Should hip fractures be operated upon only by specialist hip unit surgeons in order to lower rates of surgical site infection?

PURPOSE: The purpose of this study was to compare outcomes of hip fractures treated by orthopaedic surgeons, performed by specialist vs. non-specialist surgeons. The rate of surgical site infection (SSI) obtained is taken as the main variable. METHODS: This was a prospective controlled cohort study of 814 patients presenting with hip fractures, operated on by a group of orthopaedic surgeons within the same hospital department. Patients were classified according to whether the surgeons belonged to a specialist hip unit (group A = 212 cases) or not (group B = 602 cases). RESULTS: Multivariate logistic regression showed that there was no relation between gender, SSI, Charlson's index, preoperative period, surgical technique or study groups (A or B). Only age was a determinant factor (rank-sum test p = 0.03; OR 95% CI = 1.07, p = 0.005). CONCLUSIONS: Since there were no differences in the SSI outcome between surgeons working in a specialist hip unit and the general orthopaedic surgeons, delaying operative treatment for hip fractures to enable treatment in such a unit or creating a new unit of this type is not necessary. In this respect, the only significant variable is the patient's age.

Ethnic differences in the use of intrapartum epidural analgesia.

BACKGROUND: Obstetric epidural analgesia (EA) is widely applied, but studies have reported that its use may be less extensive among immigrant women or those from minority ethnic groups. Our aim was to examine whether this was the case in our geographic area, which contains an important immigrant population, and if so, to describe the different components of this phenomenon. METHODS: Cross-sectional observational study. SETTING: general acute care hospital, located in Marbella, southern Spain. Analysis of computer records of deliveries performed from 2004 to 2010. Comparison of characteristics of deliveries according to the mothers' geographic origins and of vaginal deliveries noting whether EA was received, using univariate and bivariate statistical analysis and multiple logistic regression (MLR). RESULTS: A total of 21,034 deliveries were recorded, and 37.4% of these corresponded to immigrant women. EA was provided to 61.1% of the Spanish women and to 51.5% of the immigrants, with important variations according to geographic origin: over 52% of women from other European countries and South America received EA, compared with around 45% of the African women and 37% of the Asian women. These differences persisted in the MLR model after adjusting for the mother's age, type of labor initiation, the weight of the neonate and for single or multiple gestation. With the Spanish patients as the reference category, all the other countries of origin presented lower probabilities of EA use. This was particularly apparent for the patients from Asia (OR 0.38; 95%CI 0.31-0.46), Morocco (OR 0.49; 95%CI 0.43-0.54) and other Africa (OR 0.55; 95%CI 0.37-0.81). CONCLUSIONS: We observed a different use of EA in vaginal deliveries, according to the geographic origin of the women. The explanation for this involves a complex set of factors, depending both on the patient and on the healthcare staff.

Complications in immediate breast reconstruction after mastectomy.

OBJECTIVES: Immediate post-mastectomy breast reconstruction (IBR) is a procedure that has proven advantages, but it also entails risks. The aim of this study was to identify risk factors for reconstruction failure. METHODS: A review was made of all the IBR carried out at a general hospital from 2002 to 2009. Retrospective information was obtained about postoperative complications and the characteristics of patients and treatments applied. The minimum follow-up period was 9 months. Cox's regression analysis was performed on the variables related to the reconstruction failure requiring the removal of the prosthesis, with an explanatory model in which all the study variables were introduced and a predictive model that contained only the variables known before the intervention. RESULTS: A total of 115 IRB interventions carried out on 112 women with breast cancer were analyzed. The mean follow-up period was 25.5 months. In sixty cases (52.2 percent), there were no complications; in sixteen cases (13.9 percent) minor complications appeared, and in 39 (33.9 percent) the complications were moderate. In twenty-six cases (22.6 percent), a reconstruction failure occurred. Cox's regression model revealed that the reconstruction failures were related to the patient's age (Hazard Ratio 1.08), to neoadjuvant chemotherapy (HR 6.24) and to postoperative tamoxifen (HR 3.10). The predictive model included the age of the patient (HR 1.05) and the use of neoadjuvant chemotherapy (HR 5.11). CONCLUSIONS: A significant proportion of the patients receiving IBR developed reconstruction failure. Multivariate analysis identified three variables related to this complication, two of which were known before the intervention.

Allograft plus OP-1 enhances ossification in posterolateral lumbar fusion: A seven year follow-up.

PURPOSE: To study the results of the combination of allograft plus BMP-7 in comparison with allograft alone in posterolateral lumbar arthrodesis. PATIENTS AND METHODS: A blinded controlled consecutive prospective cohort of skeletally mature patients study. One hundred and ten patients underwent posterolateral lumbar instrumented arthrodesis. Allograft randomly compacted onto either the right or the left side of the articular and the posterior aspect of the transverse processes of lumbar spine. The same procedure performed on the contralateral side, but allograft was previously mixed with osteogenic protein (OP-1). Clinical, x-ray and CT-scan long follow-up performed. Univariable and multivariable logistic regression analyses. RESULTS: More bone continuity was found with allograft plus OP-1 than with allograft alone (p>0.0038). The amount of bone mass was greater on the OP-1 side (p<0.001). No local or systemic adverse effect were noted. CONCLUSIONS: Allograft on one side plus allograft with BMP-7 on the other achieved a fusion rate of 93 per cent. Allograft combined with BMP-7 was more effective than allograft alone.

[Consequences of obesity in outcomes after cardiac surgery. Analysis of ARIAM registry]. / Consecuencias de la obesidad en los resultados de la cirugía cardiaca. Análisis del registro ARIAM.

BACKGROUND AND OBJETIVE: Obesity is a disease that affects a large part of the population and has been associated with worse outcomes after cardiac surgery. The aim of our study is to evaluate the consequences of obesity related to postoperative complications, hospital length of stay and mortality. METHODS: Observational, prospective, multicenter study of patients included in ARIAM registry of adult cardiac surgery between March 2008 to March 2011. We analyzed clinical variables, the surgical procedure, postoperative complications and mortality, comparing the group of patients with body mass index (BMI) greater or less than 30 kg/m(2). RESULTS: The study included 4,172 patients with a mean age of 64.03 (SD 12.08) years, BMI 28.53 (4.7) and EuroSCORE 5.58 (2.91). In 1,490 patients (35.7%) BMI was greater than 30. There were no differences in the development of overall postoperative complications (33% in obese and non-obese 35.8%, P=.07), although there were less appreciated reoperation rate or stroke (P<.05), as well as further development postoperative renal failure (P=.009). After adjusting for severity and length of cardio by pass time, obese patients had lower mortality without being statistically significant. OR 0.94 (0.79-1.04). There were no differences in ICU length of stay, but obese patients had greater Ward length of stay 9.04 (10.43) vs. 8.18 (9.2) days, P=.01. CONCLUSIONS: Obese patients undergoing cardiac surgery have a mortality, rate of complications and length of stay similar to non-obese. Obese patients required less reoperations but developed more frequently postoperative renal failure.

Using moxibustion in primary healthcare to correct non-vertex presentation: a multicentre randomised controlled trial.

OBJECTIVE: To compare the effectiveness of additional moxibustion at point BL67 with moxibustion at a non-specific acupuncture point and with usual care alone to correct non-vertex presentation. METHODS: This was a multicentre randomised controlled trial in which 406 low-risk pregnant women with a fetus in ultrasound breech presentation, with a gestational age of 33-35 weeks, were assigned to (1) true moxibustion at point BL67 plus usual care; (2) moxibustion at SP1, a non-specific acupuncture point (sham moxibustion) plus usual care; or (3) usual care alone. The primary outcome was cephalic presentation at birth. Women were recruited at health centres in primary healthcare. RESULTS: In the true moxibustion group, 58.1% of the full-term presentations were cephalic compared with 43.4% in the sham moxibustion group (RR 1.34, 95% CI 1.05 to 1.70) and 44.8% of those in the usual care group (RR 1.29, 95% CI 1.02 to 1.64). The reduction in RR of the primary outcome in women allocated to the true moxibustion group compared with the usual care group was 29.7% (95% CI 3.1% to 55.2%) and the number needed to treat was 8 (95% CI 4 to 72). There were no severe adverse effects during the treatment. CONCLUSIONS: Moxibustion at acupuncture point BL67 is effective and safe to correct non-vertex presentation when used between 33 and 35 weeks of gestation. We believe that moxibustion represents a treatment option that should be considered to achieve version of the non-vertex fetus. TRIAL REGISTRATION: Current Controlled Trials ISRCTN10634508.

How many distal bolts should be used in unreamed intramedullary nailing for diaphyseal tibial fractures?

INTRODUCTION: Unreamed intramedullary nailing (UIMN) is an effective treatment procedure for the majority of tibial fractures, with locking constituting the technical support for the buttressing and neutralisation principles underlying intramedullary nailing. It has been claimed that the added versatility obtained from the use of more bolts in distal locking is very important. Several studies have been made concerning the optimum number of locking bolts in distal tibial fractures; however, to the best of our knowledge, no study has dealt with the question of whether two or three bolts should be used in diaphyseal fractures. MATERIAL AND METHODS: In this paper, we evaluate the results of treating 86 diaphyseal tibial fractures (type 42 according to the AO classification) with Expert Tibial UIMN (Synthes™, West Chester, PA, USA) and distal blocking with either two or three bolts. Mean patient age was 35 years (21-51). RESULTS: We found that the consolidation time is shorter, less radiation time is needed and the material cost is lower when two bolts are used. No other differences were found regarding mean operative time, wound healing, pain at fracture site, joint function, angular deviation or rotation. CONCLUSIONS: For type 42 AO tibial fractures treated with Expert Tibial UIMN, distal blocking should be performed with only two bolts.

Acupuncture in patients with acute low back pain: a multicentre randomised controlled clinical trial.

Reviews of the efficacy of acupuncture as a treatment for acute low back pain have concluded that there is insufficient evidence for its efficacy and that more research is needed to evaluate it. A multicentre randomized controlled trial was conducted at 4 primary-care centres in Spain to evaluate the effects of acupuncture in patients with acute nonspecific low back pain in the context of primary care. A total of 275 patients with nonspecific acute low back pain (diagnosed by their general practitioner) were recruited and assigned randomly to 4 different groups: conventional treatment either alone or complemented by 5 sessions over a 2-week period of true acupuncture, sham acupuncture, or placebo acupuncture per patient. Patients were treated from February 2006 to January 2008. The primary outcome was the reduction in Roland Morris Disability Questionnaire scores of 35% or more after 2weeks' treatment. The patients in the 3 types of acupuncture groups were blinded to the treatments, but those who received conventional treatment alone were not. In the analysis adjusted for the total sample (true acupuncture relative risk 5.04, 95% confidence interval 2.24-11.32; sham acupuncture relative risk 5.02, 95% confidence interval 2.26-11.16; placebo acupuncture relative risk 2.57 95% confidence interval 1.21-5.46), as well as for the subsample of occupationally active patients, all 3 modalities of acupuncture were better than conventional treatment alone, but there was no difference among the 3 acupuncture modalities, which implies that true acupuncture is not better than sham or placebo acupuncture.

Effects of acupuncture on patients with fibromyalgia: study protocol of a multicentre randomized controlled trial.

BACKGROUND: Fibromyalgia is a multidimensional disorder for which treatment as yet remains unsatisfactory. Studies of an acupuncture-based approach, despite its broad acceptance among patients and healthcare staff, have not produced sufficient evidence of its effectiveness in treating this syndrome. The present study aims to evaluate the effectiveness of individualized acupuncture for patients with fibromyalgia, with respect to reducing their pain and level of incapacity, and improving their quality of life. METHODS/DESIGN: Randomized controlled multicentre study, with 156 outpatients, aged over 17 years, diagnosed with fibromyalgia according to American College of Rheumatology criteria, either alone or associated with severe depression, according to the criteria of the Diagnostic and Statistical Manual for Mental Disorders. The participants will be randomly assigned to receive either "True acupuncture" or "Sham acupuncture". They will be evaluated using a specific measurement system, constituted of the Fibromyalgia Impact Questionnaire and the Hamilton rating scale for depression. Also taken into consideration will be the clinical and subjective pain intensity, the patient's family structure and relationships, psychological aspects, quality of life, the duration of previous temporary disability, the consumption of antidepressant, analgesic and anti-inflammatory medication, and the potential effect of factors considered to be predictors of a poor prognosis. All these aspects will be examined by questionnaires and other suitably-validated instruments. The results obtained will be analysed at 10 weeks, and 6 and 12 months from the start of treatment. DISCUSSION: This trial will utilize high quality trial methodologies in accordance with CONSORT guidelines. It may provide evidence for the effectiveness of acupuncture as a treatment for fibromyalgia either alone or associated with severe depression. TRIAL REGISTRATION: ISRCTN trial number ISRCTN60217348 (19 October 2010).

Age as a risk factor of nosocomial infection after hip fracture surgery.

Surgery for the treatment of hip fractures is considered the gold standard even among nonagerians with a heavy comorbidity burden. Therefore, a study of an association between surgical complications and some variables in elderly individuals appears to be very important. We designed a transverse study in which we determined patient age at the time of development of a nosocomial infection (NI) in patients who underwent surgery to treat a hip fracture. Univariate and multivariate analyses were performed by simple and multiple logistic regression. We found that age was a determinant in NI after surgical treatment for hip fracture. The older the patient was, the higher the risk of development of an NI after surgical treatment for hip fracture (operative hypothesis). However, the risk of infection changed depending on the treatment. No association with other variables was found.

Role of mental disorders in nosocomial infections after hip fracture treatment.

The association between mental disorders (MDs) and iatrogenic complications after hip fracture surgery has been poorly studied. Among iatrogenic complications, nosocomial infections (NIs) are a major factor in hip fracture surgery. The aim of this paper was to determine whether patients with a MD and a hip fracture develop more NIs after hip surgery than patients with no MD. We studied 912 patients who underwent surgery for a hip fracture (223 patients with a MD who underwent surgery for a hip fracture and 689 control patients without a MD who also underwent surgery for a hip fracture) and followed them after surgery. Univariable and multivariable analyses were performed using simple and multiple logistic regression analysis (confidence interval, crude and adjusted odds ratios, and P value). We found that MDs, gender, and comorbidities were not associated with a higher risk of developing a NI after surgery for a hip fracture. Only age increases the risk of a NI.

[Functional results in myringoplasties]. / Resultado funcional de las miringoplastias.

GOAL: The aim of this study was to assess hearing improvement after myringoplasty. MATERIAL AND METHODS: We present a retrospective study with a total of 119 cases undergoing myringoplasty at our Department analyzing the air conduction thresholds before and 6 months after surgery. We conducted an analysis of variance for the different variables and contrasted hypotheses using Student's T-test. RESULTS: We obtained a hearing improvement at all frequencies, except at 8.000 Hz, at which surgery noticeably worsens hearing. The lower the frequency, the higher the hearing improvement, with the best results at 250 Hz, where the mean hearing improvement reached 13.49 dB. CONCLUSIONS: Myringoplasty is an effective technique in the recovery of hearing thresholds secondary to a tympanic membrane perforation.