Initial risk perception and feeling of preparedness of primary care physicians regarding the COVID-19 pandemic in Belgium, France and Spain in February 2020.

BACKGROUND: The knowledge of risk perceptions in primary care could help health authorities to manage epidemics. METHODS: A European multi-center cross-sectional study was conducted in France, Belgium and Spain to describe the perceptions, the level of anxiety and the feeling of preparedness of primary healthcare physicians towards the COVID-19 infection at the beginning of the pandemic. The factors associated with the feeling of preparedness were studied using multivariate logistic regressions. RESULTS: A total of 511 physicians participated to the study (response rate: 35.2%). Among them, only 16.3% (n=82) were highly anxious about the pandemic, 50.6% (n=254) had the feeling to have a high level of information, 80.5% (n=409) found the measures taken by the health authorities suitable to limit the spread of COVID-19, and 45.2% (n=229) felt prepared to face the epidemic. Factors associated with feeling prepared were: being a Spanish practitioner (adjusted OR=4.34; 95%CI [2.47; 7.80]), being a man (aOR=2.57, 95%CI [1.69; 3.96]), finding the measures taken by authorities appropriate (aOR=1.72, 95%CI [1.01; 3.00]) and being highly informed (aOR=4.82, 95%CI [2.62; 9.19]). CONCLUSIONS: Regarding the dramatic evolution of the pandemic in Europe in the weeks following the study, it appears that information available at this time and transmitted to the physicians could have given a wrong assessment of the spread and the severity of the disease. It seems essential to better integrate the primary care physicians into the information, training and protection channels. A comparison between countries could help to select the most effective measures in terms of information and communication.

[Validation of the SCORE index and SCORE for old people in the Castilla y Léon cardiovascular disease risk cohort]. / Validación del índice SCORE y el SCORE para personas mayores en la cohorte de riesgo de enfermedad cardiovascular en Castilla y León.

INTRODUCTION AND OBJECTIVES: The Systematic Coronary Risk Evaluation (SCORE) is the most extended index in Europe for overall cardiovascular risk assessment. This study aims to validate the calculated risk with the observed 10-year cardiovascular mortality in a population cohort aged 40 to 75 years. METHODS: In 2014 the SCORE and the SCORE OP (for older people) were calculated in a population aged 40 to 64 years-old and 65 to 75 years-old, respectively. In 2014 the 10-year mortality was estimated with the Kaplan-Meier estimator and survival model. Sensitivity, specificity, predictive values, risk ratio of a SCORE value≥5%, and the area under the curve (C statistic) were calculated. RESULTS: Cardiovascular mortality estimated by SCORE was 3 times higher than the observed mortality. The sensitivity of a SCORE≥5% was 20% in women and 28.6% in those less than 65 years old. Predictive positive values were also low, particularly in women with 0.6%. Neither women nor those aged less than 65 years had a significant C statistic. CONCLUSIONS: The SCORE index does not suitably reflect the cardiovascular mortality pattern in Castilla y León. The prediction models for morbidity and mortality need to be periodically updated in order to adjust the prevention and treatment protocols. The SCORE OP has better validity parameters than the SCORE calculated below that age.

Prevalence of cognitive impairment in Spain: The Gómez de Caso study in health sentinel networks. / Prevalencia de deterioro cognitivo en España. Estudio Gómez de Caso en redes centinelas sanitarias.

INTRODUCTION: Cognitive impairment, a clinical entity causing complete or partial intellectual dysfunction, is a major public health concern that poses a challenge for health and social services. The purpose of this study is to estimate the prevalence of this disorder in people aged 65 and older visiting the primary care physician in 5 health sentinel networks. METHOD: A sample of patients visiting their primary care doctor on 4 randomly selected days completed the Mini-Cog screening test. Diagnosis of cognitive impairment was confirmed with the Mini-Mental State Examination and the Alzheimer's Questionnaire. We estimated raw and adjusted rates using demographic and social variables. RESULTS: We included 4,624 patients from 5 autonomous communities and representing a population of 1,723,216 inhabitants. The adjusted prevalence rate was 18.5% (95% CI 17.3-19.7], with differences between sentinel networks. Women showed higher adjusted rates than men: 18.5 vs. 14.3%. The highest prevalence rate was observed in people aged 85 and older (45.3%); prevalence rates vary depending on education level and marital status. CONCLUSIONS: Cognitive impairment is a frequent reason for consultations in primary care. Its prevalence is higher in women and increases exponentially with age. A number of sensitive, validated tools have been proven useful in screening for and confirming cognitive impairment. Using these tools in primary care settings enables early treatment of these patients.

[Estimation of the prevalence of cerebral palsy in the Autonomous Community of Castilla y León (Spain) using a disabilities register]. / Estimación de la prevalencia de parálisis cerebral en la comunidad de Castilla y León mediante el registro de minusvalías.

INTRODUCTION: The prevalence of cerebral palsy in Western countries is estimated to be around 2 cases/1,000 inhabitants. The objective of this study was to estimate the prevalence of cerebral palsy in the Autonomous Community of Castilla y León and to assess potential differences among the nine provinces of this region. PATIENTS AND METHODS: The number of patients with CP in 1999, separated by provinces and by age groups, was obtained from the Community Sectorial Program for Persons with Disabilities. These data originally came from handicap evaluations carried out in each base center. Prevalences were calculated using population data from the National Institute of Statistics. RESULTS: A total of 335 patients aged 0-13 years were registered as having a diagnosis of cerebral palsy in 1999. The prevalence of cerebral palsy was 1.05 cases/1,000 inhabitants aged 0-13 years. Statistically significant differences were found in the prevalence of cerebral palsy among provinces (p < 0.0001). The highest prevalence was found in Salamanca, with 1.87 cases/1,000 inhabitants, while the lowest prevalence was found in Segovia, with 0.33 cases/ 1,000 inhabitants. CONCLUSIONS: The prevalence of cerebral palsy in childhood in Castilla y León was lower than that reported in western countries. Substantial differences were found among provinces. The prevalence of cerebral palsy is probably underreported in some provinces. These differences could be due to a disparity in diagnostic criteria, especially in young children.

Deep-vein thrombosis in high-energy skeletal trauma despite thromboprophylaxis.

We report the incidence and location of deep-vein thrombosis in 312 patients who had sustained high-energy, skeletal trauma. They were investigated using magnetic resonance venography and Duplex ultrasound. Despite thromboprophylaxis, 36 (11.5%) developed venous thromboembolic disease with an incidence of 10% in those with non-pelvic trauma and 12.2% in the group with pelvic trauma. Of patients who developed deep-vein thrombosis, 13 of 27 in the pelvic group (48%) and only one of nine in the non-pelvic group (11%) had a definite pelvic deep-vein thrombosis. When compared with magnetic resonance venography, ultrasound had a false-negative rate of 77% in diagnosing pelvic deep-vein thrombosis. Its value in the pelvis was limited, although it was more accurate than magnetic resonance venography in diagnosing clots in the lower limbs. Additional screening may be needed to detect pelvic deep-vein thrombosis in patients with pelvic or acetabular fractures.

[Factors associated with control of hypertension in the cohort from the study of Cardiovascular Disease Risk in Castilla y León (RECCyL)]. / Factores asociados al control de la presión arterial en la cohorte del estudio del Riesgo de Enfermedad Cardiovascular en Castilla y León (RECCyL).

INTRODUCTION: Cardiovascular diseases and related risk factors suppose a challenge to public health due to the mortality and health costs involved. This study has aimed to assess the blood pressure control in a population cohort and to identify the factors associated with poor control. MATERIAL AND METHODS: A cardiovascular health examination was carried out in a random sample of 4013 individuals aged 15 years and above who were living in Castilla y Leon in 2004. The study included the medical history, physical exam and blood tests. A new health study was performed in 2009, including 2954 people from the initial sample, 1306 of whom were patients with hypertension. Strict blood pressure control was defined as <140/90 mm Hg. Bivariate analysis was performed and odds ratio was calculated by a regression logistic model. RESULTS: Blood pressure levels were above the established levels in 55.9%, without differences between men and women. The regression model showed that diabetes, obesity, smoking habit and previous systolic blood pressure values, with odds ratio of 3.87, 1.58, 1.49 and 1.13 per 5 mm Hg, respectively, are independently associated with uncontrolled blood pressure. Age did not show statistical significance. CONCLUSION: More than half of the patients with hypertension are not well controlled. This study provides information about the characteristics of the patients with poor control of hypertension in Castilla y León, which will allow policy makers to develop new primary and secondary prevention activities.

A prospective evaluation of the timing of postoperative radiotherapy for preventing heterotopic ossification following traumatic acetabular fractures.

PURPOSE: Preoperative and immediate postoperative irradiation of traumatic acetabular fractures (TAF), although known to reduce heterotopic ossification (HO), can cause significant organizational and logistic difficulties. We sought to determine an acceptable time interval between surgery and radiation without compromising control, as well as to update our large experience and to further validate our treatment philosophy. METHODS AND MATERIALS: Beginning in June 1995, we began a prospective study, irradiating 152 patients on postoperative days 1, 2, or 3. There were also 17 patients delayed further secondary to medical difficulties. RESULTS: All patients treated since June 1995 received 700 cGy/1 fx. Fifty-eight patients received radiation within 24 hours of surgery, 41 within 2 days, 53 within 3 days, 13 within 4 days, and 4 were delayed further. Delaying irradiation for up to 4 days postoperatively caused no statistical increase in HO (p = 0.625). Of 263 patients in our retrospective cohort, HO occurred in 5.3% of patients who received irradiation versus 60% of patients who did not. CONCLUSION: In our prospective study, we noted no perceptible increase in HO with up to a 3-day interval between surgery and radiotherapy. This allows a more structured treatment schedule and allows the patient more time to heal and recover. Updated results from our overall series continue to demonstrate that adjuvant radiation decreases the incidence and severity of HO after TAF.

The management of complex orthopedic injuries.

As advancements are made in the prevention of automobile fatalities, an increase in the incidence of pelvic and lower extremity injuries has occurred. These remain the leading causes of impairment and loss of years of productive life. Pelvic trauma has a high initial mortality rate when severe. However, with early resuscitation and transport, more survivors arrive in our trauma centers harboring these injuries. Owing to early stabilization and mobilization of the traumatized patient, a decrease in complications in these patients has been noted. Both the trauma surgeon and the orthopedic trauma surgeon should work as a team and remain in continuous communication during the treatment of these patients. Open fractures are among the most difficult problems to manage; early and aggressive decisions can prevent a lifetime of complications and physical impairment. As previously stated, to obtain good outcomes, open fractures must be treated initially at the accident scene followed by timely transport to the trauma center for definitive care. It must be remembered that the golden time to prevent major complications is 6 hours. Intra-articular fractures of the lower extremity involve a major weight bearing joint. Post-traumatic arthritis and impairment develop in joints where joint congruity is not achieved. To preserve normal function, there should be articular congruity, stable fixation, axial alignment with the rest of the extremity, and restoration of full range of motion. Immediate stabilization of long bone fractures has many advantages in the multiply injured patient, such as improved long-term function, prevention of deep venous thrombosis and decubitus ulcer, decreased need for analgesia, and reduction in the incidence of adult respiratory distress syndrome and fat emboli. Patients with femoral shaft fractures should undergo immediate stabilization of the fracture within 24 hours of injury. We have presented a series of orthopedic injuries that have high mortality and high morbidity which, if not treated expediently, yield a high degree of impairment.

Mechanical prophylaxis against deep-vein thrombosis after pelvic and acetabular fractures.

BACKGROUND: Deep-vein thrombosis is a common complication following pelvic and acetabular fractures. The hypothesis of this study was that pulsatile mechanical compression is superior to standard sequential mechanical compression for decreasing the prevalence of deep-vein thrombosis in patients with pelvic or acetabular fracture. METHODS: A prospective, randomized, blinded study of two methods of mechanical prophylaxis against deep-vein thrombosis was conducted. One hundred and seven patients were randomized into either Group A (fifty-four patients), in which a thigh-calf low-pressure sequential-compression device was used, or Group B (fifty-three patients), in which a calf-foot high-pressure pulsatile-compression pump was used. All patients underwent duplex ultrasonography and magnetic resonance venography. The two groups were comparable with regard to demographics, fracture type, fracture treatment, time from the injury to the prophylaxis, and patient compliance. RESULTS: Deep-vein thrombosis developed in ten patients (19%) in Group A, with seven (13%) having a large or occlusive clot and one (2%) having a documented pulmonary embolism. Deep-vein thrombosis developed in five patients (9%) in Group B, with two (4%) having a large or occlusive clot and none having a documented pulmonary embolism. Nine of the nineteen detected thromboses were in the deep pelvic veins. The difference in the prevalence of large or occlusive clots between the two groups demonstrated a trend but, with the numbers available, was not significant (p = 0.16). Increased patient age and the time elapsed from the injury to the surgery were found to be associated with higher rates of thrombosis. CONCLUSIONS: Pulsatile compression was associated with fewer deep-vein thromboses than was standard compression, with the difference representing a trend but not reaching significance with the number of patients studied.

Bridging bone gaps with the Ilizarov technique. Biologic principles.

For the treatment of bone gaps of less than 4 cm, cancellous autografting remains the treatment of choice. But for gaps exceeding 4 cm, the distraction osteogenesis is a viable option. The following conditions should be satisfied: (1) patient selection; (2) stable fixation; (3) osteotomy by corticotomy; (4) 7- to 14-day latency period before initiating distraction; and (5) a controlled rate and rhythm of distraction of 1 mm per day (0.25 mm, four times a day). This type of treatment leaves the pathologic focus alone, and bone healing occurs on the healthy bone. The quality of bone regenerate may be improved by a motorized unit and by better soft-tissue coverage using early grafts and flaps. Interface healing is probably improved by cancellous grafting and internal fixation after the transport period, thus decreasing the fixator time.

The use of the Ilizarov concept with the AO/ASIF tubular fixateur in the treatment of segmental defects.

For the treatment of segmental defects of less than 4 cm, cancellous autografting remains the treatment of choice. Pedicled or free cortical grafts (fibula, ribs, iliac crest) often are not strong enough, particularly when used in the femur. Allografts, especially appealing because of the theoretic unlimited supply, should not be considered for segmental diaphyseal defects because they remain dead spacers, remodelled only very slowly and incompletely, and are often complicated by late infection. The technique of distraction histogenesis used by Putti and Anderson, improved and further differentiated towards corticotomy and fragment transport by Ilizarov, is a further possibility of treating long, segmental bone defects. Already clinical and experimental data clearly show that the effect of distraction histogenesis can be obtained using many different types of external fixators. Therefore, we should use as simple a fixator construction as possible. The standard unilateral sagittal frame we suggest is derived from a two-tube AO fixator using only a few additional elements. The majority of cases with segmental defects and minor additional axial or rotational deformities (which can be corrected primarily) can be treated with such a fixator. The quality of the regenerate may be improved with a motorized, continuous transport system and by better soft-tissue coverage using early flaps. Interface healing is very probably improved by cancellous grafting and internal fixation after the transport period, thus decreasing the fixator time.

Closed interlocking nailing of the femur complicated by an intramedullary calcified lesion.

The interlocking intramedullary nail has greatly expanded the indications for closed intramedullary nailing of the femur. We describe a complication caused by the presence of a calcified lesion located at the proximal metaphyseal-diaphyseal junction of the femur. This lesion could not be penetrated by hand reamers. We used a long 3.5-mm drill bit to place a hole in the infarct, which then allowed passage of the hand reamer. The operation then proceeded in the standard fashion without complications.

External fixation of the femur.

External fixation of the femur remains a viable option in the acute treatment of fractures or in reconstructive procedures. As in any method of fixation, the surgeon must be familiar with the device used, the mechanical properties of the device, the application technique of such devices, and, most importantly, the postoperative management of the patient.

[Ischemic heart disease risk in the west Valladolid health area]. / Riesgo de enfermedad isquémica del corazón en el área de salud de Valladolid oeste.

INTRODUCTION AND OBJECTIVES: Cardiovascular diseases, especially ischemic heart disease present a high morbidity and mortality rate in our country. The aim of this study is to estimate the average coronary risk of people living in the west Valladolid Health District. METHODS: Cross-sectional study in a random sample of 369 people between 35 and 64 years of age from the general population, of systolic blood pressure, total serum cholesterol and cigarette smoking. With these three factors, plus sex and age, individual coronary risk was calculated through the Dundee Coronary Risk-Disk method. RESULTS: The coronary risk in the studied district, which is to say the individual probability of suffering a coronary event within five years of life, was estimated in 5.22 (95% CL: 4.75-5.69), higher among men, 5.66 (95% CL: 4.95-6.36), than among women, 4.63 (95% CL: 4.15-5.11). A descendent trend in coronary risk as age increases was found. CONCLUSIONS: This method is relatively easy to obtain for community studies and simple to use for individual risk. The coronary risk of a person from the studied population has similar levels to figures found in other studies from our settings. The community levels of isolated coronary risk factors do not permit the establishment the best option in coronary risk control, and only a multicausal approach will allow us to evaluate the most efficient interventions for each age group and sex.

Use of the AO/ASIF external fixator in children.

Sixteen children with 20 fractures were treated with the AO/ASIF tubular fixator (Synthes, Ltd., Paoli, PA). Most of the fractures were open, but the fixator was also used in closed fractures in children with head injuries or other forms of trauma. There were 10 fractures of the tibia, 5 of the femur, 3 of the pelvis, and 2 involving the humerus. Average follow-up was 26 months, with the fixators in place for an average of 7 weeks. Fracture union occurred after an average of 16 weeks. This system is easier to apply, less complicated, and lighter than other types of fixators.

Controversies in acetabular fractures.

Open reduction and internal fixation has become the standard of care for the treatment of most displaced acetabular fractures. As surgical techniques have become refined, long term results of surgical fixation have improved. During the past 10 to 15 years, several controversies have surfaced in the orthopaedic literature regarding the treatment of acetabular fractures. The recent literature regarding acetabular fixation was reviewed. Controversies include the most efficacious surgical approach for complex acetabular fractures; the effectiveness of intraoperative sciatic nerve monitoring; the most effective method of prophylaxis against deep vein thrombosis; and the indications for and method of prophylaxis against heterotopic bone formation.

Lawn mower injuries in children: a preventable impairment.

Every year there are seven million new lawn mowers purchased in the United States, each of which is capable of injuring young children, especially those > 14 years of age. A total of 33 children injured by a lawn mower were reviewed to identify the mechanism of injury, to determine the factors responsible for the accident, to determine an effective treatment regime, and to evaluate the permanent impairment for these patients. Classified according to their mechanism of injury, 14 children were injured as bystanders, 13 injured as riders, and six injured as operators. Categorized according to the anatomical location of injury, there were eight head and eye injuries, 12 upper extremity injuries, and 13 lower extremity injuries. There were 13 amputations (39.3%). The treatment management was satisfactory, but 23 children had an impairment > 40% of the whole person. We believe that the incidence of these injuries can be reduced by public awareness. Each orthopaedic surgeon should take on the task of educating the public about the dangers and wounding capacity of these machines and instructing the proper safety precautions that should be taken when mowing the lawn, especially when children are involved. The bottom line is that children should not be allowed in the yard while the lawn is being mowed nor should they be allowed to mow the lawn until they are > or = 15 years of age.

The etiology of valgus angulation after metaphyseal fractures of the tibia in children.

We conducted a retrospective study of proximal metaphyseal fractures of the tibia in children who developed valgus deformities. We reviewed the cases in an effort to determine the most likely etiology of post-fracture tibia valga, which occurs despite careful treatment and follow-up. We reviewed seven major theories presented in the literature regarding the etiology of this problem. Our conclusion was that all the theories were not prerequisites for the development of valgus angulation, but rather may be secondary mechanisms. We suggest that the most likely primary mechanism is an increased vascular response causing an asymmetric growth stimulation of the medial metaphysis of the proximal tibia.

The Altdorf hip clamp.

Forty-one osteotomies internally fixed with the Altdorf hip clamp were reviewed at Nemours Children's Hospital (Jacksonville, FL). They were divided according to pathology: cerebral palsy, 19 patients; congenital dislocated hip, 2 patients; Legg-Calvé-Perthes disease, 8 patients; and other, 2 patients. There were 15 boys and 18 girls, with an average age of 6.9 years (range 2.6-12 years). No intraoperative complications have been reported. Long-term complications are as follows: nonunion, one patient; superficial wound infection, one patient; and loss of position of greater than 15 degrees, two patients.