The global approach to rehabilitation following an osteoporotic fragility fracture: A review of the rehabilitation working group of the International Osteoporosis Foundation (IOF) committee of scientific advisors.

PURPOSE: To conduct a review of the current state of the evidence for rehabilitation strategies post-fragility fracture. METHODS: Narrative review conducted by the Rehabilitation Working Group of the International Osteoporosis Foundation Committee of Scientific Advisors characterizing the range of rehabilitation modalities instrumental for the management of fragility fractures. RESULTS: Multi-modal exercise post-fragility fracture to the spine and hip is strongly recommended to reduce pain, improve physical function, and improve quality of life. Outpatient physiotherapy post-hip fracture has a stronger evidence base than outpatient physiotherapy post-vertebral fracture. Appropriate nutritional care after fragility fracture provides a large range of improvement in morbidity and mortality. Education increases understanding of osteoporosis which in turn increases utilization of other rehabilitation services. Education may improve other health outcomes such as pain and increase a patient's ability for self-advocacy. CONCLUSION: Rehabilitation interventions are inter-reliant, and research investigating the interaction of exercise, nutrition, and other multi-modal therapies may increase the relevance of rehabilitation research to clinical care.

Impact of nutrition on muscle mass, strength, and performance in older adults.

Muscle strength plays an important role in determining risk for falls, which result in fractures and other injuries. While bone loss has long been recognized as an inevitable consequence of aging, sarcopenia-the gradual loss of skeletal muscle mass and strength that occurs with advancing age-has recently received increased attention. A review of the literature was undertaken to identify nutritional factors that contribute to loss of muscle mass. The role of protein, acid-base balance, vitamin D/calcium, and other minor nutrients like B vitamins was reviewed. Muscle wasting is a multifactorial process involving intrinsic and extrinsic alterations. A loss of fast twitch fibers, glycation of proteins, and insulin resistance may play an important role in the loss of muscle strength and development of sarcopenia. Protein intake plays an integral part in muscle health and an intake of 1.0-1.2 g/kg of body weight per day is probably optimal for older adults. There is a moderate [corrected] relationship between vitamin D status and muscle strength. Chronic ingestion of acid-producing diets appears to have a negative impact on muscle performance, and decreases in vitamin B12 and folic acid intake may also impair muscle function through their action on homocysteine. An adequate nutritional intake and an optimal dietary acid-base balance are important elements of any strategy to preserve muscle mass and strength during aging.

IOF position statement: vitamin D recommendations for older adults.

This position paper of the International Osteoporosis Foundation makes recommendations for vitamin D nutrition in elderly men and women from an evidence-based perspective.

Global vitamin D status and determinants of hypovitaminosis D.

UNLABELLED: This review describes the vitamin D status in different regions of the world with the objective of understanding the scope of hypovitaminosis D and the factors related to its prevalence that may contribute to the pathogenesis of osteoporosis and fragility fractures. INTRODUCTION: Vitamin D status has been linked to the pathogenesis of hip fractures as well as other skeletal and non-skeletal disorders. The purpose of this review is to provide a global perspective of vitamin D status across different regions of the world and to identify the common and significant determinants of hypovitaminosis D. METHODS: Six regions of the world were reviewed-Asia, Europe, Middle East and Africa, Latin America, North America, and Oceania-through a survey of published literature. RESULTS: The definition of vitamin D insufficiency and deficiency, as well as assay methodology for 25-hydroxyvitamin D or 25(OH)D, vary between studies. However, serum 25(OH)D levels below 75 nmol/L are prevalent in every region studied whilst levels below 25 nmol/L are most common in regions such as South Asia and the Middle East. Older age, female sex, higher latitude, winter season, darker skin pigmentation, less sunlight exposure, dietary habits, and absence of vitamin D fortification are the main factors that are significantly associated with lower 25(OH)D levels. CONCLUSION: Reports from across the world indicate that hypovitaminosis D is widespread and is re-emerging as a major health problem globally.

The prevalence of radiographic vertebral fractures in Latin American countries: the Latin American Vertebral Osteoporosis Study (LAVOS).

UNLABELLED: In the first population-based study of vertebral fractures in Latin America, we found a 11.18 (95% CI 9.23-13.4) prevalence of radiographically ascertained vertebral fractures in a random sample of 1,922 women from cities within five different countries. These figures are similar to findings from studies in Beijing, China, some regions of Europe, and slightly lower than those found in the USA using the same standardized methodology. INTRODUCTION: We report the first study of radiographic vertebral fractures in Latin America. METHODS: An age-stratified random sample of 1,922 women aged 50 years and older from Argentina, Brazil, Colombia, Mexico, and Puerto Rico were included. In all cases a standardized questionnaire and lateral X-rays of the lumbar and thoracic spine were obtained after informed consent. RESULTS: A standardized prevalence of 11.18 (95% CI 9.23-13.4) was found. The prevalence was similar in all five countries, increasing from 6.9% (95% CI 4.6-9.1) in women aged 50-59 years to 27.8% (95% CI 23.1-32.4) in those 80 years and older (p for trend < 0.001). Among different risk factors, self-reported height loss OR = 1.63 (95% CI: 1.18-2.25), and previous history of fracture OR = 1.52 (95% CI: 1.14-2.03) were significantly (p < 0.003 and p < 0.04 respectably) associated with the presence of radiographic vertebral fractures in the multivariate analysis. In the bivariate analyses HRT was associated with a 35% lower risk OR = 0.65 (95% CI: 0.46-0.93) and physical activity with a 27% lower risk of having a vertebral fracture OR = 0.73 (95% CI: 0.55-0.98), but were not statistically significant in multivariate analyses CONCLUSION: We conclude that radiographically ascertained vertebral fractures are common in Latin America. Health authorities in the region should be aware and consider implementing measures to prevent vertebral fractures.

Estudio del síndrome de 'Burnout' en cirujanos pediatras españoles / Study of the Burnout syndrome in spanish pediatric surgeons

Fundamento. El síndrome de 'burnout' es un estado de decaimiento físico, emocional y mental, caracterizado por cansancio, sentimiento de desamparo, desesperanza, vacío emocional, y por el desarrollo de una serie de actitudes negativas hacia el trabajo, la vida y la gente. Se genera específicamente en aquellas profesiones que tienen una relación constante y directa con otras personas manteniendo una relación de ayuda. Hipótesis. El síndrome 'burnout' puede estar afectando al colectivo de cirujanos pediatras españoles puesto que la profesión y la especialidad presentan factores de riesgo. Objetivos. Determinar la prevalencia del síndrome y la de sus componentes. Material y métodos. Estudio descriptivo realizado con cirujanos socios de la S.E.C.P. A ellos se les envió una encuesta, entre noviembre de 2000 y enero de 2001. La encuesta consta de tres partes: una primera que versa sobre datos sociodemográficos, la segunda la constituye el Maslach Burnout Inventory (MBI) que cuantifica el síndrome, y la tercera la forma el cuestionario 'Font Roja' que mide la satisfacción con el trabajo. El MBI consta de 22 apartados y el Font Roja de 24. Respectivamente, exploran los componentes del síndrome y los distintos factores de la satisfacción de los profesionales con el trabajo. A cada opción se le asigna un valor de 0 a 4 en la escala de Likert. Se considera 'burnout' cuando se puntúa alto en cansancio emocional y despersonalización y bajo en realización personal. Resultados. Se recibieron un total de 85 encuestas (tasa de respuesta: 45,5 por ciento). Varones: 81,2 por ciento. Edad media: 49,8. La afectación por el síndrome de 'burnout' se situó en niveles medios (43,88 ñ 5,59), teniendo mayor relevancia los factores: cansancio emocional y despersonalización. El 5,9 por ciento de los encuestados presenta un alto nivel de 'burnout', siendo mediano en el 75,3 por ciento y bajo en el 18,8 por ciento. En el 62,3 por ciento existe cansancio emocional-, en el_ 80,0 por ciento despersonalización y en sólo el 17,7 por ciento falta de realización personal. El grado de satisfacción laboral está por encima de la media (70,46 ñ 11,23). Los factores que promueven un mayor nivel de satisfacción son: satisfacción laboral intrínseca, relación social en el trabajo y adecuación para la tarea. Conclusiones. Existe un grado moderado de síndrome 'burnout' con un grado medio de satisfacción laboral. Aunque contradictoria esta circunstancia es posible, pues se trata de profesionales satisfechos con su profesión (probable elección vocacional) que a la vez viven unas condiciones de trabajo difíciles que les generan una situación de desgaste profesional importante (AU)

[Study of "burnout" syndrome in Spanish pediatric surgeons]. / Estudio del síndrome de "Burnout" en cirujanos pediatras españoles.

BACKGROUND: The "burnout syndrome" is characterized by emotional exhaustion, despersonalization and decrease of the feeling of personal accomplishment, above all, in the field of professional achievement. It appears to be frequent in the helping professions and the human services workers, and in its origin labour factors seem to intervent. HYPOTHESIS: The "burnout syndrome" can be affecting to the collective of spanish pediatric surgeons since the profession presents risk factors. OBJECTIVES: The purpose of this study was to evaluate the prevalence of "burnout" and level of work satisfaction among spanish pediatric surgeons, and related factors. METHODS. DESIGN: [corrected] Crossover descriptive study. SUBJECTS: Random sample of members of the Spanish Society of Pediatric Surgery. MEASUREMENTS: A survey for self-administration with social and demographic variables, a spanish version of the Maslach Bournout Inventory (MBI), and the Font Roja questionnaire was used. The MBI consists of 22 items and the Font Roja of 24. Respectively, they explore the components of the syndrome and the factors of satisfaction with the work. It is considered "burnout" when it is scoring high in emotional exhaustion and despersonalization and low in personal achievement. RESULTS: 85 people responded (response rate: 45.5%. Male: 81.2%. Mean age: 49.8 years. Burnout scores were in the average range (43.88 +/- 5.59). The emotional exhaustion subscale of the MBI averaged 19.16 +/- 5.35, with 75.3% in the moderate range. The despersonalization score averaged 11.79 +/- 3.68, with 45.9% of respondents scoring in the high range. The personal achievement subscore averaged 12.93 +/- 3.68, with 82.4% scoring in the low range. The overall mean satisfaction: 70.46 +/- 11.23. The factors that promote a greater satisfaction level are: intrinsic occupational satisfaction, social relationship in the work and appropriateness for the task. CONCLUSIONS: It exists a moderate level of "burnout syndrome" with a middle level of work satisfaction. Though contradictory this circumstance is possible, since it is considered professional satisfied with their profession (vocational election) that at the same time lives some difficult work conditions that generate a situation of high exhaustion professional.

[Evaluation of thoroughness and legibility of informed consent documents in pediatric surgery]. / Evaluación de la exhaustividad y legibilidad de documentos de consentimiento informado en cirugía pediátrica.

BACKGROUND: The written information that is provided to the patient must gather a series of characteristics, quantitative and qualitative, so that fulfill the ethical criteria that govern the theory of the Informed Consent. AIMS: To evaluated the degree of exhaustivity and readability of a series of Informed Consents forms in Pediatric Surgery units. MATERIAL AND METHODS: 1. Forms: We evaluated 118 consent forms submitted by 17 pediatric surgery units. 2. Exhaustivity: The studied variables have been: name of the hospital, name of the patient, name of the physician, date, description of the procedure, objectives, risks mention, personalized risks, possibility of recovery, benefits of the procedure, alternatives, possibility from withdrawing the assent, arrangement to widen the information, comprehension of the document, express assent and signatures. All the variables are dichotomics, being collected your presence or absence. 3. Readability: Each document has been introduced in the program "Corel Word Perfect". It was applied to the usefulness "Grammatik" and were collected: number of words, number of phrases, Flesch/Kincaid index, Orational Complexity index and LEGIN index. RESULTS: 1. Exhaustivity: The paragraphs presence in the different forms by order of frequency were: physician signature (100%), express assent (100%), signatures (100%), date (98%), name of the patient (97%), comprehension of the forms (97%), name of the physician (94%), risks mention (92%), name of the hospital (85%), description of the procedure (78%), possibility from withdrawing the assent (70%), personalized risks (67%), arrangement to widen information (43%), to explain alternatives (41%), objectives of the procedure (36%), benefits (36%), and possibility of the recovery (16%). 2. Readability: 11.1% of the forms fulfills the Flesch index, 27.9% the Orational Complexity index, and 22.1% LEGIN index. CONCLUSIONS: Most of the documents offer sufficient quantity of information with respect to the formal aspect and the risks an less with respect to the benefits. This seems to indicate your defensive character. Equally, they are difficult to reading and by difficult to understanding.

Geographic differences in bone mineral density of Mexican women.

The aim of this study was to generate standard curves for normal spinal and femoral neck bone mineral density (BMD) in Mexican women using dual-energy X-ray absorptiometry (DXA), to analyze geographic differences and to compare these with 'Hispanic' reference data to determine its applicability. This was a cross-sectional study of 4460 urban, clinically normal, Mexican women, aged 20-90 years, from 10 different cities in Mexico (5 in the north, 4 in the center and 1 in the southeast) with densitometry centers. Women with suspected medical conditions or who had used drugs affecting bone metabolism, were excluded. Lumbar spine BMD was significantly higher (1.089 +/- 0.18 g/cm2) in women from the northern part of Mexico, with intermediate values in the center (1.065 +/- 0.17 g/cm2) and lower values (1.013 +/- 0.19 g/cm2) in the southeast (p < 0.0001). Similarly, femoral neck BMD was significantly higher in women from the north (0.895 +/- 0.14 g/cm2), intermediate in the center (0.864 +/- 0.14 g/cm2) and lower (0.844 +/- 0.14 g/cm ) in the southeast part of Mexico (p < 0.0001). Northern Mexican women tend to be taller and heavier than women from the center and, even more, than those from the southeast of Mexico (p < 0.0001). However, these differences in BMD remained significant after adjustment for weight (p < 0.0001). A significant loss (p < 0.0001) in BMD was observed from 40 to 69 years of age at the lumbar spine and up to the eighth decade at the femoral neck. Higher and lower lumbar spine values, as compared with the 'Hispanic' population, were observed in Mexican mestizo women from the northern and southeastern regions, respectively. In conclusion, there are geographic differences in weight and height of Mexican women, and in BMD despite adjustment for weight.

Demanda urgente en cirugía infantil. Estudio de utilización inapropiada / Appropriateness utilization of a pediatric surgery emergency service

Introducción. Diversos estudios han demostrado que, entre uno y dos tercios de los casos, la demanda urgente de atención es considerada inapropiada. Esta situación conlleva un aumento de los costes sanitarios y supone para el usuario una atención médica fragmentada. En el ámbito de la especialidad de Cirugía Pediátrica no hemos encontrado ningún trabajo realizado a tal efecto. Objetivos. 1. Cuantificar el grado de inadecuación de la demanda urgente en Cirugía Pediátrica. 2. Conocer los factores asociados a la demanda inadecuada. Pacientes y métodos. Diseño: estudio de observación transversal. Ambito: pacientes visitados por cirujano pediatra en Servicio de Urgencias Pediátrica* de un hospital universitario. Muestra: aleatoria (a: 0,05; precisión: 0,05) de los pacientes atendidos durante 1998. Variables de estudio: dependiente: inadecuación; independientes: edad, género, distancia desde el domicilio, diagnóstico, nivel de estudios de los padres, asistencia previa y si acude por iniciativa propia. Mediante entrevista: motivos que inducen a la demanda. Unidad de análisis: se consideró urgencia hospitalaria, siguiendo los criterios de la OMS, cuando se trata de emergencia vital o cuando existe necesidad de usar medios diagnósticos o terapéuticos no disponibles en un nivel de atención inferior. Análisis: el tratamiento estadístico consistió en un análisis de frecuencias relativas, prueba x2 para comparar frecuencias y 't' de Student para comparar medias. Resultados. De los 2.226 pacientes atendidos en urgencias, se han estudiado 441 (edad: 5,54 años; 63 por ciento varones). Los diagnósticos más frecuentes han sido: heridas y pequeños traumatismos (39,7 por ciento), dolor abdominal (22,2 por ciento), quemaduras (3,6 por ciento), apendicitis (3,2 por ciento) y hernias (3,2 por ciento). El 86,2 por ciento acudieron por iniciativa propia. La proximidad (19,9 por ciento), la alarma por los síntomas (13,1 °Io) y el desconocimiento de la existencia de otros niveles de atención (10 por ciento) han sido las causas argüidas por los padres para la demanda de atención. El 63,9 por ciento de las visitas se consideraron inapropiadas. Se ha encontrado relación estadística entre uso inapropiado y edad superior a un año (p < 0,02), distancia domicilio-hospital (p < 0,003), acudir por iniciativa propia (p < 0,001) y expectativa de los padres (p < 0,02). No existe relación con el género o el nivel de estudios de los padres. Conclusiones. En los Servicios de Urgencias existe un elevado número de consultas inadecuadas. La accesibilidad, la disponibilidad de medios, la rapidez de la atención .y quién toma la decisión de acudir son variables predictoras de la sobreutilización (AU)

[Demand of emergency pediatric surgery. Study of inappropriate utilization]. / Demanda urgente en cirugía infantil. Estudio de utilización inapropiada.

BACKGROUND: Several studies have demonstrated that, between 30-60% of the cases, the urgent attention demand is considered inappropriate. This situation causes an increase in the sanitary costs and supposes for the patient a partial medical care. In the area of the Pediatric Surgery we have not found any work accomplished to such effect. DESIGN: Transverse observational study. SETTING: Emergency Service of a University Hospital. PATIENTS: a sample random (alpha: 0.05; precision: 0.05) of the patients attended during 1998. MAIN OUTCOME MEASURES: Dependent: appropriateness. Independent: age, gender, proximity, diagnostic, studies of the parents, previous assistance, if attends by own initiative and motives that induce to demand. It was considered hospital emergency, continuing the criteria of the WHO, when it is considered vital emergency or when there is using of therapeutic or diagnostic means nor available in an primary level of health care. The statistic treatment consisted of a relative frequencies analysis, test x2 and t Student. RESULTS: Of 2,226 cases attended in emergency service, they have 441 reviewed (age: 5.54 years; 63% male). The most frequent diagnoses have been: injuries and small traumatisms (39.7%), abdominal pain (22.2%), burns (3.6%), appendicitis (3.2%) and hernias (3.2%); 86.2% attended by own initiative. The proximity (19.9%), the alarm by the symptoms (13.1%) and the ignorance of the existence of other level of health care (10%) have been the causes by the parents for attention demand. The 63.9% of the visits were considered inappropriate. It has been found relationship between inappropriate use and age (p < 0.02), proximity (p < 0.003), to attend by own initiative (p < 0.001), and expectation of the parents (p < 0.02). It does not exist relationship to the gender or the studies level of the parents. CONCLUSIONS: These data suggest that in the Emergency Services exists a high appropriateness. The accessibility, the availability of means, the rapidity of the attention and who takes the decision of attending are variable associated to the appropriateness.

[The use of resources. Unnecessary stays in pediatric surgical services]. / Utilización de recursos. Estancias innecesarias en un servicio de cirugía infantil.

BACKGROUND: There is wide-spread consensus that a part of the use of hospital resources is inadequate in the sense that the patients receive services that do not provide them with any significant benefits, or that could be more beneficial, or less costly, with a lower care standard. OBJECTIVE: The main aim of this work is to determine the percentage of inadequate stays in a pediatric surgery service and to identify the causes that provoke them. METHOD: It was a concurrent study in pediatric patients entered, at least 24 hours, by different disease for surgery, observation or study. Revising trained applied the pediatric version of the Appropriateness Evaluation Protocol on the medical records of these patients. It has been measured if the stay was appropriated or not, and the cause. RESULTS: The studied patients (279) caused a total of 1,001 stays of those which 373 (37.3%) were deemed to be unnecessary. The diseases with greater number of inappropriate stays were cryptorchidia (97.3%), hernia (88.9%), hypertrophic pyloric stenosis (50%), and soft tissues surgery (43.1%). A 68.2% of the unnecessary stays were responsibility of the hospital-service-surgeon, a 22.6% to the associated environment-familiar, and a 9.2% to the lack of alternative resources to the hospital. CONCLUSIONS: A meaningful proportion by day of hospital stay would be avoided. The unnecessary stays search facilitates the weak points identification on those which to develop improvement actions.