serious and non-serious variances. A total of 65 patients underwent total knee replacement during the study. Eleven serious variances were recorded in eight of these patients (12.3%) with a surprisingly high number of cardiac events. A total of 52 patients underwent total hip replacement with nine serious variances recorded in seven of these patients (13.5%). Clinical pathways can be used as a means of incorporating evidence-based medicine into clinical practice. Variance analysis of the pathways can be utilised as a process of quality control and to improve patient outcomes. Serious variances within this study were higher than anticipated.

Respiratory dysfunction in Parkinson's disease.

The respiratory picture in the patient with parkinsonism may be described as one in which there is a stiff thorax which resists rapid movement, assumes a resting state of overexpansion, and exhibits poor coordination of repetitive function. In consequence there is progressive limitation in the capacity to ventilate. Respiratory care becomes important when the patient becomes sedentary.

Ewing's tumour. A study of behaviour and treatment in forty-seven cases.

Forty-seven histologically confirmed cases of Ewing's tumour are reported, with typical age, sex and skeletal distributions. The disease-free survival curves are like those for osteosarcoma of corresponding types of bone, but with higher mortality. The two-year disease-free survival rates were 24 percent for tumours of long bones and 5 per cent for those of other bones. Osseous metastases were most frequent, although the lung was the commonest single site involved. There were secondary deposits in lymph nodes in nine patients, possibly also in four more with mediastinal enlargement. Although initially radiosensitive, one-third of tumours recurred locally, almost always with the appearance of metastases. Neither whole bone irradiation nor high dosage alone ensures complete control of the primary tumour, and it is suggested that recently reported improved results of treatment should be attributed to adjuvant multi-drug chemotherapy. Inadequate control of the primary tumour diminishes the chance of survival and for some sites radical operation merits reconsideration.