Factors Impacting Fall Severity in Hospitalized Patients: A Retrospective Cohort Study.

Objectives: This retrospective case-controlled study aimed to evaluate the association between the severity of fall-related injuries and fall-risk-increasing drugs (FRIDs) in hospitalized patients. Methods: Data were collected from Changhua Christian Hospital, Taiwan, of all adult inpatients who experienced falls between January 2017 and December 2021, and were divided into two groups based on whether they sustained severe fall-related injuries. Retrospective data that may affect the severity of fall-related injuries and the use of FRIDs were investigated. Results: Among 1231 documented cases of falls, 26 patients sustained severe fall-related injuries. Older patients and those with osteoporosis were more susceptible to more severe injuries from a fall. The use of mobility aids and osteoporosis medications showed protective effects against fall injuries. No significant association was observed between fall-related injuries and comorbidities or FRIDs. Multivariate analysis confirmed the inverse correlation between the use of mobility aids, osteoporosis medications, and fall severity. Patients with osteoporosis exhibited significantly higher odds of sustaining more severe injuries with a fall (odds ratio = 3.02, 95% confidence interval: 1.21-7.53). Conclusions: This study highlights the importance of addressing risk factors associated with fall severity among hospitalized patients. Providing mobility aids to persons at greater risk.

Associations between doses of fall-risk-increasing drugs (FRIDs) and falls of hospitalized patients.

Falls are a serious public health problem in the aging population because of the associated clinical and socioeconomic impact. Although previous studies have investigated fall-risk-increasing drugs (FRIDs), few studies have focused on dosage among adult inpatients. This study aimed to evaluate associations between fall risk and dosage of different FRIDs classes in hospital inpatients. Inpatients who experienced falls at medical or surgical wards of Changhua Christian Hospital from January 2017 to December 2021 were identified and matched by age, sex, and hospital ward to randomly selected controls (four per case). Anonymous patient data were extracted from the hospital medical data repository, including demographic characteristics, comorbidities, fall-risk scores, and drug prescriptions. Medication dosages were computed using the anatomical therapeutic chemical classification and the defined daily dose system of the World Health Organization. A total of 852 cases and 3408 controls were identified as eligible. Reducing the use of CNS-active medications, administering lower doses of sedative-hypnotics, prescribing sufficient dopaminergic anti-Parkinson agents, and using NSAIDs instead of opioids are imperative in preventing falls among hospitalized patients according to the findings in the study.

Functional outcome prediction of ischemic stroke patients with atrial fibrillation accepting post-acute care training.

Background: Ischemic stroke poses a major threat to human health and represents the third leading cause of death worldwide and in Taiwan. Post-acute care (PAC) training has been reported to be beneficial for post-index stroke events. However, knowledge is still lacking on the outcome of stroke events with cardiac origin. The focus of the current study is to investigate the effectiveness of PAC in this subgroup of patients as well as identify key baseline pointers that are capable of early prediction of patients' physical recovery. In addition, the authors hypothesize that the routinely arranged non-invasive carotid duplex that evaluates the characteristics of the carotid lumen could play a significant role in providing an early outcome prediction. Methods: For the current research, 142 ischemic stroke patients with underlying cardiac arrhythmia (atrial fibrillation) were retrospectively recruited. The patients' basic demographics, neuroimaging, carotid duplex, and basic biochemistry datasets were accurately documented. The pre and post-admission National Institutes of Health Stroke Scale (NIHSS) (6-month follow-ups), Barthel Index, and mRS score (12-month follow-ups) were also recorded. All statistical analyses were performed using R for Windows (version 3.6.3). Barthel Index, NIHSS, and mRS scores obtained before and after hospitalization were compared to determine the patients' outcomes and were classified as improved or unimproved. A multivariate logistic analysis was designed and applied to assess the significance of risk factors and to obtain the odds ratios (ORs). The receiver operating characteristic (ROC) curve and the Youden Index was used to find the important cut-off point information, and the area under the curve (AUC) was calculated to provide accuracy. Results: The average age of the 142 ischemic stroke patients enrolled in the current study was about 66 years, of which 88 patients were male and 54, female. Many of them had other comorbidities: 86 patients had mixed hyperlipidemia (60.56%), 115 had hypertension (80.99%), and 49 suffered from diabetes mellitus (34.51%). The mRS showed an improvement in the condition of only 40 patients (28.175%), whereas the Barthel Index showed improvement in 71 patients (50%), and 68 patients (47.89%) showed recovery on the NIHSS. The Barthel Index and NIHSS were selected because they already had an almost equal number of samples among the improved and unimproved groups (50%), rather than mRS, which had a lower number (28.17%) of improved cases. While conducting the EuroQol-5 Dimension (EQ-5D) assessment, anxiety/depression stood out as the most prominent issue, affecting 44 patients (30.99%). Self-care was another factor that was involved in the ongoing improvement of 36 patients (25.35%). Multivariate logistic analysis of both NIHSS and Barthel Index showed improvement with a contralateral plaque index statistical significance (P<0.05), whereas NIHSS showed a relevant significance in anxiety/depression and Barthel Index registered usual activity in the data analysis (P<0.05). ROC curve and Youden index analysis showed similar results in both NIHSS and Barthel Index of contralateral plaque index of 4.5, this being the cutoff point value for this group of patients. Conclusion: In the current study, nearly half of the enrolled patients showed favorable functional recovery. The outcome assessments seem to correlate well with NIHSS and Barthel Index scores, rather than mRS. The anxiety/depression and usual activities domains of the EQ-5D results are associated with and have a great impact after the patients undertake the PAC rehabilitative strategy. Moreover, the variables obtained through carotid duplex and plaque index might also play a significant role in determining the patient's functional outcome.

Exploring the Effectiveness of PAC Rehabilitation for Elders with Hip Surgery: A Retrospective Study.

BACKGROUND: Hip fractures are high risk and high-impact events in the elderly population; despite orthopedic hip surgery, the disability and mortality rate remains significant. The National Health Insurance Agency in Taiwan established a fragility fracture PAC rehabilitation program to provide functional recovery for these patients after the surgery. However, the current literature on PAC rehabilitation is outdated, and there is an urgent need for the re-evaluation of the program. METHODS: This is a retrospective cohort study that enrolled 159 patients in the PAC rehabilitation program, followed by hip repair surgery. Outcome measures were the differences in participants' pre- and post-PAC scores in 1) Barthel index, 2) Numerical Rating Scale (NRS), and 3) Harris Hip Scores (HHS) as surrogate indicators of the functional status, followed by the analysis of subgroups, including sex, age, site of the fracture, type of procedure, and the number of comorbidities. RESULTS: After completing PAC rehabilitation, 86.2% of the patients successfully returned to the community with either home or out-patient rehabilitation. The re-admission rate was 3.1% and 3.8% in 14-days and in 30-days follow up, respectively. The difference in pre- and post-Barthel index, NRS, and HHS showed significant improvement (p<0.001), without significant variations between the subgroups. Additionally, the Barthel index showed a positive correlation to HHS and a negative correlation to NRS. CONCLUSION: This study revealed that the current form of post-surgery fragility fracture PAC program effectively improves functional status, reduces the re-admission rate, and facilitates the patient transition back to the community. The results should improve patients' and physicians' confidence in such a program.

Bilateral anterior shoulder dislocation as a result of manipulation: A case report.

RATIONALE: Bilateral anterior shoulder dislocation is clinically rare and has been reported to be related to high-speed sports. PATIENT CONCERNS: A 76-year-old woman presented with bilateral shoulders pain after traditional Chinese manipulation. DIAGNOSES: She was diagnosed with bilateral anterior dislocations, and a closed reduction was immediately performed. INTERVENTION: The patient was referred for rehabilitation 3 days later, and bilateral rotator cuff injuries were identified from musculoskeletal ultrasound. After 4 weeks of physical therapy, the patient's shoulder pain had reduced and the passive ROM was nearly full. OUTCOMES: At 1-year follow-up, only mild intermittent shoulder pain was noted, and there was no limitation of shoulder ROM. LESSONS: This case illustrates that patients with acute shoulder injuries who receive proper diagnosis and treatment can achieve good outcomes. Therefore, patients with musculoskeletal disorders should seek qualified specialists for accurate diagnosis and appropriate management.

Gait asymmetry, ankle spasticity, and depression as independent predictors of falls in ambulatory stroke patients.

BACKGROUND: Falls are the leading cause of injury in stroke patients. However, the cause of a fall is complicated, and several types of risk factors are involved. Therefore, a comprehensive model to predict falls with high sensitivity and specificity is needed. METHODS: This study was a prospective study of 112 inpatients in a rehabilitation ward with follow-up interviews in patients' homes. Evaluations were performed 1 month after stroke and included the following factors: (1) status of cognition, depression, fear of fall and limb spasticity; (2) functional assessments [walking velocity and the Functional Independence Measure (FIM)]; and (3) objective, computerized gait and balance analyses. The outcome variable was the number of accidental falls during the 6-month follow-up period after baseline measurements. RESULTS: The non-faller group exhibited significantly better walking velocity and FIM scale compared to the faller group (P < .001). The faller group exhibited higher levels of spasticity in the affected limbs, asymmetry of gait parameters in single support (P < .001), double support (P = .027), and step time (P = .003), and lower stability of center of gravity in the medial-lateral direction (P = .008). Psychological assessments revealed that the faller group exhibited more severe depression and lower confidence without falling. A multivariate logistic regression model identified three independent predictors of falls with high sensitivity (82.6%) and specificity (86.5%): the asymmetry ratio of single support [adjusted odds ratio, aOR = 2.2, 95% CI (1.2-3.8)], the level of spasticity in the gastrocnemius [aOR = 3.2 (1.4-7.3)], and the degree of depression [aOR = 1.4 (1.2-1.8)]. CONCLUSIONS: This study revealed depression, in additional to gait asymmetry and spasticity, as another independent factor for predicting falls. These results suggest that appropriate gait training, reduction of ankle spasticity, and aggressive management of depression may be critical to prevent falls in stroke patients.

Potential risk of malposition of nasogastric tube using nose-ear-xiphoid measurement.

BACKGROUND: Correct placement of nasogastric tubes provide proper functionality and maximize benefit and minimize risk. The Nose-Ear-Xiphoid (NEX) body surface estimate method is a long-lasting technique, and this study was conducted to evaluate the correlation between NEX method and the secure insertion depth of nasogastric tube. MATERIALS AND METHODS: Thirty patients with nasogastric tube insertion who received whole body positron emission tomography with computerized tomography scan (PET-CT) were recruited. All data were gathered in the image center, which included Nose-Ear (NE), Ear-Xiphoid (EX), Nose-Ear-Xiphoid (NEX), glabella-xiphoid (GX) and glabella-umbilicus (GU) lengths. The distances of the inserted portion of the nasogastric tube between the cardiac and the nostril were measured by multiplanar reconstruction algorithm. RESULTS: Only one patient successfully placed all side-holes into the stomach while using NEX method to estimate inserting depth. Twenty-nine patients (96.7%) failed to place correctly. Fourteen participants had one or more side-holes in both the esophagus and the stomach sides. Fifteen patients could not pass through any side-hole across the gastroesophageal junction. They had shorter EX distances (p = 0.02), but no difference among the NE distances. Body height had the highest statistical correlation with nasogastric tube length (adjusted R(2) = 0.459), as compared with the NEX, GX and GU body surface methods. CONCLUSION: This study suggests that NEX method is inappropriate for adult patients to estimate the ideal inserting length of nasogastric tube. Physicians should realize these underinsertions with any side-hole above the gastroesophageal junctions may increase the potential risk of complications.

Feasibility of a novel two-piece nasogastric feeding tube for patients with dysphagia.

INTRODUCTION: The exposed section of a traditional nasogastric (NG) tube can interfere with patients' social activities and thereby result in distress. This study was conducted to evaluate the feasibility and safety of a novel two-piece NG tube for patients with dysphagia. METHODS: Ten patients with dysphagia were recruited between November 2011 and May 2012. Patients who were unconscious or in critical condition, had a traditional NG tube < 50 cm or > 60 cm in fixed length, or were unable to follow instructions or sign consent forms were excluded. The two-piece NG tube, which was placed in the patients for one week, comprised a removable external tube that can be joined to an internal tube via a T-connector, which was placed close to the naris. Events related to safety (e.g. nasal pressure sores, number of unplanned extubation, displacement and spontaneous migration of the NG tube, other unpredictable injuries) and effectiveness (e.g. liquid food spills, tube obstruction, perfusion rate, other adverse circumstances) were assessed daily. RESULTS: All patients received feeding without complication using the two-piece NG tube and none experienced premature removal of the tube. No serious NG tube complications or malfunctions were observed. CONCLUSION: The results of this study indicate that the two-piece NG feeding tube is a feasible option for patients with dysphagia. Future improvements to the connector may help enhance its performance. A rigorous randomised controlled trial to examine the effects of the two-piece NG tube on patients' quality of life and quality of medical care is being planned.

Relationship between severity of shoulder subluxation and soft-tissue injury in hemiplegic stroke patients.

OBJECTIVE: The aims of this study were: (i) to determine whether the severity of post-hemiplegic shoulder subluxation in stroke patients correlates with soft-tissue injury; and (ii) to determine the shoulder subluxation measurement cut-off points that are indications for further ultrasound examination for soft-tissue injuries in these patients. DESIGN: Cross-sectional study. PATIENTS: A total of 39 stroke patients with shoulder subluxation. METHODS: Shoulder subluxation was evaluated by physical examination, radiography and ultrasound. Soft-tissue injuries were assessed by ultrasound. Subluxation parameters were entered into stepwise logistic regression analyses to predict biceps and supraspinatus tendonitis. With the assumption that shoulder subluxation can be a predisposing factor for tendonitis, receiver operating characteristic curves for shoulder subluxation parameters of the affected side were used to determine cut-off points for optimal sensitivity and specificity of biceps and supraspinatus tendonitis. RESULTS: Shoulder subluxation lateral distance, measured by physical examination, is a predictor for supraspinatus tendonitis (odds ratio = 34.9, p = 0.036). Further ultrasound investigation for soft-tissue injury is indicated when subluxation lateral distance, measured by physical examination is ≥ 2.25 cm or, measured by radiographic examination, ≥ 3.18 cm for lateral distance, ≥ 3.08 cm for vertical distance, or ≥ 2.65 cm for horizontal distance. CONCLUSION: When post-hemiplegic shoulder subluxation measurements exceed the above-mentioned cut-off points in physical or radiographic examinations, further ultrasound evaluation for soft-tissue injury is recommended.

Spontaneous totally thrombosed pseudoaneurysm mimicking a tendon tear of the wrist.

Wrist pseudoaneurysm is commonly caused by iatrogenic procedures such as blood gas puncture, arterial-venous shunting for hemodialysis, or noniatrogenic causes such as blunt trauma. The mechanism of pseudoaneurysm formation is arterial wall damage with subsequent blood leakage that collects in surrounding tissue. This article presents a case of a 32-year-old woman who had sudden onset left wrist pain with a snap sound and a mass 1 cm in diameter after pulling a heavy object while working. A wrist flexor tendon tear was diagnosed after evaluation. Musculoskeletal ultrasound revealed a partially thrombosed pseudoaneurysm. The wrist pseudoaneurysm was totally thrombosed and symptoms subsided after 3 weeks of follow-up. This case study reminds us that pseudoaneurysm could be easily confused with other wrist diseases. We discuss the differential diagnosis and management of wrist pseudoaneurysm as a reference for clinical practice.

Acupuncture stimulation improves balance function in stroke patients: a single-blinded controlled, randomized study.

The disturbance of balance function is one of main etiology resulting in falling down in stroke patients. A number of studies report that acupuncture may improve the motor function of stroke patients. Therefore, the aim of the present study was to investigate the effect of acupuncture on balance function. We designed a single-blinded, controlled, randomized study. A total of 30 stroke patients were randomized into experimental and control groups. Experimental groups received acupuncture treatment accompanied by the manual twisting of needles and obtaining of qi (the subjects experienced sensations of soreness, numbness, swelling and heaviness, while the acupuncturist experienced a sensation of needle resistance), whereas the control group did not receive manual twisting of needles and without obtaining of qi. All of the subjects were first-time stroke patients; infarction location was limited to either the left or right hemisphere, and all subjects were able to walk for at least 6 meters. Acupuncture stimulation (AS) was applied to Baihui (GV 20) acupoint as well as to 4 spirit acupoints (1.5 cun anterior, posterior, left and right laterals from Baihui acupoint, respectively) for 20 min. Balance function outcome measures were: (1) the displacement area of the patient's center of gravity; (2) the time taken for a patient to stand vertically from a seated position; (3) the time taken for a patient to walk a distance of 6 meters; (4) muscle strength of both lower extremities. Results indicated that the displacement area from the center of gravity decreased in the experimental group, but not in the control group. There was greater reduction in the displacement area in the experimental group than in the control group. Following AS, the time taken to reach a standing position from a seated position, as well as the time taken to walk 6 meters was decreased equally in both the experimental and control groups. The muscle strength of the hip flexor and knee extensor were increased in the paralyzed and non-paralyzed sides of patients in the experimental group, but not in the control group. The results of the present study suggest that acupuncture stimulation may induce an immediate effect that improves balance function in stroke patients.

Exacerbation of symptoms of lumbar disc herniation complicated by a schwannoma: a case report.

Herniation of the lumbar disc is a common cause of low back pain. Conservative management with physiotherapy, such as lumbar spine traction, is usually effective. Although a schwannoma of the lumbar spine is relatively uncommon, the clinical manifestations are similar to those of lumbar disc herniation, making the diagnosis difficult. This case report describes a 51-year-old male who had suffered from low back pain for 3 years and who was diagnosed with L2/L3 lumbar disc herniation. The low back pain was well-controlled by conservative treatment and the symptoms improved progressively. Two months prior to our evaluation, however, the symptoms worsened acutely, and were accompanied by the onset of symptoms of cauda equina syndrome. A small tumor at the site of the L2/L3 disc herniation, observed incidentally during magnetic resonance imaging, was responsible for the symptoms of spinal stenosis at the lumbar region. The patient underwent laminectomy, tumor resection, and discectomy with near-complete resolution of symptoms. In patients with lumbar disc herniation that improves with conservative treatment, the recurrence of symptoms should prompt a thorough review of the medical history, physical examination, and imaging studies to establish the diagnosis and prevent delay in treatment.