RESUMEN
Decision-making is one of the most difficult tasks of medical judgment, especially when cases involve paediatric patients with different cultural characteristics. It is the obligation of clinical ethics, taking the interdisciplinary approach as a tool to comprehensively analyse the clinical, social, cultural and legal aspects, among other topics, when choosing the treatment options that will be more beneficial for the patient. A clinical case, should enable this process of analysis and teamwork to be understood in practical way in order to address difficult medical problems.
Asunto(s)
Amputación Quirúrgica/ética , Toma de Decisiones Clínicas/ética , Disentimientos y Disputas , Ética Médica , Traumatismos de la Pierna/cirugía , Relaciones Profesional-Familia/ética , Adolescente , Toma de Decisiones Clínicas/métodos , Asistencia Sanitaria Culturalmente Competente/ética , Humanos , Indígenas Sudamericanos , Traumatismos de la Pierna/etnología , Masculino , Consentimiento por Terceros/éticaRESUMEN
BACKGROUND: The Short Musculoskeletal Function Assessment (SMFA) questionnaire is one of the most commonly used scales to evaluate functional status and quality of life (QOL) of patients with a broad range of musculoskeletal disorders. However, a Chinese version of the SMFA questionnaire for the psychometric properties of skeletal muscle injury patients in China is still lacking. The current study translated the SMFA into Chinese and assessed its reliability and validity among Chinese patients with skeletal muscle injury of the upper or lower extremities. METHODS: The original SMFA was translated from English into Chinese and culturally adapted according to cross-cultural adaptation guidelines. A multicenter cross-sectional study was conducted, comprising 339 skeletal muscle injury patients (aged 20-75 years) from 4 hospitals. The SMFA, the health survey short form (SF-36) along with a region-specific questionnaire (including the disabilities of the arm, shoulder, and hand questionnaire (DASH), the hip disability and osteoarthritis outcome score (HOOS), the knee injury and osteoarthritis outcome score (KOOS), and the foot function index (FFI)) were completed according to the region of injury. Reliability was estimated from the internal consistency using Cronbach's α and validity was assessed via convergent validity, known-groups comparison, and construct validity. RESULTS: Cronbach's α coefficient was over 0.75 for two subscales and four categories of the SMFA, suggesting that the internal consistency reliability of the SMFA was satisfactory. Known-groups comparison showed that the dysfunction index and the bother index of the SMFA discriminated well between patients who differed in age, gender, injury location, and operation status rather than in subgroups based on the body mass index (BMI). The convergent validity of the SMFA was good, as moderate to excellent correlations were found between the subscales of the SMFA and the four subscales of SF-36 (physical function, role-physical, bodily pain, and social functioning) and the region-specific questionnaires. The construct validity was proved by the presence of a six-factor structure that accounted for 66.85 % of the variance. CONCLUSION: The Chinese version of the SMFA questionnaire is a reliable and valid instrument to measure patient-reported impact of musculoskeletal injuries in the upper or lower extremities.
Asunto(s)
Traumatismos del Brazo/diagnóstico , Traumatismos de la Pierna/diagnóstico , Músculo Esquelético/lesiones , Enfermedades Musculoesqueléticas/diagnóstico , Encuestas y Cuestionarios , Actividades Cotidianas , Adulto , Anciano , Traumatismos del Brazo/etnología , Traumatismos del Brazo/fisiopatología , Traumatismos del Brazo/psicología , Pueblo Asiatico/psicología , China , Costo de Enfermedad , Estudios Transversales , Características Culturales , Evaluación de la Discapacidad , Emociones , Estudios de Factibilidad , Femenino , Estado de Salud , Humanos , Traumatismos de la Pierna/etnología , Traumatismos de la Pierna/fisiopatología , Traumatismos de la Pierna/psicología , Masculino , Persona de Mediana Edad , Músculo Esquelético/fisiopatología , Enfermedades Musculoesqueléticas/etnología , Enfermedades Musculoesqueléticas/fisiopatología , Enfermedades Musculoesqueléticas/psicología , Valor Predictivo de las Pruebas , Psicometría , Calidad de Vida , Reproducibilidad de los Resultados , Traducción , Adulto JovenRESUMEN
BACKGROUND: Workers with persistent disabilities after orthopaedic trauma may need occupational rehabilitation. Despite various risk profiles for non-return-to-work (non-RTW), there is no available predictive model. Moreover, injured workers may have various origins (immigrant workers), which may either affect their return to work or their eligibility for research purposes. The aim of this study was to develop and validate a predictive model that estimates the likelihood of non-RTW after occupational rehabilitation using predictors which do not rely on the worker's background. METHODS: Prospective cohort study (3177 participants, native (51%) and immigrant workers (49%)) with two samples: a) Development sample with patients from 2004 to 2007 with Full and Reduced Models, b) External validation of the Reduced Model with patients from 2008 to March 2010. We collected patients' data and biopsychosocial complexity with an observer rated interview (INTERMED). Non-RTW was assessed two years after discharge from the rehabilitation. Discrimination was assessed by the area under the receiver operating curve (AUC) and calibration was evaluated with a calibration plot. The model was reduced with random forests. RESULTS: At 2 years, the non-RTW status was known for 2462 patients (77.5% of the total sample). The prevalence of non-RTW was 50%. The full model (36 items) and the reduced model (19 items) had acceptable discrimination performance (AUC 0.75, 95% CI 0.72 to 0.78 and 0.74, 95% CI 0.71 to 0.76, respectively) and good calibration. For the validation model, the discrimination performance was acceptable (AUC 0.73; 95% CI 0.70 to 0.77) and calibration was also adequate. CONCLUSIONS: Non-RTW may be predicted with a simple model constructed with variables independent of the patient's education and language fluency. This model is useful for all kinds of trauma in order to adjust for case mix and it is applicable to vulnerable populations like immigrant workers.
Asunto(s)
Evaluación de la Discapacidad , Modelos Teóricos , Enfermedades Musculoesqueléticas/rehabilitación , Traumatismos Ocupacionales/rehabilitación , Reinserción al Trabajo/estadística & datos numéricos , Accidentes de Tránsito/psicología , Accidentes de Tránsito/estadística & datos numéricos , Adulto , Traumatismos del Brazo/etnología , Traumatismos del Brazo/psicología , Traumatismos del Brazo/rehabilitación , Traumatismos de la Espalda/etnología , Traumatismos de la Espalda/psicología , Traumatismos de la Espalda/rehabilitación , Cultura , Escolaridad , Emigrantes e Inmigrantes/psicología , Emigrantes e Inmigrantes/estadística & datos numéricos , Femenino , Predicción , Humanos , Entrevista Psicológica , Lenguaje , Traumatismos de la Pierna/etnología , Traumatismos de la Pierna/psicología , Traumatismos de la Pierna/rehabilitación , Actividades Recreativas , Masculino , Persona de Mediana Edad , Traumatismo Múltiple/etnología , Traumatismo Múltiple/psicología , Traumatismo Múltiple/rehabilitación , Enfermedades Musculoesqueléticas/etnología , Enfermedades Musculoesqueléticas/psicología , Traumatismos Ocupacionales/etnología , Traumatismos Ocupacionales/psicología , Estudios Prospectivos , Psicología , Curva ROC , Reproducibilidad de los Resultados , Encuestas y Cuestionarios , Suiza/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Low vitamin D status increases the risk of stress fractures. As ultraviolet (UV) light is required for vitamin D synthesis, low UV light availability is thought to increase the risk of vitamin D insufficiency and poor bone health. The purpose of this investigation was to determine if individuals with low UV intensity at their home of record (HOR) or those with darker complexions are at increased risk of developing stress fractures and lower limb fractures during U.S. Army Basic Combat Training (BCT). METHODS: This was a retrospective cohort study using the Armed Forces Health Surveillance Center data repository. All Basic trainees were identified from January 1997 to January 2007. Cases were recruits diagnosed with stress fractures and lower limb fractures during BCT. The recruit's home of record (HOR) was identified from the Defense Manpower Data Center database. The average annual UV intensity at the recruits' HOR was determined using a U.S National Weather Service database and recruits were stratified into low (≤3.9); moderate (4.0-5.4), and high (≥5.5) UV index regions. Race was determined from self-reports. RESULTS: The dataset had 421,461 men and 90,141 women. Compared to men, women had greater risk of developing stress fractures (odds ratio (OR) = 4.5, 95% confidence interval (95%CI) = 4.4-4.7, p < 0.01). Contrary to the hypothesized effect, male and female recruits from low UV index areas had a slightly lower risk of stress fractures (male OR (low UV/high UV) = 0.92, 95%CI = 0.87-0.97; females OR = 0.89, 95%CI = 0.84-0.95, p < 0.01) and were at similar risk for lower limb fractures (male OR = 0.98, 95%CI = 0.89-1.07; female OR = 0.93, 95%CI = 0.80-1.09) than recruits from high UV index areas. Blacks had lower risk of stress and lower limb fractures than non-blacks, and there was no indication that Blacks from low UV areas were at increased risk for bone injuries. CONCLUSIONS: The UV index at home of record is not associated with stress or lower limb fractures in BCT. These data suggest that UV intensity is not a risk factor for poor bone health in younger American adults.
Asunto(s)
Fracturas por Estrés/diagnóstico , Fracturas por Estrés/etnología , Traumatismos de la Pierna/diagnóstico , Traumatismos de la Pierna/etnología , Personal Militar , Rayos Ultravioleta , Adolescente , Adulto , Estudios de Cohortes , Etnicidad/etnología , Femenino , Fracturas Óseas/diagnóstico , Fracturas Óseas/etnología , Humanos , Masculino , Grupos Raciales/etnología , Estudios Retrospectivos , Factores de Riesgo , Estados Unidos/etnología , Adulto JovenRESUMEN
BACKGROUND AND OBJECTIVE: Delay in seeking medical care is one criterion used to identify victims of abuse. However, typical symptoms of accidental fractures in young children and the time between injury and the seeking of medical care have not been reported. We describe patient and injury characteristics that influence the time from injury to medical care. METHODS: Parental interviews were conducted for children <6 years old with accidental extremity fractures. Demographic characteristics, signs and symptoms of the injury, and fracture location and severity were described and examined for their association with a delay (>8 hours) in seeking medical care. RESULTS: Among 206 children, 69% had upper extremity fractures. The median time to the first medical evaluation was 1 hour, but 21% were seen at >8 hours after injury. Although 91% of children cried after the injury, only 83% were irritable for >30 minutes. Parents observed no external sign of injury in 15% of children, and 12% used the injured extremity normally. However, all parents noted at least 1 sign or symptom. Minority children (odds ratio [OR]: 2.54 [95% confidence interval [CI]: 1.18-5.47), those with lower extremity injuries (OR: 2.23 [95% CI: 1.01-4.90]), those without external signs of injury (OR: 3.40 [95% CI: 1.36-8.51]), and those with continued extremity use (OR: 3.26 [95% CI: 1.22-8.76]) were more likely to delay seeking medical care. CONCLUSIONS: Although some children did not manifest all expected responses, no child with an accidental fracture was asymptomatic. Delay in seeking medical care was associated with more subtle signs of injury; however, delays identified in minority patients are unexplained.
Asunto(s)
Traumatismos del Brazo/terapia , Conducta Infantil , Fracturas Óseas/terapia , Traumatismos de la Pierna/terapia , Traumatismos del Brazo/diagnóstico , Traumatismos del Brazo/etnología , Preescolar , Servicio de Urgencia en Hospital , Femenino , Fracturas Óseas/diagnóstico , Fracturas Óseas/etnología , Humanos , Lactante , Traumatismos de la Pierna/diagnóstico , Traumatismos de la Pierna/etnología , Masculino , Grupos Minoritarios , Aceptación de la Atención de Salud , Factores de TiempoRESUMEN
BACKGROUND: Recent studies have demonstrated that black patients receive substandard care compared with white patients across healthcare settings. The purpose of this study was to evaluate the association of race on the management (salvage vs. amputation) of traumatic lower extremity open fractures. METHODS: Data analysis was conducted using the American College of Surgeon's National Trauma Data Bank. Open tibial and fibular (OTFF) and open femoral (OFF) fractures among adults above the age of 18 were identified by International Classification of Diseases, 9th Revision codes. Injuries were identified as amputated based on the presence of one of three types of knee amputations. Statistical analysis included logistic regression stratified for sex, age, race, mechanism of injury, severity, and insurance type. RESULTS: From the National Trauma Data Bank, 10,082 OFF and 22,479 OTFF were identified. Amputation rates were 3.1% for OFF and 4.2% for OTFF. With age stratification, the ratio of amputation odds for blacks to amputation odds for whites (i.e., the Racial Odds for Amputation Ratio [ROAR]) demonstrated a significant interaction between black and age in both the OFF (p = 0.028) and OTFF (p = 0.008) groups. In younger patients, a lower ROAR (p = 0.016) favored salvage in blacks, while the ROAR in older patients favored amputation in blacks (p = 0.013). The higher prevalence of penetrating injuries in blacks only accounted for 12.7% of the lower ROAR among younger adults. CONCLUSIONS: There exists a racial disparity in the management of lower extremity open fractures. Older blacks have greater odds of amputation that is not explained by mechanism. In contrast, younger blacks have lower odds for amputation that is only partially explained by mechanism of injury.
Asunto(s)
Amputación Quirúrgica/estadística & datos numéricos , Fracturas Abiertas/cirugía , Disparidades en Atención de Salud/etnología , Traumatismos de la Pierna/cirugía , Adolescente , Adulto , Negro o Afroamericano/estadística & datos numéricos , Factores de Edad , Amputación Quirúrgica/métodos , Bases de Datos Factuales , Femenino , Fracturas del Fémur/diagnóstico , Fracturas del Fémur/etnología , Fracturas del Fémur/cirugía , Fijación Interna de Fracturas/métodos , Fijación Interna de Fracturas/estadística & datos numéricos , Fracturas Abiertas/diagnóstico por imagen , Fracturas Abiertas/etnología , Humanos , Incidencia , Puntaje de Gravedad del Traumatismo , Traumatismos de la Pierna/diagnóstico , Traumatismos de la Pierna/etnología , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Pronóstico , Radiografía , Estudios Retrospectivos , Medición de Riesgo , Fracturas de la Tibia/diagnóstico , Fracturas de la Tibia/etnología , Fracturas de la Tibia/cirugía , Resultado del Tratamiento , Estados Unidos , Población Blanca/estadística & datos numéricos , Adulto JovenAsunto(s)
Bombas (Dispositivos Explosivos) , Muerte , Traumatismos de la Pierna , Médicos , Bombas (Dispositivos Explosivos)/historia , Explosiones/historia , Historia del Siglo XIX , Traumatismos de la Pierna/etnología , Traumatismos de la Pierna/historia , Traumatismos de la Pierna/psicología , Prácticas Mortuorias/economía , Prácticas Mortuorias/educación , Prácticas Mortuorias/historia , Prácticas Mortuorias/legislación & jurisprudencia , Pacientes/historia , Pacientes/legislación & jurisprudencia , Pacientes/psicología , Médicos/economía , Médicos/historia , Médicos/legislación & jurisprudencia , Médicos/psicología , Federación de Rusia/etnologíaRESUMEN
The purpose of this article is to show the importance of traditional healers in primary health care (PHC) services. Most countries, despite adopting PHC, have not incorporated traditional healers into this service. The article also illustrates how traditional healers fulfil three of Morrell's four PHC objectives, and how incorporating traditional healers into health services will fulfil the fourth objective. The first contact between a black African patient and health care services usually takes place in the traditional healing system. Therefore health workers should realise that the traditional care system is important if PHC is to succeed. Traditional healers are the most important primary health care service in an African setting. This is highlighted by 2 cases described in the article.