Hip Fractures in Finland — A Comparison of Patient Characteristics and Outcomes in Six Hospitals

Background and Aims:

To compare six Finnish hospitals for the quality of treatment of hip fractures and to obtain information for the development of care.

Material and Methods:

Data of 1179 consecutive hip fracture patients (about 200 patients per hospital) was collected prospectively, using similar standardized forms and focusing on background factors and the four-month functional outcome.

Results:

There were significant differences between the hospitals in patient characteristics (age, place of residence, walking ability, use of walking aids, morbidity and type of fracture) and in the unadjusted outcome variables at four months' follow-up (place of residence, mobility, use of walking aids and pain in injured hip). After adjustment for baseline characteristics, there was a significant difference in the post-fracture walking ability between the centres but no significant differences in post-fracture place of residence. Unadjusted mortality did not vary between the centres, but adjustment resulted in significant differences. The most marked difference in surgical methods between the hospitals was seen in the use of either sliding hip screw or Gamma Nail for trochanteric fractures, but this difference was not reflected in the results of multivariate analysis.

Conclusions:

We found minor differences in mobility and mortality between the participating hospitals, and these might serve them as a stimulus for improving their standard of good practice. Continuous quality improvement by repeating the audit cycle is recommended in order to reach and then improve the prevalent standards in the care of hip fracture patients. Confounding factors should be adjusted when comparing the medical centres treating hip fractures, and the evaluation of the results should be multidimensional.

Geriatric and physically oriented rehabilitation improves the ability of independent living and physical rehabilitation reduces mortality: a randomised comparison of 538 patients

OBJECTIVE

To examine effects of physical and geriatric rehabilitation on institutionalisation and mortality after hip fracture.

DESIGN

Prospective randomised study.

SETTING

Physically oriented (187 patients), geriatrically oriented (171 patients), and health centre hospital rehabilitation (180 patients, control group).

SUBJECTS

A total of 538 consecutively, independently living patients with non-pathological hip fracture.

MAIN MEASURES

Patients were evaluated on admission, at 4 and 12 months for social status, residential status, walking ability, use of walking aids, pain in the hip, activities of daily living (ADL) and mortality.

RESULTS

Mortality was significantly lower at 4 and 12 months in physical rehabilitation (3.2%, 8.6%) than in geriatric rehabilitation group (9.6%, 18.7%, P=0.026, P=0.005, respectively) or control group (10.6%, 19.4%, P=0.006, P=0.004, respectively). At 4 months more patients in physical (84.4%) and geriatric rehabilitation group (78.0%) were able to live at home or sheltered housing than in control group (71.9%, P=0.0012 and P<0.001, respectively). No significant difference was found between physical rehabilitation and geriatric rehabilitation (P=0.278). Analysis of femoral neck and trochanteric fractures showed that significant difference was true only for femoral neck fractures (physical rehabilitation vs geriatric rehabilitation P=0.308, physical rehabilitation vs control group P<0,001 and geriatric rehabilitation vs control group P<0.001). Effects of intensified rehabilitations disappeared at 12 months. No impact on walking ability or ADL functions was observed.

CONCLUSIONS

Physical rehabilitation reduced mortality. Physical and geriatric rehabilitation significantly improved the ability of independent living after 4 months especially among the femoral neck fracture patients but this effect could not be seen after 12 months.

Exhaust expulsion of the porcine reproductive and respiratory syndrome virus (PRRSV) through ultrasound machines

Objective: Three experiments (EXP) were conducted to investigate if air contaminated with PRRS virus (Ingelvac PRRS MLV vaccine containing the North American strain) can be sucked into ultrasound machines and then expelled back into an infected (EXP-1) or a clean environment (EXP-3) through the action of ventilation fans, and if covering the machines prevents exhaust expulsion of the virus (EXP-2). Materials and methods: The experimental apparatus basically comprised of a plastic chamber, an ultrasound unit HS 1201, a device that allowed for virus aerosolization and a pipe system that allowed the air to return into the chamber (EXP-1) or to be expelled into the atmosphere (EXP-3), or was blocked by using a rubber membrane (EXP-2). In EXP-1, different virus concentrations were tested (i. e. 104, 105 and 106 TCID50, each concentration in three replicates and two runs). In EXP-2, the highest concentration, i. e. 106 TCID50 was used (three replicates and two runs). EXP-3 immediately followed EXP-2 without introduction of new virus (two runs). Virus exhaust expulsion was monitored by swabbing the pipe system with the swabs being subjected to RT-nPCR and culture. Results: In EXP-1, 106 TCID50 PRRSV, but none of the other concentrations, gave constantly virus-positive results by RT-nPCR. In EXP-2, covering completely prevented virus exhaust expulsion. In EXP-3, two out of eight swabs were positive by RT-nPCR. Cell culture of positive swabs was negative. Conclusion: The study suggests exhaust expulsion of PRRSV through ultrasound machines equipped with a ventilator fan into an infected and a clean environment, but failed to demonstrate infectivity of the expelled virus. Preventing exhaust air expulsion by complete covering prevents the expulsion of the virus.

No effect of ethinylestradiol treatment on melatonin secretion in healthy pubertal girls

The present study investigated the impact of high estrogen doses on melatonin blood concentrations in healthy young girls. Melatonin secretion was investigated in 7 girls (chronological age 13.2 +/- 0.2 years; bone age 12.8 +/- 0.2 years) before and during treatment with ethinylestradiol (EE2, daily dose 0.5 mg/d orally) aimed at the reduction of final prospective height in familial tall stature. Melatonin, LH, FSH, E2 and EE2 were measured by radioimmunoassay. In all subjects, LH and FSH were completely suppressed, but melatonin secretion, day/night plasma values as well as the area under the curve (AUC) remained unchanged under pharmacological administration of ethinylestradiol. We therefore conclude that melatonin secretion is not affected by pharmacological doses of the synthetic estrogen derivative ethinylestradiol in healthy young girls. The decrease of melatonin blood concentrations during puberty is not caused by increasing concentrations of estrogens but must be due to some other process.

Growth hormone (GH) determinations by RIA and IFA during GH stimulation tests in children with short stature

Growth hormone deficiency (GHD) as a syndrome comprises multiple pathogenetically distinct entities caused by disorders of secretion or peripherial action of growth hormone (GH). Confirmation of the diagnosis of GH deficiency in children is based on provocative testing for human growth hormone (hGH). Immunofunctional assay (IFA) allows quantitation of only biological active GH forms in circulation. The aim of this study was to compare the results of GH determinations by radioimmunoassay (RIA) and IFA, and to establish cut-off-levels for IFA in insulin tolerance test (ITT). We have investigated 32 children (30 males and 2 females) with short stature. All patients underwent insulin tolerance test (ITT), GH was measured in duplicate by radioimmunoassay (RIA, Seria) and IFA (DSL). Children with peak GH concentration below 10 ng/ml in ITT (by RIA) underwent arginin tolerance test (ATT, arginin 0,5 g/kg). The correlation between the results of growth hormone determination by radioimmunoassay and immunofunctional assay was excellent and cut-off-level in stimulatory test was established for the immunofunctional assay.

Factors related to occurrence of hip fracture during a fall on the hip

Recently, it has been shown that hip fractures can be effectively prevented by use of hip protectors. To determine who would gain most benefit from use of hip protectors, we conducted a study with the aim to clarify factors that contribute to the occurrence of fracture in individuals who fall on their hip. Hip fracture patients were compared with individuals who had fallen on their hip without sustaining a fracture. The study group consisted of 123 consecutive hip fracture patients aged 70 years or over (mean age 82 years, female 82 years and male 80 years). The control group comprised 132 individuals (mean age 81 years, female 81 years and male 80 years) obtained from a prospective study on falls, who had experienced a fall that caused a visible soft tissue injury (bruise or wound) at the hip or gluteal region without sustaining a fracture. Patients were questioned about associated diseases, medications, place of residence, walking ability, need for locomotor aids and some activities in daily living (ADL). Patients who sustained a hip fracture were more likely to be women, living in long-term institutional care, using neuroleptics, dependent in ADL and had more history of previous stroke with hemiparesis, more Parkinsonism and lower body mass indexes (BMI) than those who did not sustain a fracture on fall on the hip. According to a logistical regression model, institutional residence, low BMI and history of stroke with hemiplegic status differed between fracture cases and controls. Institutional residence, low BMI and history of hemiplegic stroke discriminate hip fracture patients from fallers who sustain a soft tissue injury on the hip region. In clinical practice, patients who have these characteristics would be potential candidates to use hip protectors and other preventive measures.

Effect of age on some blood variables relating to bone metabolism in women

BACKGROUND

The available laboratory parameters reflecting bone metabolism are not adequate for reliable diagnosis of osteoporosis. They display a marked biological variation and are inaccurate in individual cases. Therefore precise knowledge of these variations, as upon aging in healthy people is important.

AIMS

The purpose was to examine the age- and weight-related variation of some blood constituents relating to mineral metabolism and commonly used in hospital laboratories in healthy women aged over 40, and to estimate their mutual correlations and normal values in different age groups.

METHODS

The study series consisted of 238 healthy Caucasian women without any diseases related to bone metabolism and aged 40-86 years, who were divided into the following age categories: 40-45, 50-55, 60-65, 70-75 and over 80 years.

RESULTS

Markers of bone formation, alkaline phosphatase (AP) and osteocalcin, and marker of bone resorption, tartrate resistant acid phosphatase (TrAcP), as well as parathyroid hormone, phosphorus and creatinine increased with age, whereas 25-hydroxyvitamin D and oestradiol decreased. All these parameters except calcium showed a significant age relation. Only the relation of weight versus osteocalcin and weight versus TrAcP remained significant when the effect of age was included in the multiple regression analysis or the partial correlation coefficients were examined. There was a significant correlation between serum osteocalcin and serum AP. Serum TrAcP had a significant positive correlation with serum osteocalcin and serum AP. Percentage fat mass correlated significantly with AP and TrAcP.

CONCLUSION

Our observations may be useful when these markers of bone metabolism having inadequate sensitivity and specificity, are used as a battery in the diagnosis of osteoporosis and other metabolic bone diseases and in the assessment of normality in population studies.

Mortality and quality of life after trochanteric hip fracture

The objective was to evaluate the survival and some aspects of the quality of life of patients with trochanteric hip fracture after long-term follow-up in comparison with the age- and sex-matched controls without fracture. Two hundred consecutive patients (mean age at fracture 77 y) with trochanteric hip fractures were compared with the age- and sex-matched controls representing an average population from the same area. After a mean 7 y follow-up period a questionnaire concerning their place of residence, ambulation, causes leading to impairment, need for locomotor aids and management of activities in daily living (ADL) functions was sent to the surviving patients and controls. Mortality increased gradually being 4.5 percent above the control level one month after the fracture, 6.0 percent above at three months, 3.5 percent above at one year, 4.5 percent above at two years, 6.5 percent above at five years and 9.0 percent above at six years. Thirty (48%) of the surviving 62 patients and 83 (90%) of the 92 surviving controls were living in their own homes and 2 (3%) and 4 (4%) in service apartments respectively. Seventeen (27%) of patients alive were institutionalized in a chronic care hospital unit and 13 (21%) in an old people's home as compared with 2 (2%) and 3 (3%) of the controls respectively. Twenty-two (35%) of the patients and 73 (79%) of the controls were able to move about independently. The patients were significantly worse at ADL-management, required more home help and had fewer social contacts and outdoor hobbies than the controls. In conclusion surgically-treated trochanteric hip fractures markedly increase mortality rate, reduce independence and impair walking ability and ADL-functions, and thus seriously affect the health-related quality of life of the patients. This fact should be considered in the planning of the healthcare of elderly people.

[Investigations on the concentration and emission of ammonia and nitrous oxide in various deep litter keeping systems for fattening pigs and in slatted floor keeping]

Concentration of ammonia and nitrous oxide was measured in an air conditioned pig site with two chambers during six rounds (app. 650 measuring days) with different deep litter and a slatted floor keeping system for fattening pigs. Emissions and gaseous nitrogen losses were calculated. With exception of a system with mixing twice a week deep litter keeping leads to decrease of NH3 concentration (up to 26%), partly also of NH3 emission, but to higher N2O emissions compared to liquid manure system. With exception of ENVIROZYME deep litter keeping all other deep litter systems cause higher gaseous nitrogen losses compared to slatted floor keeping.

[Determination of concentration and emission of gases relevant to animal and environmental hygiene in different systems for fattening of pigs with the aid of multigas monitoring]

Multigasmonitoring is a method to measure continuously gases relevant from the view point of animal and environmental hygiene with high sampling rate and to calculate emission. The methodical procedure has been described by example from different deep litter systems with additives and slatted floor system with liquid manure storage for fattening pigs. It has been shown that the emission of ammonia from an obviously good working deep litter system can be lowered by approximately 30% in comparison with slatted floor. The mean concentration of nitrous oxide in deep litter system with additives was approximately 2 ppm, whereas in the liquid manure system the N2O concentration was less than the outdoor value.

Intravenous adenosine as first-line prehospital management of narrow-complex tachycardias by EMS personnel without direct physician control

This study was conducted to evaluate the safety and efficacy of intravenous adenosine therapy for prehospital treatment of narrow-complex tachycardias with a presumptive field diagnosis of paroxysmal supraventricular tachycardia (PSVT) by paramedics without direct physician control. A ten-month prospective case series was designed in an urban EMS system that has paramedics operating under standing orders before physician radio contact. All patients with PSVT field diagnosis were included. Diagnosis of PSVT was made by regular, narrow-complex tachycardia with a heart rate greater than 160 beats/min by field ECG. Interpretation was performed solely by paramedics; ECG transmission was not available. In hemodynamically stable patients, vagal maneuvers were followed by intravenous placement and administration of adenosine was recommended by the manufacturer. If three adenosine boluses failed to convert the arrhythmia, patients were monitored and transported, with electrical cardioversion available. Data collection included demographic, history, medications, vital signs, and EGG tracings. Of 14 included patients, 31 were correctly diagnosed with PSVT (75.6%), with mean ventricular rate of 205 beats/min (SD 7 beats/min); one had sinus tachycardia; nine had atrial fibrillation (AF) (22%). Of the 31 cases correctly diagnosed as PSVT, 28 converted to sinus rhythm after adenosine (90.3%). Of those converted, 16 required a single dose (57.1%), nine required one additional dose (32.1%), and three required two additional doses (10.8%). None reverted to PSVT after adenosine conversion during the study period (conversion to arrival at emergency department). No significant difference in length of asystolic pause or in outcome was detected between the true PSVT cases and the AF cases receiving adenosine.(ABSTRACT TRUNCATED AT 250 WORDS)

Daily Pattern of Activity of a Captive Mountain Pygmy-possum, Burramys parvus (Broom)(Marsupialia: Burramyidae)

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