Orthogeriatric care pathway: a prospective survey of impact on length of stay, mortality and institutionalisation.

INTRODUCTION: Care pathways for elderly hip fracture patients are increasingly implemented but there has been only limited evaluation of their use. Our objective was to investigate the impact of such a care pathway on the use of healthcare resources and on patients' outcomes. MATERIALS AND METHODS: The prospective survey covered 493 hip fracture patients 65 years of age or older that were treated either before "Usual Care = (UC)" or after "Co-Managed-Care = (CMC)" implementation of the care pathway. Primary outcome was length of stay (LoS). Secondary outcomes were 1-year mortality and change in residential status from prefracture baseline to 1-year after surgery. Data were analysed by descriptive and interferential statistics and adjustment for baseline differences amongst the two patient groups was done. RESULTS: Patients in the CMC sample had more preexisting comorbidities (CCI 2.5 versus 2.1). Prior to the fracture, a larger proportion amongst them needed help in ADL (49 versus 26%), and they were more likely to reside in a nursing home (36 versus 29%). Prefracture mobility status was equal in both samples. In the CMC sample LoS was significantly shorter (LoS 8.6 versus 11.3 days, p < 0.01) and patients were less likely to experience a complication (59 vs 73%, p < 0.01) while being in the hospital. There was no significant difference in 1-year mortality or in change of residential status. CONCLUSIONS: A care pathway for elderly hip fracture patients allowed decreased LoS without affecting mortality or change of residential status 1 year after fracture compared to prefracture baseline.

Activation and inhibition of bimanual movements in school-aged children.

The development of motor activation and inhibition was compared in 6-to-12 year-olds. Children had to initiate or stop the externally paced movements of one hand, while maintaining that of the other hand. The time needed to perform the switching task (RT) and the spatio-temporal variables show different age-related evolutions depending on the coordination pattern (in- or anti-phase) and the type of transition (activation, selective inhibition, non selective inhibition) required. In the anti-phase mode, activation perturbs the younger subjects' responses while temporal and spatial stabilities transiently decrease around 9 years when activating in the in-phase mode. Aged-related changes differed between inhibition and activation in the anti-phase mode, suggesting either the involvement of distinct neural networks or the existence of a single network that is reorganized. In contrast, stopping or adding one hand in the in-phase mode shows similar aged-related improvement. We suggest that selectively stopping or activating one arm during symmetrical coordination rely on the two faces of a common processing in which activation could be the release of inhibition.

Shock wave therapy as an innovative technology in skeletal disorders: study on transmembrane current in stimulated osteoblast-like cells.

Extracorporeal shock wave treatment (ESWT) is successfully used in various musculoskeletal disorders and pathologies. Despite the increasing use of this kind of therapy, some aspects of its mechanism of action are still unclear. In vitro bone cell behavior under ESWT were previously investigated by the present author and MG63 osteoblast-like cells showed an enhancement in proliferation and in the osteoblast differentiation after therapy with a low-energy flux density. The aim of the present study was to evaluate the effect of ESWT on the permeabilization of cell membrane. We characterized physiological changes in the MG63 associated with ESWT generated by an ESW device and patch clamp recording was performed to study ion channels. Experiments were carried out using the whole-cell recording configuration of the patch-clamp technique and the ionic current measurements were performed on cell samples of ESW treated and control groups. The patch-clamp technique showed the effect of ESWT on the amplitude of transmembrane currents. The treatment with ESW enhanced the transmembrane current as well the voltage dependence of Ca-activated and K channels that mediate these currents: the differences between treated cells and control at 80mV were over 1000 pA (p<0.05). These modifications of ion channels activity positively influence cell proliferation (MTT test, p<0.0001) without interfering with the normal synthesis activity of stimulated osteoblasts.

[Pain management in surgical wards. Quality and solutions for improvement in the early postoperative period]. / Schmerzmanagement auf chirurgischen Bettenstationen. Qualität und Optimierbarkeit frühpostoperativer Schmerzbetreuung.

INTRODUCTION: Following guidelines pain levels should not exceed a score of 3 on the visual analog scale (VAS 1-10). We were interested in the actual surgical pain management of the postoperative period and the potential influences of a nurse-controlled intravenous morphine administration (NCA) on its quality. METHODS: Interventional study: interview of patients and nursing staff and examination of records concerning pain treatment following surgery. RESULTS: The interviews were conducted with 110 patients before and 125 patients after the intervention program. Before the intervention, one-half of the patients noted that they were never asked about their pain intensity within the first 24 h after surgery. Only 42% of the records showed at least one VAS documentation. Every fourth individual experienced a pain intensity > 3 without having received a supplementary pain medication. Following the morphine intervention program, documentation of pain scores increased significantly (72%; p < 0.0001) and more patients were familiar with the VAS (64% vs 46%; p < 0.0004). Median maximum as well as actual pain at the time of the interview decreased by one point (VAS). The percentage of patients whose supplementary pain prescription was totally used showed a significant increase (p = 0.035). Following morphine administration, no single individual complained about an undue waiting time in comparison to 15% of patients previously. Even though the morphine intervention project caused more work for the nursing staff, 75% of the personnel were convinced that the procedure was worth this investment. CONCLUSION: This data revealed a relevant deficiency of surgical pain management. Already basic instructions on pain management can significantly improve this treatment. Assigning additional authority to the nursing staff, such as a nurse-based intravenous opioid administration, can significantly raise the motivation of the personnel as well as the satisfaction of the patients involved.

[Optimizing postoperative pain therapy on acute surgical wards]. / Optimierung der postoperativen Schmerztherapie auf chirurgischen Akutstationen.

UNLABELLED: The aim of this interdisciplinary project was the improvement of postoperative pain management on surgery wards of an university hospital: Pain medication should be enlarged with the possibility to administer an opium-medication i.v. (non only s.c.) when needed (VAS > 3), which has been tested on two wards. The study shows the resulting changes of the intervention for patients and nurses. For recording, there has been patient questionnaires and document analysis before and after the new possibility to administer medication, and a nurses opinion survey. RESULTS: 110 resp. 125 patients and 39 nurses have been interviewed. Although there were only few patients (8%) during the second registration who did get the morphine i.v., there were clear tendencies: More patients have been asked about their pain-intensity and recognized the visual analog scale (VAS) (p = 0.0004) and less patients found, that they had to wait for a pain-medicament too long. There was a significant reduction of maximal pain-scores (p = 0.02) and also a significant improvement of nursing supplementary pain medication (p = 0.035). Actual pain-scores and use of basis-analgesia were slightly reduced resp. improved with the intervention. Overall patient-satisfaction regarding the treatment of their pain was high in both groups (> 95%). Nurses found (88%), that the new possibility to administer the morphine i.v. when needed, was good, even though this intervention and the controls of the vital signs requires more work. They said, that very often, it is worth the extra work, and for 31% of them, the focus on pain became more important through the intervention. CONCLUSIONS: The enlargement to administer pain medication and asking/registering pain intensity regularly, created more sensitivity for the patient's pain-experience among nurses, and this lead to better use of the prescribed pain medication and to better pain management overall. Further quality-improvement in post-operative pain relief seems possible by continuing on that way in the future.