Inter-rater reliability of classification systems of scapular dyskinesis.

Prevalence of scapular dyskinesis varies across records, with overhead athletes being more frequently affected than non-overhead athletes A number of methods have been described to evaluate scapular kinematics and scapular dyskinesis. The "yes/no" and the "4-type" classification systems are widely accepted and diffusely used among orthopaedics and physical therapists. The inter-rater reliability for both the "yes/no" and the "4-type" classification systems may be different. Moreover, differences between physical therapists and orthopaedic surgeons may exist. Seven examiners (2 orthopaedic surgeons and 5 physical therapists) were asked to evaluate a mixed sequence of video recordings of healthy subjects and patients affected by shoulder, scapular or clavicular disorders and to assess scapular dyskinesis using the "yes/no" and the "4-type" classification systems. Cohen's kappa coefficient (κ) and weighted kappa were used to measure inter-rater reliability. Twenty-four subjects were enrolled. In general, the "4- type" system has higher κ values than ''yes/no'' classification system and orthopaedic surgeons achieve higher reliability than physical therapists for both systems. The clinical evaluation of active shoulder movements permits reproducible assessment and classification of scapular dyskinesis, in particular for the "4-type" classification system. The "4-type" classification system can be used to assess and classify scapular dyskinesis, especially among orthopaedic surgeons.

[Treatment-process analysis of orthopaedic trauma surgery patients at an outpatient setting in a university hospital]. / Prozessanalyse der ambulanten Behandlung unfallchirurgischer Patienten an einer universitären Poliklinik.

BACKGROUND: The cost pressure in a competitive environment forces hospitals and physicians to optimize clinical processes. In order to secure competitive advantages, a continuous evaluation of relevant processes is necessary. OBJECTIVE: Administrative and medical processes in a university outpatient department for orthopedics and traumatology were evaluated using the lean method in order to reduce patient waiting times. MATERIAL AND METHODS: Over a period of 2 weeks all patients who were treated in the department for orthopedic and trauma surgery on an outpatient basis were included in the assessment of the process. Personnel in the policlinic were prepared and trained to record times for appointments made by telephone, arrival time at the hospital, first contact, administrative procedure, first contact with the doctor, length of stay in the radiology and anesthesiology departments and completion of treatment. In addition, potential inefficiencies were identified through patient flow analysis and personal interviews with personnel in the administration and outpatient departments as well as residents and senior physicians. RESULTS: A total of 126 patients were enrolled in the study. The average length of stay of patients in the outpatient clinic was 144 min (range 30-371 min). A necessary imaging examination increased the length of stay by an average of 53 min and a necessary premedication by an average of 78 min compared to patients with no further consultations. CONCLUSION: By analyzing the pathways and times of patients, various reasons for waiting times in the university outpatient clinic could be shown. This study shows that a structured application of lean management and a dedicated analysis create added value for patients by reducing waiting times.

[Challenges of discharge management in geriatric traumatology : Example of an integrated orthogeriatric service]. / Herausforderungen des Entlassmanagements in der Alterstraumatologie : Beispiel einer integrierten traumatologisch-geriatrischen Komplexbehandlung.

BACKGROUND: Geriatric patients are currently responsible for almost one third of all emergency hospital admissions. An increase of 50% is expected in the next decade. This age redistribution poses new challenges for inpatient care and discharge management. The requirements of an orthopedic trauma surgery clinic in the care of this patient group can be clarified with the help of this first collaboratively created geriatric orthopedic trauma surgery complex treatment unit of a university hospital. OBJECTIVE: What influence do age and delirium have on discharge management, length of inpatient stay and discharge destination in a geriatric cohort? MATERIAL AND METHODS: All patients who received inpatient treatment as part of the orthopedic trauma surgery geriatric complex treatment (GKB) between May 2017 and December 2019 were evaluated. An analysis of the demographics, length of inpatient stay, discharge destinations and evaluation of the Barthel index collected on admission and discharge, the mini-mental state examination (MMSE) and the geriatric depression scale (GDS) were carried out. RESULTS: Out of 312 patients, 110 men and 193 women with a median age of 81 years, 77 patients (24.6%) showed delirium when enrolled in the GKB and 39 (12.5%) dementia. Older patients presented more often with delirium than younger people (p = 0.013), especially those aged 70-79 years (p = 0.037). Dementia patients suffered more frequently from postoperative delirium (p < 0.01). The mean hospital stay was 17.79 days (±4.6 days). The GKB was regularly completed in 60.7% of all cases and 39.3% patients dropped out early. Patients with delirium were discharged significantly less often into their own home but into short-term care or nursing homes (p = 0.038). A general correlation between delirium development and the discharge destination was noticeable (p = 0.004). CONCLUSION: Patients with dementia are more likely to develop delirium postoperatively, which leads to an increase in the length of inpatient stay, an increase in treatment costs and more work for the discharge management team. In addition, the discharge to the patients' home is impaired by delirium, which means that the growing need for places in short-term care and nursing homes also creates socioeconomic burdens.

[Process optimization in the operating room area]. / Prozessoptimierung im operativen Bereich.

BACKGROUND: The operating room (OR) accounts for the highest fraction of hospital costs and also has the largest proportion of revenue. Classical goals of optimizing OR efficiency are to increase the quality of treatment and economic success. As the reduction of qualified personnel as the largest cost factor was favored for many years, nowadays a shortage of nursing personnel is threatening the surgery departments in many German hospitals. OBJECTIVE: Which improvements are possible while the OR already suffers from restrictions? What are critical resources, what are the critical burdens and how can they be optimized? MATERIAL AND METHODS: An analysis of the OR organization of an orthopedic and traumatology department with reduced OR capacity due to a shortage of OR and anesthesia nursing personnel was performed. This was followed by the evaluation of possible alterations with the corresponding advantages and disadvantages. After selection and implementation, the qualitative and quantitative differences were examined before and after the alterations. RESULTS: Multifaceted problem areas could be identified. The establishment of a fast track OR with concentration of additional resources on many fast points in an OR instead of on a few complex cases was selected and implemented. The installation of a holding area for patients waiting for surgery eliminated transportation delays almost entirely. Alterations in the OR planning and capacity distribution reduced nocturnal operating times. Despite reduction of the OR capacity both the number of operations performed and the incision to suture times could be increased. CONCLUSION: Optimization of the processes in the OR is possible and necessary, despite the lack of personnel. Even only a few structural changes can eliminate bottlenecks, resulting in qualitative and quantitative improvements.

[Medical service providers as bottleneck in orthopedics and trauma surgery : Problems and solution strategies in interdisciplinary collaboration]. / Medizinische Dienstleister als Nadelöhr in Orthopädie und Unfallchirurgie : Probleme und Lösungsstrategien in der interdisziplinären Zusammenarbeit.

BACKGROUND: Due to limited financial and human resources, efficient planning of patient flows, operation preparations and perioperative diagnostics are of great importance. In the present study potential problems and solution strategies in the interdisciplinary collaboration between orthopedic surgeons, trauma surgeons and colleagues in anesthesiology and radiology departments are presented. MATERIAL AND METHODS: After implementation of a process management system, the data were collated and the number of patients, the utilization of external departments in the consultation, waiting times and patient adherence to appointments were analyzed. Patient satisfaction was determined using a questionnaire. In addition, the current literature was searched regarding the topic of process optimization and interdisciplinary cooperation. RESULTS: The waiting time for an appointment in the outpatient clinic consultation in orthopedics and trauma at the University Hospital Bonn was between 9.15 and 11.23 days. Of the patients 10-20% from the consultation presented in the premedication outpatient department. Radiological imaging was performed in 22-28% of the cases. Patient satisfaction was recorded using a questionnaire gathering information on medical treatment, organization and infrastructure as well as treatment success. The importance of an efficient and digitally organized cooperation is generally promoted in the literature; however, there is insufficient data on the subject of process organization and economic interdisciplinary cooperation. CONCLUSION: By implementing a process management, deficiencies in the workflow and interdisciplinary collaboration can be identified and optimized in a structured manner. This also improves patient and employee satisfaction and the quality of treatment.

[Influence of the trauma mechanism on cervical spine injuries]. / Einfluss des Unfallmechanismus auf die Verletzungen der Halswirbelsäule.

BACKGROUND: The influence of trauma-related kinematics on the injury pattern of the cervical spine is currently not considered in the available classification systems, only the force vector. Whether the strength of the trauma has an additional influence on the number and complexity of the injuries and whether this can be classified, has not yet been finally investigated. OBJECTIVE: What influence do different kinematics apart from the traumatic force vector have on injuries of the cervical spine? MATERIAL AND METHODS: Based on the AOSpine classification system for the upper and subaxial cervical spine, data from 134 trauma patients from a first level trauma center were retrospectively analyzed. Analogue to the S3 guidelines on polytrauma, patients were assigned to six trauma groups and the injuries were classified on the basis of computed tomography (CT) cross-sectional imaging. RESULTS: A higher trauma energy had a significant impact on the number of cervical spine injuries (p = 0.005). In low velocity accidents C2 was the most frequently injured vertebra (51%; p = 0.022) and high velocity accidents showed more C7 fractures (37%; p = 0.017). Furthermore, upper cervical spine injuries occurred more often in low energy trauma and older female patients (e.g. falling from a standing position). Subaxial cervical spine involvement was found significantly more often in high velocity accidents and younger male patients (p = 0.012). CONCLUSION: Exact knowledge of the trauma mechanism is helpful in the primary treatment of an injured person. Injury patterns can be better estimated and the appropriate diagnostics can be initiated. The results underline the importance of immediate cervical spine immobilization even after minor trauma. In high velocity trauma, patients more often suffer from lower cervical spine injuries, especially C7. Due to the accumulation of multilevel spinal injuries in high velocity trauma, radiographic imaging of the whole spine is advisable.

Erratum to: Three-dimensional thoracoscopic vertebral body replacement at the thoracolumbar junction.

Erratum to:Oper Orthop Traumatol 2018 https://doi.org/10.1007/s00064-018-0559-3 The article was wrongly published under the article type "Review". Please note that the article is an "Original Paper".The publisher apologizes to authors and ….

Three-dimensional thoracoscopic vertebral body replacement at the thoracolumbar junction.

OBJECTIVE: The aim is to stabilize the thoracolumbar spine with a thoracoscopically implanted vertebral body replacement (VBR). To improve intraoperative depth perception and orientation, implantation is performed under three-dimensional (3D) thoracoscopic vision. INDICATIONS: Vertebral burst fractures at the thoracolumbar junction (A4 AOSpine classification), pseudarthrosis, and posttraumatic instability with increasing kyphosis. CONTRAINDICATIONS: Severe pulmonary dysfunctions, pulmonary or thoracic infections, previous thoracic surgery, and pulmonary adhesions. SURGICAL TECHNIQUE: The patient is lying in a right lateral decubitus position. Localization of the fractured vertebra. Minimally invasive transthoracic approach. Perform single lung ventilation and insert the 3D thoracoscope two intercostal spaces above the working portal. Utilization of special binocular glasses for 3D vision of the operation field and secure resection of the fractured vertebra. Measurement of the bony defect and insertion of the expandable cage. Control of correct cage position under fluoroscopy. Insertion of a chest tube and inflate the left lung. POSTOPERATIVE MANAGEMENT: Chestâ€¯× ray Remove chest tube when output is <500 ml/24 h Early mobilization on the ward 6 weeks no weight-bearing >5 kg RESULTS: Between 2012 and 2017, 12 patients received a VBR under 3D thoracoscopic vision. After a mean follow up of 26 months, no cage dislocation was noticed and all patients recovered from the initial back pain. Complications were notable in two cases (17%) with a small pneumothorax after removal of the chest tube and postoperative pneumonia in one patient (8%). All responded to conservative treatment. Revision surgery was not necessary.

[Biological downsizing : Acetabular defect reconstruction in revision total hip arthroplasty]. / Biologisches Downsizing : Azetabuläre Knochendefekte in der Hüftrevisionsendoprothetik.

BACKGROUND: Periacetabular bony defects remain a great challenge in revision total hip arthroplasty. After assessment and classification of the defect and selection of a suitable implant the primary stable fixation and sufficient biological reconstitution of a sustainable bone stock are essential for long term success in acetabular revision surgery. Biological defect reconstruction aims for the down-sizing of periacetabular defects for later revision surgeries. TECHNIQUE: In the field of biological augmentation several methods are currently available. Autologous transplants feature a profound osseointegrative capacity. However, limitations such as volume restrictions and secondary complications at the donor site have to be considered. Structural allografts show little weight bearing potential in the long term and high failure rates. In clinical practice, the usage of spongious chips implanted via impaction bone grafting technique in combination with antiprotrusio cages for the management of contained defects have shown promising long time results. Nevertheless, when dealing with craniolateral acetabular and dorsal column defects, the additional implantation of macroporous metal implants or augments should be considered since biological augmentation has shown little clinical success in these particular cases. PROSPECT: This article provides an overview of the current clinically available biological augmentation methods of peri-acetabular defects. Due to the limitations of autologous and allogeneic bone transplants in terms of size and availability, the emerging field of innovative implantable tissue engineering constructs gains interest and will also be discussed in this article.

Group psychotherapy for patients with coronary heart disease.

Group therapy with cardiac patients is a relatively new specialty. The field is supported by a substantial epidemiological and experimental literature demonstrating links between heart and mind. There are several clinical trials that have demonstrated less morbidity, improved quality of life, and, to some extent, lower mortality for patients who have received psychosocial intervention, generally group therapy, compared to control patients. Different theoretical orientations and a small number of clinical techniques have been developed to help cardiac patients make an adjustment to heart-healthy living. This article provides a brief review of the literature in cardiac psychology, suggestions for developing a psychotherapy practice specialty with cardiac patients, techniques for treating these patients, and conclusions by a psychologist-cardiologist team that has been active in this area for more than a decade.

Changing mortality from coronary heart disease among smokers and nonsmokers over a 20-year interval.

A comparison of coronary heart disease (CHD) mortality in two large American Cancer Society studies, Cancer Prevention Study (CPS) I (1959-1965) and CPS-II (1962-1968) suggests that surprisingly large declines occurred in two groups so defined to minimize the influence of change of smoking status. CHD mortality fell essentially in half when comparing nearly 300,000 persons who were actively smoking cigarettes at entry into CPS-I with about 228,000 persons who were similarly actively smoking at entry into CPS-II, about 20 years later. CHD mortality also declined by more than 50% among nearly half a million lifelong nonsmokers recruited for CPS-I in the early 1960s and for CPS-II in the mid-1980s. Possible explanations for these large declines include unmeasured decreases in smoking related to trial design, errors in ascertainment of causes of death, greater improvement among smokers of other risk factors for CHD, and changes in cigarettes or the pattern of smoking that have been salutary for CHD, but not for lung disease or lung cancer; none of these putative explanations can be supported by data from these studies. CHD mortality, much lower in absolute terms in recent years, is still much higher among smokers vs nonsmokers, so that the beneficial trends observed from CPS-I to CPS-II should stimulate further exploration of how CHD is related to smoking, and not serve as an excuse to ignore continued smoking.

Psychosocial characteristics of psychiatric inpatients with reproductive losses.

Rising fertility rates among the severely and persistently mentally ill require a better understanding of the family planning needs of this population. In the present study, 82 women hospitalized for major psychiatric disorders were divided into three groups: abortion (n = 22), relinquishment (n = 28), and no children (n = 32). Statistical analyses of demographic, diagnostic, and birth control data showed that those who aborted or relinquished custody of their children were likely to come from ethnic minority populations and have a history of substance abuse. More than 70 percent of the women who had abortions reported sexual and/or physical assaults as either children or adults. Only 34 percent of all participants indicated that they used contraceptives. Increased awareness of reproductive histories and family planning needs of women with major psychiatric disorders is suggested.

Great expectations: challenges for women as mental health administrators.

Although women have made many strides in the area of leadership, stereotypes still exist that limit their power. Traditional concepts of femininity have not typically been associated with strength and competence. This article describes an inpatient unit at San Francisco General Hospital, University of California, San Francisco, which is led by a group of women. The unit houses a women-focused treatment team specializing in treating women who have serious mental illness with histories of severe trauma, including poverty and violence. The article describes the challenges and rewards available to women leaders in this type of setting. Four areas of women's leadership are explored: the stereotypes women have about each other as leaders, the expectations and biases of staff and trainees, the projections of patients onto women leaders, and women's leadership in relation to department administration. Strategies for addressing biases in these areas and developing women's leadership conclude the article.

Characteristics of a contemporary population with angina pectoris. TIDES Investigators.

To characterize a contemporary, nonhospitalized population with angina pectoris, data were obtained from a geographically diverse cohort of 5,125 outpatients with chronic stable angina cared for by 1,266 primary care physicians between September and November of 1990. Diagnosis was based on history supported by evidence for coronary artery disease (coronary angiography, old myocardial infarction, or an abnormal stress test, either alone or in combination). The mean age of the patients was 69 years and 53% were women. Seventy percent had > 1 associated illness and 64% took > 1 cardiovascular drug. Median angina frequency was approximately 2 episodes/week and increased angina frequency (p < 0.0001) was associated with decreased overall feeling of well-being. Although effort angina was present in 90% of patients, 47% also had rest angina and 35% had mental stress-evoked angina. Female gender (relative risk [RR] 1.09; 95% confidence interval [CI] 1.02 to 1.16), concomitant illness (RR 1.17; CI 1.09 to 1.25), and pharmacotherapy (RR 1.14; CI 1.07 to 1.22) were associated with excess risk for rest angina. Younger age (RR 1.30; CI 1.20 to 1.41), female gender (RR 1.16; CI 1.07 to 1.26), concomitant illness (RR 1.13; CI 1.03 to 1.24), and pharmacotherapy (RR 1.28; CI 1.15 to 1.93) were associated with excess risk for mental stress angina. These data suggest that contemporary outpatients with angina are frequently women and elderly patients with high rates of associated illness, rest, and mental stress-related angina.

History of drugs for thrombotic disease. Discovery, development, and directions for the future.

The history of the antithrombotic agents--aspirin, heparin, warfarin, and the thrombolytics--is a rich and lively odyssey of serendipity, perseverance, vision, and conflict involving a number of striking personalities. The history of aspirin spans ages and continents from Hippocrates' analgesic for women in labor to the rediscovery of the white willow bark by English country scholar Reverend Edward Stone. Bayer chemist Felix Hoffmann reinvented aspirin for his ailing father; suburban physician L.L. Craven pioneered the prophylactic antithrombotic uses of aspirin; and Sir John Vane elucidated aspirin's mechanism of action as the inhibition of prostaglandin synthetase. Heparin was discovered by McLean, working as a medical student in 1915 in search of a pure procoagulant in dog liver. His original impure material differed somewhat from today's heparin, but purified heparin was rapidly accepted for a myriad of clinical uses; to this day, diverse new properties of this complex glycosaminoglycan continue to be elucidated. The oral anticoagulants emerged from veterinary research in the 1920s on a hemorrhagic disorder afflicting cattle that consumed spoiled sweet clover hay. Several chance encounters led Karl Link and his University of Wisconsin team to the identification of dicumarol as the offending agent in 1939 and its widespread therapeutic use by Wright and others in the 1940s. Link later developed warfarin as a rodenticide, but its use in humans soon followed in the 1950s. Vitamin K was discovered in the 1930s; its involvement in the mechanism of the anticoagulant agents was not delineated until the 1970s. The intrinsic ability of clotted blood to liquify and the fibrinolytic properties of normal urine were noted in the 1800s. Tillett and Sherry's group stumbled on the fibrinolytic properties of streptokinase in the 1930s and pioneered the therapeutic use of streptokinase in the 1940s and of urokinase in the 1960s. Several teams found tissue-type plasminogen activator in various body sites beginning in the 1940s, leading to its cloning and widespread use in the 1980s; anisoylated plasminogen-streptokinase activator complex is an example of rational drug design. The discoverers of these diverse agents have not only provided physicians with a potent armamentarium of antithrombotic drugs but also helped elucidate much basic science and vividly demonstrated the merits of perseverance, independent thought, and adherance to the scientific method.

Angina: evolution of the role of nitrates.

In recent years, concern has been expressed over attenuation of therapeutic effect in patients receiving continuous nitroglycerin therapy for the treatment of angina. Studies have shown that exercise tolerance time does not improve with continuous nitroglycerin regimens, although the frequency of anginal attacks may decrease. Intermittent therapy, which incorporates a nitrate-free interval, improves both exercise time and clinical angina. The optimal duration of the nitrate-free interval has yet to be determined. Future research is likely to focus more on supply-side factors in angina. Of the available antianginal drugs, nitrates have been shown to be highly effective coronary vasodilators, particularly in areas of stenosis.