Percutaneous Suspensory Stabilization of Chronic Distal Radioulnar Joint (DRUJ) Dislocation Using an Adjustable Loop Endobutton Construct: Case Report / Fixação suspensiva percutânea de luxação crônica da articulação radioulnar distal (ARUD) usando um dispositivo de endobutton de laço ajustável: Relato de caso

Abstract Chronic distal radioulnar joint (DRUJ) dislocation has been treated historically with complex osteotomies and reconstructive procedures, often resulting in intractable stiffness and loss of function. It is desirable to use a technique of fixation that will not only restore the wrist biomechanics but also be cosmetically appealing to the individual. We present a novel technique of reduction and fixation of a chronically dislocated DRUJ in a 26-year-old male using a minimally invasive approach, with successful restoration of DRUJ function and no postoperative complications.

Resumo Luxação crônica da articulação radioulnar distal (ARUD) foi tratada historicamente com osteotomias complexas e procedimentos reconstrutivos, geralmente resultando em rigidez intratável e perda de função. É desejável usar uma técnica de fixação que não apenas restaure a biomecânica do punho, mas também seja esteticamente atraente para o indivíduo. Apresentamos uma nova técnica de redução e fixação de uma ARUD deslocada cronicamente em um homem de 26 anos, usando uma abordagem minimamente invasiva, com restauração bem-sucedida da função da ARUD e sem complicações pós-operatórias.

Relative Prevalence of and Factors Associated with Anxiety and Depression in Degenerative Triangular Fibrocartilage Complex Lesion Patients - a Casecontrol Study.

Triangular fibrocartilage complex (TFCC) lesions are a common cause of ulnar wrist pain. Data, including mental status assessment, were prospectively collected from patients who underwent arthroscopy. The HADS was used to assess the prevalence of depression and anxiety. Patients with degenerative TFCC lesions were at an increased risk of anxiety and depression. Early screening for anxiety and depression in degenerative TFCC lesions patients should be recommended.

Comparison of the demographic and wound characteristics of non-suicidal and suicidal self-wrist cutting injuries.

Patients who commit self-wrist cutting injuries (SWCIs) are a heterogeneous group composed of patients with non-suicidal self-injury (NSSI) and suicide attempt (SA). The purpose of this study was to compare the demographic features and wound characteristics of patients with NSSI and SA.A retrospective review of 300 patients who visited the emergency department (ED) for treatment of SWCIs between January 2011 and December 2015 was performed. Data collected from the electronic medical records included age, sex, the reason for SWCIs, presence of suicidal ideation, concomitant intoxication with alcohol or drugs, past psychiatric history, whether or not the patient received psychiatric counseling at the ED, the principal psychiatric diagnosis, the number and severity of external wounds, and subsequent follow-up at the psychiatric or hand surgery outpatient department (OPD). The patients were divided into the NSSI and SA groups according to the presence of suicidal ideation and other variables were compared between the two groups.There were 138 NSSI patients and 162 SA patients. The NSSI group was younger (33.9 years vs 40.9 years, P < .01), more female-dominant, and more non-compliant with psychiatric treatment than the SA group. Compared with the SA group, fewer NSSI patients had past psychiatric histories (26.1% vs 45.7%, P < .01) and more patients refused psychiatric counseling (30.4% vs 9.9%, P < .01) and follow-up at the psychiatric OPD (8.0% vs 17.3%, P < .01). In contrast, the number (P = .31) and severity (P = .051) of wounds and the rate of follow-up at the hand surgery OPD (P = .43) were not statistically different between the two groups.Although the NSSI and SA groups showed different demographic features and degrees of compliance with psychiatric treatment, wound characteristics were not different between the two groups. Therefore, hand surgeons cannot estimate patients' suicidal intent based on wound characteristics and all patients should be advised to receive psychiatric treatment.

A hidden mismatch between experiences of young athletes with overuse injuries of the wrist and sports physicians' perceptions: a focus group study.

BACKGROUND: Although overuse wrist injuries can have serious consequences, young athletes often do not immediately report their injury to a physician. This qualitative study aimed to identify symptoms and limitations related to overuse wrist injuries that young athletes consider important and to compare those with sports physicians' opinions, in order to improve the diagnostic process for early identification of overuse wrist injuries. METHODS: Twenty-one athletes aged 13-25 years in wrist-loading sports (gymnastics, tennis, judo, field hockey, volleyball and rowing) with a (previous) overuse wrist injury were included. In five focus groups, participants discussed important signals and limitations of their injury, as well as a list of relevant items previously composed by sports physicians. Data were grouped into themes and (sub)categories and subsequently coded. RESULTS: Of the resulting 224 signals and 80 limitations, respectively 81 and 20 were labelled important. Athletes considered both pain and limitations during daily life activities important indicators of overuse wrist injury, as well as long pain duration, acute onset of pain, and accompanying symptoms like swelling, cracking and discoloration. All of the sports physicians' items were also considered important by the athletes, but sport-related pain and limitations were regarded by many athletes as a natural part of their sport. CONCLUSIONS: Discrepancies exist between the opinions of young athletes and sports physicians on sport-related pain reporting and competing regardless of pain or limitations. Although clinicians may be inclined to focus on these aspects, they are advised to also inquire specifically about limitations and pain during daily life activities in young athletes with overuse wrist injuries.

Patient-reported outcomes after a distal radius fracture in adults: a 3-4 years follow-up.

Background and purpose - There are few reports on the outcome of distal radius fractures after 1 year. Therefore we investigated the long-term patient-reported functional outcome and health-related quality of life after a distal radius fracture in adults. Patients and methods - We reviewed 823 patients, treated either nonoperatively or operatively in 2012. After a mean follow-up of 3.8 years 285 patients (35%) completed the Patient-Rated Wrist Evaluation (PRWE) and EuroQol-5D. Results - The mean PRWE score was 11. The mean EQ-5D index value was 0.88 and the mean EQ VAS for self-rated health status was 80. Nonoperatively treated type A and type B fractures had lower PRWE scores compared with operatively treated patients, whereas the EQ-5D was similar between groups. The EQ VAS for patients aged 65 and older was statistically significantly lower than that of younger patients. Interpretation - Patients had a good overall long-term functional outcome after a distal radius fracture. Patients with fractures that were possible to treat nonoperatively had less pain and better wrist function after long-term follow-up than patients who needed surgical fixation.

Hand Posturing Is a Nonverbal Indicator of Catastrophic Thinking for Finger, Hand, or Wrist Injury.

BACKGROUND: Prior research documents that greater psychologic distress (anxiety/depression) and less effective coping strategies (catastrophic thinking, kinesophobia) are associated with greater pain intensity and greater limitations. Recognition and acknowledgment of verbal and nonverbal indicators of psychologic factors might raise opportunities for improved psychologic health. There is evidence that specific patient words and phrases indicate greater catastrophic thinking. This study tested proposed nonverbal indicators (such as flexion of the wrist during attempted finger flexion or extension of uninjured fingers as the stiff and painful finger is flexed) for their association with catastrophic thinking. QUESTIONS/PURPOSES: (1) Do patients with specific protective hand postures during physical examination have greater pain interference (limitation of activity in response to nociception), limitations, symptoms of depression, catastrophic thinking (protectiveness, preparation for the worst), and kinesophobia (fear of movement)? (2) Do greater numbers of protective hand postures correlate with worse scores on these measures? METHODS: Between October 2014 and September 2016, 156 adult patients with stiff or painful fingers within 2 months after sustaining a finger, hand, or wrist injury were invited to participate in this study. Six patients chose not to participate as a result of time constraints and one patient was excluded as a result of inconsistent scoring of a possible hand posture, leaving 149 patients for analysis. We asked all patients to complete a set of questionnaires and a sociodemographic survey. We used Patient Reported Outcomes Measurement Information System (PROMIS) Depression, Upper Extremity Physical Function, and Pain Interference computer adaptive test (CAT) questionnaires. We used the Abbreviated Pain Catastrophizing Scale (PCS-4) to measure catastrophic thinking in response to nociception. Finally, we used the Tampa Scale of Kinesophobia (TSK) to assess fear of movement. The occurrence of protective hand postures during the physical examination was noted by both the physician and researcher. For uncertainty or disagreement, a video of the physical examination was recorded and a group decision was made. RESULTS: Patients with one or more protective hand postures did not score higher on the PROMIS Pain Interference CAT (hand posture: 59 [56-64]; no posture: 59 [54-63]; difference of medians: 0; p = 0.273), Physical Function CAT (32 ± 8 versus 34 ± 8; mean difference: 2 [confidence interval {CI}, -0.5 to 5]; p = 0.107), nor the Depression CAT (48 [41-55] versus 48 [42-53]; difference of medians: 0; p = 0.662). However, having at least one hand posture was associated with a higher degree of catastrophic thinking (PCS scores: 13 [6-26] versus 10 [3-16]; difference of medians: 3; p = 0.0104) and a higher level of kinesophobia (TSK: 40 ± 6 versus 38 ± 6; mean difference: -2 [CI, -4 to -1]; p = 0.0420). Greater catastrophic thinking was associated with a greater number of protective hand postures on average (rho: 0.20, p = 0.0138). CONCLUSIONS: Protective hand postures and (based on prior research) specific words and phrases are associated with catastrophic thinking and kinesophobia, less effective coping strategies that hinder recovery. Surgeons can learn to recognize these signs and begin to treat catastrophic thinking and kinesophobia starting with compassion, empathy, and patience and be prepared to add formal support (such as cognitive-behavioral therapy) to help facilitate recovery. LEVEL OF EVIDENCE: Level III, diagnostic study.

The impact of wrist fracture, surgical repair and immobilization on patients: a qualitative study.

OBJECTIVE: To investigate patients' experience following wrist fracture, surgical repair and immobilization. DESIGN: A qualitative investigation involving individual participant interviews. SETTING: A metropolitan trauma service. SUBJECTS: In all, 31 participants were consecutively recruited from three groups within a randomized controlled trial comparing immobilization for one ( n = 11), three ( n = 10) or six weeks ( n = 10) following surgical treatment for wrist fracture. INTERVENTION: Individual interviews were conducted within three months of cast removal. Questions prompted discussion of the experience of fracture, surgery and immobilization. Interviews were audio-recorded, transcribed verbatim. At least two independent researchers performed coding and theming following principles of thematic analysis. RESULTS: Two themes were identified: (1) impact of the injury varies widely and (2) health care consumers want trustworthy dialogue. Participant reports indicated that recovery from wrist fracture, surgery and immobilization is challenging with significant changes to social role and increased dependence. For many, lack of empathy from health professionals and limited acknowledgement of the personal impact of injury led to dissatisfaction. Health professionals did not consistently tailor communication or adopt strategies to address specific needs for pain management, education and support requirements. There was no evidence that processes were implemented to enhance participant recall and comprehension. Most participants experienced their cast as a barrier to function. However, within the group of participants immobilized for one week, a number felt the cast was removed too soon. CONCLUSION: Participant reports indicate that recovery from surgically repaired wrist fracture is challenging. Opportunities exist to refine care in pain management, education and active engagement of patients in their care.

[Influences of different rehabilitative methods on function of hands and psychological anxiety of patients with deeply burned hands retaining denatured dermis and grafting large autologous skin].

Objective: To investigate influences of different rehabilitative methods on function of hands and psychological anxiety of patients with deeply burned hands retaining denatured dermis and grafting large autologous skin. Methods: Forty-four patients with deeply burned hands, conforming to the study criteria were admitted to Department of Burns and Reconstructive Surgery of Xiangya Hospital of Central South University from January 2014 to June 2015. Patients were divided into propaganda education rehabilitation group (PER, n=23) and specially-assigned person rehabilitation group (SAPR, n=21) according to the random number table and patients' willingness. On post injury day 3 to 7, 36 burned hands in group PER and 33 burned hands in group SAPR underwent operation of retaining denatured dermis and grafting large autologous skin. Patients in 2 groups received anti-scar treatment of hands with silicone gel from postoperative day 10. Besides, patients in group PER underwent active functional exercise under guidance of duty nurse and received psychological guidance from duty nurse with grade two psychological consultant certificate. Patients in group SAPR underwent active and passive functional exercise under guidance of rehabilitation therapist and received psychological guidance from psychotherapist with intermediate title. In postoperative month (POM) 1, 3 and 6, ranges of active motion of burned finger joints of patients in 2 groups were measured with joint goniometer to calculate excellent and good ratio of total active motion (TAM) range. Values of grip strength of burned hands of patients were measured with electronic hand dynamometer, and psychological anxiety was scored with Self-rating Anxiety Scale (SAS). Data were processed with chi-square test, independent sample t test, McNemar test, analysis of variance of repeated measurement, SNK test and Bonferroni correction. Results: (1) Ratio of excellent and good of TAM range of burned finger joints of patients in group SAPR in POM 6 was obviously higher than that in group PER (χ(2)=10.745, P<0.0167 ). Ratio of excellent and good of TAM range of burned finger joints of patients in 2 groups in POM 3 were obviously higher than that in POM 1 of the same group, respectively (with P values below 0.0167). (2) Values of grip strength of burned hands of patients in group SAPR in POM 1, 3, and 6 were respectively (8.2±2.6), (21.6±2.6) and (30.1±2.3) kg, obviously higher than those in group PER [ (5.3±1.3), (12.8±2.7), (20.0±1.8) kg, respectively, with t values from 5.934 to 20.403, P values below 0.01]. Values of grip strength of burned hands of patients in 2 groups in POM 3 and 6 were obviously higher than those at the previous time point of the same group (with P values below 0.05). (3) SAS scores of patients in group SAPR in POM 1, 3 and 6 were significantly lower than those in group PER (with t values from 2.944 to 4.758, P values below 0.01). SAS scores of patients in 2 groups in POM 3 and 6 were significantly lower than those at the previous time point of the same group (with P values below 0.05). Conclusions: Compared with rehabilitation of propaganda and education, rehabilitation under specially-assigned person can improve TAM range of burned finger joints, value of grip strength, and psychological anxiety of patients with deeply burned hands retaining the denatured dermis and grafting large autologous skin.

Obstacles to the Care of Patients With Multicomponent Volar Wrist Lacerations at a County Hospital.

BACKGROUND: Multicomponent volar wrist lacerations of "spaghetti wrist" injuries are devastating injuries of the upper extremity. These patients require long-term commitment to rehabilitation. Patients presenting to our county hospital represent a unique and complex patient population in terms of psychosocial considerations. We aimed to identify obstacles to care and optimal recovery in this patient population. METHODS: A patient database was queried for ICD-9 codes related to major upper extremity nerve injuries, which were treated by plastic surgery faculty at San Francisco General Hospital from 2008 to 2014. A retrospective chart review was performed to identify patients with spaghetti wrist injuries. Charts were reviewed for patient demographics including age, occupation, handedness, psychiatric illness, isolated versus polytrauma, and employment status. Injuries were categorized for mechanism of injury, structures involved, and timing and method of surgical treatment. Outcomes were assessed for motor recovery, sensory recovery, and tendon function. RESULTS: We identified 18 patients with multicomponent volar wrist lacerations. Average patient age was 31 years. The most common mechanism of injury was accidental/work-related (n = 9, 50%), followed by self-inflicted (n = 4, 22%). Thirty-nine percent (n = 7) of patients had a psychiatric diagnosis, most commonly depression (n = 4, 22%). Eighty-nine percent (n = 16) of patients had an isolated injury to the upper extremity, and 39% (n = 7) had an injury to the dominant hand. Fifty percent (n = 9) of patients were lost to follow-up, with 28% (n = 5) having no known care plan. Motor, sensory, and tendon function outcomes for those with adequate follow-up were comparable to previously published studies. DISCUSSION: Multicomponent volar wrist lacerations can be devastating, and although we are able to provide patients with appropriate timely surgical care, these patients require long-term care far beyond the operating room for optimal outcomes. Psychiatric illness, socioeconomic limitations, poor patient compliance, and irregular follow-up are obstacles to care. These issues highlight the need for better social support systems and mental health care to provide access to the services necessary to optimize recovery.

Wrist fractures and their impact in daily living functionality on elderly people: a prospective cohort study.

BACKGROUND: Wrist fractures are the most common arm fractures in older adults. The impact of wrist fractures on daily functionality has been less studied than that of other types and so, less is known about the complexity of factors related to the functional impact of these fractures. This study is aimed to assess the role of individual and health care factors and its association with daily living functional changes after a wrist fracture. METHODS: A prospective cohort of patients aged 65 or more, affected by a fracture due to a fall, was conducted. These patients were identified at the emergency rooms of the six participating hospitals. As independent factors, the following were studied: socio-demographic data, characteristics of the fracture, health-related quality of life, wrist function and provided treatment. The main outcome was functional status measured by the Barthel Index for daily living basic activities and the Lawton Instrumental Activities of Daily Living (IADL) Scale for daily living instrumental activities. Data were collected at baseline just after the fall and after six months of follow-up. Patients were considered to have deteriorated if their functional status as measured by Barthel Index or Lawton IADL scores decreased in a significant way during the six months of follow up. RESULTS: Barthel Index and/or Lawton IADL scores fell at six months after the fracture in 33% of participants. This functional decline was more frequent in patients with comorbidity (p < 0.0001), polypharmacy (p < 0.0001), low health-related quality of life prior to the fall (p < 0.0001) and lower educational level (p = 0.009). The derived multivariate models show that patients that become dependent six months after the fall, have advanced age, severe chronic diseases, low functional performance prior to the fracture, and repeated episodes of accidental falls. This profile is consistent with a frailty phenotype. CONCLUSIONS: Wrist fractures are associated to the occurrence of dependence, especially in frail patients. These patients could benefit from being identified at the time the fracture is treated, in order to tackle their complex needs and so, prevent some of the burden of dependence generated by these fractures.

Self-cutting and risk of subsequent suicide.

BACKGROUND: Some studies suggest that people who self-cut have a higher risk of suicide than those who self-poison. Self-cutting ranges from superficial wrist cutting to severe self-injury involving areas such as the chest, abdomen and neck which can be life threatening. This study aimed to investigate whether the site of self-cutting was associated with risk of subsequent suicide. METHODS: We followed-up 3928 people who presented to hospital following self-harm between September 2010 and December 2013 in a prospective cohort study based on the Bristol Self-harm Surveillance Register. Demographic information from these presentations was linked with coroner's data to identify subsequent suicides. RESULTS: People who presented with self-cutting to areas other than the arm/wrist were at increased risk of suicide compared to those who self-poisoned (HR 4.31, 95% CI 1.27-14.63, p=0.029) and this increased risk remained after controlling for age, sex, history of previous self-harm and psychiatric diagnosis (HR 4.46, 95% CI 1.50-13.25, p<0.001). We observed no such increased risk in people presenting with cutting to the arm/wrist. LIMITATIONS: These data represent the experience of one city in the UK and may not be generalisable outside of this context. Furthermore, as suicide is a rare outcome the precision of our estimates is limited. CONCLUSIONS: Site of self-injury may be an important indicator of subsequent suicide risk.

Analysis of Deliberate Self-Wrist-Cutting Episodes Presenting to the Emergency Department.

BACKGROUND: Previous suicide attempts increase the risk of a completed suicide. However, a large proportion of patients with deliberate self-wrist cutting (DSWC) are often discharged without undergoing a psychiatric interview. AIMS: The aims of this study were to investigate the differences in the characteristics and outcomes of patients with DSWC and those with deliberate self-poisoning (DSP) episodes. The results of this study may be used to improve the efficacy of treatment for DSWC patients. METHOD: We retrospectively reviewed the medical records of 598 patients with DSWC and DSP who were treated at the emergency department of Seoul Saint Mary's Hospital between 2008 and 2013. We assessed sociodemographic information, clinical variables, the reasons for the suicide attempts, and the severity of the suicide attempts. RESULTS: A total of 141 (23.6%) patients were included in the DSWC group, and 457 (76.4%) were included in the DSP group. A significantly greater number of patients in the DSWC group had previously attempted suicide (p = .014). A total of 63 patients (44.7%) in the DSWC group and 409 patients (89.5%) in the DSP group underwent psychiatric interviews. CONCLUSION: More DSWC patients had previously attempted suicide, but fewer of them underwent psychiatric interviews compared with the DSP patients.

Power tool injuries to the hand and wrist.

Power tool injuries to the hand and wrist are complex injuries which can have a profound impact on the function of the patient. This article gives an overview of the principles, and provides a systematic approach, to the management and rehabilitation of the injured limb and patient required to minimize future disability.

The treatment of displaced intra-articular distal radius fractures in elderly patients.

BACKGROUND: From 2000 to 2012, the annual incidence of inpatient treatment for distal radius fracture in Germany rose from 65 to 86 per 100 000 persons. It is unclear whether open reduction and volar angle-stable plate osteosynthesis (ORIF), a currently advocated treatment, yields a better functional outcome or quality of life than closed reposition and casting. METHODS: In the ORCHID multi-center trial, 185 patients aged 65 and older with an AO type C distal radial fracture were randomly assigned to ORIF or closed reposition and casting. Their health-related quality of life and hand/arm function were assessed 3 and 12 months afterward with the Short Form 36 (SF-36) questionnaire and the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. The radiological findings, range of movement of the wrist, and EuroQol-5D (EQ-5D) scores were documented as well. RESULTS: Among the 149 patients in the intention-to-treat-analysis, there was no significant difference in SF-36 scores between the two treatment groups at one year (mean difference, 3.3 points in favor of ORIF; 95% confidence interval, -0.2 +6.8 points; p = 0.058). The DASH scores showed moderately strong, but clinically unimportant effects in favor of ORIF, and there was no difference in EQ-5D scores. ORIF led to better radiological results and wrist mobility at 3 months, with comparable results at 12 months. 37 of the patients initially allotted to nonsurgical treatment underwent secondary surgery due to significant loss of reduction. CONCLUSION: The findings with respect to mobility, functionality, and quality of life at 12 months provide marginal and inconsistent evidence for the superiority of volar angle-stable plate osteosynthesis over closed reduction and casting in the treatment of intra-articular distal radius fractures. Primary nonsurgical management is also effective in suitable patients.

Psychometric properties of two questionnaires in the context of total wrist arthroplasty.

INTRODUCTION: Patient-rated outcome measures are frequently used to assess the results of total wrist arthroplasty, but their psychometric properties have not yet been evaluated in this group of patients. The purpose of our study was to assess the psychometric properties of the Danish Quick Disabilites of Arm Shoulder and Hand (QuickDASH) and Patient-rated Wrist Evaluation questionnaires in patients with total wrist arthroplasty. METHODS: In a prospective cohort of 102 cases, we evaluated the QuickDASH. Furthermore, in a cross-sectional study and a test-retest on a subgroup of the patients, we evaluated the Patient-rated Wrist Evaluation. RESULTS: Internal consistency and reproducibility were very high (Cronbach's alpha 0.96/0.97; Spearman's rho 0.90/ 0.91; intraclass coefficient 0.91/0.92), and there were no floor or ceiling effects. The responsiveness of the QuickDASH was high (standardised response mean 1.06 and effect size 1.07). The construct validity of both scales was confirmed by three a priori formulated hypotheses: a moderate, negative correlation of scores with grip-strength; a moderate, positive correlation with pain and a very weak or no correlation with mobility. Rheumatoid patients scored significantly higher on the QuickDASH than other patients did. The scores of both questionnaires were very closely related. CONCLUSION: Both questionnaires are valid and equivalent for use in patients with total wrist arthroplasty. FUNDING: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. TRIAL REGISTRATION: not relevant.

Critical impact of patient knowledge and bone density testing on starting osteoporosis treatment after fragility fracture: secondary analyses from two controlled trials.

UNLABELLED: Most patients are not treated for osteoporosis after their fragility fracture "teachable moment." Among almost 400 consecutive wrist fracture patients, we determined that better-than-average osteoporosis knowledge (adjusted odds = 2.6) and BMD testing (adjusted odds = 6.5) were significant modifiable facilitators of bisphosphonate treatment while male sex, working outside the home, and depression were major barriers. INTRODUCTION: In the year following fragility fracture, fewer than one quarter of patients are treated for osteoporosis. Although much is known regarding health system and provider barriers and facilitators to osteoporosis treatment, much less is understood about modifiable patient-related factors. METHODS: Older patients with wrist fracture not treated for osteoporosis were enrolled in trials that compared a multifaceted intervention with usual care controls. Baseline data included a test of patient osteoporosis knowledge. We then determined baseline factors that independently predicted starting bisphosphonate treatment within 1 year. RESULTS: Three hundred seventy-four patients were enrolled; mean age 64 years, 78 % women, 90 % white, and 54 % with prior fracture. Within 1 year, 86 of 374 (23 %) patients were treated with bisphosphonates. Patients who were treated had better osteoporosis knowledge at baseline (70 % correct vs 57 % for untreated, p < 0.001) than patients who remained untreated; conversely, untreated patients were more likely to be male, still working, and report depression. In fully adjusted models, osteoporosis knowledge was independently associated with starting bisphosphonates (adjusted OR 2.6, 95 %CI 1.3-5.3). Obtaining a BMD test (aOR 6.5, 95 %CI 3.4-12.2) and abnormal BMD results (aOR 34.5, 95 %CI 16.8-70.9) were strongly associated with starting treatment. CONCLUSIONS: The most important modifiable facilitators of osteoporosis treatment in patients with fracture were knowledge and BMD testing. Specifically targeting these two patient-level factors should improve post-fracture treatment rates.

Lower levels of cannabinoid 1 receptor mRNA in female eating disorder patients: association with wrist cutting as impulsive self-injurious behavior.

The cannabinoid 1 (CB 1) receptor as the primary mediator of the endocannabinoid (EC) system was found to play a role in eating disorders (EDs), depression, anxiety, and suicidal behavior. The CB 1 receptor is assumed to play a crucial role in the central reward circuitry with impact on body weight and personality traits like novelty-seeking behavior. In a previous study we found higher levels of CB 1 receptor mRNA in patients with anorexia nervosa (AN) and bulimia nervosa (BN) compared to healthy control women (HCW). The aim of the present study was to investigate the possible influence of the EC and the CB 1 receptor system on wrist cutting as self-injurious behavior (SIB) in women with EDs (n=43; AN: n=20; BN: n=23). Nine ED patients with repetitive wrist cutting (AN, n=4; BN, n=5) were compared to 34 ED patients without wrist cutting and 26 HCW. Levels of CB 1 receptor mRNA were determined in peripheral blood samples using quantitative real-time PCR. ED patients with self-injurious wrist cutting exhibited significantly lower CB 1 receptor mRNA levels compared with ED patients without wrist cutting and HCW. No significant differences were found between ED patients without a history of wrist cutting and HCW. Furthermore, a negative association was detected between CB 1 receptor mRNA levels and Beck Depression Inventory (BDI) scores. To our knowledge, this is the first study reporting a down-regulation of CB 1 receptor mRNA in patients with EDs and wrist cutting as SIB. Due to the small sample size, our results should be regarded as preliminary and further studies are warranted to reveal the underlying mechanisms.

Psychiatric nursing emergency: a simulated experience of a wrist-cutting suicide attempt.

A simulated wrist-cutting suicide attempt scenario was developed and implemented, with the goal of integrating the concepts of psychiatric emergency care, contraband, environmental assessment, and personal safety. Faculty also wanted to convey and provide care and support for participants through-out the visually and emotionally stimulating activity. The under-lying premise was that providing readings and lecture material on these topics was insufficient to the level of learning and performance needed by nursing students and novice nurses. How-ever, actual student clinical episodes integrating these concepts were also infrequent, unpredictable, and often not conducive to student learning. Therefore, faculty implemented a simulation teaching modality to deliver the concepts in a vivid and memorable format. A standardized rating scale on perceived learning and care from faculty during the course of the simulation was administered immediately following participation in the activity. Participants were overwhelmingly positive in their assessment of the activity, reporting an enhanced appreciation for safety in the conduct of inpatient psychiatric nursing care.Further, the faculty member's observation and post-simulation processing of the activity noted cognitive, behavioral, and emotional responses at the individual and group levels related to communication, observation and assessment, decision making,and interpersonal support

Evaluation of superficial and deep self-inflicted wrist and forearm lacerations.

PURPOSE: Self-inflicted wrist or forearm laceration is a specific type of injury presenting to emergency departments. Many investigators have described wrist-cutting from a psychiatric viewpoint. We hypothesized that the character of patients with deep wounds is different from those with superficial wounds. We investigated patients who cut their wrist or forearms as an act of self-mutilation from the viewpoint of wound severity. METHODS: We reviewed 31 patients with self-inflected wrist injuries who were treated in our medical center from 2004 through 2009. We divided them into 2 groups: deep (15 patients) and superficial (16 patients). We investigated differences in age and gender, sites of self-cutting, frequency of self-injury attempts, object used for wrist cutting, group psychiatric parameters, required wound treatments, and psychiatric history and follow-up. RESULTS: Younger patients were more likely to have injured themselves severely compared with older patients. Differences in clinical findings between deep and superficial injury groups included the following: (1) all male patients had deep injuries; (2) patients with superficial wounds were more likely to have cut themselves previously; (3) patients in the deep injury group tended to injure themselves at multiple sites; (4) patients in the deep injury group tended to perform self-cutting with any sharp-edged object at hand; (5) 50% of our patients had received no psychiatric care before being seen by us for their injury; and (6) one-third discontinued the psychiatric treatment prematurely. CONCLUSIONS: There are differences between patients who perform self-inflicted deep versus superficial wrist cutting. We also found that the ages and psychiatric diagnoses of our patients differed from previous reports. This is likely because the available literature includes only patients who received psychiatric care. We found that 50% of our patients had received no psychiatric care, which highlights the importance of hand surgeons treating these patients to initiate psychiatric consultation.