Bellwether procedures for monitoring and planning essential surgical care in low- and middle-income countries: caesarean delivery, laparotomy and treatment of open fractures

BACKGROUND: Surgical conditions represent a significant proportion of the global burden of disease, and therefore, surgery is an essential component of health systems. Achieving universal health coverage requires effective monitoring of access to surgery. However, there is no widely accepted standard for the required capabilities of a first-level hospital. We aimed to determine whether a group of operations could be used to describe the delivery of essential surgical care.

METHODS: We convened an expert panel to identify procedures that might indicate the presence of resources needed to treat an appropriate range of surgical conditions at first-level hospitals. Using data from the World Health Organization Emergency and Essential Surgical Care Global database, collected using the WHO Situational Analysis Tool (SAT), we analysed whether the ability to perform each of these procedures-which we term "bellwether procedures"-was associated with performing a full range of essential surgical procedures.

FINDINGS: The ability to perform caesarean delivery, laparotomy, and treatment of open fracture was closely associated with performing all obstetric, general, basic, emergency, and orthopaedic procedures (p < 0.001) in the population that responded to the WHO SAT Survey. Procedures including cleft lip, cataract, and neonatal surgery did not correlate with performing the bellwether procedures.

INTERPRETATION: Caesarean delivery, laparotomy, and treatment of open fractures should be standard procedures performed at first-level hospitals. With further validation in other populations, local managers and health ministries may find this useful as a benchmark for what first-level hospitals can and should be able to perform on a 24/7 basis in order to ensure delivery of emergency and essential surgical care to their population. Those procedures which did not correlate with the bellwether procedures can be referred to a specialized centre or collected for treatment by a visiting specialist team.

Non-hip and non-vertebral fractures : the neglected fracture sites

Summary: Non-hip, non-vertebral fractures (NHNVF) were compared with hip, vertebral and controls. NHNVF were younger and heavier than controls and hip/vertebral fractures in both men and women, respectively. Falls and prior fractures were less common in NHNVF than hip fractures. Glucocorticoid use was lower in NHNVF compared to vertebral fracture (VF) in men. Introduction: Although hip fracture (HF) and vertebral fractures (VF) receive the most attention in the literature and are the targeted sites for fracture prevention, non-hip, non-vertebral fracture (NHNVF) sites account for a greater proportion of fractures than the hip or vertebrae. This study aimed to assess risk factors for NHNVF and compare them with those for HF, VF and controls. Methods: Incident fractures during 2005–2007 for men and 1994–1996 for women were identified using computerised keyword searches of radiological reports, and controls were selected at random from electoral rolls for participation in the Geelong Osteoporosis Study. Participants aged 60+ years were included in this study. Results: Compared to controls, men and women with NHNVF were younger (ORs, 0.90, 95 % CI 0.86–0.94; and 0.96, 0.93–0.98, respectively) and had a lower femoral neck bone mineral density (BMD) T-score (age-adjusted; difference [men] 0.383, P = 0.002; [women] 0.287, P = 0.001). Compared to HF, men and women with NHNVF were heavier (difference [men] 9.0 kg, P = 0.01; [women] 7.6 kg, P < 0.001). Heavier weight was also a risk factor for women with NHNVF compared to VF (1.03, 1.01–1.06). In men with NHNVF, falls (0.37, 0.14–0.97) and prior fractures (0.38, 0.15–0.98) were less common compared to HF; and glucocorticoid use was less common for NHNVF (0.30, 0.11–0.85) compared to VF. Conclusions: Given the high numbers of NHNVF sustained by men and women in this study, fracture prevention strategies should focus on individuals with high risk of sustaining these types of fractures, as well as on individuals who are more likely to sustain a HF or VF.

When continuity of care breaks down: a systems failure in identification of osteoporosis risk in older patients treated for minimal trauma fractures

OBJECTIVE: Minimal trauma fractures may be the first indication of osteoporosis. Our aim was to determine the proportion of patients who underwent bone density testing for osteoporosis of those with a minimal trauma wrist fracture treated in the emergency department (ED).

DESIGN: This observational retrospective cohort study used explicit medical record review and scripted telephone interviews.

SETTING: EDs of three metropolitan hospitals in Melbourne in 2006.

PARTICIPANTS: Patients aged 50 years and over who were treated for wrist fracture due to minimal trauma. Data collected included demographic details, fracture details, causes of injury, any bone density testing and any osteoporosis-related medication change.

MAIN OUTCOME MEASURE: The proportion of patients who underwent bone density testing in the follow-up period.

RESULTS: 131 patients were studied; 83% were female, and the median age was 71 years. No patient was referred by an ED or fracture clinic for bone density testing (95% CI, 0-3.5%). Telephone follow-up data were obtained from 91 patients. Of these, 28 reported having bone density testing after their fracture, of whom 14 (50%; 95% CI, 32%-67%) were found to have osteoporosis. Seven were treated with a bisphosphonate and one with a selective oestrogen-receptor modulator.

CONCLUSION: Follow-up of patients suffering minimal trauma wrist fractures treated in the ED is poor. Systems to improve the identification and treatment of osteoporosis in this group are needed if future osteoporotic fractures and their consequences are to be avoided.

Prescribing exercise for Osteoporosis

Osteoporosis is a major public health problem because of the morbidity and mortality associated with fracture. Minimizing the risk of fracture is the primary objective of osteoporosis management. The role of exercise in osteoporosis management is to increase and maintain peak bone density and reduce the rate of bone loss and the risk of falling. This article provides recommendations focusing on a life-span approach to minimizing the risk of fracture associated with osteoporosis. Osteoporosis prevention begins in childhood, when exercise can increase peak bone strength. In young adults, it can maintain peak bone mineral density. In elderly individuals, physical activity can slow bone loss and improve fitness and muscle strength, helping prevent falls and lower the risk of fracture. Exercise goals for individuals with osteoporosis should include reducing pain, increasing mobility, and improving muscle endurance, balance, and stability in order to improve the quality of life and reduce the risk of falling. Thus, exercise plays a significant part in reducing fractures in later life.

Application of very-high-frequency (VHF) method to ceramic insulators

A VHF method (30-300 MHz) is applied to identify faults and defects in ceramic insulators. Insulators which exhibit internal cracks and fractures are used as test samples. Different artificial conditions are introduced to the test samples according to the IEC 507 standard under wet and dry conditions. Using a cascading signal processing technique and analysis methods such as FFT and fractal analysis, VHF signals acquired by digital scope are processed and analyzed. This study indicates that the fractal dimension can be used as an effective tool to isolate the common faulty conditions found on the ceramic insulators. The results from this study strongly support the prospect of using a VHF method to monitor the physical condition of ceramic insulators.

Emergency nurse practitioner care and emergency department patient flow: case-control study

Objective: The present study aimed to compare ED waiting times (for medical assessment and treatment), treatment times and length of stay (LOS) for patients managed by an emergency nurse practitioner candidate (ENPC) with patients managed via traditional ED care. Methods: A case–control design was used. Patients were selected using the three most common ED discharge diagnoses for ENPC managed patients: hand/wrist wounds, hand/wrist fractures and removal of plaster of Paris. The ENPC group (n = 102) consisted of patients managed by the ENPC who had ED discharge diagnoses as mentioned above. The control group (n = 623) consisted of patients with the same ED discharge diagnoses who were managed via traditional ED care. Results: There were no significant differences in median waiting times, treatment times and ED LOS between ENPC managed patients and patients managed via traditional ED processes. There appeared to be some variability between diagnostic subgroups in terms of treatment times and ED LOS. Conclusion: Patient flow outcomes for ENPC managed patients are comparable with those of patients managed via usual ED processes.

Should older people in residential care receive vitamin D to prevent falls? Results of a randomized trial

Objectives: To determine whether vitamin D supplementation can reduce the incidence of falls and fractures in older people in residential care who are not classically vitamin D deficient.

Design: Randomized, placebo-controlled double-blind, trial of 2 years' duration.

Setting: Multicenter study in 60 hostels (assisted living facilities) and 89 nursing homes across Australia.

Participants: Six hundred twenty-five residents (mean age 83.4) with serum 25-hydroxyvitamin D levels between 25 and 90 nmol/L.

Intervention: Vitamin D supplementation (ergocalciferol, initially 10,000 IU given once weekly and then 1,000 IU daily) or placebo for 2 years. All subjects received 600 mg of elemental calcium daily as calcium carbonate.

Measurements: Falls and fractures recorded prospectively in study diaries by care staff.

Results: The vitamin D and placebo groups had similar baseline characteristics. In intention-to-treat analysis, the incident rate ratio for falling was 0.73 (95% confidence interval (CI)=0.57–0.95). The odds ratio for ever falling was 0.82 (95% CI=0.59–1.12) and for ever fracturing was 0.69 (95% CI=0.40–1.18). An a priori subgroup analysis of subjects who took at least half the prescribed capsules (n=540), demonstrated an incident rate ratio for falls of 0.63 (95% CI=0.48–0.82), an odds ratio (OR) for ever falling of 0.70 (95% CI=0.50–0.99), and an OR for ever fracturing of 0.68 (95% CI=0.38–1.22).

Conclusion: Older people in residential care can reduce their incidence of falls if they take a vitamin D supplement for 2 years even if they are not initially classically vitamin D deficient.

Men and osteoporosis

BACKGROUND: While strict criteria have been developed for defining osteoporosis in women (bone mineral density measurements more than 2.5 standard deviations below the mean for young adult normal women, i.e. t-score value < -2.5), there still remains a controversy regarding the definition in men. Spinal fractures occur in 5% and hip fractures in 6% of men older than 50 years. There are significant differences between men and women with respect to the pathogenesis of osteoporosis, underlying medical conditions and postfracture sequelae.

OBJECTIVE: To provide an overview of the pathogenesis, diagnosis and prevention of osteoporosis in men.

DISCUSSION: Osteoporosis is increasingly recognised. Data from the Dubbo Osteoporosis Epidemiology Study suggests that 30% of men in Australia aged over 60 years will suffer from an osteoporotic fracture. It is estimated that 30-60% of men presenting with spinal fractures will have another illness contributing to their bone loss. Osteoporotic fractures in men are associated with higher morbidity and mortality than in women. Lifestyle changes together with daily calcium supplementation should be implemented and vitamin D3 should be considered in men with osteopenia.

Serum vitamin D and falls in older women in residential care in Australia

Objectives: To determine the prevalence of vitamin D deficiency in older people in residential care and the influence that the level of vitamin D may have on their incidence of falls.

Design: Prospective cohort.

Setting: Residential care facilities for older people in several states of Australia.

Participants: Six hundred sixty-seven women in low-level care and 952 women in high-level care, mean age 83.7 years.

Measurements: Serum 25-hydroxyvitamin D (25D) levels and recognized risk factors for falls including current medication use, a history of previous fractures, weight, tibial length (as a surrogate for height), cognitive function, walking ability, and frequency of going outdoors were determined. The women in low-level care and high-level care were followed for an average of 145 and 168 days, respectively. Falls were recorded prospectively in diaries completed monthly by residential care staff.

Results: Vitamin D deficiency (defined as a serum 25D level below 25 nmol/L) was present in 144 (22%) women in low-level care and 428 (45%) in high-level care. After excluding 358 bed-bound residents and adjusting for weight, cognitive status, psychotropic drug use, previous Colles fracture, and the presence of wandering behavior, log serum 25D level remained independently associated with time to first fall. The adjusted hazards ratio was 0.74 (95% confidence interval=0.59–0.94; P=.01), implying a 20% reduction in the risk of falling with a doubling of the vitamin D level.

Conclusion: Vitamin D deficiency is common in residential care in Australia. A low level of serum vitamin D is an independent predictor of incident falls.

The effect of osteoporotic vertebral fracture of predicted spinal loads in vivo

he aetiology of osteoporotic vertebral fractures is multi-factorial, and cannot be explained solely by low bone mass. After sustaining an initial vertebral fracture, the risk of subsequent fracture increases greatly. Examination of physiologic loads imposed on vertebral bodies may help to explain a mechanism underlying this fracture cascade. This study tested the hypothesis that model-derived segmental vertebral loading is greater in individuals who have sustained an osteoporotic vertebral fracture compared to those with osteoporosis and no history of fracture. Flexion moments, and compression and shear loads were calculated from T2 to L5 in 12 participants with fractures (66.4 ± 6.4 years, 162.2 ± 5.1 cm, 69.1 ± 11.2 kg) and 19 without fractures (62.9 ± 7.9 years, 158.3 ± 4.4 cm, 59.3 ± 8.9 kg) while standing. Static analysis was used to solve gravitational loads while muscle-derived forces were calculated using a detailed trunk muscle model driven by optimization with a cost function set to minimise muscle fatigue. Least squares regression was used to derive polynomial functions to describe normalised load profiles. Regression co-efficients were compared between groups to examine differences in loading profiles. Loading at the fractured level, and at one level above and below, were also compared between groups. The fracture group had significantly greater normalised compression (p = 0.0008) and shear force (p < 0.0001) profiles and a trend for a greater flexion moment profile. At the level of fracture, a significantly greater flexion moment (p = 0.001) and shear force (p < 0.001) was observed in the fracture group. A greater flexion moment (p = 0.003) and compression force (p = 0.007) one level below the fracture, and a greater flexion moment (p = 0.002) and shear force (p = 0.002) one level above the fracture was observed in the fracture group. The differences observed in multi-level spinal loading between the groups may explain a mechanism for increased risk of subsequent vertebral fractures. Interventions aimed at restoring vertebral morphology or reduce thoracic curvature may assist in normalising spine load profiles.

Guidelines for treatment of osteoporosis in men

BACKGROUND: Osteoporosis is associated with significant morbidity and mortality in men. Published randomised controlled trials assessing the benefits of therapy in men with osteoporosis are limited, but those available need to be used to develop management guidelines.

OBJECTIVE: To present evidence based guidelines for the treatment of osteoporosis in men.

DISCUSSION: It is estimated that 30-60% of men presenting with spinal fractures have another illness contributing to their bone disease. Therefore assessment and treatment of coexisting medical conditions is a vital part of management of osteoporosis. While primary prevention of fractures remains crucial, treatment to ensure further fractures do not occur is equally important. Alendronate is the treatment of choice for men with osteoporosis and fractures, with cyclical etidronate an appropriate alternative and testosterone replacement therapy is indicated in hypogonadal men presenting with osteoporosis.

Human sarcopenia reveals an increase in SOCS-3 and myostatin and a reduced efficiency of Akt phosphorylation

Age-related skeletal muscle sarcopenia is linked with increases in falls, fractures, and death and therefore has important socioeconomic consequences. The molecular mechanisms controlling age-related muscle loss in humans are not well understood, but are likely to involve multiple signaling pathways. This study investigated the regulation of several genes and proteins involved in the activation of key signaling pathways promoting muscle hypertrophy, including GH/STAT5, IGF-1/Akt/GSK-3β/4E-BP1, and muscle atrophy, including TNFα/SOCS-3 and Akt/FKHR/atrogene, in muscle biopsies from 13 young (20 ± 0.2 years) and 16 older (70 ± 0.3 years) males. In the older males compared to the young subjects, muscle fiber cross-sectional area was reduced by 40–45% in the type II muscle fibers. TNFα and SOCS-3 were increased by 2.8 and 1.5 fold, respectively. Growth hormone receptor protein (GHR) and IGF-1 mRNA were decreased by 45%. Total Akt, but not phosphorylated Akt, was increased by 2.5 fold, which corresponded to a 30% reduction in the efficiency of Akt phosphorylation in the older subjects. Phosphorylated and total GSK-3β were increased by 1.5 and 1.8 fold, respectively, while 4E-BP1 levels were not changed. Nuclear FKHR and FKHRL1 were decreased by 73 and 50%, respectively, with no changes in their atrophy target genes, atrogin-1 and MuRF1. Myostatin mRNA and protein levels were significantly elevated by 2 and 1.4 fold. Human sarcopenia may be linked to a reduction in the activity or sensitivity of anabolic signaling proteins such as GHR, IGF-1, and Akt. TNFα, SOCS-3, and myostatin are potential candidates influencing this anabolic perturbation.

Multivitamin supplementation improves nutritional status and bone quality in aged care residents

Objectives: To assess the effectiveness of a multivitamin (MV) tablet on nutritional status, quantitative heel ultrasound (QUS), mobility, muscle strength and falls. The design comprised two groups matched on mobility levels, randomized to receive a daily MV or placebo (P) tablet for 6 months. The setting was an Australian residential care facility.

Subjects: A total of 92 aged care residents. Serum micronutrients, body weight, QUS, rate of falls, hand grip strength, and the timed up and go test were assessed at baseline and 6 months.

Results: A total of 49 participants consumed a MV and 43, a matched P for 6 months. There was a greater increase in the MV vs P group for serum 25(OH)D (mean differencestandard error, 33.42.6 nmol l-1), folate (13.42.8 nmol l-1), and vitamin B12 (178.040.3 pmol l-1) (all P<0.001). Adequate 25(OH)D concentrations (50 nmol l-1) were found among 77% of participants in the MV group vs 10% taking P (P<0.001). Adjusting for baseline levels, the increase in QUS was greater in the MV vs P group (3.02.0 dB MHz-1 vs -2.92.1 dB MHz-1, respectively, P=0.041). There was a trend towards a 63% lower mean number of falls in the MV vs P group (0.30.1 falls vs 0.80.3 falls, P=0.078).

Conclusions: MV supplementation raised serum vitamin B12 and folate concentrations and increased serum 25(OH)D, which was accompanied by an apparent positive effect on bone density. We also found a trend towards a reduction in falls and this could contribute to a reduction in fractures.